ROXY – 26048
Gone - 4-26-2018 Manhattan
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GONE 4/26/18 Poor 10 year old ROXY is a gentle friendly girl who was brought in not feeling well. She has swelling in her abdomen and needs further tests to determine if it is from FIP or other causes. She is emaciated and has an ulcerated mammary tumor. ROXY deserves to have further medical eval but needs help immediately!
MANHATTAN CENTER
Roxy 26048
Location: Manhattan
Intake Date: 4/24/18
Intake Type: Stray
Medical Behavior: Blue
Sex: Female
Age: 10 years
Original Location: 10458
DVM Intake Exam
Estimated age: 12
Microchip noted on Intake? n
Microchip Number (If Applicable):
History : ID Hold
Subjective: QARH, ate tuna on the table
Observed Behavior – allowed for a full PE, gentle
Evidence of Cruelty seen – n
Evidence of Trauma seen –
Objective
T = –
P = 200
R = wnl
BCS = 2.5/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Fractured canine 104 and 205
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Cranial right ulcerative mammary tumor, Severely distended abdomen with a clear fluid – 1ml withdrawn on abdomenocentesis
U/G: Vulva Unremarkable – no discharge
MSI: Ambulatory x 4, skin free of parasites, no masses noted, hair coat discheveled
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: externally normal
Assessment:
1) Ascites – clear fluid withdrawn on abdominocentesis
2) Cranial right ulcerated mammary tumor
3) Emaciation
4) Fractured canine 104, 204
Ddx – R/O FIP vs CHF vs Neoplasia
Prognosis: Poor
Plan:
CBC Chem
Analyse fluid from abdomen as a transudate or exudate via cytology
Sedated Radiographs of the chest and abdomen
SURGERY:
Permanent waiver due to illness and age
CBC
Reduced HCT (21), Elevated WBC (26.79) characterised by a neutrophilia (20.56)
– moderate anemia and inflammatory leukogram
Chemistry
Mod elevated BUN – pre renal, muscle wasting, dietary
Mild elevation in globulins – inflammation, infection
Radiographs
Lateral and V/D Abdomen – reduced serosal/abdominal detail secondary to severe fluid opacity. Cranial abdominal organs pressed cranial due to fluid.
Lateral and V/D Chest – lung fields clear, heart sized normal
A: Ascites
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