EVA – A1123403

EVA – A1123403

**ULCERATED MAMMARY TUMOR**

FEMALE, GRAY / WHITE, PIT BULL MIX, 9 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 08/26/2017, From NY 11207, DueOut Date 08/29/2017,

Medical Behavior Evaluation BLUE
Medical Summary Estimated age: 8-10 years Microchip noted on Intake? History : stray dog found tied up outside building; finder took her to the vet prior to bringing her to MACC; ulcerative mammary gland tumor with persistent mild bleeding; currently on Clavamox, 100 mg tramadol given orally this morning Subjective: QAR Observed Behavior – sleeps very soundly, quiet in cage, possible mild sedative effect from tramadol; very sweet, wags tail excitedly when praised, allows all handling; does not react to other dogs or cats in the room Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective   BCS 6/9 EENT:  OU-nuclear sclerosis; AU-cropped, dark waxy discharge; crusting, mild hypertrophy of nasal planum Oral Exam: mm lgt pk, sl tacky; CRT <2 sec; moderate to severe tartar, staining; gingival hyperplasia PLN:  No enlargements noted H/L: grade III L systolic heart murmur; eupnic, normal lung sounds in all fields ABD:  slightly tense abdomen, no obvious abnormalities U/G:  female intact; vulva enlarged with lichenification and thickening; firm mammary gland tumor in L caudal most gland, skin is erythematous with superficial ulceration of gland between chains, intermittent bloody discharge weeping from area; 2 smaller pea sized firm MGT in R caudal gland MSI: ambulatory x 4 with decreased weight bearing on hind limbs; significant chronic thickening of tarsi with decreased flexion dandruff, few crusting staph lesions over dorsum superficial pressure sores/callouses over elbows, stifles, tarsi  CNS:  mentation appropriate – no signs of neurologic abnormalities Rectal: not performed  Assessment : Heart murmur, MGT-mildly ulcerated, Dental disease/gingival hyperplasia, Tarsal osteoarthritis (suspected) Plan : Tramadol 50 mg PO BID until placement, can adjust long term pain management protocol based on bw and response to tramadol Rec’d CBC/chem, Rec’d excision of MGT after placement, Prognosis: guarded SURGERY: permanent waiver due to age/heart murmur
Weight 56.6

 

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