STEVE – 31460
Safe - 6-20-2018 Manhattan
SAFE 6/20/18 Despite having chemical burns, Steve is still a friendly kitty! Meet him today @MACC!. STEVE is a 2 yr old boy who has some wounds on his neck and back. He was a neighborhood stray that was brought in by someone who said the wounds appeared to be getting worse. STEVE needs a new home where he can get some follow up vet care.
Care Center Location: Manhattan
ZIP Code From: 10472
Intake Type: Stray
Medical Behavior: Green
Age: 2 years
Weight: 7 lbs
L V T Notes: 8:17 PM
as per 1516 lowered Robenacoxib inj to 0.35cc SID x 5 days
Vet Notes: 10:37 AM
Hx of wounds on dorsal edge of scapula (bilateral), dorsal aspect of carpus (bilateral), and R side of face/neck. Cleaned and bandaged 6/17.
BAR, eating well
Tries to get cone off. If cone removed, he begins to paw/scratch at wound on face/neck.
**E-collar must stay on until wound healed**
EENT: Eyes clear, small amount of dry debris at medial canthus OU. No nasal discharge.
R face/neck wound: Moderate strike-through of bandage. Bandage removed and wound left open. Healthy bed of pink granulation tissue with a few scabs. Mild-moderate discharge.
Scapula wounds: crust on the left scapula has fallen off, underlying skin healthy with small open wounds still present. Lesion over right scapula crust still present and tightly adhered to underlying skin.
Carpal lesions: No discharge. Scab present on right dorsal carpus.
1. Chemical burns: dorsal scapula and face/neck- healing
2. Pressure sores: dorsal carpus bilaterally
1. Continue clavamox and gabapentin
2. Daily wound care- povidone cleanse
3. Additional analgesia-
Rx: Simbadol 0.5 ml SQ SID for 5 days
Robenacoxib 0.8 ml SQ TID for 5 days
Vet Notes: 5:23 PM
Sedated wound evaluation/cleaning
Sedation: Dexdormitor 0.14 ml IM and Butorphanol 0.07 ml IM
Soaked lesions on dorsal scapulas with dilute chlorhex solution. Mild crusting tightly adhered to underlying skin left in place. Lesions left open to heal,
Wound on right lateral aspect of face/neck soaked in chlorhex solution and scab gently debrided to reveal healthy, pink granulation tissue.
Applied SSD, tresaderm, soft padding, conforming bandage, and minimal vet wrap.
Assessment: suspect chemical/liquid burn vs. self-induced trauma.
1. Padded e-collar placed
2. Remove head bandage 6/18
3. Re-evaluate if needs to be left open or re-bandaged.
L V T Notes: 4:47 PM
Assisted Dr. 1540 with sedated bandage change. As per Dr. 1540 Gave 0.07 mls of butorphanol and 0.14 mls of dexdomitor IM for sedation. Reversed with 0.07 mls IM of antisedan.
Spay-Neuter Waiver Documentation
Vet Notes: 12:44 PM
[Spay/Neuter Waiver – Medical Condition]
Your newly adopted pet has been diagnosed with A WOUND and the staff veterinarians are issuing a temporary waiver from the spay/neuter requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.
Vet Notes: 9:32 AM
DVM Intake Exam
Estimated age: estimate 2 years old based on dentition
Microchip noted on Intake? Scan neg- place when wounds on back healed
History : Stray from the neighborhood, finder saw wounds getting worse over back and brought him in.
Subjective: BAR, laying in kennel with feet tucked under and eyes closed. All wet food eaten.
Observed Behavior – Came to front of kennel and head butted hands while purring. Short growl when right side of neck touched, but allowed all handling.
Evidence of Cruelty seen – None
Evidence of Trauma seen – Wounds on right lateral aspect of neck/face, dorsal aspect of carpus bilaterally, and dorsal aspect of scapula bilaterally
BAR, MM pink and moist, BCS 4/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Permanent dentition present, teeth clean
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Male intact adult
MSI: Ambulatory x 4, skin free of parasites, no masses noted. ~1 x 1 cm circular, hairless lesion on dorsal aspect of carpus (R and L) with overlying crust. 7 x 4 cm lesion on dorsal aspect of scapula (R and L) with no fur and thin crust/scab. Large crust on right lateral aspect of neck/face with fur loss and mucopurulent discharge- growled when touched (painful). Tip of right ear has lesion that is contracting down.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally
1. Clean (+/- sedation) neck wound
2. Clavamox 62.5 mg susp: give 1 ml by mouth BID for 10 days.
3. Gabapentin 200 mg/ml susp: give 0.35 ml by mouth BID for 7 days
Temporary waiver due to wounds
L V T Notes: 6:32 AM
[LVT Intake Exam]
Microchip Scan: negative, did not place due to wounds
Evidence of Cruelty: no
Observed Behavior: allows all handling, friendly and affectionate but painful over back
Sex: possibly intact male
Estimated Age: appx 2y
Subjective: stray from the neighborhood, finder saw wounds getting worse over back and brought him in; possible flea bite dermatitis (fleas seen) with self trauma or other self traumatic wounds on right side face/between the shoulders/two small marks on both forelimbs (areas are scabbed with purulent d/c and alopecia)
Oral Exam: minimal staining
Musculoskeletal: WNL 5/9 BCS
Preliminary Assessment: self-trauma
Plan: DVM intake, in medical for potential debridement of wounds, cleaned some with novalsan solution, CT and MC when calm
Resting on bedding, soft eyes and body. Meowed and came to front when spoken to, sat in place when door opened. Leaned and arched into pets, purred.
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View all entries in: Safe Cats 2018-06