SNOW – 33195

MANHATTAN CENTER

Snow 33195

Care Center Location: Manhattan

ZIP Code From: 10453

Intake Type: Stray

Medical Behavior: Blue

Age: 3 years

Sex: Female

Weight: 7 lbs

Medical:

6-Jul-2018
Progress Exam
Vet Notes: 2:42 PM

SO
fracture of the right radius and ulna.
Currently on simbadol
Reported to not be eating on 7/5 but actively eating tuna in kennel throughout day, today.

BAR; Growling when approached.
EENT — eyes are clear with no discharge. no nasal discharge. no sneezing. Appears eupnic.
Bandage is intact, clean and dry. toes are appropriately spaced with no swelling observed.

A
fractured radius and ulna
anorexia — resolved

P
continue with simbadol 0.5ml SQ q24h
Monitor appetite and hydration
continue to offer kitten food and tuna if not interested in adult food
5-Jul-2018
Progress Exam
Vet Notes: 1:35 PM

SO
fracture of the right radius and ulna.
Currently on simbadol; today is last day of onsior inj.
Reported to not be eating, drooling when food place in front of her.

EENT — eyes are clear with no discharge. no nasal discharge. no sneezing. Appears eupnic.
Bandage is intact, clean and dry. toes are appropriately spaced with no swelling observed.

A
fractured radius and ulna
anorexia

P
continue with simbadol 0.5ml SQ q24h
Monitor appetite and hydration
mirtazapine 15mg tablet — give 0.25 tablet PO one time.
offer kitten and tuna if not interested in adult food.
3-Jul-2018
Tech Exam
L V T Notes: 1:34 PM

Administered 0.07mls of Butorphanol 10mg/ml IM, 0.2mls Dexdomitor 0.5mg/ml IM @ 12:43pm for sedated radiographs and examination. Two view RFL rads were taken and reviewed by Rounds DVM and stored in vet documents.. RFL cleaned, a splint was placed by DVM, and face cleaned. Patient was reversed with 0.1mls Antisedan 5mg/ml IM @ 1:25pm. Patient recovered without incident. Administered 0.5mls of Simabadol 1.8mg/ml @ 1:30pm.
3-Jul-2018
DVM Intake
Radiograph Review
Vet Notes: 3:08 PM

Radiograph review:

Closed fracture of the right radius and ulna.
The radius is a mid-diaphyseal short oblique fracture while the ulna is a comminuted fracture.

Update on physical exam and follow up treatments:

O: Oral exam reveals a minor laceration to the right mandibular labia caudal to the canine, moderate buccal swelling and a laceration to the tongue. Palpation of the skull did not reveal any indication of a fracture, zygomatic arch intact and the mandible was easily movable.

A: Fracture of the right radius and ulna – Needs immediate surgery
Soft tissue injuries to the right side of the face – Conservative treatment should suffice

P:
1. Clean away blood and debris
2. Splint the right forelimb
3. Onsior 0.35ml SQ SID today and tomorrow
4. Immediate referral for orthopedic surgery
5. SQ saline 150ml SID for 2 days
6. Offer a slurry of food when feeding

Vet Notes: 12:54 PM

[DVM Intake]
DVM Intake Exam

Estimated age: 3Y
Microchip noted on Intake? no
Microchip Number (If Applicable):

History : Stray brought in by bystander to BxCC, states was watching over cat for one day prior after realizing the “broken arm”. Cat was brought in after noticing cat would not eat or drink

Subjective: BAR not interested in food, seemingly painful in the mouth. Witnessed gagging and trying to manipulate mandible as if something was inside mouth. Litter box not used but there was urine staining. No evidence of vomiting. 5-7% dehydrated.

Observed Behavior – Reserved, but allowed most of physical assessment

Evidence of Cruelty seen – No

Evidence of Trauma seen – Yes

Objective

P= 224
R= 32
BCS 5/9

EENT: Eyes clear, ears clean, no nasal discharge noted, OD ocular discharge
Oral Exam: Strongly resisted any manipulation to the mouth, could only visualize left side briefly. Fractured LMand Canine
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic could not auscultate thoroughly because of purring
ABD: Non painful, no masses palpated
U/G: No leaking or discharge
MSI: Ambulatory x 3, RF limb had mid-diaphyseal crepitation, skin free of parasites, no masses noted, healthy hair coat. No spay scar noted, blood and debris on face along the right mucocutaneous junction of the right maxilla, up to the right nares.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Not done

Assessment

Right front limb radial/ulnar fracture – suspect only radial fracture
Right perioral injury – cannot evaluate further as of now, will revisit when sedated

Prognosis: Good with treatment

Plan:

1. Further exam under sedation:
– Butorphanol 0.07ml IM
– Dexdomitor 0.2ml IM
– Simbadol 0.5 ml SQ
– Sedated Physical exam, including cleaning of facial debris
– Right front limb 2 view radiographs
– +/- Skull radiographs (pending sedated physical results)
2. Simbadol 0.5ml SQ SID for 7 days

SURGERY:
Temporary waiver due to Right front limb fracture

Assessed by OS, reviewed by
3-Jul-2018
Vet Assistant Observations
Medical Assistant: 9:09 AM

Snow can not put pressure on her right front leg and there seems to be dried blood, I can not find a wound. Her nose has an abrasion and has dried blood coming from her nose.Right side of teeth and face stained with blood.

As per on call vet give 1 tab onsior 6 mg PO

 

Behavior:

Animal Behavior Saved At: 5-Jul-2018 13:53:45.000
Animal ID:
33195
Animal Name: Snow
Age: 3 Years (approx)
Tag Number:
Breed: Domestic Short Hair
Gender: Female
Spayed / Neutered: No
Handler: 990828
Observer:
Behavior Assessment Date:
7/5/2018
Retest Date:

Retest Reason:

Next Test Date:

KNOWN HISTORY:
Snow was brought in as a stray, so there is no information on their behavior history or tendencies in a home environment. Her finder was able to pick her up and bring her to the care center. She head-butted the microchip scanner during intake and meowed. She allowed all handling during the intake process.
MEDICAL BEHAVIOR:
07/03/18
Observed Behavior – Reserved, but allowed most of physical assessment
Cage Condition:
Cage is neat
Reaction to assessor:
Snow was lying down by the back, curled up and looking out with almond-shaped eyes.
Reaction when softly spoken to:
Snow looks at the assessor briefly, and then looks away.
Reaction to cage door opening:
Snow becomes alert and looks at the opening.
Reaction to touch:
Snow slowly sniffs the assessor’s hand, and then lowers her head in anticipation of touch. She allows gentle strokes on her head and body, but her ears tilt to the side and her body twitches.
ACTIVITY LEVEL:
Moderate
VOCAL:
Quiet
CHARACTER TYPE:
Shy

Sweet

Curious
BEHAVIOR DETERMINATION:
Experience
Behavior Asilomar
TM – Treatable-Manageable
BEHAVIOR SUMMARY:
Please note that this cat is being treated for a medical condition at the time of evaluation. It is difficult to determine at this time how the medical condition may be affecting the behavior. She interacts with the observer and seems to appreciate attention, but she remains tense and seems uncomfortable. We recommend that this cat go to a home with experienced cat parents.

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