LIA – A1116078

MANHATTAN CENTER

LIA –  A1116078

FEMALE, BRN TABBY, DOMESTIC SH MIX,4 weeks
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 06/21/2017, From NY 10452, DueOut Date 06/21/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 4 weeks Microchip noted on Intake? not scanned History : not known Subjective: QAR, euhydrated, trembling, NWB R hind Observed Behavior – allows all but protests, painful Evidence of Cruelty seen – none Evidence of Trauma seen – yes, bleeding from nose and fracture Objective BCS 5/9 EENT: Eyes clear, ears clean, moderate bloody nasal discharge. Nares are swollen. Oral Exam: all deciduous dentition present, no visible ulcers, bleeding, or fractures PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, no evidence of pneumothorax ABD: Non painful, no masses palpated, intact bladder palpable U/G: female MSI: Non-weight bearing on the right hind. Right hind dangles and moves side-to-side at the mid-femur when kitten is held. Painful/reluctant on left hip extension – right hip extension not attempted due to unstable femoral fracture. CNS: QAR to dull but responsive to pain. Palpebral reflex intact, no menace (may be age-related). Assessment: likely polytrauma to face, hind end – closed femoral fracture +/- pelvic fractures or luxations +/- skull fracture Plan: gave 0.1 ml simbadol SQ on intake continue simbadol 0.03 ml SQ SID x 5 days pelvic, femoral rads pending. Seek New Hope. Prognosis: Open SURGERY: Temporary waiver due to underage, trauma, fractures
Weight 0.9

Initial Exam (6/21/17)

DVM Intake Exam

Estimated age: 4 weeks

Microchip noted on Intake? not scanned

History : not known

Subjective: QAR, euhydrated, trembling, NWB R hind

Observed Behavior – allows all but protests, painful

Evidence of Cruelty seen – none

Evidence of Trauma seen – yes, bleeding from nose and fracture

Objective

BCS 5/9

EENT: Eyes clear, ears clean, moderate bloody nasal discharge. Nares are swollen.

Oral Exam: all deciduous dentition present, no visible ulcers, bleeding, or fractures

PLN: No enlargements noted

H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, no evidence of pneumothorax

ABD: Non painful, no masses palpated, intact bladder palpable

U/G: female

MSI: Non-weight bearing on the right hind. Right hind dangles and moves side-to-side at the mid-femur when kitten is held. Painful/reluctant on left hip extension – right hip extension not attempted due to unstable femoral fracture.

CNS: QAR to dull but responsive to pain. Palpebral reflex intact, no menace (may be age-related).

Assessment: likely polytrauma to face, hind end – closed femoral fracture +/- pelvic fractures or luxations +/- skull fracture

Plan:

gave 0.1 ml simbadol SQ on intake

continue simbadol 0.03 ml SQ SID x 5 days

pelvic, femoral rads pending. Seek New Hope.

Prognosis: Open

SURGERY: Temporary waiver due to underage, trauma, fractures

Re-Exam (6/21/17)

Pelvic rads reviewed – only one VD view was taken and there is significant motion artifact due to pt discomfort (not sedated). There is a mid-shaft, significantly displaced, right femur fracture. This fracture requires immediate reduction and surgical repair.

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