SUGAR – 17818
Safe - 1-12-2018 Manhattan
SAFE 1/12/18 SUGAR is a 9 yr old whose owner dumped at the shelter. She has a wound on the side of her face that owner says has been there for a year. Sugar may have dental issues and wound may be self-inflicted due to pain. She will need follow up care and a furever home.
Care Center Location: Manhattan
ZIP Code From: 10460
Intake Date: 1/7/18
Intake Type: Owner surrender
Medical Behavior: Blue
Age: 9 years
Sex: Spayed female
Weight: 8 lbs
DVM Intake Exam
Estimated age: Reported 9 years old and spayed – exam is consistent with a cat 4-9 years old
Microchip noted on Intake? Scanned neg on intake – MC placed during exam
History : Pt has had a wound on her face for about a year.
Subjective: Calm, alert
Observed Behavior – Allows all handling
BAR-H, MMs pink and moist, BCS 5/9
EENT: Large scabbed dry wound on the right side of pt’s face – approx 1 cm x 2 cm – just dorsal to the mandible. Eyes clear, ears clean, no nasal or ocular discharge noted.
Oral Exam: Cs and Is appear clean; difficult to see PMs
PLN: Right mandibular LN is slightly enlarged.
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Soft, non painful, no masses palpated
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally
1. Wound to right side of face – R/O dental disease, suspect self-trauma due to pain
1. Recommend dental rads and sedated oral exam – suspect dental disease as the cause of the wound on the right side of the face
2. Gabapentin 0.8 ml PO BID x14 days
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View all entries in: Safe Cats 2018-01