GARFIELD – 11109

Brooklyn Center

Garfield 11109, 2 lbs, 8 Weeks Old, possibly hit by car yesterday

Vet Notes: 11:22 AM

Progress exam-pneumothorax and R femoral fx

History : Intake 10/29-HBC with R femoral fx and penumothorax. Had thoracocentesis (withdrew 1mL of air from left side and 3mL from right side) and was given simbadol, SQ LRS, and heat support. Also had pale mm and was given capstar for fleas.
rad RHL — right closed femoral fx of the proximal diaphysis
lateral CXR — pneumothorax

Subjective: QAR, ~5% dehydrated, nervous, scared, but good for exam and medical handling. No c/s/v/d. Mild increase in RR but seems comfortable. Eating well on his own. No c/s/v/d.

Objective
P = wnl
R = ~40bpm
BCS 3/9
EENT: Eyes clear, ears have mild brown waxy debris, mild crusty nasal d/c
Oral Exam: kitten dentiton, no oral ulcers noted, mm light pink
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs have mild increase in BV sounds and increase in RR
ABD: Non painful, no masses palpated
U/G: MI
MSI: Ambulatory x 3 with RHL lameness and swelling around R thigh, no masses noted, dirty hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment:
HBC 10/29
pneumothorax
right closed femoral fx of the proximal diaphysis
Increased RR/RE – r/o secondary to pain vs trauma
Increased HR-resolved
dehydrated-improving
pale mm – r/o due to fleas-resolved
hypothermic

Prognosis: Fair to poor

Plan:
Simbadol 0.24mg/kg SQ SID until 11/1
Heat support PRN
Start doxycycline 10mg/kg PO SID x10d until 11/9
Start LRS SQ 20ml/kg SID x3d until 11/1
Monitor in medical recovery
Rec femoral fracture repair vs amputation
VET

29-Oct-2017
DVM Intake
Vet Notes: 3:25 PM

[DVM Intake]
DVM Intake Exam

Estimated age: 8 wks
Microchip noted on Intake? neg

History : Finder of animal accidently ran over him with vehicle

Subjective: QAR, nervous, scared, but good for exam and medical handling.

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = 240
R = inc RR/RE. 56 at intake. 32 after simbadol and rest in cage.
BCS 4/9

MM very light pink and tacky, skin turgor delayed. 7% dehydrated.
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: decid dentition
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact male, no testicles descended
MSI: Ambulatory x 3. RHL toe touching to nwb. No overt signs of pain on ortho exam of RHL and LHL, possible discomfort at right hip. Flea infested, no masses noted, wet dirty hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally

Assessment
HBC
pneumothorax
right closed femoral fx of the proximal diaphysis
tachycardic and increased RR/RE – r/o secondary to pain vs trauma
dehydrated
pale mm – r/o due to fleas
hypothermic

Prognosis: guarded to poor

Plan:
simbadol 0.24mg/kg SQ
thoracocentesis — given 0.2mg/kg torb IM. withdrew 1mL of air from left side and 3mL from right side
rad RHL — right closed femoral fx of the proximal diaphysis
lateral CXR — pneumothorax
heat support
capstar
warm LRS 25mL SQ

If by the end of today, RR/RE becomes increased again, despite the thoracocentesis, will humanely euthanize.

SURGERY:
Temporary waiver due to trauma

Addendum:
Approx 2.5 hours post thoracocentesis, p’s RR/RE has improved. RR while sleeping is 44bpm, but still with some inspiratory effort. Consider HE tomorrow if no improvement or worsens.

P:
Continue Simbadol 0.24mg/kg SQ x 3d, extend prn.
Repeat lateral CXR tomorrow
Femoral fracture repair when possible

 

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