MARTIN – A1045939
MARTIN – A1045939
MALE, WHITE, PIT BULL MIX, 8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 07/30/2015, From NY 10026, DueOut Date 08/02/2015,
Medical Behavior Evaluation GREEN
Medical Summary S/O: Appearance: QAR, laying in sternal recumbancy in cage with head and neck outstreched, increased respiratory rate and effort. Dehydrated. Large amount of vomit in cage. Integument: dirty haircoat, multiple callouses and skin tags and small healing wounds EENT: no nasal discharge, mild mucoid ocular dischar OU with tear staining OU, pale pink MM’s Oral cavity: MM pale pink, CRT <2sec, inflamed/enlarged gingiva, tacky mm’s PLN: WNL H/L: No murmur or arrhythmias, pulses moderate quality, increased brochovesicular sounds, increased RR and RE. ABD: tense on abdominal palpation, severely distended abdomen. fluid wave palpable, deep palpation not possible due fluid in abdomen U/G: male intact, 2 descended testes M/S: weakly amb x 4 BCS: 2/9, severe diffuse muscle wasting Neuro: mentally appropriate, QAR A: A1. Geriatric (approx 8-12 yr) male intact pit bull A2. Ascites (straw colored fluid obtained on abdominocentesis): secondary to neoplasia vs. less likely right sided heart failure (no murmur detected, no evidence of heart disease) A3. Probable anemia (base on pale MM’s): anemia of chronic disease vs. hemorrhage vs. other A4. Poor body condition – severe diffuse muscle wasting (BCS 2/9): secondary to A2 vs. poor nutrition A5. Difficulty breathing: likely due to pressure of abdominal contents on the diaphragm vs. pulmonary metastasis vs. pneumonia (possibly aspiration pneumonia resulting from vomiting) A6. Vomiting: secondary to A2 A7. Dehydrated The large amount of fluid in Martin’s abdomen is most likely due to cancer. Heart failure can also cause the accumulation of fluid in the abdomen, but no heart murmur is detected, making this much less likely. Martin’s advanced age, pale mm’s and poor body condition also support suspect neoplasia. He is currently vomiting mutiple times and having a difficult time breathing (this could be from aspirating on his vomit, or it could be due to the pressure of his abdominal contents pushing on his diaphragm, or he could also have cancer spread to his lungs). He appears to be very uncomfortable and is likely suffering from his condition. P: Recommend humane euthanasia due to grave prognosis and poor quality of life.
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