JUNE – A1040885
*GONE* 06/21/15- ***MUST LEAVE BY 5PM TONIGHT*** June was hit by a care, needs immediate care!! Pull from MACC!!
Meet June!! June is a very friendly boy, that came to the care center after likely being hit by a car. He is currently on pain medication and has air in his chest. He will need immediate medical care including a chest tap and rads. Please pull June by 5pm tonight.
JUNE – A1040885
I am a neutered male, gray tabby and white Domestic Shorthair mix.
The shelter staff think I am about 4 years old.
I weigh 10 pounds.
I was found in NY 10455.
I have been at the shelter since Jun 20, 2015.
Bottom lip seems to be pulled from gingiva (dragging wound), starting to granulate; minimal staining, upper right canine fracture
Panting but no other injuries seen, could be related to mouth pain
Held off dewormer
Negative fleas/earmites (activyl)
Moved to medical
S/O: Vet check for exposed gingiva/abraded lip. Patient was BAR on presentation. Not interested in food overnight. Urinated several times in litter pan. Allowed handling, tolerable of exam. Patient sat sternally.
mm = pink, moist
hydration = adequate
EENT = clear OU, clean AU, nnd; Patient resented oral examination due to lower lip avulsion at most rostral aspect of chin. Dried blood around lower lip; no new discharge present. No other lesions noted on oral exam – possible blood seen around upper molars in back, but patient would not hold still long enough for thorough exam.
H/L = heart auscults muffled. nma, no obvious crackles or wheezes. Patient is tachypneic and exhibits increased resp. effort
Abdomen = snp, dough-like palpation, no masses palp
LN = wnl
MS = ambx4; BCS: 6/9
A: Tachypneic – r/o stress/fear vs. pain vs. pneumothorax vs. hernia vs. hemothorax vs. other
increased resp. effort – r/o pain vs. pneumothorax vs. diaphramatic hernia vs. hemothorax vs. other
lower lip avulsion – likely due to trauma (HBC vs. high rise)
P: Performed thoracocentesis – Positive pressure; pulled off approx 50 mL air from the right side of the chest; approx 30 mL air from the left side. Patient’s breathing improved slightly, but likely more in chest – thorax palpates with limited re-coil (firm) – Pneumothorax
Administered 0.44 mL Buprenex SL (0.3 mg/mL)
Administed 2 mL of Clindadrops (25 mg/mL)
Rec. chest and abdominal x-rays + further monitoring, poss. chest tube placement, etc.
Will speak to New Hope re: placement.
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