INDIA – A1043953
7-15-2015 Brooklyn
SAFE 7/15/15
Brooklyn Center
India A1043953 – 5 yr. female Persian
S/O: PATIENT PRESENTED LATERALLY BUT ABLE TO PICK HEAD UP
ALERTED BY VET ASSISTANT OF FRACTURED RHL AT THE AREA OF THE TARSUS
RIGHT TARSUS WAS OBSERVED TWISTED ABNORMALLY AND AND THE SURROUNDING TISSUES WERE DIRTY AND ERYTHEMATOUS – NO OPENED WOUND SEEN. PATIENT WAS PAINFUL AND RESENTED PALPATION OF LIMB.
EENT = CLEAN OU, CLEAN AU, NND, TEETH WITH MODERATE CALCULUS
H/L =
MM = PINK, MOIST
HYDRATION = PROLONGED SKIN TENTING – APPROX. 5% DEHYDRATION
INTEG = SHAVED COAT, CLEAN COAT – SUPERFICIAL ABRASION OVER LEFT INGUINAL REGION
MS = BCS = 3-4/9; ABLE TO AMBULATE X 3 DUE TO FRACTURED TARSUS – CROUCHED GAIT
POST EXAM – PATIENT SPLAYED LEFT LEG OUT WHILE ATTEMPTING TO STAND ACCIDENTLY
A: FRACTURED R TARSUS
MILD DEHYDRATION
PX: FAIR TO GOOD
P: CONVENIA ADMINISTERED 0.25 ML SQ ONCE IN CASE OPEN FRACTURE
BUPRENEX ADMINISTERED 0.15 ML SQ ONCE
CONTINUE ON BUPRENEX – 0.15 SQ/SL BID X 10 DAYS
RADIOGRAPHS TAKEN – L COMMINUTED ILIAL BODY FRACTURE AT THE LEVEL OF THE ACETABULUM. RIGHT TARSAL FRACTURE/DISLOCATION WITH CRANIAL DISPLACEMENT.
WILL INFORM NEW HOPE
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