LITTLE BOY – 23372

Manhattan Center

23372 Little Boy 2Y Male Black Domestic Short Hair 8lbs

Stray:3/20/2018

Medical

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
21-Mar-2018
DVM Intake
Vet Notes: 4:10 PM

[DVM Intake]
DVM Intake Exam

Estimated age: approx 2 years
Microchip noted on Intake? neg on intake, placed by LVT
Microchip Number (If Applicable):

History :community cat that was being cared for by an elderly women; suspected hit by car and has severe wound along his tail and caregiver was concerned she would be unable to care for him during his recovery; was given simbadol, onsior and one dose of clavamox overnight per on call vet

Subjective:QAR

Observed Behavior -docile and affectionate, a little shy but allows all handling; good appetite

Evidence of Cruelty seen -n

Evidence of Trauma seen -degloving injury along 90% of tail; episode of hematuria in cage

Objective
BCS 5/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam:mm pk, moist; CRT <2 sec; adult dentitia with no significant tartar or staining; both upper canines fractured, R side is more severe with only about 30-40% of tooth remaining; L is tip fracture but with suspect root exposure
PLN: No enlargements noted
H/L: eupnic, clear lung sounds, no murmurs/arrhythmias, intermittent purring
ABD: Non painful, no masses palpated
U/G: male intact, 2 scrotal testicles; episode of hematuria with small blood clot in cage
MSI:
-ambulatory x 4, has crouched gait but may be behavioral; no obvious lameness, paresis, fractures or instability; comfortable on spinal and pelvic palpation; good ROM of hindlimbs with normal proprioception and withdrawal
-partial thickness/superficial ulcerative/degloving injury along 90% of tail, no obvious exposure of underlying musculature or tendons but skin is ulcerated with moderate inflammation, multiple abrasions and focal areas of mild active bloody discharge; tip of tail feels cooler to the touch but appears to have tail tone and sensation distally
CNS: Mentation appropriate
Rectal:grossly normal; anal tone intact

Assessment
1. Suspect HBC
2. Tail degloving injury
3. Fractured canines
4. Hematuria, suspect traumatic

Prognosis:good

Plan:
-convenia 0.4 ml SQ
-continue simbadol 0.5 ml SQ SID x 5 days
-continue onsior 0.4 ml SQ SID x 3 days
-sedate tomorrow for pelvic rads to ensure no concerns and to clean/debride tail as needed
-monitor to ensure hematuria resolves, suspect traumatic
-suspect tail injury will heal with time but could consider tail amputation especially if tail tone is noted to be decreased or absent or wound is not healing appropriately

SURGERY:temp waiver due to recent trauma
VET 991382

21-Mar-2018
LVT Intake
LVT Intake
L V T Notes: 4:45 AM

BARH
scan negative
male intact
inserted during the initial # 981020025327290
age approx 2 yrs
mild tartar
degloving injury in tail
as per on call vet 1 ml clavamox, 0.5 ml sibadol, 0.4 ml onsior given
clean EEN
clean coat
BCS 5/9
NOSF

Behavior

Animal Behavior Saved At: 21-Mar-2018 17:25:26.000
Animal ID:
23372
Animal Name: Little Boy
Age: 2 Years (approx)
Tag Number:
Breed: Domestic Short Hair
Gender: Male
Spayed / Neutered: No
Handler:
Observer:
Behavior Assessment Date:

Retest Date:

Retest Reason:

Next Test Date:

ENRICHMENT NOTES:
Dozing in litter box, woke and came forward when spoken to, soft eyes and body. Leaned and arched enthusiastically into pets, purred loudly. Lay down at the front after door closed, rolled over.

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