7/5/2018

[DVM Intake] DVM Intake Exam Estimated age:7 Microchip noted on Intake? n Microchip Number (If Applicable): n History : Stray, cannot walk on hind end Subjective: QARH Observed Behavior - gentle Evidence of Cruelty seen - n Evidence of Trauma seen -yes Objective T = - P = 160 R = 60 BCS = 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: moderate calculus PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: superficial abrasion across cranial and caudal abdomen U/G: INTACT female MSI: Ambulatory x 2, not placing weight on hind end Hind legs - delayed placement, withdrawal reflect present (deep pain present) Pain on extension of hind limbs Pain on palpation of lumbar sacral vertebrate Ambulatory x 2, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal Assessment 1) Hind Limb paralysis vs paresis - r/o pelvic fracture vs hind limp practure 2) Tachycardia, tachypnea - r/o pain Prognosis: Plan: Analgesia - 1) Rimadyl 0.3 ml SQ SID for 3 days 2) Buprenorphine 0.040 mg/kg (0.5 ml) BID for 3 days Sedated Rads - Lateral and V/D Pelvis - Lateral and V/D Right + Left hind limbs Temporary waiver due to condition

7/6/2018

SO stray; pain on lumbosacral palpation. Unable to stand on hind end. BAR, allows all handling. very friendly! EENT -- eyes are clear with no discharge, no nasal discharge. ears are clean Oral -- dc 2/5; pd 2/5 H/L -- tachycardia (r/o 2nd to pain, no pain meds given last night); lung sounds are clear in all fields. Skin -- bruising and erythema along the ventral abdomen. MS -- pain on LS palpation; unwilling to place R PL; will place L PL but prefers to sit . A pelvic fracture dental disease P continue with sedated radiograph and analgesia plan as rx by intake strict kennel rest recommend orthopedic consultation for possible surgical correction rimadyl 25mg tablet -- give 0.5 tablet once daily x 5 days tramadol 50mg tablet --- give 0.25mg PO q12h x 5 days Radiographic review -- fracture to the left ischium and right ileum

7/6/2018

[Spay/Neuter Waiver - Medical Condition] Your newly adopted pet has been diagnosed with AN INJURY and the staff veterinarians are issuing a temporary waiver from the spay/neuter requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.

7/7/2018

SO stray; 2 fractures of the pelvis; ambulatory, though prefers to sit. Reported to not be taking rimadyl tablet (found in kennel). Eating food well. BAR, allows all handling. very friendly! EENT -- eyes are clear with no discharge, no nasal discharge. ears are clean Oral -- dc 2/5; pd 2/5 Skin -- bruising and erythema along the ventral abdomen. A pelvic fractures dental disease P strict kennel rest ensure P is eating (on carprofen) recommend orthopedic consultation for possible surgical correction discontinue rimadyl 25mg tablet continue tramadol 50mg tablet --- give 0.25mg PO q12h x 5 days Carprofen 50mg/ml -- give 0.29ml SQ q24h x 5 days

7/8/2018

Recheck in medical for pelvic fx: S/O: QARH, resting in bedding - allows handling, seems comfortable - maintaining good appetite - amb x 2, healing skin abrasions/bruising on abdomen A: stable, pelvic fx with healing skin wounds P: cont. with current tx (cage rest, pain meds) + needs follow-up for fx repair asap

7/9/2018

SO 2 pelvic fractures; ambulatory, though prefers to sit. Eating well. BAR, allows all handling. Timid today, staring whale eyed. EENT -- eyes are clear with no discharge, no nasal discharge. ears are clean Skin -- bruising and erythema along the ventral abdomen, healing A pelvic fractures dental disease P strict kennel rest ensure P is eating (on carprofen) recommend orthopedic consultation for possible surgical correction continue tramadol 50mg tablet --- give 0.25mg PO q12h x 5 days Carprofen 50mg/ml -- give 0.29ml SQ q24h x 5 days

7/11/2018

S/O - Reported to be eating and drinking with no signs of diarrhea or vomitting. A - Extend Rimadyl and Tramadol P - Rimadyl 12.5 mg PO SID for 3 days Tramadol 25 mg PO BID for 3 days

7/12/2018

S/O Pt barh. Eating and drinking. Not moving alot in kennel but urinating and defecating on her own. Abdomen - dry, non painful, eyrthema still present. Seems comfortable. No signs of infection. Progressing well. MSK - Knuckling reflex delayed, placement reflex present, deep pain preseent weight bearing on hind legs. A - Abdomen abrasion healing - Urinating and defecating - Reflexes present on hind - knuckling delayed - Weight bearing but not ambulating - Analgesia seems well controlled Prognosis Fair P - continue on current tx plan RECOMMEND A ORTHOPEDIC VETERINARY CONSULTATION

7/13/2018

Pt _ QAR. Eating and drinking. No Bowel movements reported. EENT - No ocular or nasal dis-charge. Abdomen - Bladder full, no fecal matter palpated. Superficial abrasions healing appropriately A - Pt comfortable, eating and drinking - No bowel movements P - Cont on current tx plan - Monitor Bowel movements - Extend Tramadol 1/2 Tab 50 mg BID for 3 days

7/14/2018

Pt placed awaiting pick up - placed in east holding to alleviate space in medical S/O - Pt BARH. Eating and drinking. Abdomen soft non painful No bowel movements since 13th July - 2018 Pt does not appear to be painful - analgesia controlled well A - Pt comfortable, Adequate Analgesia P - Move to Small dog Holding to alleviated space in medical - Continue to monitor pt daily

7/14/2018

Pt not taking Carprofen pills - discontinue Switch to Oral Meloxican Suspension 7 lb dose SID for 3 days

Upon intake, Bambi panted heavily, but allowed all handling. She seemed calmer when someone held her and she could bury her head into your armpit or somewhere dark.