DIAMOND – 16916
Safe - 1-3-2018 Brooklyn
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SAFE 01/03/18
DIAMOND – 16916
Care Center Location: Brooklyn; ZIP Code From: 11208; Intake Date: 12/26/17
Intake Type: Stray; Medical Behavior: Green; Age: 11 years; Sex: Spayed Female
Weight: 74 lbs
DVM Intake Exam: Estimated age: ~11yrs. Microchip noted on Intake? yes History : Stray
Subjective: QARH. Observed Behavior – Allows all handling for exam but appears nervous, difficult drawing blood. Objective: P = WNL R = WNL BCS 6/9 EENT: nuclear sclerosis, ears clean, no nasal discharge noted Oral Exam: Moderate dental tartar, pale pink mm PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: tender, no masses palpated, tense abdomen U/G: Spayed MSI: Ambulatory x 4, skin free of parasites, ~2cm open wound (ruptured mass?) at left flank, alopecia surrounding area, crusted discharge on fur along left side of body and ventral abdomen, alopecia are neck and shoulders, alopecia along length of tail. CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: Geriatric, ruptured mass – possible mast cell tumor vs other Plan: Blood work and radiographs pending — hydromorphone 1.5ml IM given for pain and to help with handling for diagnostics. Prognosis: Poor
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