FRITZ – 33297
Gone - 7-7-2018 Manhattan
GONE 7/7/18 FRITZ was hit by a car and has a fractured jaw. He needs immediate medical care. Fostering will help him get the treatment he needs.
MANHATTAN CENTER
Fritz 33297
Care Center Location: Manhattan
ZIP Code From: 10454
Intake Type: Stray
Medical Behavior: Green
Age: 2 years
Sex: Male
Weight: 7 lbs
5-Jul-2018
VET 991088
Hx: HBC on 7/2, pt has mandibular symphyseal fracture and there was a concern about head trauma.
S: Pt appears tense and uncomfortable in kennel
O: QAR, MMs pink
EENT: Left side of mandible is obviously displaced dorsally, mild bloody oral discharge. No discharge OU, AU, nose.
H/L: NSR, NMA. Eupnic, quiet lung sounds.
Abd: Soft, no pain on palpation, no masses palpated
M/S/I: Amb x4. No skin lesions noted.
Neuro: Alert and appropriate, no sign neurological deficiencies
A: Mandibular symphyseal fracture
Short-term prognosis: Good with reduction of fracture today
P: Repair fracture today
4-Jul-2018
Tech Exam
L V T Notes: 12:07 PM
As per Dr. 1493, substituted Buprenorphine for Simbadol since Simbadol was not available for AMTX.
0.04 mg/kg dosage so 0.04 x 3.18kg = 0.1272/.3 = 0.424 mls of Buprenorphine 0.3 mg given IM
4-Jul-2018
Tech Exam
L V T Notes: 11:46 AM
Fritz seems to be doing okay today – he is quiet and alert. There was some red discharge from nose that we cleaned.
We revised the fluid rate from 15 to 12 ml per hour as per animal care request.
3-Jul-2018
Blood Work Interpretation
Radiograph Review
Vet Notes: 5:54 PM
Cbc/Chem
Mild Lymphocytosis and Neutrophilia – suspect secondary to inflammation
Mild Hyperglycemia (210) – suspect secondary to stress
Lateral and V/D Full Body Xray- unremarkable
No signs of pulmonary or abdominal contusions or skeletal fractures
No signs of pneumonthorax
A – No signs of obvious internal trauma at this time
P- Treat medically in house until 7/5/2018 when DVM available to repair symphyseal fracture
3-Jul-2018
DVM Intake
Vet Notes: 5:17 PM
DVM Intake Exam
Estimated age: 2
Microchip noted on Intake? n
Microchip Number (If Applicable): n
History : stray – found injured by transport staff
Subjective: reported hbc, lethargic, not alert
Observed Behavior –
Evidence of Cruelty seen –
n
Evidence of Trauma seen –
yes
Objective
T = –
P = 240
R = 60
BCS
EENT: mydriasis, Eyes clear, ear mites, no nasal or ocular discharge noted
Oral Exam: Mandibular swelling, mandibular symphyseal fracture
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Intact male – two descended testicles
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: externally normal
Assessment
1) Mandibular symphyseal fracture and swelling – traumatic injury?
2) Tachycardia, tachypnea – pain ?
3) Dull/lethargic – suspect head trauma?
4) Mydriasis – suspect head trauma?
5) Ear mites AU
ddx – traumatic injury
Prognosis: poor to fair
Plan:
1) Analgesia 0.4 ml simbadol SQ 0.4 ml onsior sq
2) CBC/Chem
3) Full body xrays – sedated 0.15 ml midazolam 0.15 ml butorphanol IM
4) IVF @ 15ml/hr for 24hrs LRS (2 x maintenance)
SURGERY:
Temporary waiver due to injury
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