BAILY – 25948
Safe - 4-27-2018 Manhattan
BAILY – 25948
Intake Date : 4/22/18 Intake Type: Stray intake
Medical Behavior: Green Age: 8 years Sex: Spayed female
Weight: 54 lbs.
DVM Intake Exam; Estimated age:8 years; Microchip noted on Intake? History :stray dog found with vulvular discharge; Subjective:QAR; Observed Behavior -docile, sweet, allows all handling; Objective ; BCS 5.5/9; EENT: OU-mild crusting around eyes, mild episcleral injection; ears clean, no nasal or ocular discharge noted; Oral Exam:mm pk, tacky; CRT 2 sec; moderate dental tartar/staining; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: soft, nonpainful; U/G: intact; mild mucoid vulvular discharge; large, firm mammary gland tumor associated with L caudal gland; mild viscous bloody discharge from nipple; MSI: -RH: mild lameness with mild muscle wasting of thigh muscles; no discomfort on extension of stifle; mild decreasedhip extension with possible discomfort, she is very stoic but turns to look on end range; -copious amount of dried mucoid discharge along hind limbs, suspect vulvular discharge; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal:grossly normal; Assessment; 1. Mammary gland tumors; 2. Pyometra, suspected; 3. RH lameness, mild-r/o hip arthritis/dysplasia vs other Prognosis: guarded to fair; Plan: -CBC/chem -place IVC, start LRS 60 ml/hr -recommend OHE ASAP +/- MGT excision and histopathology
CBC: Hct 38.3% – low end of normal range ; WBC 53.42 k/ul – abnormal WBC distribution but neuts reading 30 k/ul, lymphs 8.2 k/ul, monos 4.9 k/ul ; Plt 239 k/ul; Chemistry:Glu 89 mg/dl; Creat 0.8 mg/dl, BUN 9 mg/dl; High phos – 7.1; Elevated T. protein (8.9) and globulins (6.4); Normal liver values, electrolytes; ASSESSMENT: -Consistent with moderate infection -Concern for mild anemia once rehydrated
Surgery report Due to pyometra:1. Unasyn 16 ml IV q8 x2 days – follow with Clavamox 2. Enrofloxacin 100 mg/ml 2.5 ml IM SID – if eating, okay to switch to oral; Ventral Midline Incision; Ovaries Ligated with: 0 PDS in two modified Miller’s knots per pedicle; Uterine Body Ligated with: 0 PDS in one modified Miller’s knot and one transfixation ligature; Abdominal Closure: Linea: 0 PDS in simple continuous. SQ: O PDS in simple continuous. Skin: 2-0 Monocryl in intradermal pattern. Green Linear Tattoo Placed on Midline; Pt to remain on LV LRS after sx
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