JADE – 23107

Brooklyn Center

Jade 23107 – 6 yr. old male white cat, stray:

18-Mar-2018
Spay-Neuter Waiver Documentation
Vet Notes: 11:48 AM

[Spay/Neuter Waiver – Medical Condition]

Your newly adopted is currently permanently waived from the spay/neuter requirements of the City of NY by the staff veterinarians due to a tumor. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.
VET 991416

18-Mar-2018
Blood Work Interpretation
Radiograph Review
L V T Notes: 11:27 AM

2 view CXR-no ortho abnormalities, cardiac silhouette and lung fields nsf, no signs of metastasis

CBC pending
Chem pending
VET 991416

18-Mar-2018
Progress Exam
Vet Notes: 11:13 AM

Progress exam

History : Stray intake 3/17-started on simbadol for testicular mass/abscess/wound.

Subjective: Sedated with telazol and maintained on isoflurane for PE.

Objective
P = wnl
R = wnl
BCS 5/9
EENT: Eyes clear, no nasal or ocular discharge noted
H/L: Eupneic, normal RR/RE
U/G: the penis is extruded with mild darkening of the tissue at the tip but otherwise healthy. Around the penis circumstantially the prepuce has eroded and is very red with thickened edges. There is a large ulcerated pedunculated ~5cm mass attached to the outside of the scrotum with purulent d/c, it is also necrotic, the right testicle is difficult to palpate due to the swelling of the scrotum
CNS: sedated

Assessment:
Mass- testicular neoplasia vs torsion vs granuloma vs abcesess vs other

Prognosis: Fair

Plan:
Sedate with telazol 0.1ml/10# to assess scrotum/testicles
Continue simbadol until 3/20
Continue clavamox 13.75mg/kg PO BID until 3/28
Clipped and scrubbed hindend and scrotum/mass/penis
Recommend surgical consult-will likely need a PU with the mass removal in order to get margins on the mass, also rec histopath of the mass
BW scheduled
CXR scheduled
Recheck daily
VET 991416

18-Mar-2018
Pre-Op Exam
Vet Notes: 9:38 AM

Progress exam

History : Stray intake 3/17-started on simbadol for testicular mass/abscess/wound.

Subjective: BARH. Very uncomfortable around hindend and allowed limited handling. Will fully assess once sedated.

Objective
P = wnl
R = wnl
BCS 5/9
EENT: Eyes clear, no nasal or ocular discharge noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
U/G: very inflamed around hindend with lots of brown debris, stalked testicle vs tumor hanging from scrotum-limited exam
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat, large amount of dried purulent discharge around hind limbs
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment:
Mass- testicular vs abcesess vs other

Prognosis: Fair

Plan:
Sedate with telazol 0.1ml/10# to assess scrotum/testicles
Continue simbadol until 3/20
Start clavamox 13.75mg/kg PO BID x10d until 3/28
Recheck daily
VET 991416

17-Mar-2018
DVM Intake
Vet Notes: 3:26 PM

DVM Intake Exam

Estimated age: ~5-7yrs
Microchip noted on Intake? No

History : Stray
Subjective: BARH
Observed Behavior – Allows handling, appears painful at hindend
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: Mild dental staining, overall teeth in good condition, pink mm
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Male – penis (with spikes) protruding from inflamed ulcerated prepuce, open wound extending internally, stalked mass ~3-4cm stemming from dorsal prepucial region — unable to palpate testicles
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat cranially, large amount of dried bloody/purulent discharge around tail and hind limbs
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment: Mass- testicular vs other

Prognosis: Fair – will require surgery
Plan: Simbadol 0.52ml SQ given (scheduled for 0.48ml SQ going forward SID x 3 days. Scheduled for sedated clip, clean and explore

SURGERY:
Permanent waiver due to mass

For more information on adopting from the NYC AC&C, or to find a rescue to assist, please read the following: http://urgentpodr.org/adoption-info-and-list-of-rescues.

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