BIANCA – 27881

BROOKLYN CENTER

Bianca 27881

Location: Brooklyn

Intake Date: 5/12/18

Intake Type: Owner Surrender

Medical Behavior: Blue

Sex: Female

Age: 4 years

Weight: 7 lbs

Zip Code: 11237

Vet Notes: 12:58 PM

H: Concern for potential mammary mass on intake (vs lactation/benign hyperplasia vs mastitis). Plan for three view chest radiographs and bloodwork today.

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: unremarkable
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact female, right chain of mammary glands feel enlarged with the caudal most mammary gland being semi-firm (recently had kittens per history). Expressed small amount of milk from one of the mammary glands.
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

Chest radiographs (three view): no overt pulmonary metastasis noted.

CBC- Non-regenerative anemia (Hct 24.7)
Chem- unremarkable

Assessment:
1) Non-regenerative anemia- r/o anemia of chronic disease/secondary to parturition/lactation vs less likely neoplasia vs less likely renal disease (given normal chem)
2) Enlarged mammary glands (one chain)- suspect benign hyperplasia/lactation vs less likely neoplasia

Plan: Ok for surgery- scheduled

Vet Notes: 6:06 PM

[DVM Intake]
DVM Intake Exam

Estimated age: 1 year
Microchip noted on Intake? No
Microchip Number (If Applicable):

History : owner surrender, recently had kittens

Subjective:

Observed Behavior – timid, but allowed handling

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective
P = wnl
R = wnl
BCS 5/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: unremarkable
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact female, right chain of mammary glands feel enlarged with the caudal most mammary gland being semi-firm (recently had kittens per history)
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
Prominent mammary glands- as the patient recently had kittens and is young, the top differential would be benign mammary hyperplasia (secondary to a spike in progesterone). However, although less likely cannot completely r/o the possibility that this is a mammary tumor (adenocarcinoma) vs less likely mastitis (no obvious evidence of infection noted)

Prognosis: open- cannot r/o possibility of mammary tumor vs benign mammary hyperplasia

Plan:
Plan for three view chest radiographs tomorrow- from there, make decision to spay

SURGERY:
Temporary waiver due to medical condition

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