SIMBA – 21790

DVM Intake Exam

Estimated age: 2yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History : O surrender. O can no longer care for p. p is indoor/outdoor, recently came home with wound to shoulder.

Subjective: BAR. Nervous, tense, ears down. Ok during PE, but would not allow examination of left shoulder wound. When p was taken out of the cage, serosanguinous to mildly purulent discharge was leaking out.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = wnl
BCS 4/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Fx left max canine.
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: MI
MSI: Ambulatory x 4, skin free of parasites, no masses noted, good hair coat. Puncture wound on cranial left shoulder. Abrasions on dorsal left paw and medial right paw.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment
Wound left shoulder
Abrasions on front paws
Intact male
Indoor/outdoor

Prognosis: good

Plan:
– sedated wound clip, clean, explore, and flush. butorphanol 0.2mg/kg and dexdomitor 10mcg/kg IV or IM.
– start simbadol 0.66mL SQ SID x 5 days
– start clavamox 1.5mL PO BID x 14 days
– start onsior 0.5mL SQ SID x 3 days

Simba 21790, a 2yo MI DSH feline, presented to MACC on 2/28/18 with wounds consistent with bite wounds. The cranial left shoulder with associated abscess is the affected area. No neurologic symptoms associated with rabies are present at this time. Will continue to monitor.

SURGERY:
Okay for surgery