RUSTY – 23109

Brooklyn Center

Rusty 23109 – 12 yr. spayed orange tabby, stray:

Vet Notes: 1:02 PM

No overt metastatic lesion on any of 3 thoracic views
spondylosis T11- L2/3
skull – thickening of bone on left side – suggests boney involvement vs superimposition – dental rads would ideally be needed for further interpretation

Vet Notes: 9:35 AM

[Progress Exam Template]

S:10- 12 yr fs dsh – allows handling, except mouth, grumbling and lip smacking

O: noted to be eating, but lesion left mandible
EENT:left eye sl exophthalmic os compared to of, firm left submandibular ln, rt side ok
Oral Exam: resents examination awake – hemorrhagic gingival mass of left mandible, bone does not feel swollen, limited exam awake
sedated exam – 2 1/2 cm hemorrhagic granulation tissue mid to caudal left mandibular area
H/L: tachycardic, flow murmur w/ sedation, ssp
Abd: no overt masses/megally/pain
MSI: decreased hind
Mentation:bar

A: gingival vs other soft tissue mass vs dental abscess vs other abscess injury
submandibular lymphadenopathy left
mild exophthalmos os – likely secondary to oral mass
flow murmur – r/o tachycardia vs cardiac dz vs hyperthyroid
P: due today for screening labwork and x-rays
sedated w/ d/t and midazolam for more complete exam (notes above)
PX – guarded to poor if neoplasia
good if dental or other abscess
would recommend full dental rads/biopsy on placement

Is the Initial Medical Status being Changed?
New Medical Status:n
Is the Initial Behavior Status being Changed?
New Behavior Color: n
VET-P 991444

17-Mar-2018
DVM Intake
Vet Notes: 2:59 PM

DVM Intake Exam

Estimated age: ~12yrs
Microchip noted on Intake? no

History : Stray
Subjective: BAR. ~5% dehydration
Observed Behavior – Active, allows handling but grumbling throughout exam, hissed 2-3 times
Evidence of Cruelty seen – no
Evidence of Trauma seen – no

Objective
P = WNL
R = WNL
BCS 4/9

EENT: Nuclear sclerosis, hyperpigmentation of ears, small ceruminous cysts, no nasal or ocular discharge noted
Oral Exam: raised irregular oral mass along left side of mandible, tooth roots exposed with caseous material, halitosis; otherwise moderate dental tartar/gingivitis
PLN: No enlargements noted
H/L: gallop rhythm heard at left side of chest, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Spay scar palpated
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment: Geriatric, oral mass – R/O SCC vs other

Prognosis: Guarded
Plan: Rec simbadol 0.42ml SQ q24 x 3 days, convenia 0.3ml SQ today, LRS 100ml SQ q24 x 3 days. Scheduled blood work and radiographs. Monitor appetite.

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