JO – A1116827

JO – A1116827

**PELVIC FRACTURE -NEEDS FOLLOW UP CARE ASAP**

MALE, WHITE / BROWN, SHIH TZU, 2 yrs, 6 mos
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 06/28/2017, From NY 11203, DueOut Date 07/01/2017,

Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 2-3 yrs Microchip noted on Intake? yes (0A01561547) History : Stray picked up by field. Subjective: Dog is QARH. Observed Behavior – A little shy/timid, but warms up quickly; turns to humans for comfort safety (leans head into body/pets). Little restraint required for exam. Allows all body parts to be touched; turns head when hip(s) extended, only sign of discomfort.  Objective T = NA P = wnl R = wnl BCS 3/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: underbite; grade 0-1/4 dental dz PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: wnl; both testicles palpable scrotally MSI: Ambulatory x 4 (bunny hops); decreased CPs both pelvic limbs, pain on extension of pelvic limbs, skin free of parasites, no masses noted, coat matted CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: wnl (good anal tone); normal prostate; no blood on glove, small amount of light brown/gray pastey stool Gave 0.06cc dexmedotomidine + 0.08cc butorphanol IV for sedation prior to radiographs and clipping of mats. Applied artificial tears OU. Gave 0.06cc atimpamezole IM for reversal. RIGHT LATERAL AND VD PELVIC RADS reveal bilateral ischial and pubis fractures and possible left SI subluxation Chem + e-lytes – mild-moderate increase in ALT, otherwise unremarkable Assessment: Pelvic fracture(s), Matted Plan: Recommend rescue placement. Pelvic fx should heal on own with strict rest & NSAID if finances are a concern, but consulting with a radiologist and/or surgeon would be a good idea in case surgery is an option. Should be sedated to re-radiograph in 4-6 weeks. Okay for neuter, but recommend doing in house, and handling with care (not tying back legs). Start Rimadyl 25mg – 1/2 tab PO q12h and Tramadol 50mg – 1/2 tab PO q12h Keep in medical until placed Prognosis: Good SURGERY: Okay for surgery
Weight 9.2

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