ROXY – 26048

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ABD: Cranial right ulcerative mammary tumor, Severely distended abdomen with a clear fluid – 1ml withdrawn on abdomenocentesis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1) Ascites – clear fluid withdrawn on abdominocentesis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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