9/8/2019

[DVM Intake] DVM Intake Exam Estimated age: 8-10 years Microchip noted on Intake? No History : Stray. Subjective: BAR Observed Behavior -Very food motivated. Tense and vigilant but with food, he was distracted and allowed handling. Evidence of Cruelty seen -No Evidence of Trauma seen -No Objective T = P =120 bpm R =eup BCS 5/9 EENT: Eyes clear, severely matted pinnae AU but otherwise clean AU, no nasal or ocular discharge noted Oral Exam: 2/4, underbite PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, no c/s ABD: Non painful, no masses palpated U/G: M/I MSI: Ambulatory x 4, generalized alopecia with yeasty debris on dorsum and comedones lower back, matted coat on all 4 limbs, ear and around eyes, none appear stranulating, 8 mm red dermal growth right neck, scabbed over and healing superficial wound left axilla, long nails, FL paws look mildly swollen dorsally from matting, superficial wound on paw pad bottom of LFL paw CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: 2 masses on left side of anus (dorsal one is ~1 cm and multilobular, the one below is ~6-8 mm and also multilobular), full ag, easy to express, normal secretion Assessment: -Generalized alopecia-r/o hormonal (hypoT4 vs. Cushing's) vs. allergies vs. alopecia x vs. other -Yeasty coat, dermatitis -Matted limbs and around eyes -Mass right neck -Masses left anus x 2 -Superficial healing wound left axilla -Swollen FL paws -Elevated liver enzymes-r/o Cushing's disease vs. liver dz (infection vs. inflammation vs. neoplasia vs. other) -Elevated WBC count-r/o infection vs. inflammation vs. neoplasia Prognosis: Fair to good Plan: -CBC/chem/T4 -Sedation: torb 0.25 mL IM, dexmedetomidine 0.15 mL IM and ketamine 0.15 mL IM -Shave matts and medicated bath today (repeat medicated baths weekly with Malaseb shampoo) -Nail trim performed -Gave Convenia 0.8 mL SQ -Enrofloxacin 204 mg tabs-Give 1/3 tablet PO SID x 14 days for possible liver infection -Recommend ultrasound and work-up for Cushing's disease -Recommend placement for the above and also CXR 3 view, mass removal on right neck and on anus x 2 with biopsy and neuter SURGERY: Permanent waiver due to elevated liver enzymes, needs work-up for Cushing's

9/8/2019

[Spay/Neuter Waiver - Permanent] Your newly adopted pet has been diagnosed with elevated liver enzymes and the staff veterinarians are issuing a PERMANENT waiver from the spay/neuter requirements of the City of NY. ACC does not have the facility to safely sterilize your pet with his/her current condition. However, your veterinarian will provide consultation on whether this procedure can or should be performed under their supervision. Follow up care at your regular veterinarian is recommended to ensure continued treatment and proper oversight of your pet's health. All costs for follow up care and subsequent surgery is at the expense of the adopter.

9/8/2019

CBC: -Neutrophilia (moderate)-r/o infection vs. inflammation vs. neoplasia -Monocytosis-See above Chemistry: -Elevated liver enzymes (ALT and ALP moderate, GGT severe)-r/o Cushing's dz vs. liver dz (infection vs. inflammation vs. neoplasia) vs. gall bladder dz (infection vs. stones vs. neoplasia vs. mucocele) Total T4: wnl