JOSIE – 25335
Gone - 4-18-2018 Manhattan
JOSIE – 25335
Care Center Location: Manhattan, ZIP Code From: 10304, Intake Type: Stray
Medical Behavior: Green, Age: 8 years, Sex: Female, Weight: 14 lbs
DVM Intake Exam; Estimated age: Estimated 7-10 years old based on dentition and general appearance; Microchip noted on Intake? Scanned neg on LVT exam – MC placed at that time; History : Given to the client 2 days ago – she has seen this dog before for a while though. Client reports that pt vomits whenever she eats or drinks. Subjective: Alert, panting and pawing at the bars of her kennel excitedly when ignored; Observed Behavior – Allows all handling; Objective; BAR, MMs pink and moist, BCS 2/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted; Oral Exam: Severe tartar and gingival recession, some teeth missing; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Tucked up, non painful, no masses palpated; U/G: Female intact. No vulvar discharge. Many small firm nodules associated with the mammary glands: left 2nd ; MG (multiple small nodules < 1 cm dia), left 4th MG (small nodule < 1 cm dia), right 4th MG (big nodule 1-2 cm), left 5th MG (big nodule 1-2 cm), right 5th MG (small nodule <1 cm). MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Assessment: 1. Underweight, hx anorexia/vomiting after eating – R/O liver disease, kidney disease, IBD, infectious gastroenteritis, foreign body, other cause; 2. Mammary masses – R/O benign vs. malignant; 3. Severe dental disease; Prognosis: Fair; Plan: 1. CBC/chemistry 2. Consider abd rads 3. Continue Cerenia 0.65 ml SQ SID x4 days 4. Feed i/d 5. Recommend mammary gland biopsy 6. Recommend dental cleaning, rads and extractions SURGERY: Temporary waiver due to vomiting and emaciation
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