LUDDY – A1110401

LUDDY – A1110401

**MUST LEAVE BY 5PM 4/30 – MULTIPLE ULCERATED MASSES **CONTACT A NEW HOPE RESCUE TO HELP**

FEMALE, CHOCOLATE, AM PIT BULL TER MIX, 12 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 04/29/2017, From NY 10468, DueOut Date 05/02/2017,

Medical Behavior Evaluation No Initial Behavior
Medical Summary 04/29/17 09:58 DVM Intake Exam Estimated age: 12 years Microchip noted on Intake? History : stray, finder reports lethargic, not eating Subjective: Observed Behavior – calm,. resist oral exam, but allows all other handling with minimal restrain, eating canned diet and drinking water, urinated WNL Evidence of Cruelty seen – possibly, large number of large masses Evidence of Trauma seen – no Objective T = not done P = 100 R = 18 BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: severe dental tartar & calculi, severe atrition of most teeth, injected erythematous gingiva with gingival hyperplasia, resists oral exam, approx 4cm long and 2cm thick gingival mass along the mandibular R arcade PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female intact, multiplle mammary masses, approx 12cm x 10cm ulcerated hemorrhagic mass associated with cadual L mammaries with multilobulated masses cranial to the large mamm mass, swollen vulva no discharge MSI: Ambulatory x 4, stifle and elbow crepitus, ROM not performed, sparse haircoat, generalized mm atrophy, approximately 12 cam diameter alopecic soft pedunculated thick-stalked dermal mass on caudal L thigh CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment neoplasia severe dental dz geriatric Plan 75mg Rimadyl once place with NH or EHR Prognosis: open for mammary masses as 50% are benign, pedunculated mass on caudal thigh may be benign or malignant FNA indicated, mass on mandible may be hyperplastic or neoplastic Permanent waiver due to age and neoplasia
Weight 61.0

RE-EXAM

04/30/17 :

S: was eating well yesterday, vomited overnight, reported urinating large volume this morning, drinking large amounts of water

O:approx 5% dehydrated based on skin turgor. EENT:  Eyes clear, ears clean, no nasal discharge noted. Oral Exam:  severe dental tartar & calculi, severe attrition of most teeth, injected erythematous gingiva with gingival hyperplasia, resists oral exam, approx 4cm long and 2cm thick gingival mass along the mandibular R arcade. PLN:  No enlargements noted. CV: taky mm, CRT <2sec, NMA, S&S pulses. Resp: eupnic, mild inspiratory stertor. ABD: not  palpated. U/G:  female intact, multiple mammary masses, approx 12cm x 10cm ulcerated hemorrhagic mass associated with cadual L mammaries with multilobulated masses cranial to the large mamm mass, swollen vulva no discharge. MSI:  Ambulatory x 4, has trouble maintaining footing on slippery surfaces, stifle and elbow crepitus, ROM not performed, sparse haircoat, generalized mm atrophy, approximately 12 cam diameter alopecic soft pedunculated thick-stalked  dermal mass on caudal L thigh. CNS:  quiet but appropriate mentation

A: neoplasia, severe dental dz, geriatric, dehydrated. P: 400ml LRS SQ, 2.5ml Cerenia SQ, place with NH or EHR

Prognosis: open for mammary masses as 50% are benign, pedunculated mass on caudal thigh may be benign or malignant FNA indicated, mass on mandible may be hyperplastic or neoplastic. Permanent waiver due to age and neoplasia

 

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