SILVESTER – 22826 aka A1066722

DVM Intake Exam

Estimated age: 5
Microchip noted on Intake? yes
Microchip Number (If Applicable):

History : Brought in fell from high-rise

Subjective: QAR

Observed Behavior – moderate lameness on hindlimb

Evidence of Cruelty seen – n

Evidence of Trauma seen – y

Objective

T =
P =
R =
BCS

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam:
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Neutered

MSI: Grade 2 lameness on hind end, mild superficial abrasion on left hock, illicited a pain response on palpation of dorsal spine, Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat

CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: NP

Assessment: Traumatic hind-end injury, still ambulatory but painful on palpation of pelvis

Suspect MSK Injury vs Pelvic fracture

Plan: Send to medical for sedation and X-ray of pelvis and abdomen – lateral and V/D

Give pain medications in medical:

Simbadol – 0. 24 mg/kg SID SQ
Onsior – 2 mg/kg SID SQ

Medical:

16-Mar-2018
Progress Exam
Vet Notes: 4:12 PM

Hx: High rise fall. Previous owner may have lived on the 2nd floor of the building. Rads show right SI luxation and possible collapsed disc space at L6/L7 and LS junction. Pt was given Simbadol, dexamethasone and one injection of Onsior (mistakenly) and pt has continued on the Simbadol.

S: Alert. Initially resting in the kennel – when I started to pet him, pt moved into the litterbox and urinated for a LONG time, then settled down and allowed brief exam.

O: BAR-H, BCS 8/9, MMs pink and moist
EENT: No discharge OU, AU, nose.
PLNs: Not significantly enlarged.
H/L: NSR, NMA. Eupnic, quiet lung sounds.
Abd: Large, soft, no pain on palpation, no masses palpated
M/S/I: Amb x4 but pt is ataxic in the hind legs. No skin lesions noted.
Neuro: Alert and appropriate. Mild ataxia in hind legs.

A:
1. High rise fall, SI luxation and mild ataxia
2. Onsior and dexamethasone were given concurrently
3. Obese

Short-term prognosis: Good-fair. This injury will likely heal on its own with crate rest.

P:
1. Continue Simbadol
2. Recommend crate rest for 6-8 weeks
3. Pt may have chronic pain in the pelvic region and it is worthwhile to try therapies to minimize this: cold laser, acupuncture, weight loss, other
4. Recommend weight loss of 3-4 lbs

16-Mar-2018
Tech Exam
L V T Notes: 11:18 AM

Administered Simbadol 1.8mg/ml 0.7mls SQ at 8:56AM from Bottle # 75

15-Mar-2018
Tech Exam
L V T Notes: 8:52 AM

Administered 0.7mls of Simbadol 1.8mg/ml SQ, 0.7mls of Onsior 20mg/ml @ 8:45am. Onsior was mistakenly administered and reported to the rounds DVM.
15-Mar-2018
Progress Exam
Radiograph Review
Vet Notes: 9:11 AM

2 view full body radiographs: thorax unremarkable, stomach and intestines appear empty and normal; normal fecal material in descending colon; large intraabdominal fat pad; orthopedic structures unremarkable; possible collapsed disk space at L6/L7 and LS junction noted on v/d view; possible R SI luxation

A
1. Possible collapsed disk space LS
2. Possible R SI luxation

Vet Notes: 9:07 AM

Reportedly fell out of a building; weak in the hind end on presentation but able to stand and ambulate; painful in LS spine; radiographs showed possible collapsed disk space at LS junction; recommended to have received onsior and simbadol but was never administered

S/O
-QAR, docile, shy
-no appetite overnight
-mm pk, moist; CRT <2 sec
-no nasal discharge or sneezing
-OU: open and clear
-eupnic, clear lung sounds, no murmurs/arrhythmias
-soft abdomen
-very painful on gentle touch of LS spine
-ambulatory mild to moderate paraparesis, suspect it is exacerbated by pain; mildly delyaed CP on RH, more delayed but present on LH
-broken nails with mild dried blood on RH
-anal tone present

A
1. Paraparesis, LS pain-suspect traumatic disk herniation +/- R SI luxation
2. Overweight

P
-gave dexamethasone SP 4 mg/ml: 0.3 ml IM
-start simbadol 0.7 ml SQ SID x 4 days
-due to miscommunication, he received one dose of onsior (0.7 ml SQ) instead of simbadol after having already received dexamethasone injection
-rec’d monitoring for vomiting, pale mm, diarrhea etc and not restarting steroids or NSAIDs for 3-5 days
-prognosis: good, given strong ambulation status, suspect crate rest for 4-6 weeks and pain management may be a reasonable treatment plan but weight loss is highly recommended after placement to protect spine and joints
-would benefit from cold laser therapy along LS spine +/- acupuncture
14-Mar-2018
Tech Exam
L V T Notes: 12:12 PM

Sedated per 1382 with 0.2ml Dexdomitor, 0.2ml Butorphanol (10mg/ml, bottle 4) at 11:40am. at 11:50, also added Ketamine (100mg/ml, bottle 18).

Two view radiographs of the pelvis and abdomen were obtained.

Combo test negative

Reversed with antiseden 0.2ml IM

14-Mar-2018
DVM Intake
Vet Notes: 11:38 AM

[DVM Intake]
DVM Intake Exam

Estimated age: 5
Microchip noted on Intake? yes
Microchip Number (If Applicable):

History : Brought in fell from high-rise

Subjective: QAR

Observed Behavior – moderate lameness on hindlimb

Evidence of Cruelty seen – n

Evidence of Trauma seen – y

Objective

T =
P =
R =
BCS

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam:
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Neutered

MSI: Grade 2 lameness on hind end, mild superficial abrasion on left hock, illicited a pain response on palpation of dorsal spine, Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat

CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: NP

Assessment: Traumatic hind-end injury, still ambulatory but painful on palpation of pelvis

Suspect MSK Injury vs Pelvic fracture

Plan: Send to medical for sedation and X-ray of pelvis and abdomen – lateral and V/D

Give pain medications in medical:

Simbadol – 0. 24 mg/kg SID SQ
Onsior – 2 mg/kg SID SQ
Behavior:

Animal Behavior Saved At: 16-Mar-2018 15:22:47.000
Animal ID:
22826
Animal Name: Silvester
Age: 5 Years
Tag Number:
Breed: Domestic Short Hair
Gender: Male
Spayed / Neutered: Yes
Handler:
Observer:
Behavior Assessment Date:
3/16/2018
Retest Date:

Retest Reason:

Next Test Date:

KNOWN HISTORY:
Silvester was brought in as a stray, so we don’t have any behavioral history or tendencies in a home environment.
MEDICAL BEHAVIOR:
3/15/18 docile, shy
ENRICHMENT NOTES:
3/15/18
High-rise injury, possible collapsed disk. Crouched at back wall, tense, eyes dilated. Pressed face into corner when spoken to. Looked up, became alert when door opened. Sat up, sniffed hand, leaned into pets, slowly ate a few treats. Remained stiff, unwilling to come forward.
Cage Condition:
No change
Reaction to assessor:
Silvester remains neutral lying down on his cage bedding during the approach.
Reaction when softly spoken to:
Silvester becomes alert with eyes wide open.
Reaction to cage door opening:
Silvester remains immobile in place, ears erect and forward.
Reaction to touch:
Silvester accepts the touch and head rubs the assessor’s hand. However, after a few strokes he becomes agitated when petted along the back and swats off the hand and growls to stop the interaction.
ACTIVITY LEVEL:
Laid back
VOCAL:
Quiet
CHARACTER TYPE:
Curious

Independent
POTENTIAL CHALLENGES:
Other
Potential challenges comments:
Please note that this cat has a severe medical condition so we may not be seeing any true behavior and behavior may change when the cat’s medical condition improves.
BEHAVIOR DETERMINATION:
Experienced, adult only
Behavior Asilomar
TM – Treatable-Manageable
BEHAVIOR SUMMARY:
Silvester tolerates attention and petting but may be stressed in the shelter, and may be intimidated by small children. Due to the behaviors seen in the care center, we feel that this cat will do best in an experienced, adult only home who understands this cat may need time to warm up to his new home and family at his own pace.

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WAS SAFE 3/10/16