Medical notes of injured rescued calico cat tell us a lot

Manhattan Animal Care Center: These are the extensive medical records for a sweet looking stray calico cat (female obviously) who was injured and brought to the animal center by a ‘bystander’. We are not told how she was injured. Her right foreleg is fractured and her face is scratched. It could easily be a car accident of some sort. She came to the shelter on 02-Jul-2018. Posted on Facebook on 8th July 2018. I think she is still in need of a new home so I am crossposting.

The medical notes are interesting because they tell us about the thinking of the medics. They make the assessment that this is not a case of cat cruelty but an accident.

“Evidence of Cruelty seen – No.”

The staff were cautious about the cat’s behaviour and I presume therefore the suitability of the cat for adoption. The caution is because the cat was undergoing medical treatment.

“It is difficult to determine at this time how the medical condition may be affecting the behavior.”

The assessment is that she is tense and seems uncomfortable but interacts. Under the circumstances I’d call that damn good. She’s probably very adoptable. The expression on her face gives me that feeling.

Here are the extensive medical notes:

Hello, my name is Snow. My animal id is #33195. I am a female calico cat at the Manhattan Animal Care Center. The shelter thinks I am about 3 years old.

I came into the shelter as a stray on 02-Jul-2018.

Snow is at risk due to a fracture of her right forelimb, which has been treated at the care center, but her recovery requirements from this point forward are beyond that which we can provide. We suggest that Snow would be best suited to a cat experienced home.

My medical notes are…
Weight: 7.875 lbs

Medical Assistant

3/07/2018

Snow can not put pressure on her right front leg and there seems to be dried blood, I can not find a wound. Her nose has an abrasion and has dried blood coming from her nose.Right side of teeth and face stained with blood.

As per on call vet give 1 tab onsior 6 mg PO

Vet Notes

3/07/2018

[DVM Intake]
DVM Intake Exam

Estimated age: 3Y
Microchip noted on Intake? no
Microchip Number (If Applicable):

History : Stray brought in by bystander to BxCC, states was watching over cat for one day prior after realizing the “broken arm”. Cat was brought in after noticing cat would not eat or drink

Subjective: BAR not interested in food, seemingly painful in the mouth. Witnessed gagging and trying to manipulate mandible as if something was inside mouth. Litter box not used but there was urine staining. No evidence of vomiting. 5-7% dehydrated.

Observed Behavior – Reserved, but allowed most of physical assessment

Evidence of Cruelty seen – No

Evidence of Trauma seen – Yes

Objective

P= 224
R= 32
BCS 5/9

EENT: Eyes clear, ears clean, no nasal discharge noted, OD ocular discharge
Oral Exam: Strongly resisted any manipulation to the mouth, could only visualize left side briefly. Fractured LMand Canine
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic could not auscultate thoroughly because of purring
ABD: Non painful, no masses palpated
U/G: No leaking or discharge
MSI: Ambulatory x 3, RF limb had mid-diaphyseal crepitation, skin free of parasites, no masses noted, healthy hair coat. No spay scar noted, blood and debris on face along the right mucocutaneous junction of the right maxilla, up to the right nares.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Not done

Assessment

Right front limb radial/ulnar fracture – suspect only radial fracture
Right perioral injury – cannot evaluate further as of now, will revisit when sedated

Prognosis: Good with treatment

Plan:

1. Further exam under sedation:
– Butorphanol 0.07ml IM
– Dexdomitor 0.2ml IM
– Simbadol 0.5 ml SQ
– Sedated Physical exam, including cleaning of facial debris
– Right front limb 2 view radiographs
– +/- Skull radiographs (pending sedated physical results)
2. Simbadol 0.5ml SQ SID for 7 days

SURGERY:
Temporary waiver due to Right front limb fracture

Assessed by OS, reviewed by 1088

3/07/2018

Radiograph review:

Closed fracture of the right radius and ulna.
The radius is a mid-diaphyseal short oblique fracture while the ulna is a comminuted fracture.

Update on physical exam and follow up treatments:

O: Oral exam reveals a minor laceration to the right mandibular labia caudal to the canine, moderate buccal swelling and a laceration to the tongue. Palpation of the skull did not reveal any indication of a fracture, zygomatic arch intact and the mandible was easily movable.

A: Fracture of the right radius and ulna – Needs immediate surgery
Soft tissue injuries to the right side of the face – Conservative treatment should suffice

P:
1. Clean away blood and debris
2. Splint the right forelimb
3. Onsior 0.35ml SQ SID today and tomorrow
4. Immediate referral for orthopedic surgery
5. SQ saline 150ml SID for 2 days
6. Offer a slurry of food when feeding

5/07/2018

SO
fracture of the right radius and ulna.
Currently on simbadol; today is last day of onsior inj.
Reported to not be eating, drooling when food place in front of her.

EENT — eyes are clear with no discharge. no nasal discharge. no sneezing. Appears eupnic.
Bandage is intact, clean and dry. toes are appropriately spaced with no swelling observed.

A
fractured radius and ulna
anorexia

P
continue with simbadol 0.5ml SQ q24h
Monitor appetite and hydration
mirtazapine 15mg tablet — give 0.25 tablet PO one time.
offer kitten and tuna if not interested in adult food.

6/07/2018

SO
fracture of the right radius and ulna.
Currently on simbadol
Reported to not be eating on 7/5 but actively eating tuna in kennel throughout day, today.

BAR; Growling when approached.
EENT — eyes are clear with no discharge. no nasal discharge. no sneezing. Appears eupnic.
Bandage is intact, clean and dry. toes are appropriately spaced with no swelling observed.

A
fractured radius and ulna
anorexia — resolved

P
continue with simbadol 0.5ml SQ q24h
Monitor appetite and hydration
continue to offer kitten food and tuna if not interested in adult food

7/07/2018

SO
fractured radius and ulna, R.

BAR, growling when approached in kennel.
Eating tuna readily but does not eat canned or kibble cat food.
Toes are appropriately spaced. No strike-thru on bandage.

A
Fractured radius and ulna, right

P
continue tx plan as rx

8/07/2018

Recheck in med. for fx R radius/ulna:

S/O: QARH BCS 5/9
– no c/s, u/d ok
– appears to be eating small amounts of food
– allowed limited handling
– splint/bandage intact/dry
– wound on right side of face/mandible scabbed over, resists palp. of mouth, poss. crepitus when trying to open mouth

A: stable healing fx + wounds
P: with current tx and rec’ sedated recheck to eval. splint and face wounds more thoroughly

L V T Notes

3/07/2018

Administered 0.07mls of Butorphanol 10mg/ml IM, 0.2mls Dexdomitor 0.5mg/ml IM @ 12:43pm for sedated radiographs and examination. Two view RFL rads were taken and reviewed by Rounds DVM and stored in vet documents.. RFL cleaned, a splint was placed by DVM, and face cleaned. Patient was reversed with 0.1mls Antisedan 5mg/ml IM @ 1:25pm. Patient recovered without incident. Administered 0.5mls of Simabadol 1.8mg/ml @ 1:30pm.

Details on my behavior are…
Behavior Condition: 2. Blue

Behavior History

Snow headbutted the microchip scanner and meowed. he allowed counselor to collar her and place her into the kennel. In the kennel she attempts to walk around but because she can not apply pressure on her paw she would lay down.

Date of Intake: 7/2/2018

Basic Information:: Snow is an approximately 3 year old , femaledomestic short hair cat. She is in our care because her finder noticed she had an injury and decided it was best to bring her into our care.

Previously lived with:: unknown

How is this cat around strangers?: Snow allowed finder to pick her up.

How is this cat around children?: behavior unknown

How is this cat around other cats?: behavior unknown

How is this cat around dogs?: behavior unknown

Behavior Notes: Snow allowed finder to place her into a carrier in the car she was relaxed and fell asleep.

Bite history:: Snow did not attempt to bite or scratch finder

Energy level/descriptors:: unknown

Has this cat ever had any medical issues?: Yes

Medical Notes: snow can not apply pressure to her front left paw, she has an abrasion on her nose and dried blood around it

For a New Family to Know: behavior in a home is unknown

Behavior Assessment

KNOWN HISTORY:: Snow was brought in as a stray, so there is no information on their behavior history or tendencies in a home environment. Her finder was able to pick her up and bring her to the care center. She head-butted the microchip scanner during intake and meowed. She allowed all handling during the intake process.

MEDICAL BEHAVIOR:: 07/03/18
Observed Behavior – Reserved, but allowed most of physical assessment

Cage Condition:: Cage is neat

Reaction to assessor:: Snow was lying down by the back, curled up and looking out with almond-shaped eyes.

Reaction when softly spoken to:: Snow looks at the assessor briefly, and then looks away.

Reaction to cage door opening:: Snow becomes alert and looks at the opening.

Reaction to touch:: Snow slowly sniffs the assessor’s hand, and then lowers her head in anticipation of touch. She allows gentle strokes on her head and body, but her ears tilt to the side and her body twitches.

ACTIVITY LEVEL:: Moderate

VOCAL:: Quiet

CHARACTER TYPE: : Shy ,Sweet,Curious

BEHAVIOR DETERMINATION: : Experience

Behavior Asilomar: TM – Treatable-Manageable

BEHAVIOR SUMMARY:: Please note that this cat is being treated for a medical condition at the time of evaluation. It is difficult to determine at this time how the medical condition may be affecting the behavior. She interacts with the observer and seems to appreciate attention, but she remains tense and seems uncomfortable. We recommend that this cat go to a home with experienced cat parents.