INKO – 15812

Manhattan Center

Inko 15812 2Y Gray Tabby S DSH

Stray: 12/9/17

Medical:

10-Dec-2017
DVM Intake
Vet Notes: 10:03 AM

DVM Intake Exam

Estimated age:3-5 years
Microchip noted on Intake? neg

History :cat found in middle of street, suspect hit by car; ear tipped AS

Subjective:QDR

Observed Behavior – docile, allows handling but seems very painful, mews softly with handling

Evidence of Cruelty seen -n

Evidence of Trauma seen -moderate to severe facial swelling, bloody nasal discharge, traumatic conjunctivitis

Objective

BCS 5/9

EENT:
OU-moderate blepharospasm, bleparitis, elevated 3rd eyelid; OS-miotic, pupil appears vertical, absent PLR; OD-PLR present but decreased
moderate bloody nasal discharge, nasal congestion
Oral Exam:mm pale pk, tacky; swelling of soft palate but no obvious instability; palpable symphyseal crepitus/instability; moderate to severe swelling of tongue; blood tinged hypersalivation; severely fractured upper L canines, missing lower R canine
PLN: No enlargements noted
H/L: intermittent gallop arrhythmia, mild inspiratory dyspnea, decreased lung sounds dorsally with referred upper airway noise ventrally
ABD: Non painful, no masses palpated
U/G: female, suspect spayed
MSI: ambulatory x 4 with no obvious lameness or ataxia; coat overall healthy and clean
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:depressed mentation but alert/responsive; no ataxia noted; CP/withdrawal intact x 4

Assessment
1. Head trauma, symphyseal fracture

Prognosis:fair

Plan:
Hydromorphone 0.15 ml SQ, 0.12 ml midazolam SQ for catheter and radiographs
Placed IVC, gave 50 ml bolus then continue at 15 ml/hr

hyperventilation noted with hydromorphone, will d/c and give simbadol this afternoon

SURGERY:
VET

10-Dec-2017
Tech Exam
L V T Notes: 9:41 AM

RF cephalic 22g catheter placed. Running a bolus of LRS/ 50ml over 30 minutes.
LVT
10-Dec-2017
9-Dec-2017
LVT Intake
L V T Notes: 8:17 PM

HBC – cat appeared stable except for potential head trauma. There appeared to be no injury to front or hind limbs or abdomen.

Cat is congested, bleeding at nose and mouth –
could see upper left canine was broken, and bottom right canine was missing. Right pupil was normal but left pupil was a vertical slit. N

Spoke with on-call vet ad was instructed to gave pain meds Onsior 0.3 mls; (didn’t have access to simbadol.) Gave fluids SQ – LRS 125 mls.
LVT
9-Dec-2017

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