LUKE – 31258
Safe - 6-20-2018 Brooklyn Rescue: Starting Over Animal Rescue Please honor your pledges: PayPal Email: [email protected]
SAFE 6/20/18 *ORANGE TABBY WITH POSSIBLE PELVIC FRACTURES NEEDS ORTHO CONSULT ASAP! Sweet LUKE!** The cat was unable to walk. Laying in a public park, appeared very lethargic, finder tried to feed the cat but the cat vomited the food and liquid out. The cat was not interested in food. They kept him for one day but noticed that his energy level was decreasing.
Brooklyn Center
Luke 31258
Location: Brooklyn
Intake Date: 6/15/18
Intake Type: stray
Medical Behavior: Green
Sex: male neutered
Age: 4 years
Weight: 7 lbs
Original Location: 11413
Vet Notes: 3:13 PM
DVM Intake Exam
Estimated age: 1yr
Microchip noted on Intake? no
Microchip Number (If Applicable):
History: The cat was unable to walk. Laying in a public park, appeared very lethargic, finder tried to feed the cat but the cat vomited the food and liquid out. The cat was not interested in food. They kept him for one day but noticed that his energy level was decreasing.
Subjective: Cat is QAR/dull/depressed
Observed Behavior – cat is laying quietly in transport box with increased resp rate. Allows all handling with minimal to no restraint.
Evidence of Cruelty seen – no
Evidence of Trauma seen – yes (road rash)
Objective
T = 100.3F
P = 200
R = 60
BCS 5/9
EENT: Eyes clear, ears mild amount brown waxy debris, no nasal or ocular discharge noted
Oral Exam: healthy adult dentition; no oral lesions noted; mm-light pink, slightly tacky
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lung sounds slightly increased bilaterally, possible crackles
ABD: Non painful, no masses palpated
U/G: bladder is palpable, soft
MSI: Non-ambulatory in hind, weak w/d; able to move both forelimbs. Skin free of parasites, no masses noted, partial alopecia dorsal neck and shoulders, road rash right ventral abdomen and both hind feet
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: not performed
Assessment: Non-ambulatory paraparetic, Tachypnea, Road rash; Suspect HBC
Prognosis:
Fair
Plan: Keep in medical for monitoring.
Gave 0.5mls Simabdol SQ, repeat q24 x 3d
PCV/TS – 36/6.4
Placed 22g IV catheter left cephalic
Systolic BP 70 prior to starting fluid bolus
Started fluids at 76mls/hr for 15-20 mins, repeat BP was 74, continued bolus for another 15-20 mins and repeat BP at that time was 100. Decreased fluids to 11mls/hr until 8pm. Catheter capped and e-collar placed. RR decreased and cat seemed brighter.
Added ACR for chest rads and BW for 6/16.
SURGERY:
Already neutered
Origin Address
Is this cat having litter box issues?
No
If yes, Please elaborate:
Unknown behavior.
Basic Information:
Finder stated that the cat was relaxed but also appeared lethargic. The cat allowed to be pet but meowed when picked up due to the possible injury on his leg.
Previously lived with:
Unknown behavior.
How is this cat around strangers?
Unknown behavior.
How is this cat around children?
Unknown behavior.
How is this cat around other cats?
Unknown behavior.
How is this cat around dogs?
Unknown behavior.
Behavior Notes
Unknown behavior.
Bite history:
Unknown behavior.
Energy level/descriptors:
Unknown behavior.
Medical Notes
The cat appeared injured, lethargic and unable to walk. Injury on the right leg.
For a New Family to Know
Unknown behavior.
Behavior Notes:
During intake the cat was laying down and leaned his head by the carrier. He allowed to be pet and closed his eyes. He appeared lethargic. He did not eat or drink water. However he allowed to be gently picked up with a blanket and placed in a carrier.
ENRICHMENT NOTES:
06/16/18
Resting near the front of the kennel, lifts head up when I approach. Sniffs hand, accepts gentle petting along his body. Social and friendly despite injury. Sweet little guy.
Medical History Report
2336 Linden Boulevard
Brooklyn NY 11208
212-788-4000
Animal ID
Name
Type
Mixed
Color(1)
Color(2)
Gender
31258
Luke
Cat
Yes
Orange Tabby
None
Male
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
Yes
4 Years
985113001923575
8 lbs 6.08 oz
Veterinary Clinic Software Record #:
Weight: 8 lbs 6.08 oz
Date of Weighing: 6/15/2018
Date Spayed / Neutered:
Schedule Surgery Date:
Stitches Removal Date:
Clinic Name:
Previously Spayed / Neutered: No
General Vet Notes:
Previous Medical Details:
Known Allergies or Medical Conditions:
Feeding Requirements:
Indemnities/Waivers:
Medical Notes
Notes
Date
No Medical Notes Stored
Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
6/16/2018
FeLV/FIV Snap
Negative
6/16/2018
Microchip Implantation
6/16/2018
Gabapenth (50 Mg/Ml)
6/16/2018
Flea/Tick Treatment – Paradefense
6/16/2018
Internal Parasite Treatment – Pyrantel
6/16/2018
Fvr-Cp 1 Of 2
6/16/2018
Rabies
Vet Treatments Due
Date Due
Vet Treatment Type
6/30/2018
Fvr-Cp 1 Of 2
6/30/2018
Flea/Tick Treatment – Paradefense
6/16/2019
Rabies
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Simbadol 1.8mg/ml
0 ml
0.5mls every 1 day(s)
16-Jun-2018
23-Jun-2018
2
VET-P 991167
Simbadol – give 0.5mls SQ q24h x 3d. First dose give on intake 6/15/18.
Robenacoxib INJ 20 mg/ ML
0.8 ml
0.4ml every 1 day(s)
17-Jun-2018
18-Jun-2018
1
VET 991524
Give 0.4ml SQ once a day
Gabapentin 50 mg/ML
11.2 ml
0.8ml, 2 times every 1 day(s)
16-Jun-2018
23-Jun-2018
3
VET 991524
Give 0.8ml by mouth twice a day
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
17-Jun-2018
Progress Exam
Vet Notes: 12:31 PM
H: Intake on 6/15. Noted to be laying in the street. Non-ambulatory with road rash, QAR/dull, Mildly tachypneic
– Placed IVC, bolused fluids then started on maintenance until the evening
– Given one dose of Simbadol
6/16
CBC: Mild anemia (Hct 29.2), non regenerative (29.6). Moderate leukocytosis (34) with neutrophilia (28.72)
Chem: Mild hyperglycemia (180), mild elevation in ALT (235)
Two view pelvic/hindlimb radiographs- right femoral head fracture; appear to be multiple fractures of the pelvic symphysis, fracture of left ischium
Two view chest radiographs- diffuse mild bronchoniterstitial pattern noted, but no areas of consolidation seen
S: BAR. Eating well. No csvd. Moderate amount of urine in box. Affectionate at front of cage, but does not want hind area touched. Due to discomfort in hind area, limited exam performed.
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Heart: No murmurs or arrhythmias.
Lungs: Eupneic, mildly harsh lung sounds ausculted on right side.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: Neutered male. No discharge.
Musculoskeletal: Ambulatory x 3- Able to put weight on LHL and walk (though reluctant), but drags RHL (still has motor) and sits with limb splayed outward.
BCS = 5/9
Integument: road roash noted on both limbs with mild to moderate right inguinal brusing- static
Neuro: Appropriate mentation. Motor present in both hindlimbs.
Rectal: Not performed. Externally normal.
Assessment
1) possible pelvic fractures, right femoral head fracture- likely secondary to trauma
2) Anemia (mild, non-regenerative)- given #1, suspect acute hemorrhage secondary to trauma, but cannot r/o anemia of chronic disease/inflammation vs less likely neoplasia
3) Mild elevation in LES- likely secondary to trauma , but cannot r/o primary liver disease
Prognosis: fair with appropriate management
Plan:
Continue Simbadol 0.24mg/kg SQ SID for 7 days
Continue Onsior 2mg/kg SQ SID x 3 days
Continue gabapentin 10mg/kg PO BID x 7 days
Rec NH placement- recommend ortho consult and FHO
VET 991524
16-Jun-2018
LVT-E 990081
16-Jun-2018
16-Jun-2018
Progress Exam
Radiograph Review
Vet Notes: 3:09 PM
H: Intake on 6/15. Noted to be laying in the street. Non-ambulatory with road rash, QAR/dull, Mildly tachypneic
– Placed IVC, bolused fluids then started on maintenance until the evening
– Given one dose of Simbadol
S: BAR. Eating well (has difficulty eating with cone on, but eats when you bring food to face). No csvd. Sitting in litter, so unable to assess eliminations. Initially does ok, but starts to growl and hiss (likely from pain/being manipulated). Due to temperament, limited exam performed.
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Heart: No murmurs or arrhythmias.
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: Neutered male. No discharge. Bladder soft to moderate in size, soft
Musculoskeletal: Non-ambulatory in hindlimbs- able to move both hindlimbs
BCS = 5/9
Integument: road roash noted on both limbs with mild to moderate inguinal brusing
Neuro: Appropriate mentation. Motor present in both hindlimbs.
Rectal: Not performed. Externally normal.
CBC: Mild anemia (Hct 29.2), non regenerative (29.6). Moderate leukocytosis (34) with neutrophilia (28.72)
Chem: Mild hyperglycemia (180), mild elevation in ALT (235)
Two view pelvic/hindlimb radiographs- right femoral head fracture; appear to be multiple fractures of the pelvic symphysis, fracture of left ischium
Two view chest radiographs- diffuse mild bronchoniterstitial pattern noted, but no areas of consolidation seen
Assessment
1) Pelvic fractures, left femoral head fracture- likely secondary to trauma (HBC). Not able to walk, but can move both limbs.
2) Anemia (mild, non-regenerative)- given #1, suspect acute hemorrhage secondary to trauma, but cannot r/o anemia of chronic disease/inflammation vs less likely neoplasia
3) Mild elevation in LES- likely secondary to trauma , but cannot r/o primary liver disease
Prognosis: fair with appropriate management
Plan:
Extend Simbadol 0.24mg/kg SQ SID for 7 days
Start Onsior 2mg/kg SQ SID x 3 days
Start gabapentin 10mg/kg PO BID x 7 days
Rec NH placement- needs FHO +/- internal fixation of pelvis (vs crate rest)- recommend ortho consult
VET 991524
16-Jun-2018
15-Jun-2018
L V T Notes: 6:57 PM
PCV/TP – 36/6.4
15-Jun-2018
DVM Intake
Vet Notes: 3:13 PM
DVM Intake Exam
Estimated age: 1yr
Microchip noted on Intake? no
Microchip Number (If Applicable):
History: The cat was unable to walk. Laying in a public park, appeared very lethargic, finder tried to feed the cat but the cat vomited the food and liquid out. The cat was not interested in food. They kept him for one day but noticed that his energy level was decreasing.
Subjective: Cat is QAR/dull/depressed
Observed Behavior – cat is laying quietly in transport box with increased resp rate. Allows all handling with minimal to no restraint.
Evidence of Cruelty seen – no
Evidence of Trauma seen – yes (road rash)
Objective
T = 100.3F
P = 200
R = 60
BCS 5/9
EENT: Eyes clear, ears mild amount brown waxy debris, no nasal or ocular discharge noted
Oral Exam: healthy adult dentition; no oral lesions noted; mm-light pink, slightly tacky
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lung sounds slightly increased bilaterally, possible crackles
ABD: Non painful, no masses palpated
U/G: bladder is palpable, soft
MSI: Non-ambulatory in hind, weak w/d; able to move both forelimbs. Skin free of parasites, no masses noted, partial alopecia dorsal neck and shoulders, road rash right ventral abdomen and both hind feet
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: not performed
Assessment: Non-ambulatory paraparetic, Tachypnea, Road rash; Suspect HBC
Prognosis:
Fair
Plan: Keep in medical for monitoring.
Gave 0.5mls Simabdol SQ, repeat q24 x 3d
PCV/TS – 36/6.4
Placed 22g IV catheter left cephalic
Systolic BP 70 prior to starting fluid bolus
Started fluids at 76mls/hr for 15-20 mins, repeat BP was 74, continued bolus for another 15-20 mins and repeat BP at that time was 100. Decreased fluids to 11mls/hr until 8pm. Catheter capped and e-collar placed. RR decreased and cat seemed brighter.
Added ACR for chest rads and BW for 6/16.
SURGERY:
Already neutered
VET-P 991167
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