SMOKEY – 11070

MANHATTAN CENTER

**HOLD FOR DOH-V**

Smokey 11070

Location: Manhattan

Intake Date: 10/28/17

Intake Type: Owner surrender

Medical Behavior: Green

Age: 7 years

Sex: Male

Weight: 11 lbs 8 oz

DVM Intake Exam

Estimated age:reported to be 11 months old but dental staining/tartar and overall body condition more consistent with 5-7 years

Microchip noted on Intake?

History : owner surrender; owner stated that he has a wound above left eye that started as a scratch but has worsened due to smokey scratching it; reports he has been lethargic and not eating for about 1 week; given convenia and simbadol overnight per on call vet

Subjective:QAR

Observed Behavior -docile and friendly; allows handling

Evidence of Cruelty seen -n

Evidence of Trauma seen -n

Objective

BCS 5/5

EENT:

OU-mild to moderate blepharospasms; wound above OS with serousanguinous drainage into eye

Oral Exam:mm pk, sl tacky; CRT <2 sec; moderate to severe tartar/staining

PLN: No enlargements noted

H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic

ABD: Non painful, no masses palpated

U/G: male intact, 2 scrotal testicles

MSI: ambulatory x 4 with no lameness noted

-open wound above R eye with exposure of SQ tissue, wound margins are irregular due to mild tissue necrosis but suspect this started as puncture or animal scratch wound; copious amount of dried blood in fur; viscous bloody discharge

-golf ball sized firm SQ swelling on medial aspect of distal RH limb; palpates as possible mass but suspect it may be wound with fibrosis; overlying skin appears bruised and there was a large amount of dried bloody fluid in fur

CNS: Mentation appropriate – no signs of neurologic abnormalities

Rectal:grossly normal

Assessment

Wound above L eye-suspect bite or scratch wound

Bruised swelling on RH-suspect trauma/wound with fibrosis; r/o soft tissue mass

Prognosis:fair to good

Plan:

Sedated with 0.2 ml ketamine/0.2 ml dexdomitor

Clipped/cleaned/Flushed wound above eye with dilute nolvasan, left open to drain

Clipped area along RH swelling, no obvious wound but lots of dried blood in fur

FNA of swelling revealed dark bloody fluid

Convenia already given, d/c clavamox; if additional antibiotic needed, then rec’d baytril

Cerenia 0.5 ml SQ SID x 3 days

SQF 150 ml SQ SID x 4 days

Onsior 0.5 ml SQ SID x 3 days, first dose given

Simbadol 0.55 ml SQ SID x 5 days

DOH-V status

Monitor for resolution of swelling on RH, if persistent, then rec’d repeat FNA +/- biopsy

SURGERY:

Okay for surgery

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