JELZ – A1106155

Manhattan Center

JELZ – A1106155  1Y Male White&Gray DSH

Stray:3/13/2017

 

INTIAL EXAM

3/14

DVM Intake Exam Findings

 

History    Stray – lame on LFL

Subjective    Initially friendly, allows exam. Does not like exam of LFL and hisses and growls when this leg is touched.

 

Objective

EENT:  Eyes clear, ears clean, no nasal discharge noted

Oral Exam:  Clean teeth

PLN:  No enlargements noted

H/L:  Possible subtle grade 1-2/6 ejection quality systolic murmur. NSR. Lungs clear, eupnic.

ABD:  Non painful, no masses palpated

U/G:  Male intact, testicles soft and symmetrical.

MSI:  Ambulatory x 4. Right hind foot – tarsal pad has small ulceration with litter stuck in it. Left front leg – large full-thickness wound on ventral aspect of antebrachium, about 5-8 cm long and 1-3 cm wide. There is moderate yellow purulent discharge, and the skin covering half of the wound is present but avulsed, dry and crusty.

CNS:  mentation appropriate – no signs of neurologic abnormalities

 

Assessment: Large wound to left front leg, small ulceration on RHL pad.

 

Plan:

1. Continue antibiotics – amoxiclav 45.7 mg/ml 1 ml PO BID x14 days

2. Continue Simbadol for pain management – 0.4 ml SQ SID x10 days

3. Placed wet to dry bandage during exam using sterile saline and sterile gauze. Tomorrow, sedate for bandage change and debridement.

 

Re Exam:

3/15/17

Sedated for bandage change – Ket 0.06, bupr 0.06, dex 0.03. Masked with iso. Dexdomitor reversed immediately after with antisedan due to 2/6 heart murmur ausculted.

 

LFL bandage removed – 3x 4 cm oblong wound mid antebrachium in ventral side – skin sloughed off but good granulation bed. Clipped/ cleaned and flushed. Placed wet to dry bandage.

RRL – 3 between paw pads. 1 wound approx 0.5 cm deep wound. Cleaned. Placed 2 loose sutures to oppose but not completely close – to allow for drainage. Bandage.

A) Large wound LFL – will need to heal by second intention with bandage changes.

RR paw – small wounds

P) Sedate tomorrow for bandage change LFL. Consider telfa and leave bandage on for 2-3 days.

Keep RRL bandage on for 2-3 days and check. s/r 7-10 days.

No litter, use yesterday’s news.

On simbadol and clavamox.

 

Profile:

03/13/17 18:39

 

Jelz is a white and gray tabby DSH with a possible injured paw. Jelz was found wandering loose and allowed finder to pick him up and pet him.  Finder described Jelz as very friendly and sweet. During intake Jelz was purring loudly. Jelz allowed to be scanned and collared with a loose body and enjoyed being pet. Jelz allowed to be picked up and held with no problem. Purred the entire intake.

 

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