PUGSLEY – 11076
Safe - 10-29-2017 Brooklyn
PUGSLEY – 11076
**NEEDS INTENSIVE CARE BY 5PM TODAY, 10/29/17 FOR HEAD TRAUMA**
4-6 Years Old, Small Tan Mix, Male, 16 lbs, Stray 10/27/17
Medical: 10/29/17: DVM Intake Exam; Estimated age: ~4-6 years; Microchip noted on Intake? negative; History : stray hit by car this morning; Subjective: Obtunded with severe right head/body turn. Euhydrated. Unable to stand or respond to stimuli. Observed Behavior – unable to fully assess behavior due to head trauma; Evidence of Trauma seen – yes; Objective ; P = wnl ; R = eupneic ; BCS 5/9; EENT: No ocular d/c, ears have blood on pinna and superficially in canal, no nasal discharge noted; Oral Exam: adult dentition with moderate dental tartar, no oral lesions noted, tongue is dark purple; PLN: No enlargements noted; H/L: NSR, Grade 4/6 HM, CRT < 2, Lungs clear, eupneic; ABD: Non painful, no masses palpated; U/G: MI, 2 testicles descended; MSI: laterally recumbent, skin free of parasites, no masses noted, very dirty and wet hair coat with blood on it, unable to rule out fractures at this time due to compromised patient; CNS: obtunded, anisocoria with OD>OS, absent menace and PLRs, decreased to absent palpabral and CNs, CP present x4, severe right head/body turn; Assessment: Head trauma-hit by car; Grade 4/6 HM; Plan: Continue to monitor while at BACC; Hydromorphone 0.1mg/kg IV q4-6 hours ; Placed IVC; Mannitol 1g/kg IV slowly followed by furosemide 1mg/kg IV 20 minutes later-can repeat every 2 hours if responds -First given at 9:30am -Second dose given at 12:30pm; IVF @ 60ml/kg/day; If no significant improvement after mannitol and furosemide, rec EHR; Prognosis: guarded; SURGERY: permanent waiver from surgery due to heart murmur
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