SAM SAM – A1104582

MANHATTAN CENTER

SAM SAM – A1104582

MALE, WHITE / ORG TABBY, DOMESTIC SH MIX,10 mos
OWNER SUR – EVALUATE, NO HOLD Reason PETINJURED
Intake condition INJ SEVERE Intake Date 02/24/2017, From NY 10468, DueOut Date 02/27/2017,

2/24/17

Sex: Male intact (cryptorchid)
Scan: Negative
Estimated age: Reported to be 10 months old; exam is consistent with this
Fleas: No flea dirt.

Hx: Fell out of a 3rd story window (4th floor off the ground) this morning.

S: Passive, allows all handling

O: BAR-H, BCS 5/9, MMs pink and moist
EENT: Epistaxis – bright red/pink bloody nasal discharge. Pt resists oral exam but no mandibular instability is palpable. Moderate dark granular discharge AU. Clean eyes and adult teeth.
PLNs: Not enlarged.
H/L: Referred upper airway sounds – nasal congestion. Slightly harsh lung sounds. RR 15 breaths/min. Slightly increased resp effort. HR 160, NMA, NSR.
Abd: Soft, no pain on palpation, no masses palpated
M/S/I: Amb x4. No skin lesions noted. Paws – pads intact, not swollen or bruised. No sign limb fractures.
UG: Male intact, but only one testicle palpable – cryptorchid (abd).

A:
1. High rise trauma – facial trauma with epistaxis and likely nasal swelling
2. Cryptorchid
3. Likely ear mites

Short-term prognosis: Good

SURGERY: Temporary waiver for high rise trauma, but re-evaluate in a few days, as this condition may resolve quickly.

P:
1. Metacam 5 mg/ml inj 0.15 ml SQ once
2. Ivermectin 0.1 ml SQ today and in 14 days
3. Simbadol 0.5 ml SQ SID x5 days, then re-evaluate to see if it needs to be extended
4. Consider chest and skull rads
5. LRS 150 ml SQ today
6. Nebulize with saline only today BID
6. Recommend neuter in the near future as cryptorchid testicles are prone to becoming cancerous

2/24
Hx: Fell out of a 3rd story window (4th floor off the ground) this morning.

Eating

O: BAR-H, BCS 5/9, MMs pink and moist
EENT: Epistaxis – bright red/pink bloody nasal discharge. No mandibular instability is palpable. Moderate browndischarge AU. Clean eyes and adult teeth.
PLNs: Not enlarged.
H/L: Referred upper airway sounds – nasal congestion. Slightly harsh lung sounds. RR 15 breaths/min. Slightly increased resp effort. HR 160, NMA, NSR.
Abd: Soft, no pain on palpation, no masses palpated
M/S/I: Amb x4. No skin lesions noted. Paws – pads intact, not swollen or bruised. No sign limb fractures.
UG: Male intact, but only one testicle palpable – cryptorchid (abd).

A:
1. High rise trauma – facial trauma with epistaxis and likely nasal swelling
2. Cryptorchid
3. r/o Mites

P:Chest radiographs: brochiolar pattern due to inflammation, lung seems very bussy (poss mild pleural effusion on the caudal drosal area)

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