UNA – A1115944

UNA – A1115944

**POSSIBLY HIT BY CAR**

FEMALE, TAN, AM PIT BULL TER MIX, 4 yrs
STRAY – STRAYAVAI, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 06/20/2017, From NY 11205, DueOut Date 06/23/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 3-4 years Microchip noted on Intake? no History: Surrendered by good sam, no medical history Subjective: QAR/dull, reluctant to rise but will walk, toe-touching RH. Generalized erythema/warm to the touch. Observed Behavior: allows all handling, nice girl.  Evidence of Trauma seen – yes, suspect road rash and fractures Objective T = 104.0 P = 160 R = 20 BCS 5/9 EENT: Eyes clear, no nasal discharge noted. Ears are erythematous and stenotic but have minimal discharge and no odor. Oral Exam: mild dental tartar and gingivitis PLN: No enlargements noted H/L: Grade 2/6 left apical systolic murmur, no arrhythmia, strong synchronous pulses. Lungs auscult clear, no dyspnea, no clinical evidence of pneumothorax. ABD: Non painful, no masses palpated, no palpable fluid wave. U/G: female, enlarged vulva and nipples, no visible spay scar. MSI: Ambulatory x 3, toe-touching lame RH. RH visibly swollen with possible palpable incongruity of the distal femur. Pain on right hip/pelvic palpation. All other limbs palpate WNL. Multiple areas of excoriations/road rash, worst on the ventrum and inguinal regions, left elbow, left hock. All four paws have areas of sloughing pads and moderate pododermatitis. Generalized erythema and patchy hair loss. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: no palpable pelvic fracture, loose normal stool with no melena/frank blood Assessment: likely polytrauma (HBC), chronic thermal injury to all four pads, hyperthermia (fever vs. exposure), likely chronic ear infections/skin infections, heart murmur (likely incidental) Plan: Gave hydromorphone 3 mL and Cerenia 3 mL and started on IVF 65 mL/hr, heart rate reduced to 100. Temperature reduced to 99.7 within an hour of intake without active cooling. Xrays show no fractures of pelvis, right femur, ribs, but dog is extremely painful on palpation of pelvis even with opioids on boards. Ddx: fracture not shown on rads, sacral luxation. Further imaging may be required for definitive diagnosis. Seek NewHope. Maintain in ICU on hydromorphone Q8H PRN throughout stray hold. Discontinue IVF tonight if stable. Prognosis: Open – definitive diagnosis not available. SURGERY: Temporary waiver due to trauma
Weight 69.0

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