LUNITA – A1106804

BROOKLYN CENTER

LUNITA – A1106804

UNKNOWN GENDER, GRAY, DOMESTIC SH,8 mos
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 03/22/2017, From NY 11221, DueOut Date 03/25/2017,
Medical Behavior Evaluation GREEN
Medical Summary 3-22-17 History – Stray 8Mo No MIC F Subjective – BAR Observed Behavior – Friendly, approachable, easy to handle Evidence of Cruelty seen – None Evidence of Trauma seen – YES 3/5 BCS EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: NAD H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Entire MSI: FR significantly swollen, abrasions, non weight bearing; HL abrasions, swollen mid-digits bearing weight okay; some hair loss Right side INTG: Abrasion above nose; abrasion @OS pinna skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Not performed Assessment – RTA; swollen FR leg; abrasions; non weight bearing Plan – Intake Sedate with 0.2mL Dexdormitor + 0.2mL Buprenorphine Clipped and cleaned; soft bandage with triple abx ointment; Radiographs – Retake tomorrow for clear view Start on clavamox BID1mL x10d’s Start on Onsior SID 2mg/kg inj x3d’s > 0.28mL
Weight 6.2

Medical::

3-22-17

History –

Stray

8Mo

No MIC

F

Subjective – BAR

Observed Behavior – Friendly, approachable, easy to handle

Evidence of Cruelty seen – None

Evidence of Trauma seen – YES

3/5 BCS

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

Oral Exam: NAD

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

ABD: Non painful, no masses palpated

U/G: Entire

MSI: FR significantly swollen, abrasions, non weight bearing; HL abrasions, swollen mid-digits bearing weight okay; some hair loss Right side

INTG: Abrasion above nose; abrasion @OS pinna skin free of parasites, no masses noted, healthy hair coat

CNS: mentation appropriate – no signs of neurologic abnormalities

Rectal: Not performed
Assessment – RTA; swollen FR leg; Sl degloving of RF – healthy tissue, granulation tissue present; abrasions; non weight bearing

Plan – Intake

Sedate with 0.2mL Dexdormitor + 0.2mL Buprenorphine

Clipped and cleaned; soft bandage with triple abx ointment;

Radiographs – Retake tomorrow for clear view

Start on clavamox BID1mL x10d’s

Start on Onsior SID 2mg/kg inj x3d’s > 0.28mL

Enrichment::

03/23/17

Injured. Rolls around in her litter box. Very sweet, purrs softly and solicits attention. Rises up and gives soft head butts. Social and friendly.

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