- NYC Veterinary Specialists - Queens -

107-28 71st Road • Forest Hills, New York 11375 • (718) 263-0099 Main (718) 263-0098 Fax

Medical Record

for

“Tanzi”

Patient Information:

Tanzi (#18415)

Rhodesian Ridgeback

Tan

Male

7 year

______________________________________________________________________

February 03, 2009

TPR (9:09 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

Temperature = 101.6

Pulse= 180

Respiratory Rate= 30

Weight: 41.000 kg, 90.20 lb, 1.19 m2

LABORATORY (9:10 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

PRESENTING COMPLAINT (10:13 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

02-03-09: Chemo

HISTORY (10:13 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

Here for chemotherapy.

Had a couple of days of tolerable vomiting and diarrhea. Resolved now.

No bloody discharge from penis/prepuce in many days.

PHYSICAL EXAMINATION (10:14 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

BAR. H Pk 1s

EENT: No ocular or nasal discharge. Mucous membranes pink and moist, crt <2s. Mild dental calculus. Clean ears.

PLN: all wnl,NP axillaries, inguinals, & popliteals

HL: No murmurs or arryhthmias, strong synchronous pulses, normal BV sounds.

ABD: soft non-painful

UG: Intact male, testes smooth and symmetrical.

MSI: BCS = 4.5/9, well muscled.

DIAGNOSIS (10:17 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

LSA, high grade, stage IVa: PLNs, spleen, liver, +/- lungs–CR(?)

CHOP chemotherapy started 1/8/9

Suspect prostatitis–resolved

Diarrhea–resolved

DIAGNOSTICS (10:17 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

CBC in-house

Pre-Adria echo done last week

TREATMENT (10:18 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

ADRIA #1–35.8 MG IV IN SALINE INFUSION

BENADRYL–35.8 MG IV

DISCHARGE INSTRUCTIONS (10:23 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

Everything went fine today.

Tanzi is due in 1 week for re-evaluation to determine his remission status. In order to accomplish this, he will need the following tests (see attached financial estimate): physical examination, routine CBC, lymph node aspirate and cytology test, chest radiographs and abdominal ultrasound. If, on the abdominal ultrasound, anything abnormal or suspicious is seen in the spleen or liver, a fine needle aspirate of that may also be necessary.

If Tanzi is determined to be in remission next week, then on Thursday, he will need to be dropped-off in Manhattan for his radiation therapy simulation. The first radiation treatment would be given on Tuesday of the following week.

WRITTEN COMMUNICATION (10:23 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

DISCHARGE ORDERS for “Tanzi”

February 03, 2009

SEEN BY: Timothy A Rocha DVM DACVIM Oncology

REFERRING VETERINARIAN: Dr. Teresa Paoloni

REFERRING CLINIC: Veterinary Care Unlimited

OWNER: Charles Monteiro

PHONE:

PATIENT: “Tanzi”, Rhodesian Ridgeback, Male, 7 years

Discharge Instructions:

Everything went fine today.

Tanzi is due in 1 week for re-evaluation to determine his remission status. In order to accomplish this, he will need the following tests (see attached financial estimate): physical examination, routine CBC, lymph node aspirate and cytology test, chest radiographs and abdominal ultrasound. If, on the abdominal ultrasound, anything abnormal or suspicious is seen in the spleen or liver, a fine needle aspirate of that may also be necessary.

If Tanzi is determined to be in remission next week, then on Thursday, he will need to be dropped-off in Manhattan for his radiation therapy simulation. The first radiation treatment would be given on Tuesday of the following week.

Diagnostics:

CBC in-house

Pre-Adria echo done last week

Treatment:

ADRIA #1–35.8 MG IV IN SALINE INFUSION

BENADRYL–35.8 MG IV

Diagnosis:

LSA, high grade, stage IVa: PLNs, spleen, liver, +/- lungs–CR(?)

CHOP chemotherapy started 1/8/9

Suspect prostatitis–resolved

Diarrhea–resolved

Please don’t hesitate to call if you have any questions or concerns regarding Tanzi’s progress at home. Also, keep in mind that our hospital is open 24 hours a day, in the event of an emergency.

________________________________________

Timothy A Rocha DVM Karen Oberthaler VMD

DACVIM Oncology DACVIM Oncology

WRITTEN COMMUNICATION (10:24 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

February 03, 2009

Dr. Teresa Paoloni

Veterinary Care Unlimited

84-09 Rockaway Blvd.

Ozone Park, NY 11416

Fax: (718) 296-1266

Dear Dr. Paoloni:

Thank you for referring Charles Monteiro and his dog Tanzi. I am always glad to participate in the medical care of your patients.

Reason for Visit 02-03-09: Chemo

Diagnosis:

LSA, high grade, stage IVa: PLNs, spleen, liver, +/- lungs–CR(?)

CHOP chemotherapy started 1/8/9

Suspect prostatitis–resolved

Diarrhea–resolved

Diagnostics:

CBC in-house

Pre-Adria echo done last week

Treatment:

ADRIA #1–35.8 MG IV IN SALINE INFUSION

BENADRYL–35.8 MG IV

Discharge Instructions: Everything went fine today.

Tanzi is due in 1 week for re-evaluation to determine his remission status. In order to accomplish this, he will need the following tests (see attached financial estimate): physical examination, routine CBC, lymph node aspirate and cytology test, chest radiographs and abdominal ultrasound. If, on the abdominal ultrasound, anything abnormal or suspicious is seen in the spleen or liver, a fine needle aspirate of that may also be necessary.

If Tanzi is determined to be in remission next week, then on Thursday, he will need to be dropped-off in Manhattan for his radiation therapy simulation. The first radiation treatment would be given on Tuesday of the following week.

Thanks again for allowing me this opportunity to meet Tanzi and Charles Monteiro. If you have any more questions regarding Tanzi’s case or any others, please feel free to call.

Sincerely,

_____________________________________________

Timothy A Rocha DVM

DACVIM Oncology