14/01/2018

DVM Intake Exam Estimated age: ~8-10 years Microchip noted on Intake? negative History : stray Subjective: BARH Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective P = wnl R = eupneic BCS 6/9 EENT: Eyes have mild injected sclera ou, ears have mild crusty debris, no nasal discharge noted Oral Exam: adult dentition with mild dental disease, no oral lesions noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated, possible cranial organomegaly but difficult to assess due to large habitus U/G: FI, ~4cm MGT in caudal left mammary chain, no vulvar d/c MSI: Ambulatory x 4, skin free of parasites, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: ~4cm MGT in left caudal mammae Dental disease Geriatric Plan: Continue to monitor while at BACC CXR pending AXR pending CBC machine not working-recommend doing when machine functional Chem pending Rec removal and histopath of MGT and spay Prognosis: Good to fair depending on MGT SURGERY: permanent waiver due to MGT and age

14/01/2018

[Spay/Neuter Waiver – Age] It is the policy of ACC not to perform surgery on any animal over the age of 8-10 years due to the higher risks incurred in a shelter setting. The veterinarian is hereby issuing a permanent spay/neuter waiver, from the spay/neuter requirements of the City of NY due to the estimated age of this animal. ACC does recommend you consult with your veterinarian to determine if surgical sterilization is appropriate.

16/01/2018

Bloodwork: CBC-leukocytosis 29.46 (5.05 – 16.76 K/µL) with neutrophilia 21.92 (2.95 – 11.64 K/µL), monocytosis 3.04 (0.16 – 1.12 K/µL), eosinophilia 1.24 (0.06 – 1.23 K/µL), and basophilia 0.14 (0 – 0.1 K/µL) Chem-mild hyperglobulinemia 4.7 (2.5 – 4.5 g/dL) T4-low normal 1 (1-4) AXR-cranial abdomen difficult to assess due to debris in stomach, bridging spondylosis deformans from caudal toracic vertebrae and all lumbar vertebrae, no other obvious abnormalities CXR-only right lateral available-heart appears enlarged, no obvious signs of metastasis Plan: Start on clavamox 13.75mg/kg PO BID x10 d for leukocytosis Recheck BW day 10

22/01/2018

Progress exam History : stray intake 1/14 1/16: Bloodwork: CBC-leukocytosis 29.46 (5.05 – 16.76 K/µL) with neutrophilia 21.92 (2.95 – 11.64 K/µL), monocytosis 3.04 (0.16 – 1.12 K/µL), eosinophilia 1.24 (0.06 – 1.23 K/µL), and basophilia 0.14 (0 – 0.1 K/µL) Chem-mild hyperglobulinemia 4.7 (2.5 – 4.5 g/dL) T4-low normal 1 (1-4) AXR-cranial abdomen difficult to assess due to debris in stomach, bridging spondylosis deformans from caudal toracic vertebrae and all lumbar vertebrae, no other obvious abnormalities CXR-only right lateral available-heart appears enlarged, no obvious signs of metastasis Subjective: BAR. Barking at the front of the cage with diarrhea smeared around cage. No cvs. Objective 9 EENT: Eyes clear, no nasal discharge noted H/L: eupneic, normal RR/RE MSI: Ambulatory x 4, healthy hair coat, large MGT CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: ~4cm MGT in left caudal mammae Diarrhea Dental disease Geriatric Plan: Continue to monitor while at BACC start metronidazole 15mg/kg PO BID x5d until 1/27 Continue clavamox until 1/27 Rec removal and histopath of MGT and spay Prognosis: Good to fair depending on MGT

Upon intake Pumpernickel was relaxed and calm. She was a little timid when she heard the other dogs in the building but she allowed the counselor to collar him.