Maryland SPCA
3300 Falls Road
Baltimore, MD 21211
(410) 235-8826
Medical History Report
Animal ID Name
Type
Breed
97316
Ms. Boxer Dog
Color(2)
Gender Spayed / Neutered Age
None
Female
Mixed
Secondary Breed
Labrador Retriever Yes
Yes
Color(1)
Yellow
Maryland Tag Other Identification Primary Microchip #
Adult
981020013716209
Veterinary Clinic Software Record #:
Weight: 40.8 lbs
Incoming Shelter/Rescue: Animal Friends of Barbour
County
Date of Weighing: 1/23/2015
Initial Exam
Date: 23-Jan-2015
Weight: 40.8 lbs
ears
Normal
eyes
Normal
skin
Abnormal
teeth
Abnormal
heart
Normal
lungs
Normal
Result: Abnormal
Comments: BAR. No spay scar- multiple masses in mammary chain- vet to check. No microchip. Skin tag on left
rear thigh. All four K9s broken, all incisors worn/broken, mild under-bite, pre-molars/ molars clean [blood pulled for
dental] Vet to check. Mild waxy buildup in both ears- cleaned in exam. Nails trimmed. [cf/em]
T: 101.8f, CRT: < 2 sec, HR: 132, RR: Panting
Date Spayed / Neutered: 1/28/2015
Stitches Removal Date:
Clinic Name:
MDSPCA Pump House
Previously Spayed / Neutered:
No
General Vet Notes:
Previous Medical Details:
Known Allergies or Medical Conditions:
Schedule Surgery Date:
Feeding Requirements:
Most Recent Date In Care: 26-Jan-2015
Date Adopted:
Origin: Transfer In
Lost/Found City / Zip Code / Jurisdiction:
/ / Baltimore City
Adopted and Returned Dates (if any):
No adopted/return dates in system
Indemnity/Waivers:


Dental Waiver
The MD SPCA has observed that the animal you are adopting has severe dental disease and may need
veterinary follow up.
Dental issues that have been noticed may include heavy tartar, loose or missing teeth, gum inflammation
and infection, or excessive/crowded teeth. Bacterial build-up and a history of poor dental care or diet can
increase the risk of severe dental disease.
Treatment for this condition may include oral medications, vet check-ups, or a dental procedure. It is a good
idea to discuss this condition with your vet to create a treatment plan.
You may go home with medication that the SPCA has been using to treat your animal. Please consult your
vet and follow his or her suggestions regarding course of treatment. The SPCA will not reimburse you for
any costs associated with this or any other treatment. The SPCA is not a veterinary clinic and cannot
dispense advice regarding the health or vet treatment of your animal.
I have read and understood this document, and I have had sufficient opportunity to talk to staff at The
Maryland SPCA about these issues and others related to oral diseases.
Recent Injury/surgery
We believe your animal has recently sustained an injury (prior to coming to the SPCA), or had a previous
medical issue and your animal has had surgery to treat this problem.
- The surgery may not have been performed by an SPCA vet, but by an outside vet. We will advise you
about this. [circle one: Outside Vet/SPCA Vet]
- Please limit your animal's activity to allow it to heal.
- If your animal has a cast on, please keep the cast dry and as clean as possible.
- If there is an open surgery site, please keep that site dry and as clean as possible and prevent your animal
from licking or biting it. An E-collar may be necessary.
- You may go home with medications that the SPCA has been using to treat your animal. Please consult
your vet and follow his or her suggestions regarding course of treatment. The SPCA will not reimburse you
for any costs associated with this or any other treatment.
- The SPCA is not a veterinary clinic and cannot dispense advice regarding the health or vet treatment of
your animal.
I have read and understood this document, and I have had sufficient opportunity to talk to staff at The
Maryland SPCA about these issues and others related to my animal's specific injury and surgery.
Medical Notes
Notes
Date
No Medical Notes Stored
Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
1/18/2015
DA2PPv
AFOBC
1/18/2015
See Medical Notes
AFOBC- Panacur
1/19/2015
See Medical Notes
AFOBC- Panacur
1/20/2015
See Medical Notes
AFOBC- Panacur
1/22/2015
RABIES
Appalachian Animal Hospital
1/23/2015
Advantage Multi
1/23/2015
Bordetella
1/23/2015
Heartworm Antigen Test
1/23/2015
Drontal
1/28/2015
Microchip Placement
2/3/2015
DA2PPv
2/9/2015
Drontal
2/9/2015
Bordetella
Negative
Vet Treatments Due
Date Due
Vet Treatment Type
2/23/2015
Advantage Multi
8/9/2015
Bordetella
1/22/2016
RABIES
1/23/2016
Heartworm Antigen Test
2/1/2016
DA2PPv
Medications
Medication
Rimadyl
Tramadol
Amount
Dispensed
14
14 mg
Frequency
Twice daily
Twice daily
Date
From
Date To
Vet Name
1/27/2015 2/2/2015
Dr.
Francesco
Sollini,
DVM
1/27/2015 2/2/2015
Dr.
Francesco
Sollini,
DVM
Reason
Notes
Pain
Management
Carprofen 50mg:
Give 1 tablet by
mouth, twice daily
for 7 days. Start
1/28/15 in the AM
[ap]
Pain
Management
Tramadol 75mg: 1
and 1/2 of 50mg
tablets: Give by
mouth twice daily
for 7 days. Start
this PM [ap].
Other
7
Other
Other
Rimadyl
as needed
Tramadol
Doxycycline
(tablets)
Surgical Site
Infection
2/3/2015
Dr.
Francesco
2/13/2015
Sollini,
DVM
Other
E-Collar on at all
times for 10 days.
[ap]
2/3/2015
Dr.
Francesco
2/10/2015
Sollini,
DVM
Pain
Management
Carprofen 100mg:
Give 1/2 tablet by
mouth, twice daily
for 7 days. [ap]
Twice daily
2/3/2015
Dr.
Francesco
2/10/2015
Sollini,
DVM
Pain
Management
Tramadol 50mg:
Give 1 and 1/2
tablets by mouth,
twice daily for 7
days. [ap]
Once daily
Dr.
Francesco
2/10/2015 2/19/2015
Sollini,
DVM
Kennel
Cough/URI
Doxycycline
200mg: Give 1
tablet by mouth,
once daily for 10
days. [ap]
Twice daily
10
Use as
directed
14 mg
10
E-collar on as
needed [ap]
Other
Ice pack for 10
minutes along
incision area, twice
daily for 5 days.
Use a thin towel or
pillow case around
the ice pack. [ap]
8
14
1/27/2015 2/1/2015
Dr.
Francesco
Sollini,
DVM
Twice daily
1/29/2015 2/2/2015
Dr.
Francesco
Sollini,
DVM
Drug Usage
Name : Canine Ovariohysterectomy
Drug
Bottle
Date : 1/28/2015
Quantity
Used By
Holder
Date
Used By
Holder
Date
No drugs administered to this animal.
Name : N/A
Drug
Bottle
Date : 1/31/2015
Quantity
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date
Resolved
Vet Notes: 1:45 PM
11Feb2015
Recheck
S.O.A.P. Examination
Presenting Complaint - Bandage check and recheck
Dr.
Francesco
Sollini, DVM
11-Feb2015
Subjective: BARH, very small granulating area along right
mammary chain, no discharge noted from other incisions, non
painful on exam.
Assessment: Inguinal incisions is healing well. Removed sutures
from right thigh, lateral aspect small scab still present.
Plan: Bandage re-applied to be removed in 4 days. Possibly with
removal of remaining sutures. Recheck in 4 days. Keep e-collar
on until otherwise instructed. Ok to go to foster.
Vet Notes: 4:15 PM
S.O.A.P. Examination
Weight = 42.4#
CRT = < 2 sec
HR = 110
RR = PANT
Temp. = 101.6F
10Feb2015
Coughing
Presenting Complaint - Coughing
Dr.
Francesco
Sollini, DVM
10-Feb2015
Dr.
Francesco
Sollini, DVM
8-Feb2015
Dr. Cristina
Mollenkopf,
DVM
6-Feb2015
Dr. Mary Zink
5-Feb2015
Subjective: BARH, coughing occasionally, lungs sound clear.
Assessment: No masses or nodules noted on 3 views thoracic
radiographs from 2/8. At least 4 small radio-opaque pellets noted
in the subcutaneous of thoracic region. (Likely pellets from BB
Gun).
Plan: Doxycycline 200mg PO SID x 10 days. Bandage change
tomorrow 2/11/15 and then possibly send to foster.
Vet Notes: 3:23 PM
8Feb2015
Recheck
PC: Bandage change
S: BARH, eating well
O: Non-painful on exam. Mild discharge, smaller area of
granulating tissue.
A: Wounds are healing
P: Recheck wounds and bandage in 3 days [2/11]
Vet Notes: 2:08 PM
S.O.A.P. Examination
6Feb2015
Presenting Complaint - Change Bandage
Recheck
Subjective: BARH
Objective: Wound granulating in very well. Minimal discharge.
Plan: New bandage applied. Remove bandage and recheck
2/8/15.
Vet Notes: 3:51 PM
5Feb2015
Recheck
S.O.A.P. Examination
Presenting Complaint - Change Bandage and evaluate
Subjective: BARH
Objective: Wound is not producing much discharge at this point.
Wound is granulating in well.
Assessment: Mammary cancer. Surgical site-open wound
management.
Plan: Continue with prior plan. Planning to seek rescue or return
to Barbour Co. Recommend consider lat and v/d chest
radiographs to help give a prognosis prior to transfer.
Vet Notes: 2:32 PM
S.O.A.P. Examination
Presenting Complaint - Recheck
4Feb2015
Recheck
Subjective: BARH, bandage still in place, tolerating exam well,
mild discharge from incision no odor or other infection signs,
eating well.
Dr.
Francesco
Sollini, DVM
4-Feb2015
Dr.
Francesco
Sollini, DVM
3-Feb2015
Dr.
Francesco
Sollini, DVM
1-Feb2015
Plan: Recheck bandage and change as needed tomorrow.
Continue Tramadol and Carprofen as prescribed. Short leash
walks TID if possible. Keep bandage dry and clean.
Vet Notes: 5:02 PM
S.O.A.P. Examination
CRT = < 2 sec
HR = 104
RR = 24
Temp. = 101.7f
3Feb2015
Presenting Complaint - Recheck, Bandage change.
Recheck
Subjective: BARH, mild discharge from caudal incision, small
granulating are on debriding site.
Assessment: Overall improving.
Plan: Continue Carprofen 50mg PO BID x 7 more days.
Tramadol 1 and 1/2 50mg (75mg) PO BID x 7 more days. Ecollar on at all times x 10 days. Reassess and change bandage
in 2 days. (2/5)
Vet Notes: 3:55 PM
1Feb2015
Post-op
Recheck
PC: Recheck and bandage change
S: BARH
O: Mild discharge from open incisions, inflamed tissues but
clean. Bandage changed. CRT: ,2sec, HR: 110, RR: 30, T:
101.3f
A: Surgical incision dehiscence
P: Continue Carprofen and Tramadol
Bandage change done
Change bandage daily and recheck incision
Vet Notes: 12:54 PM
Histopathology, Full Written Report
History:
Mammary chains and left hind leg/thigh
Masses from: left inguinal mammary chain, skin growth left hind
leg (lateral aspect),right abdominal mammary nodule, left
inguinal mammary mass, right inguinal mammary gland nodule
and lymph nodes. No clear margins.
Received:
B1) (R abd mamm) A 2.2 cm skin biopsy
B2) (L hind lateral aspect) A 1 cm skin biopsy - all processed
B3) (L ing mamm mass) A 4 cm skin biopsy
B4) (L ing mamm mass) A 4 cm skin biopsy
B5) (Ing mamm gld nodules and LN0 A 2 X 1 cm tissue. A 3 cm
skin biopsy.
Biopsy
1Feb2015
Biopsy
Result
Microscopic Description:
These are sections of tissue derived from 6 specimens. One
specimen is designated as right abdominal mammary. The
specimen consists of
haired skin and underlying mammary tissue. Within the
mammary tissue, there is a well circumscribed mass composed
primarily of well
differentiated bone. Supporting fibrous tissue sometimes
contains glandular structures. The epithelium bordering the
glandular structures is well differentiated and present in one to
sometimes multiple layers. Mitotic figures are rare.
Microscopic Findings:
ONE SPECIMEN (SKIN AND MAMMARY GLAND, RIGHT
ABDOMINAL MAMMARY): BENIGN
MIXED MAMMARY TUMOR
Comment: This neoplasm is benign. Excision appears to be
complete and should be curative.
One specimen is designated as left hind. The specimen consists
of haired skin. Extending above the epidermal surface, there is a
thin
elongate projection composed of collagenous tissue continuous
within the subjacent dermis. The structure is bordered by
stratified squamous epithelium which is often folded and
sometimes thickened.
Microscopic Findings:
ONE SPECIMEN (SKIN, LEFT HIND): ACROCHORDON (SKIN
TAG).
Comment: There is no evidence of neoplasia. Excision appears
to be complete and should be curative.
One specimen is designated as left inguinal mammary mass.
The specimen consists of haired skin and underlying mammary
tissue. The
mammary contains a large focal nodular accumulation of
inflammatory cells consisting of a mixture of macrophages and
neutrophils with
smaller numbers of lymphocytes and plasma cells.
External Vet
1-Feb2015
Microscopic Findings:
ONE SPECIMEN (SKIN AND MAMMARY GLAND, LEFT
INGUINAL): FOCAL PYOGRANULOMATOUS MASTITIS
Comment: An infectious etiology is most likely. Cultures are
advised if lesions persist or recur.
One specimen is designated as left inguinal mammary mass.
The specimen consists of haired skin and underlying mammary
tissue.
Within the mammary tissue, there is a mass composed of cystic
spaces containing lobular and papilliferous aggregates of
epithelial cells
supported by a fine fibrovascular stroma. The cells are present in
single and often multiple layers. They range from cuboidal to
polygonal and have moderate amounts of eosinophilic
cytoplasm. Nuclei are round to oval and have a pale, finely
stippled basophilic chromatin pattern and prominent nucleoli.
mitotic figures are counted in 10 high power fields.
Microscopic Findings:
ONE SPECIMEN (SKIN AND MAMMARY GLAND, LEFT
INGUINAL): PAPILLARY INTRADUCTAL ADENOCARCINOMA.
Comment: Tumor cells are separated from the cut edges of the
sections by a scant margin (less than 1 mm in some areas). Fifty
percent of
histologically malignant canine mammary tumors do not exhibit
aggressive behavior clinically and complete excision is usually
curative. Prognostic factors indicating more aggressive neoplasia
include evidence of locally invasive growth or metastasis which
could not be evaluated in the submitted specimen, since
surrounding normal
tissue was insufficient.
2 specimens are submitted together in a container designated as
right inguinal mammary gland and lymph node. One specimen
consists of
haired skin and underlying mammary tissue. Within the
mammary tissue, there are several small, well circumscribed
masses composed of cords
and ductular structures lined by a single layer of cuboidal to
columnar cells. The cells have moderate amounts of eosinophilic
to amphophilic cytoplasm and rounded to oval, basally located
nuclei. Nuclei have a coarsely reticular chromatin pattern and
small nucleoli. Mitotic figures are rare.
Microscopic Findings:
ONE SPECIMEN (SKIN AND MAMMARY GLAND, RIGHT
INGUINAL): MULTIFOCAL TUBULAR ADENOMA.
Comment: These neoplasms are benign. Excision appears to be
complete and should be curative.
The remaining specimen consists of lymph node. The cortex
contains primary lymphoid follicles. Medullary cords contain a
mixture of small, well differentiated lymphocytes and
plasmacells. Medullary sinuses contain a mixture of similar cells
and smaller numbers of macrophages.
Microscopic Findings:
LYMPH NODE: NO HISTOLOGIC LESIONS
Comment: There is no evidence of neoplasia, inflammation or
other clinically significant changes.
PATHOLOGIST:
Pamela B. Luther, DVM, DACVP
Vets may
Vet Notes: 12:31 PM
31Jan2015
Wound
Post-op
Recheck
PC: Open wound at mammary incision site
O: Wound continues to drain a lot of serosanguinous fluid.
Replaced bandage.
A: Open wound management.
P: Continue with daily bandage changes and vet check daily [if
possible]
Continue with Tramadol and NSAID
Dr. Mary Zink
1-Feb2015
Dr.
Francesco
Sollini, DVM
28-Jan2015
Dr.
Francesco
Sollini, DVM
25-Jan2015
Vet Notes: 4:53 PM
1/29/15
Temp= 101.7
Vet Notes: 12:19 PM
S.O.A.P. Examination
28Jan2015
Post-op
Recheck
Weight = 41.6#
CRT = < 2 sec
HR = 110
RR = 26
Temp. = 103.0f
Presenting Complaint - Recheck post-op
Subjective: BARH, sensitive on palpation of incisions, bruising
along inguinal mammary gland incision, no discharge or fluid
accumulation noted along incisions.
Assessment: Recovering well after surgery, eating ok, mild
hyperthermia.
Plan: Continue Carprofen and tramadol as prescribed. Ice pack
for 10 minutes along the incision area SID x 4 days. Use a thin
towel or pillow case around ice pack. Monitor temp SID until
normal (99-102.5f) Reassess in 7 days if no alerts. Biopsy
results pending.
Vet Notes: 12:02 PM
25Jan2015
Abnormal
Growth
Dental
Issues
PC: Check teeth and mammary growths
S: BARH
O: All four canines fractured with pulp exposure, missing several
incisors on both arcades- the remaining are all worn down. Large
firm mass and smaller firm nodules involving all inguinal
mammary tissue. Left hind limb lateral aspect small skin growth.
Intact female. Weight: 41.6#, CRT: <2sec, HR: 104, RR: 24, T:
101.9f
A: Severe periodontal disease
Mammary growths and skin growth- benign vs. malignant
P: Rec resection and biopsy of mammary mass/ nodules and left
hind skin growth
Consider dental with possible multiple extractions or dental
waiver
Vet Notes: 9:13 AM
Pre-Op Chem / CBC
Chemistry :
Total Protein = 6.5
Albumin = 3.4
Globulin = 3.1
A/G Ratio = 1.1
ALT (SGPT) = 38
Alk Phosphatase = 113
Urea Nitrogen = 8
Creatinine = 0.7
Bun/Creatinine Ratio = 11
Glucose = 98
Hemolysis 1+ No significant interference.
24Jan2015
Bloodwork
Dr. Cristina
Mollenkopf,
DVM
CBC :
WBC = 7.8
RBC = 6.9
Hemoglobin = 16.7
Hematocrit = 48
MCV = 70
MCH = 24.2
MCHC = 34.8
Platelet Count = 530 [high]
Platelet EST = Increased
Neutrophils = 5616
Bands = 0
Lymphocytes = 1092
Monocytes = 468
Eosinophils = 546
Basophils = 78
24-Jan2015
Ok to schedule surgery. [cm]
Clinic Consultations
Consult
Date
Procedures
Additional
Procedures
/
Conditions
Products
Physical
Exam
Comments
Vet
Gave Covenia 1.8ml
SQ post op.
31-Jan2015
Anesthesia
- Previously
Altered
No
Dr. Sharon
Mammary chain
Kaschenbach,
growth removal:
DVM
Dehiscence/infection.
Removed sutures- a
lot of swelling
inflamed necrotic
tissue underneath.
Flushed and left
open and bandaged.
Ova incision looks
okay, but tight.
Removed couple of
sutures from ova
incision to relieve
tension. Should
change bandage
daily until less oozy.
Carprofen 50mg PO
BID x 7 days. Start
tomorrow AM.
Tramadol 1 and 1/2
of 50mg (75mg) PO
BID x 7 days. Start
this PM. E-collar on
as needed.
27-Jan2015
Addn'l
Canine
Surgical
Ovariohysterectomy
Procedure
No
In heat
Ovariohysterectomy.
Mass removal on
both abdominal
mammary glands
and left inguinal
mammary gland.
Skin growth removal
on right hind thigh,
lateral aspect.
Abdominal mammary
glands: Elliptical
incision with
approximately 2cm
Dr. Francesco
margin around
Sollini, DVM
masses, combination
of blunt and sharp
dissection for
excision of masses.
Ligature of blood
vessels with 2/0
MSA. Subcutaneous
closed with 2/0 MSA
in simple interrupted
pattern. Skin closed
with 2/0 MSA in
simple interrupted
pattern. Skin growth:
Elliptical incision with
approximately 2 cm
margin, blunt and
sharp excision skin
closed with 2/0 MSA
in simple interrupted
pattern. LRS 150 ml
IV given during
surgery.
Post Surgical Exam Performed By: _____________________________________
Vet Notes History
No notes entered