C10009769 / invoice 10000

Hx: Patient presents for: (missing 9 days , found by member of public and returned to O, since being home (less than 12 hours) dog has not been able to stand or ambualte at all , otherwise prior to this EDDU/BAR and no other concerns noted by O

PE: EYES bright , clear sclera and no inflammation of conjunctiva, EARS show no discharge and soft/pain free ear canals on palpation, ORAL exam shows no visible dental disease, CARDIAC AUSCULTATION reveals SSFP, normal rhythm and no HM, THORACIC AUSCULTATION reveals no crackles/wheezes and a normal tracheal pinch with no cough elicited, ABDOMEN is soft and palpable with no pain, LN's WNL,  UROGENITAL region including visual exam of perineum and anus WNL, NEURO: normal mentation/PLR/menace response, full neuro exam not performed. Rectal not performed.

ABNORMALITIES: 
1. palpable LHS distal femur fx with swelling
2. sig. matting and black staining with gravel attached to coat on lumbar spine
3. patient unable to stand but appears to have normal feeling (superficial and deep pain in both HL's)

*Assessment:(SUSPECT MVA) *

Reccomendations: sedation and rads (O has insurance but only $300 cash on him atm., O signed admission and consent , calling insurance to get pre-approval for poss. further costs etc., Paid $300 deposit. insurance verbally okay'ed rads and coverage for that.

RADS:
- LH distal femur Fx 
- LH luxated hip
- SIG. ++++ pelvic fx's with narrowing of pelvic canal and ischial + ilieos-cral lxuations/fx's

Tx: (Dom/Meth dose- 0.4ml/0.4ml IV, reversed with 0.4ml IV antipam. Given further 0.3ml Methadone for pain.)

UPDATED: called O , discussed PTS or refferal (GAURDED prognosis for return to function though), O coming in to see dog and rads and discuss further
 


policy number: pi22920093