GRAYSON – A1123529

Manhattan Center

A1123529 Grayson 3y Gray M DSH 7lbs.

Intake: Stray 8/28/17

Medical:

8/28

DVM Intake Exam

 

Estimated age: Adult male cat, possibly 2-5 years old

Microchip noted on Intake?  Scanned neg on intake

 

History :  Seen at the same street corner since last night

 

Subjective: Dull, hissing, allows handling when towel-restrained

 

Evidence of Trauma seen –  Enophthalmia, discharge from mouth, maggots from mouth

 

Objective

Dull, BCS 4/9, estimated 8% dehydrated, rectal temp 104.5.

EENT:  Right eye: enophthalmia, eyelids crusted shut. Left eye mild mucoid discharge. Left nare and left side of mouth (including the mandible and maxilla) are coated in many small maggots (1 mm long), and purulent discharge. Did not do careful palpation of this region due to obvious pt discomfort. Left side of the face – appears normal.

H/L:  NSR, NMA   Increased resp sounds.

ABD:  Non painful, no masses palpated

U/G:  Male intact

MSI:  No other apparent injuries besides facial trauma. Large amount of flea dirt. Good fur coat. No masses noted.

CNS:  Dull

Rectal:  Normal externally

 

Assessment:

1. Severe wound on right side of face – very small maggots so likely 3-5 days old. R/O fractured jaw vs. only soft tissue involvement.

2. Enophthalmia OD – R/O secondary to wound, possible corneal perforation vs. other

3. Flea dirt

4. Fever

5. FeLV

 

Prognosis: Fair to guarded – depends on pt’s response to treatment today and results of rads. Pt may need orthopedic surgery to stabilize jaw, or pt may do okay with wound treatment

 

P:

1. Place IVC, start IV LRS at 10 ml/hr

2. Start ampicillin 250 mg/ml 0.4 ml IV q8 x4 days – will likely decrease frequency and change route within a few days

3. Start Baytril 22.7 mg/ml 0.7 ml IV **give slowly** q24 – okay to switch to IM if IVC comes out

4. Give Hydromorphone 0.16 ml IV

5. This evening, start Simbadol 0.45 ml SQ SID x10 days

6. Gently clean face and flush out maggots

7. Recommend sedated exam and skull rads to determine the level of involvement of skull/soft tissues

 

SURGERY:  Temporary waiver due to  WOUND

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