GUNTHER – 10173
Safe - 10-20-2017 Brooklyn
SAFE 10/20/17 *NEEDS FOLLOW UP VET CARE* You’re Gonna Love Gunther @BACC!
Gunther 10173, 6 Years Old, Brown and White Tabby DSH, Male, 8 lbs, Stray 10/19/17
DVM Intake Exam
Estimated age: 6
Microchip noted on Intake? none
Subjective: QARH. Large gaping open wound L face with pus.
Observed Behavior – Allows handling but growling but may be due to pain.
Evidence of Cruelty seen -none
Evidence of Trauma seen – none
P = 180
R = eup
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Mild mod calculus with mild gingivitis.
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Male, 2 scrotal testicles
MSI: Left face – large 6 cm oblong open wound with skin avulsed and large open pocket, some pus noted along edges and on hair on LFL, no active bleeding.
Ambulatory x 4, skin free of parasites, no masses noted, otherwise healthy hair coat.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: not done
Assessment: Infected wound Left Face – r/o previous abscess that ruptured vs other
Convenia 0.39 cc sq.
Simbadol 0.52 cc SQ.
Set up for vet to sedate, clean and debride tomorrow. Vet to set up for more pain meds.
SURGERY: Temporary waiver due to wound.
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