SHADE – 15069
Gone - 12-1-2017 Manhattan
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GONE 12/1/17 *MUST BE PULLED BY 5PM NEEDS TO BE SEEN BY A VET ASAP* Traumatic head injury, fractured mandible, lung contusion – Can you help out this poor cat?
Manhattan Center
Shade 15069 1Y White / Black M DSH
Stray: 11/30/17
Medical:
Date
Reasons
Vet Notes
Vet
Date Resolved
1-Dec-2017
DVM Intake
Vet Notes: 12:54 PM
DVM Intake Exam
Estimated age: young adult, ~ 1 yr
Microchip noted on Intake? scan negative
History : found stray, injured
Subjective: Quiet, alert, sitting up in cage
Observed Behavior – calm, allowed handling but will try to flee
Evidence of Cruelty seen – no
Evidence of Trauma seen – yes, head trauma
Objective
BCS 4/9
EENT: OU clear; AU clean; moderate epistaxis
Oral Exam: fractured/dislocated mandibular symphysis with left side of mandible displaced laterally and poss. fracture of left mandibular ramus; fractured left max. canine (204)
PLN: No enlargements noted
H/L: nma, nsf; Lungs – decr. lung sounds caudal, mild wheeze +/- incr. upper airway sounds from injury
ABD: Non painful, no masses palpated
U/G: intact male, nsf
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally
– gave simbadol 0.45 ml SQ
Chest/head rads: mild/mod amount of air around caudal lungs (pneumothorax), cranial lungs appear bruised (contusions) vs other; appears to have fracture to caudal part of left mandibular ramus – difficult to tell with current radiograph
A: traumatic injury to head +/- chest
– epistaxis, fractured mandible (symphysis + ramus)
– pneumothorax/lung contusions
P: LRS IV @ 9 ml/hr x 24 hrs + reassess
– simbadol 0.45 ml SQ SID x 3 days + reasses
Px: open – needs hospitalization for traumatic injuries and repair of mandible
SURGERY: Temporary waiver due to health/injury
VET
1-Dec-2017
LVT Intake
Medical Assistant: 12:21 PM
Patient admitted around 9pm on 11/30. Called the on call vet and described the fractured canine, blood in mouth and around nose, and lethargy. mentation improved in the 15 minutes between receiving patient and checking out animal before calling. Vet 1088 recommended Onsior 6mg tablet, which was administered at 9.15pm.
Set up in medical for DVM intake this morning.
VET
1-Dec-2017
Tech Exam
L V T Notes: 10:09 AM
Administered 0.45mls SQ, Simbadol 1.8mg/ml
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