RANDY – 26396
RTO SAFE 05/03/18
RANDY – 26396
Care Center Location: Manhattan; ZIP Code From: 10039; Intake Type: Stray
Medical Behavior: Blue; Age: 9 years; Sex: Neutered Male; Weight: 14 lbs
DVM Intake Exam:Estimated age: ~9-10yrs based on PE. Microchip noted on Intake? scanned positive by LVT on intake. History : stray found; reported to have a mass in the mouth. Subjective / Observed Behavior – BAR, allows allows all handling. Resistant to oral manipulation Objective: BCS 4/9 wt: 6.7kg EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: dc 4/5; pd 4/5; 2in pink gingival mass along the left rostrolateral maxilla; multiple 0.5cm pink gingival masses along the 200 arcade. malodorous. Painful on right upper arcade. PLN: No enlargements noted H/L: No murmur ausculted; CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: neutered male. MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: grossly normal. Assessment: underweight, oral masses – r/o SCC, epulis, gingival hyperplasia, melanoma, other. , dental / periodontal disease . Prognosis: fair Plan: rimadyl 25mg tablet — give 0.5tablet PO q12h x 4 days. clindamycin sedation + chest rads. SURGERY: already neutered.
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