PAN – 26081

MANHATTAN CENTER

Pan 26081

Location: Manhattan

Intake Date: 4/24/18

Intake Type: Stray

Medical Behavior: Blue

Sex: Neutered

Age: 2 years

Original Location: 10462

DVM Intake Exam
Estimated age: 2 years
Microchip noted on Intake?
Microchip Number (If Applicable):

History :injured cat that may have been hit by car but there were also reports of a cat that fell out of a window in the area

Subjective:BAR

Observed Behavior -nervous but docile, allows handling; urinated and defecated in carrier

Evidence of Cruelty seen -n

Evidence of Trauma seen -moderate paraparesis, RH lameness

Objective
BCS 6/9

EENT: OD-1 cm corneal scar/opacity in ventromedial field with synecheae of iris (chronic) and mild intermittent rotary nystagmus, small corneal defect in this area, moderate blepharospasms; OS-clear; ears clean
Oral Exam: mm pale, tacky; adult dentitia with minimal tartar/staining
PLN: No enlargements noted
H/L: eupnic, decreased lung sounds, no murmurs or arrhythmias
ABD: Non painful, no masses palpated
U/G: male neutered
MSI:
-moderate paraparesis, able to stand with assistance
-RH lameness with crepitus and instability palpable along femur
CNS: Mentation appropriate, paraparesis in hind limbs but does have weak voluntary motor movement; withdrawal intact but decreased in hind
Rectal:grossly normal, good tone present

Assessment
1. RH lameness, suspect femoral fx
2. Trauma
3. Pale mm-r/o pain vs internal hemorrhage vs other
4. Paraparesis
5. Corneal ulcer OD

Prognosis:fair

Plan:
-sedate 0.2 ml torb/0.2 ml ketamine/0.2 ml dexdomitor IM for radiographs
-ofloxacin OD TID
-simbadol 0.6 ml SQ SID x 7 days
-onsior 0.5 ml SQ SID x 3 days

SURGERY:neutered

2 view pelvic rads: distal mid diaphyseal spiral fracture of R femur; 2 radioopaque pins present in distal femur indicating previous surgery; acetabulum is flattened and irregular; femoral head missing, suspect previous FHO; complete fracture of R ilial body with minimal displacement; complete fracture of L ischial wing with minimal displacement

Lateral thoraci rad (initial):heart elevated off sternum indicating pneumothorax; alveolar pattern in caudal mediastinum cranial to heart; pulmonary vasculature extends to caudal fields

2 view CXR (post thoracocentesis): heart still elevated off sternum but appears improved; progression of mediastinal alveolar pattern; pleural fissure line in R cranial field; heart shifted to L on v/d

A
1. R femoral fx
2. Previous FHO, pins present in distal R femur
3. Multiple pelvic fractures, minimally displaced
4. Suspect mediastinal contusion
5. Pneumothorax
6. Pleural effusion, post thoracocentesis

P
-gave 0.2 ml lasix 50 mg/ml IM
-gave flow by oxygen
-if breathing worsens overnight, then consider EHR
-if stable overnight, then continue pain management; consider surgical stabilization of R femur vs amputation; pelvic fractures likely to resolve with extended crate rest and pain management

Clipped and surgically prepped patch on R thorax; performed thoracocentesis between 7/8 ribs; recovered 500 ml of air; gave 0.2 ml lasix IM and reversed dexdomitor with 0.2 ml antisedan IM; recovered from anesthesia well and respiratory rate was 40 breaths/min at rest but increased when approached to 60 breaths/min, normal effort; lung sounds still decreased dorsally; ate a small amount of a/d; blepharospasms OD appeared worse

S/O
-QAR, docile and affectionate boy
-mm pale/lgt pk, tacky
-no nasal discharge or sneezing
-OD: mild intermittent blepharospasms but appears improved/more comfortable; superficial corneal defect in ventromedial field
-eupnic, purring on auscultation, intermittently able to auscultate; lung sounds slightly decreased but present dorsally; no murmurs or arrhythmias
-soft abdomen
-prefers to lie in sternal recumbency, good voluntary movement in LH
-non weight bearing on RH but has good voluntary movement

A
1. Pneumothorax, improving, stable
2. Pale mm-r/o pulmonary contusions vs other, improved
3. R femoral fx
4. 3 minimally displaced pelvic fractures

P
-continue onsior, simbadol
-entice to eat with chicken today, if no appetite then add mirtazapine

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