UPS – A1126924

MANHATTAN CENTER

UPS – A1126924

MALE, BLACK, DOMESTIC SH MIX,1 yr
STRAY – STRAY WAIT, NO HOLD Reason WILD INJ
Intake condition INJ MINOR Intake Date 09/28/2017, From NY 11413, DueOut Date ,

Medical Behavior Evaluation ORANGE
Medical Summary 09/29/17 18:28 DVM Intake Exam Estimated age: adult male, 1-2 yr old Microchip noted on Intake? scan negative on intake History : injured stray/feral cat Subjective: quiet, hiding in back of kennel, poor health/weak condition Observed Behavior – fearful, will try to flee, allowed minimal handling with towel – will try to bite and scratch Evidence of Cruelty seen – no Evidence of Trauma seen – yes, right rear paw injury and seems to only ambulate with front paws Objective **limited PE due to beahv** EENT: Eyes clear mild mucoid ocular d/c, no nasal discharge noted; AU not examined Oral Exam: not examined, will bite PLN: not examined at this time H/L: not examined at this time ABD: skinny, tucked abdomen U/G: intact male, small bladder MSI: Ambulatory x 2 +/-?; gernarlized muscle wasting/emaciated BCS, has motor in hind legs but seems weak with old open wound (~ 2cm) on top of right rear paw with exposed muscle/tendons, rear right leg seems weak +/- nerve damage and unable to use properly (“hangs at the hock”); dirty hair coat CNS: appears appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment: old trauma to right rear leg with open wound, emaciated body condition/gen muscle wasting – alert and ate soft food with strong appetite Plan: gave 0.45 mL Simbadol SQ – monitor overnight – needs further sedated exam in AM Prognosis: open – depending on wound management, underlying trauma +/- other SURGERY: Temporary waiver due to health and injury.
Weight 7.8

Medical:

Re-exam 9/30/17:

Re-exam for emaciated BCS and old trauma/fracture

S/O: quiet, mildly depressed in cage – ate soft food well overnight

– condition remains the same as yesterday

– mod deydrated, emaciated BCS

– OU mod mucoid ocular d/c

– H/L NSF

– Oral Exam nsf, no ulcers observed

– ABD:  skinny, tucked abdomen

U/G:  intact male, small bladder

MSI:  Ambulatory x 3, has motor x 4; decreased range of motion at right hip and will drag right rear paw below at hock/palpable old fracture below right hock; gernarlized muscle wasting/emaciated BCS, has motor in hind legs but gen. weakend; old open wound (~ 2cm) on top of right rear paw with exposed muscle/tendons; dirty coat

CNS:  appears appropriate – no signs of neurologic abnormalities

Rectal:  not performed

A: old tauma to Right hip and Right hock with healing open wound on top of right rear paw from dragging on ground; emaciated body condition/gen muscle wasting

– dehydrated, has appetite for soft food

P: cleaned wound/applied SSD; gave simbadol and LRS treatment

– OU TAB BID x 5 day, recheck

– cont to monitor in shelter – if no improvement in condition rec’ EHR

Prognosis:  guarded – depending on wound management, underlying trauma +/- other

– will need further work-up – rads + BW and surgery for old wound/hindlimb amp.

SURGERY: Temporary waiver due to health and injury.

DVM Exam 9/29/17:

Estimated age:  adult male, 1-2 yr old

Microchip noted on Intake?  scan negative on intake

History :   injured stray/feral cat

Subjective:  quiet, hiding in back of kennel, poor health/weak condition

Observed Behavior – fearful, will try to flee, allowed minimal handling with towel – will try to bite and scratch

Evidence of Cruelty seen – no

Evidence of Trauma seen – yes, right rear paw injury and seems to only ambulate with front paws

Objective  **limited PE due to beahv**

EENT:  Eyes clear mild mucoid ocular d/c, no nasal discharge noted; AU not examined

Oral Exam:  not examined, will bite

PLN:  not examined at this time

H/L:  not examined at this time

ABD:  skinny, tucked abdomen

U/G:  intact male, small bladder

MSI:  Ambulatory x 2 +/-?; gernarlized muscle wasting/emaciated BCS, has motor in hind legs but seems weak with old open wound (~ 2cm) on top of right rear paw with exposed muscle/tendons, rear right leg seems weak +/- nerve damage and unable to use properly (“hangs at the hock”); dirty hair coat

CNS:  appears appropriate – no signs of neurologic abnormalities

Rectal:  not performed

Assessment:  old trauma to right rear leg with open wound, emaciated body condition/gen muscle wasting

– alert and ate soft food with strong appetite

Plan: gave 0.45 mL Simbadol SQ

– monitor overnight

– needs further sedated exam in AM

Prognosis:  open – depending on wound management, underlying trauma +/- other

SURGERY: Temporary waiver due to health and injury.

LVT Intake:

Sex: intact male

Age: adult appx 1-5y

Mentation: BAR, dehydrated (prolonged turgor)

Eyes: raised nictitans (moreso in OS)

Ears: waxy but WNL

Nose: no d/c

Teeth: foodstuffs in mouth (fed on transport), head shy and could not assess

If abnormal BCS: WNL 5/9

Skin: WNL

Hair Coat: unkempt (some outdoor debris)

Declawed: no

Any injuries: lame hinds, withdrawal in both feet and good circulation, right leg “hangs” more than left, does not allow manipulation of hinds (unsure of pelvic fx or other, sedate rads in a.m. with DVM), faint anal tone and fecal smearing along hinds and tail

Behavior: hissing and attempting to flee on front legs, swatting when handled, can burrito to hold but cat still whips head

Medication: preventatives given, on call DVM rec 0.35ml onsior IM, 0.15ml hydromorphine IM, and (after 4hr) simbadol 0.45ml.

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