LAURYN – A1123387

BROOKLYN CENTER

LAURYN – A1123387

FEMALE, BRN TABBY, DOMESTIC SH MIX,6 mos
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 08/26/2017, From NY 11236, DueOut Date 08/29/2017,

Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 6 months Microchip noted on Intake? n History : stray Subjective: patient is BAR, seemed slightly uncomfortable when hind limbs/pelvis was touched Observed Behavior – allowed all handling except when hind limbs where manipulated. Evidence of Cruelty seen – n Evidence of Trauma seen – y Objective P = 200 R = 34 BCS – 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: wnl PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female MSI: skin free of parasites, no masses noted, healthy hair coat MS – crepitation to left hind limb at coxofemoral area CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment – r/o fracture vs luxation Plan – sedation and xray Prognosis: fair SURGERY: Temporary waiver due to radiograph results
Weight 5.0

Medical::

08/26/17:

DVM Intake Exam

Estimated age: 6 months

Microchip noted on Intake?  n

History: stray

Subjective:  patient is BAR, seemed slightly uncomfortable when hind limbs/pelvis was touched

Observed Behavior – allowed all handling except when hind limbs where manipulated.

Evidence of Cruelty seen – n

Evidence of Trauma seen – y

Objective

P =      200                     R =   34                            BCS – 5/9

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

Oral Exam:  wnl

PLN:  No enlargements noted

H/L:  NSR, NMA, CRT < 2,    Lungs clear, eupnic

ABD:  Non painful, no masses palpated

U/G:  female

MSI: skin free of parasites, no masses noted, healthy hair coat

MS – crepitation to left hind limb at coxofemoral area

CNS:  mentation appropriate – no signs of neurologic abnormalities

Rectal:  not performed

Assessment – r/o fracture vs luxation

Plan – sedation and xray

Prognosis: fair

SURGERY:    Temporary waiver due to radiograph results

Sedation – 0.05 ml Telazol IM

Radiograph findings

– complete luxation of the left coxofemoral joint

– fracture of pubis symphasis

Gave Simbadol 0.3ml SQ

08/27/17:

Cage exam-reassess pain

History : Intake 8/26-left coxofemoral luxation and fracture of pubic symphysis

Subjective:  BARH

Objective

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

Oral Exam:  wnl

PLN:  No enlargements noted

H/L: No coughing or sneezing, not ausculted

ABD:  Non painful, no masses palpated

U/G:  female

MSI: skin free of parasites, no masses noted, healthy hair coat

MS – ambulatory x4 with LHL lameness, did not perform full ortho exam due to pain

CNS:  mentation appropriate – no signs of neurologic abnormalities

Assessment –

Left coxofemoral luxation and fracture of the pubic symphysis

Plan – Continue simbadol 0.24mg/kg SQ SID

Recheck pain daily

Rec sedation and reduction of luxation vs FHO vs amputation

Prognosis: excellent

08/28/17:

Cage exam-reassess pain

History : Intake 8/26-left coxofemoral luxation and fracture of pubic symphysis

Subjective:  BARH, purring

Objective

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

Oral Exam:  wnl

PLN:  No enlargements noted

H/L: No coughing or sneezing, not ausculted

ABD:  Non painful, no masses palpated

U/G:  female

MSI: skin free of parasites, no masses noted, healthy hair coat

MS – ambulatory x4 with LHL lameness, did not perform full ortho exam due to pain

CNS:  mentation appropriate – no signs of neurologic abnormalities

Assessment –

Left coxofemoral luxation and fracture of the pubic symphysis

Plan – Continue simbadol 0.24mg/kg SQ SID x5d

Recheck pain daily

Rec sedation and reduction of luxation vs FHO vs amputation

Prognosis: excellent

Enrichment::

08/27/17:

Comes forward. Allows petting along head and body, rolling over onto kennel floor. Pulls my hand closer and gently nips it. Continues to roll and lean in for petting. Playful and friendly, has a lot of energy. Can become overstimulated and nip, but bites are gentle and do not hurt. Doesn’t break glove. Doing well! Beautiful coat.

Profile::

08/26/17:

Stray, allowed all handling. had a very soft body allowed her picture to be taken.

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