PEPPER – A1122232
Gone - 8-17-2017 Manhattan
GONE 8/17/17 — 10 yr old Pepper was found emaciated, dehydrated and with a jaw fracture. She needs immediate medical help. She has a good appetite. Please consider giving Pepper the help she needs today.
PEPPER – A1122232
FEMALE, BLACK, DOMESTIC SH MIX,10 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 08/16/2017, From NY 10026, DueOut Date 08/19/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 4-10 years based on overall appearance and dentition Microchip noted on Intake? Scanned neg on intake History : Found – no hx available Subjective: Looks around, allows all handling. Very weak. Evidence of Trauma seen – Fractured jaw Objective QAR, estimated 8-10% dehydrated, BCS 1/9, MMs pale pink EENT: No ocular discharge. Y-sutures visible in both eyes, but fundus otherwise visible through lens OU. Moderate brown thick waxy discharge AU. Clean nose. Oral Exam: Mild tartar. Fractured left mandible – laxity and deviated bone felt on palpation. PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, intestines are soft and flaccid. U/G: Female MSI: Emaciated, severe generalized muscle wasting. Pt appears to be able to stand, but prefers to lie down. Caudal half of body is covered in urine. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Normal externally Good appetite when soft food held to face. BG 118 Unable to draw blood for CBC/chemistry – pt too dehydrated and vessels too small Assessment: 1. Left mandibular fracture 2. Emaciated, dehydrated, muscle wasted – R/O secondary to chronic jaw fracture vs. hyperthyroidism vs. CKD vs. other underlying disease 3. Prominent Y-sutures of lenses, but no cataracts – incidental finding Plan 1. Administered 0.1 ml hydromorphone IM around 1:30pm. Start Simbadol 0.25 ml SQ SID x10 days – this evening. 2. Administered 150 ml SQF – start 150 ml SQF this evening (so pt will receive two doses today) 3. Perform CBC/chem/T4 this evening after pt is better hydrated 4. Seek orthopedic/dental consult ASAP SKULL RADS – one displaced piece of left mandible, extending from the left mandibular canine tooth caudally almost to PM3. Prognosis: Assuming CBC/chemistry does not reveal an additional major medical problem: Fair. Jaw would likely need to be pinned or wired shut; pt may need a feeding tube. If CBC/chemistry reveals additional issues: Poor to guarded. SURGERY: Temporary waiver due to jaw fracture and emaciation. 1088
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