MOON aka WALNUT – 9937

MOON aka WALNUT – 9937

** FOLLOW UP VET CARE NEEDED **

Stray, 2 Years Old, White/Brown Large Breed Mix 51 lbs.

Medical:: 10/17/17 Vet Notes: 10:40 AM; Brought straight to sx/tx for evaluation. Possible pellet gun injury to left eye. No other hx available. BAR, hydrated; EENT: O.S.: laceration to superior lid, inferior lid is swollen, difficult to assess globe/eye without sedation as walnut is very excited; PLN: wnl; H/L: nsf; U/G: male castrated; Neuro: nsf
ABD: benign; MSI: ambulatory x 4, in good flesh, good coat, large soft lipomatous subcutaenous mass left side of prepuce.; No microchip noted; A: injury O.S. as above, possible pellet gun; P: given 1.1 ml hydromorphone sq and 1.8 ml rimadyl sq at 10:15 am. ; may need strong sedation to fully evaluate eye, take skull rad to check for pellet.

Vet Notes: 12:16 PM; DVM Intake Exam; Estimated age: ~1-2yrs; Microchip noted on Intake? yes 46705D5170
History : Brought in by NYPD – reportedly hit with BB gun; Subjective:  Observed Behavior – BARH. Allows all handling; Objective ; P = WNL R = WNL BCS 6/9; EENT: Periocular swelling OS, wound at upper eyelid, bruising/conjunctival hemorrhage, hyphema, globe intact, ears clean, no nasal discharge noted; Oral Exam: Teeth clean, minimal dental tartar/wear; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: Neutered, tattoo seen; MSI: Ambulatory x 4, skin free of parasites, ~4cm soft round mass just left side of prepuce, healthy hair coat; CNS: mentation appropriate – no signs of neurologic abnormalities; Assessment: Trauma to left eye, masS; Plan: Hydromorphone and rimadyl given on intake. Continue with Rimadyl 50mg PO q12 x 5 days. Recheck eye in two days
Prognosis: Good

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