TOM aka LEVI – A1106911

Brooklyn Center

TOM – A1106911 aka Levi –  Stray, 4 Years Old, male, Gray Tabby DSH, 11.1 lbs.

MALE, GRAY TABBY, DOMESTIC SH MIX,4 yrs
STRAY – STRAY WAIT, HOLD RELEASED Reason PERS PROB
Intake condition INJ SEVERE Intake Date 03/23/2017, From NY 11236, DueOut Date 03/26/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Findings History hit by car Subjective open mouth, dried blood around and inside mouth Observed Behavior -painful Evidence of Cruelty seen – none Evidence of Trauma seen – yes Objective P = 230 R = 30 BCS 4.5/9 EENT: Eyes clear, ears clean, frank blood and dried blood on nose Oral Exam: cannot perform through oral exam at this time. There is dried blood in the mouth and a mandibular fracture PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment fractured mandible Medical Behavior Status Medical Status Asilomar Status Fast Track? No Plan sedation and oral exam (New Hope cannot place at this time, will asses more fully tonight) Gave 0.1 mls telazol- did not take effect Right lateral radiograph only taken (did not want him to struggle)- lungs appear to have a broncho interstitial pattern r/o asthma, contusions Cannot clean the mouth onsior convenia sq lrs 75 mls DVM check tomorrow morning, New Hope aware he will need placement tomorrow for surgical repair of his jaw vaccines felv/fiv test microchip
Weight 11.1

Medical::

03/25/17

Scan :did not scan

Sex:
S:mouth open, dried blood on mouth and nose, did not touch food from last night, did drink water, hissing in enclosure

O:no stool seen in enclosure

A:Recommend placement for feeding tube placement and surgical repair of the jaw asap.

P:buprenex

will be leaving today
PROGNOSIS:

GOOD

03/24/17

HBC, mandibular fracture

S/O: BAR. Tense in back of cage. Hissing on approach. No interest in food. Food untouched in cage from overnight, offered fresh food directly in front of cat – sniffed but didn’t eat. Clean litter

EENT: Eyes clear, normal PLR OU, no ocular discharge, small amount of dried blood around nose, mandibular symphysis fracture with right side of jaw hanging ~2-3mm lower than left, drooling, keeps mouth open at all times

HL: Normal RR/RE

NEURO: Mentally appropriate

A: Reported hit by car. Mandibular symphysis fracture

P: Will require surgical fixation of jaw. Gave buprenex 0.5ml PO. Rec buprenex 0.5ml q12 x 5 days. Rec EHR if condition declines. Good prognosis with appropriate surgery and care

3/23/17

DVM Intake Exam Findings

History hit by car

Subjective open mouth, dried blood around and inside mouth

Observed Behavior -painful

Evidence of Cruelty seen – none

Evidence of Trauma seen – yes

Objective

P = 230 R = 30 BCS 4.5/9

EENT: Eyes clear, ears clean, frank blood and dried blood on nose

Oral Exam: cannot perform through oral exam at this time. There is dried blood in the mouth and a mandibular fracture

PLN: No enlargements noted

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

ABD: Non painful, no masses palpated

U/G: intact male

MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat

CNS: mentation appropriate – no signs of neurologic abnormalities

Assessment fractured mandible

Medical Behavior Status

Medical Status

Asilomar Status

Fast Track? No

Plan

sedation and oral exam (New Hope cannot place at this time, will asses more fully tonight)

Gave 0.1 mls telazol- did not take effect

Right lateral radiograph only taken (did not want him to struggle)- lungs appear to have a broncho interstitial pattern r/o asthma, contusions

Cannot clean the mouth

onsior

convenia

sq lrs 75 mls

DVM check tomorrow morning, New Hope aware he will need placement tomorrow for surgical repair of his jaw

vaccines

felv/fiv test

microchip

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