PRINCESS – 35915
Safe - 8-4-2018 Brooklyn
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PRINCESS – 35915
Care Center Location: Brooklyn, ZIP Code From: 11412, Intake Type: ACO Impound
Medical Behavior: Blue, Age: 12 years, Sex: Female
Weight: 54.4 lbs
Vet Notes: 4:45 PM; H: Intake on 7/26. Noted to have issues walking, underweight and geriactric. Down for bloodwork and radiographs today. S: QARH (found mostly sleeping throughout the day). No csvd. Possible tapeworms reported in stool. Eats treats readily. CRT: <2s. Gums: pink, moist; Eyes: Nuclear Sclerosis OU; Ears: Thickened, scarred down pinna AD with mild ceruminous discharge AU; Nasal Cavity: No nasal discharge. Oral Cavity: Severe dental tartar/periodontal disease, oligodontia; PLN: WNL; Heart: No murmurs or arrhythmias. Pulses strong and synchronous. Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated. U/G: FI. Multiple firm masses palpated over multiple mammary glands (right caudal, left middle, left cranial); prominent vulva, No discharge. Musculoskeletal: Ambulatory x 4 with weakened/stilted hind limb gait (was sling-walked into medical); very painful on extension of both hips; moderate to severe diffuse cachexia; BCS = 3/9; Integument: ~6-8cm firm round mass caudal to right ramus of jaw, ~1cm firm mass at caudal sternum, ~1-2cm round semi firm mass at caudal lumbar spine, roughened hair coat with alopecia and seborrhea along tail, papules along ventral abdomen Neuro: Appropriate mentation. Rectal: Not performed. Externally normal. CBC: mild anemia, mildly regenerative (Hct 25.5%, Retic 123.7), mild to moderate leukocytosis (24.76) with neutrophilia (19.89), monocytosis (1.2) and eosinophilia (1.66) Chem: unremarkable; T4: Three view thoracic radiographs: mild to moderate diffuse bronchointerstitial pattern; no cardiomegaly noted; no overt metastasis identified; Two view pelvic radiographs: Severe osteophytosis/degenerative changes to left coxofemoral joint, moderate osteophytosis/degenerative changes to right coxofemoral joint; Assessment: 1) Geriactric, Cachexic- r/o underlying systemic disease (ie systemic neoplasia) 2) Osteoarthritis- hips 3) Mammary Tumors- r/o benign vs malignant 4) Other subcutaneous masses- r/o benign vs malignant 5) Mildly regenerative anemia- r/o IMHA (primary v secondary to neoplasia, tick-bourne, new medication, vaccines) vs less likely hemorrhage (GI, urinary) vs cannot r/o causes for non-regenerative anemia given mildly regenerative response (ie anemia of chronic disease/inflammation v neoplasia; Prognosis: Guarded to poor; Plan: Start Rimadyl 2.2mg/kg PO BID x 7 days; Start Gabapentin 10 mg/kg PO BID x 7 days; Recommend recheck CBC in 3 days; Recommend NH placement- recommend further workup (AUS, biopsy of mammary masses, Coombs, CBC w/path review), palliative care for OA; Move into medical for better monitoring
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View all entries in: Safe Dogs 2018-08