PRETZEL – A1115682

Brooklyn Center

PRETZEL – A1115682
MALE, GRAY TABBY, DOMESTIC SH MIX,3 mos
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 06/17/2017, From NY 11207, DueOut Date 06/20/2017,
Medical Behavior Evaluation GREEN
Medical Summary Microchip: negative Sex:male Age-3 months Mentation: relaxed, allowed all handling Eyes: clear Ears:clear/clean Nose:clear Teeth:clean BCS- 5/9 Any injuries: wound on dorsal paw in left hind leg. it’s about 1 inch round deep wound with necrotic tissue. Kitten felt pain during washing wound Hair Coat: no fleas seen Behavior: allowed all handling, relaxed, friendly Medication: washed wound with nolvasan solution, 0.16cc convenia SQ and 0.21cc simbadol SQ have been administered at intake exam as per DVM. Dr. 0844
Weight 3.5

DVM Intake Exam

Intact male

Estimated age: 14 weeks

Microchip noted on Intake? negative

History : Patient is stable. No vomititng, diarrhea, coughing or sneezing. Have a wound.

Subjective: Intact male kitten with a wiund on the dorsal left hind limb.

Observed Behavior – Friendly until the veterinarian cleaned the wound. Then he became not anxious and strted moving more. This lasted about 15 seconds

Evidence of Cruelty seen – NAF

Evidence of Trauma seen – NAF

Objective

P = 160 bpm BCS 5/9

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

Oral Exam: NAF

PLN: No enlargements noted

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

ABD: Non painful, no masses palpated

U/G: intact male

MSI: Ambulatory x 4, skin free of parasites, no masses noted, granulating lesion about 12 cm in diameter on the dorsal part of the left hindlimb.

CNS: mentation appropriate – no signs of neurologic abnormalities

Rectal: Not performed

Assessment

wound

Plan

wound cleaned with chlorhexidine solution

Clean wound once a day for 10 days

SSD cream once a day for 2 weeks

0.2 ml convenia sq

0.1 ml onsior sq q 24

Prognosis: excellent

SURGERY: Okay for surgery

ENRICHMENT:

06/18/17

Lying in back of kennel with a relaxed body. He rolls over when spoken to and allows petting along his head and body while leaning in and rolling over onto his side. Remains relaxed for duration of session. Doing well despite injury!

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