PRINCESS – A1114912

BROOKLYN CENTER

PRINCESS – A1114912

FEMALE, WHITE / ORG TABBY, DOMESTIC SH MIX,7 yrs
STRAY – PRE RTF, NO HOLD Reason PET HEALTH
Intake condition UNSPECIFIE Intake Date 06/10/2017, From NY 11385, DueOut Date 06/13/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 12-14 yo Microchip noted on Intake? no History : community cat presented for SNR Subjective: Observed Behavior – non ambulatory, allows full exam Evidence of Cruelty seen – no Evidence of Trauma seen – yes Objective T = P = 120 R = 44 BCS 3/9 persistent skin tenting EENT: bladk dc AU, fibrosed ear pinnae AU, ear tipped AS, enophthalmic witrh mild 3rd eyelid elevation OU Oral Exam: severe dental calculi on all teeth, pale mm PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: neutered male, bladder not palpable MSI:minimally ambulatory, dragging RHL, decreased withdrawal and decreased voluntary motor on LHL, SQ emphysema over L hip, palpable pelvic instability, no wounds or trauma observed CNS: QAR, weak withdrawl in hind R workse than L Assessment pelvic fx vs spinal trauma vs other chronic otitis dental dz Plan pelvic Rads: fracture of R side of pelvis 0.45ml Simbadol SQ SID x 5d 100ml LRS SQ BID x 5d check ability to urinate and defecate Prognosis: fair, healing will be prolonged due to advanced age, but the fracture will be able to heal poor if neurologic damage is present
Weight 7.6

ENRICHMENT:

06/11/17

Lying in kennel with a low body. He looks upset but he’s not – leans into petting as soon as I touch him. Allows all petting, leaning in with his head. Sweet – doing well today!

MEDICAL:

6/12:

Urine seen in litter box, no feces seen in box or cage this AM

6/11:

no urine nor feces noticed in his cage

Re-Exam

S: Rad review – L SI luxation, suspect also R SI luxation. Suspect R ilial wing/body fracture. Pubis fractures.

Pt urinated and sitting in LB. Watched patient move to other side of cage-marked weakness in hind but has motor present in both hind legs. Mildly prolonged skin turgor. Pt ate food when brought to face. Pt is VERY affectionate.

O:

MSI: BCS 2-3/9, ambx2 with marked hind end paresis. Delayed withdrawls in hind but motor present, very dirty and unkempt coat.

EENT: Marked ceruminous debris and fribrotic pinnae, severe dental dz, clear corneas with mild crusting discharge

UG: CM, medium soft bladder, urine in litter box where laying

HL: NMA, NSR

PLN: No pla

Neuro: see MSI

A:

1. Pelvic fx with hind end paresis

2. Muscle atrophy

3. Suspect chronic otitis externa (otodectes likely) with bilateral chronic aural hematomas

4. Dental dz

5. Dehydration

P: Continue LRS, simbadol, onsior

Start tresaderm for ears with ear cleaning today

Recommend blood work, placement

6/10:
DVM Intake Exam

Estimated age: 12-14 yo

Microchip noted on Intake? no

History : community cat presented for SNR

Subjective:

Observed Behavior – non ambulatory, allows full exam

Evidence of Cruelty seen – no

Evidence of Trauma seen – yes

Objective

T = P = 120 R = 44 BCS 3/9

persistent skin tenting

EENT: bladk dc AU, fibrosed ear pinnae AU, ear tipped AS, enophthalmic witrh mild 3rd eyelid elevation OU

Oral Exam: severe dental calculi on all teeth, pale mm

PLN: No enlargements noted

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

ABD: Non painful, no masses palpated

U/G: neutered male, bladder not palpable

MSI:minimally ambulatory, dragging RHL, decreased withdrawal and decreased voluntary motor on LHL, SQ emphysema over L hip, palpable pelvic instability, no wounds or trauma observed

CNS: QAR, weak withdrawl in hind R workse than L

Assessment

pelvic fx vs spinal trauma vs other

chronic otitis

dental dz

Plan

pelvic Rads: fracture of R side of pelvis

0.45ml Simbadol SQ SID x 5d

100ml LRS SQ BID x 5d

check ability to urinate and defecate

Prognosis: fair, healing will be prolonged due to advanced age, but the fracture will be able to heal

poor if neurologic damage is present

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