JEROME – A1124395
Gone - 9-6-2017 Manhattan
DIED 9/6/17 — 3 yr old Jerome is a stray brought in that appeared injured. He is ataxic and weak although he can stand – he may have had some head trauma – is also hyperglycemic and needs further medical eval. Needs rescue asap.
JEROME – A1124395
MALE, BLACK, DOMESTIC SH MIX,3 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 09/05/2017, From NY 10468, DueOut Date 09/08/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 1 year Microchip noted on Intake? History : stray cat appeared injured Subjective: QAR, slightly mentally inappropriate Observed Behavior – laterally recumbent in carrier but rouses when stimulated, is able to stand and walk but appears weak/ataxic Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective BCS 4.5/9 EENT:OU-pupils mid sized, symmetric; absent menace, positive palpebral; suspect decreased vision no nasal discharge, AU-clean Oral Exam: mm pk, sl tacky, mild hypersalivation; CRT 2 sec; no significant tartar/staining PLN: No enlargements noted H/L: eupnic, heart/lungs WNL ABD: Non painful, no masses palpated U/G:male intact, 2 scrotal testicles MSI: ambulatory x 4 when coaxed to stand and walk; mild proprioceptive ataxia; withdrawal WNL x 4; delayed proprioception on hind limbs no obvious wounds/injuries urine soaked fur CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: anal tone present Blood work and radiographs available for review CBC-moderate to severe neutrophilia (25k) Chem-hyperglycemia (220), mildly low BUN (15), mild inc ALT (218) 2 view full body radiographs-incidental mineralized GI foreign body, no obstrutive pattern, suspect that he ate an animal; shoulder physis not fully closed, small osteophyte off cranial aspect of L shoulder Assessment Hyperglycemia-suspect head trauma; r/o stress vs other Ataxia/weakness-suspect head trauma Possibly blind-suspect head trauma Shoulder osteophyte-r/o trauma vs OCD lesion vs other Plan Sedated with 0.2 ml torb/0.1 ml dexdomitor SQ for radiographs; reversed with 0.1 ml antisedan SQ Placed IVC, 75 ml bolus then continue at 10 ml/hr Simbadol Prognosis: fair SURGERY: temp waiver due to suspected head trauma
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