UNAGI – 18249
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UNAGI – 18249
*** ABDOMINAL MASS – NEEDS FOLLOW UP VET CARE ***
Location: Manhattan; Intake Date: 1/13/2018; Intake Type: Stray
Medical Behavior: Green; Sex: Neutered; Age: 6 years; Weight: 9 lbs; Zip Code: 10031
Vet Notes: 4:19 PM: DVM Intake Exam Estimated age: 6yrs Microchip noted on Intake? N Microchip Number (If Applicable): History : stray. Subjective: QAR Observed Behavior – timid but compliant for exam. Evidence of Cruelty seen – emaciated. Objective: T = DNP
P = WNL R = WNL. BCS 2/9 w/ distended abdomen EENT: Eyes clear, ears clean, no nasal or ocular discharge noted. Oral Exam: Grade 4/4 tartar- unable to visualize teeth PLN: No enlargements noted H/L: NSR, III/VI systolic murmur, CRT < 2, lungs clear, eupnic ABD: Abdomen distended and firm, difficult to palpate, suspect organomegaly (hepatomegaly?). U/G: Neutered male. MSI: Emaciated, ambulatory x 4, Grade 4 L MPL; grade 3 R MPL; skin free of parasites, no masses noted, healthy hair coat. CNS: Mentation appropriate – no signs of neurologic abnormalities. Rectal: Externally WNL Assessment: 1. Emaciated w/ distended abdomen- concern for organomegaly 2. III/VI systolic murmur. 3. Grade 4 L MPL; grade 3 R MPL. 4. Grade 4/4 dental dz Prognosis: guarded to good pending AXR findings and bloodwork Plan: CBC/Chem, AXR; rec echo w/ dental cleaning if bloodwork/rads ok SURGERY: Permanent waiver due to heart murmur.
Vet Notes: 9:14 PM: Abdominal palpation: Suspected spherical mass in right caudal abdomen (4 cm diameter) upon palpation.
Vet Notes: 11:02 AM: S/O -BAR, friendly and interactive; allows handling -mild appetite, appears to be a social eater! soft but formed stool in cage -mm pale pk, CRT 2 sec; severe dental disease -mild serous nasal discharge, likely secondary to dental disease; no sneezing noted -eupnic, grade III-IV murmur -large, firm abdominal mass palpable on R side. A:
1. Abdominal mass, r/o splenic vs hepatic vs other; r/o hemangiosarcoma vs hematoma vs lymphoma. 2. Anemia, severe, non regenerative-r/o paraneoplastic vs other. 3. Leukocytosis-r/o paraneoplastic vs other 4. Heart murmur-r/o secondary to anemia vs valvular dz P: -try to repeat chemistry today, yesterday in house machine was not working -recommend abdominal ultrasound ASAP after placement to confirm tissue of origin; depending on where the mass arises from, surgical excision may be appropriate; if arising from the liver, then biopsy may be the next most appropriate treatment. -prognosis: guarded but good if splenic hematoma
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