FREDDY – 17617

DVM Intake Exam

Estimated age:4 months
Microchip noted on Intake?placed on LVT intake
Microchip Number (If Applicable):

History :reportedly was caught in a car engine

Subjective:QAR

Observed Behavior -slightly unsocialized, regressed and hissed once when approached but then was docile and allowed handling; ravenous appetite

Evidence of Cruelty seen -n

Evidence of Trauma seen -LF lameness, large wound over dorsum

Objective
BCS 3.5/9

EENT:
-OU: moderate blepharospasm, mucoserous discharge, elevated 3rd eyelid
-mild mucoid crusting discharge along nares
-AU: greasy discharge along pinna, minimal brown waxy discharge in canals
Oral Exam:mm pk/lgt pk, tacky; deciduous canines
PLN: No enlargements noted
H/L: no murmurs or arrhythmias, eupnic, clear lung sounds
ABD: soft, doughy, nonpainful; no palpable abnormalities
U/G: male intact
MSI:
-LF: partial weight bearing lameness, paresis; external rotation of limb, uses dorsal aspect of carpus to bear weight
-superficial ulcerative wound along palmar aspect of LF carpus and ulceration of main paw pad
-large area of alopecia along L caudal dorsum extending on to tail with large, superficial ulcerative wound that is healing well with healthy granulation tissue and no active discharge; wound appears 7-10 days old
–
CNS: Mentation appropriate; RF paresis, absent proprioception and withdrawal
Rectal:grossly normal, good tone

Assessment
1. LF lameness, paresis-suspect concurrent ulnar fracture and nerve damage, possible brachial plexus avulsion
2. URI/conjunctivitis-r/o secondary to being in car engine vs viral vs bacterial
3. Wound on dorsum-r/o burn vs road rash vs other; does not appears to be consistent with bite wound
4. Underweight

Prognosis:fair to good

Plan:
-sedated with 0.1 ml ketamine/0.1 ml dexdomitor/0.1 ml torb IM for radiographs
-gave 0.1 ml convenia SQ
-gave 50 ml SQF
-gave 0.1 ml cerenia SQ
-onsior 0.1 ml SQ SID x 3 days, first dose given
-did not realize patient had simbadol overnight, gave additional 0.1 ml SQ, continue SID x 4 days
-continue doxycycline, erythromycin

-suspect nerve damage along with fibular fx, amputation may be best curative option

SURGERY: temp waiver due to URI/underweight