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.
Care Center Location: Manhattan
ZIP Code From: 10454
Intake Type: Stray
Medical Behavior: Green
Age: 2 years
Weight: 7 lbs
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
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
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.
Blood Work Interpretation
Vet Notes: 5:54 PM
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
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 –
Evidence of Trauma seen –
T = –
P = 240
R = 60
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
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
1) Analgesia 0.4 ml simbadol SQ 0.4 ml onsior sq
3) Full body xrays – sedated 0.15 ml midazolam 0.15 ml butorphanol IM
4) IVF @ 15ml/hr for 24hrs LRS (2 x maintenance)
Temporary waiver due to injury
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