SHERBET – 29872
Safe - 6-11-2018 Brooklyn Rescue: Feline Rescue of SI Please honor your pledges: http://felinerescueofstatenisland.org/donation/
SAFE 6/11/18 Sweet SHERBET Needs Follow Up Vet Care for Wound! SHERBET was brought in with an open wound on his left flank. He is very upset and needs a home with follow up vet care where he can also decompress. Sherbet is already neutered. Surgery doctor will clean wound and attempt to close. If wound is not successfully closed euthanasia will be considered.
BROOKLYN CENTER
Sherbet 29872
Location: Brooklyn
Intake Date: 6/1/18
Intake Type: ACO Impound
Medical Behavior: Red
Sex: Neutered
Age: 4 years
Weight: 7.54 lbs
Original Location: 11213
Vet Notes: 12:30 PM
29872
Sherbet
Cat
Yes
White
Brown
Male
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
Yes
4 Years (approx)
985113001792138
7 lbs 8.64 oz
Veterinary Clinic Software Record #:
Weight: 7 lbs 8.64 oz
Incoming Agency: Animal Care Centers of NYC
Date of Weighing: 6/1/2018
Date Spayed / Neutered:
Schedule Surgery Date:
Stitches Removal Date:
Clinic Name:
Previously Spayed / Neutered: Yes
General Vet Notes:
Previous Medical Details:
Known Allergies or Medical Conditions:
Feeding Requirements:
Indemnities/Waivers:
Medical Notes
Notes
Date
No Medical Notes Stored
Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
6/1/2018
Re-weigh
6/1/2018
Rabies
6/1/2018
Fvr-Cp 1 Of 2
6/1/2018
FeLV/FIV Snap
Negative
6/1/2018
Microchip Implantation
6/3/2018
Flea/Tick Treatment – Paradefense
6/3/2018
Gabapenth (50 Mg/Ml)
6/3/2018
Internal Parasite Treatment – Pyrantel
Vet Treatments Due
Date Due
Vet Treatment Type
6/15/2018
Fvr-Cp 1 Of 2
6/15/2018
Re-weigh
6/17/2018
Internal Parasite Treatment – Pyrantel
7/3/2018
Flea/Tick Treatment – Paradefense
6/1/2019
Rabies
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Robenacoxib INJ 20 mg/ ML
0 ml
0.32 every 1 day(s)
2-Jun-2018
After 2 occurrences
2
VET-P 991027
0.32ml sq
Simbadol 1.8mg/ml
0 ml
0.45 every 1 day(s)
2-Jun-2018
11-Jun-2018
3
VET-P 991027
0.45ml sq
Amoxicillin/Clavulanic Acid Drops 62.5 mg/ml
0 ml
1, 2 times every 1 day(s)
3-Jun-2018
13-Jun-2018
2
VET 991416
1ml in food BID
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
4-Jun-2018
Progress Exam
Vet Notes: 10:13 AM
Progress exam
History: Intake 6/1-large open wound on left flank. Started on onsior and simbadol. Wound treated under anesthesia with drain placed. Convenia injection given.
6/3-started on clavamox
Subjective: BAR. Limited exam due to behavior. Wound is intact but still has purulent/bloody discharge. Great appetite with normal U in cage. No csvd.
Objective:
EENT: Eyes clear, no nasal or ocular discharge noted
H/L: Normal RR/RE, eupneic
MSI: Ambulatory x 4, skin free of parasites, ~10cm closed wound on left flank with sutures and drain intact, moderate purulent/bloody d/c from drain site
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
Large closed wound on left flank with drain in place
Prognosis: Good
Plan:
Continue simbadol until 6/11
Continue clavamox 13.75mg/kg PO BID until 6/13
Sedate to assess drain +/- remove on 6/6
VET 991416
3-Jun-2018
3-Jun-2018
Progress Exam
Vet Notes: 12:20 PM
Progress exam
History: Intake 6/1-large open wound on left flank. Started on onsior and simbadol. Wound treated under anesthesia with drain placed. Convenia injection given.
Subjective: BAR. Limited exam due to behavior. No csvd. Eating well. No bm or u in his litter box.
Objective:
EENT: Eyes clear, no nasal or ocular discharge noted
H/L: Normal RR/RE, eupneic
MSI: Ambulatory x 4, skin free of parasites, ~10cm closed wound on left flank with sutures and drain intact, moderate purulent d/c from drain site
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
Large closed wound on left flank with drain in place
Prognosis: Good
Plan:
Continue simbadol until 6/11-may be able to d/c before this
Last day of onsior
Start clavamox 13.75mg/kg PO BID x10d until 6/13
Sedate to assess drain +/- remove on 6/6
VET 991416
2-Jun-2018
Progress Exam
Vet Notes: 9:31 AM
H: Intake on 6/1- large, superficial wound spanning left flank noted–> primary closure by surgeon on 6/1
– Started on Onsior (2 total doses), Simbadol and administered convenia injection
S: QAR to BAR. Ate well. No urine or BM seen in box. Hissing growling, tries to strike through cage. Visual only exam performed.
R wnl
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Lungs: Eupneic
U/G: Neutered male. No discharge.
Musculoskeletal: Have not witnessed walking, laying sternally in cage.
BCS = 4/9
Integument: ~ 5-6cm in length wound noted over left flank, closed primarily on 6/1. Incision appears cdi- mild erythema and swelling. Mild amount of serosanguinous discharge noted on blanket.
Neuro: Appropriate mentation. Full neurologic exam not performed.
Rectal: Not performed. Externally normal.
Assessment
1) Wound (large, superficial, over left flank)- Closed primarily on 6/1. Noted to have tension at the caudal aspect of the wound- concern for dehiscence, infection/abscess formation (as only given convenia injection and may be unable to do daily antibiotics due to temperament)
Prognosis: fair to good
Plan:
Continue Onsior until 6/3
Continue Simbadol until 6/11
CTM in Medical for dehiscense/infection of wound–> if worsening swelling/infection noted, start daily injectable abx
Remove penrose drain in 5 days
VET 991524
1-Jun-2018
Post Op Exam
L V T Notes: 4:10 PM
Pre Medication
Simbadol 0.45ml SQ
Anesthetic Induction
Telazol 0.15ml IM
Gas Maintenance:
Isoflorane % : 1.5
Additional Pain meds
Onsior 0.32ml SQ
Antibiotic
Convenia 0.34ml SQ
Surgeon: 1438
Vet Notes: 3:44 PM
Wound repair:
Large wound at left flank, extending to lateral hip, approx 10 cm x 4 cm. Applied sterile lubricant to wound, clipped and cleaned surrounding area. Flushed with copious amts sterile saline.
Used #10 blade to debride wound bed, freshened edges of wound. Blunt dissection to undermine skin. Tacking sutures of 3-0 and 2-0 PDS placed to eliminate dead space and decrease tension at skin edges. Drain placed with tacking suture at craniodorsal aspect of wound, exiting at caudoventral aspect of wound with tacking suture. Single cruciate suture of 2-0 PDS placed at cranial aspect of wound. Apposed approx 5 cm caudal to that with 3-0 PDS intradermally. Caudal aspect of wound has most tension, 3-0 and 2-0 PDS simple interrupted sutures placed to appose skin.
Convenia 8 mg/kg SQ
Surgeon: 1438
Additional notes: smooth recovery
VET-P 991438
1-Jun-2018
DVM Intake
Vet Notes: 12:30 PM
[DVM Intake]
DVM Intake Exam
Estimated age:4
Microchip noted on Intake?n
Microchip Number (If Applicable):
History :on street with very large open wound covering left flank. wound is largely a healthy granulation bed.
Subjective:
Observed Behavior -yowling and striking
Evidence of Cruelty seen -n
Evidence of Trauma seen -yes
Objective
T =
P =200
R =wnl
BCS 4/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam:moderate tartar
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G:neutered male
MSI: Ambulatory x 4, skin free of parasites, no masses noted, large open wound left flank
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment-open wound
Prognosis:fair
Plan:
sedated 0.15 telazol IM
onsior .32ml sq
simbadol .45ml sq
surgery doctor will clean wound and attempt to close. if wound is not successfully closed ehr will be considered
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