BAMBI – 33399
Safe - 7-15-2018 Manhattan
BAMBI – 33399
*** PELVIC FRACTURE – NEEDS FOLLOW UP VET CARE ***
Location: Manhattan; Intake Date: 7/5/18; Intake Type: Stray Medical Behavior:
Green; Sex: Female; Age: 7 years; Weight: 8 lbs; Original Location: 10460
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 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
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