JUNE – A1040885

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Manhattan Center

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.

INTIAL EXAM:

Negative MC

Neutered male

BARH

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

Fatty (3.5)

Held off dewormer

Negative fleas/earmites (activyl)

NOSF

 

Moved to medical

 

RE-EXAM:

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

CNS= appropriate

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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