6/2/2019

DVM Intake Exam Estimated age: ~4-5 years Microchip noted on Intake? negative History : stray found with large wounds Subjective: QAR, ~5-6% dehydrated Observed Behavior - brought in on pole. Reported to be biting pole and alligator rolling. In intake room had head down, whale eyes, tail tucked, very stiff. Sedated and muzzled for exam and wound treatment Evidence of Cruelty seen - no Evidence of Trauma seen - yes Objective P = wnl R = eupneic BCS 3/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: clean adult dentition, no oral lesions noted, limited exam PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MI, 2 testicles descended MSI: Ambulatory x 4 with no lameness noted before sedation, skin free of parasites, no masses noted, dry and dull hair coat, underweight, large, long superficial wound down entire left flank and slightly deeper area on lateral left neck-consistent with HBC/road abrasion, no active bleeding or discharge, scabbed over. Upper and lower lips are very swollen. Nails are raw likely from dragging on ground CNS: mentation appropriate - no signs of neurologic abnormalities Assessment: Very long wound on left flank consistent with road rash Underweight Plan: Continue to monitor while at BACC Sedated with telazol 0.5ml IM LRS 20ml/kg SQ once Gave rimadyl 4.4mg/kg SQ, start 4.4mg/kg PO SID until 6/6 Start trazodone 100mg PO BID for shelter anxiety Gave convenia 8mg/kg SQ once Scrubbed wounds with chlorhex and applied chlorhex. Once the scabs were scrubbed off it was revealed all wounds are superficial and will heal by second intention, maintained on isoflurane during this time CBC/Chem pending CXR/TXR/Pelvis rads pending Prognosis: Good SURGERY: temporary waiver due to underweight

6/2/2019

CBC: mild non-regenerative anemia 33.8 (37.3-61.7), leukocytosis 36.43 (5.05-16.76), with neutrophilia 33.34 (2.95-11.64), mild eosinopenia 0.01 (0.06-1.23) r/o inflammation/infection from wounds Chem: nsf AXR: large amount of mineral opacity (bones) noted in stomach, empty uniform gas filled SI, empty colon, decrease in detail likely due to low body hbitus, no other significant findings CXR: round soft tissue opacity caudal to heart noted on both lateral views, possibly noted on left lateral caudal side on VD but difficult to assess r/o pulmonary bulla vs mass vs artifact Pelvic rads: nsf CTM for FB obstruction/respiratory signs. Recommend repeat rads and BW with placment **Rads submitted for radiology consult 6/4

6/4/2019

H: intake on 6/3. Noted to be thin, dehydrated, have a large wound and an abnormal opacity in the lungs and bones in the stomach. Given convenia injection, SQF, started on Trazodone and Rimadyl, cleaned wounds. CBC: mild non-regenerative anemia 33.8 (37.3-61.7), leukocytosis 36.43 (5.05-16.76), with neutrophilia 33.34 (2.95-11.64), mild eosinopenia 0.01 (0.06-1.23) r/o inflammation/infection from wounds Chem: nsf AXR: large amount of mineral opacity (bones) noted in stomach, empty uniform gas filled SI, empty colon, decrease in detail likely due to low body hbitus, no other significant findings CXR: round soft tissue opacity caudal to heart noted on both lateral views, possibly noted on left lateral caudal side on VD but difficult to assess r/o pulmonary bulla vs mass vs artifact Pelvic rads: nsf S: QAR to BAR. Eating well. No csvd Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Lungs: Eupneic Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 3/9 Neuro: Appropriate mentation. Rectal: Not performed. Externally normal. Assessment: Very long wound on left flank consistent with road rash Underweight Plan: Continue to monitor while at BACC Continue rimadyl 4.4mg/kg PO SID until 6/6 Continue trazodone 100mg PO BID for shelter anxiety

6/7/2019

H: intake on 6/3. Noted to be thin, dehydrated, have a large wound and an abnormal opacity in the lungs and bones in the stomach. Given convenia injection, SQF, started on Trazodone and Rimadyl, cleaned wounds. CBC: mild non-regenerative anemia 33.8 (37.3-61.7), leukocytosis 36.43 (5.05-16.76), with neutrophilia 33.34 (2.95-11.64), mild eosinopenia 0.01 (0.06-1.23) r/o inflammation/infection from wounds Chem: nsf AXR: large amount of mineral opacity (bones) noted in stomach, empty uniform gas filled SI, empty colon, decrease in detail likely due to low body hbitus, no other significant findings CXR: round soft tissue opacity caudal to heart noted on both lateral views, possibly noted on left lateral caudal side on VD but difficult to assess r/o pulmonary bulla vs mass vs artifact Pelvic rads: nsf S: BAR. Eating well. No csvd Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Lungs: Eupneic Integument- dry and dull hair coat, wounds down entire left flank and on lateral left neck noted to have healthy granulation tissue, no active bleeding or discharge, scabbing over. No facial swelling noted Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 3/9 Neuro: Appropriate mentation. Rectal: Not performed. Externally normal. Assessment: Very long wound on left flank consistent with road rash- improving Underweight Plan: Continue to monitor while at BACC ok to d/c rimadyl Continue trazodone 100mg PO BID for shelter anxiety reweigh on 6/16 Radiology consult still pending

6/9/2019

FINDINGS: There is an ovoid and well marginated soft tissue mass in the mid aspect of the left caudal lung lobe. There is a diffuse broncho-interstitial pattern throughout the remainder of the pulmonary parenchyma. The heart and pulmonary vessels are decreased in size. The other vascular structures are within normal limits. There are no significant mediastinal, tracheal, pleural, or other thoracic abnormalities. The abdominal serosal detail is adequate for the patient's thin body condition. There are numerous bone fragments within the stomach. The small intestine is mostly gas filled and normal in size. There is small mineral fragments mixed in with the feces in the colon. There are no obvious hepatic, splenic, retroperitoneal/renal, urinary bladder/prostatic, or other visible abdominal abnormalities. There are no significant abnormalities of the coxofemoral joints/pelvis or visible stifles. The spine is within normal limits. There is swelling and mild emphysema along the dorsal cervical and thoracic spine, possibly due to subcutaneous fluid administration. There are no other significant bunions on this study. CONCLUSIONS: The mass in the left caudal lung lobe is concerning for the presence of a pulmonary tumor, although could also be due to a granuloma or abscess. The microcardia is most likely due to hypovolemia. The bone fragments in the patient's stomach is likely normal component of the patient's diet given the history. RECOMMENDATIONS: Thoracic CT with guided sampling of the mass from immediate assessment, or follow-up 3 view thoracic radiographs in 1 month to assess for any changes in the pulmonary mass in the interim are recommended.

6/9/2019

Hx: intake on 6/3. Noted to be thin, dehydrated, have a large wound and an abnormal opacity in the lungs and bones in the stomach. Given convenia injection, SQF, started on Trazodone and Rimadyl, cleaned wounds. CBC: mild non-regenerative anemia 33.8 (37.3-61.7), leukocytosis 36.43 (5.05-16.76), with neutrophilia 33.34 (2.95-11.64), mild eosinopenia 0.01 (0.06-1.23) r/o inflammation/infection from wounds Chem: nsf AXR: large amount of mineral opacity (bones) noted in stomach, empty uniform gas filled SI, empty colon, decrease in detail likely due to low body hbitus, no other significant findings CXR: round soft tissue opacity caudal to heart noted on both lateral views, possibly noted on left lateral caudal side on VD but difficult to assess r/o pulmonary bulla vs mass vs artifact Pelvic rads: nsf SO: BAR. Eating well. No csvd EENT: Eyes clear OU, no ocular or nasal discharge H/L: Eupneic, normal RR/RE Neuro: A&A MSI: Ambulatory x4. Dry and dull hair coat, wounds down entire left flank and on lateral left neck noted to have healthy granulation tissue, no active bleeding or discharge, scabbing over. No facial swelling noted Abd: visually normal A: Very long wound on left flank consistent with road rash- improving Underweight Lung neoplasia P: Continue to monitor while at BACC rec Hospice - otherwise ARL/EHR Continue trazodone 100mg PO BID for shelter anxiety

Dog is fearful aggressive needed to use control pole. A.Dominguez