RADIOLOGIST ASSESSMENT  (10:56 am  MAN Valerie Sadler, DVM DACVR/nyc)

02/10/09

Today’s exam is compared with a study dated 01/08/09.

Thorax

Findings: There is partial mineralization of the tracheal rings and proximal bronchial tree, which highlights these structures.  The pulmonary parenchyma is characterized by a very mild uniform increase in interstitial opacity.  Minimal bronchial markings are also noted.  The cardiovascular structures are within normal limits.  There are sites of spondylosis in the thoracic spine.

Impression:  Nonspecific pulmonary parenchymal changes indicative of past or current lower airway disease.  No evidence of pulmonary metastasis or intrathoracic lymphadenopathy.  Degenerative changes, spine.
Relayed the above to Dr. Oberthaler

VS/ljj

t:  02/13/09

ULTRASONOGRAPHY  (11:08 am  QUE Suliman Al-Ghazlat, DVM, DACVIM/que)

ABDOMINAL ULTRASOUND REPORT

Liver:  Slightly hyperechoic but otherwise normal

Gallbladder:  slightly distended and contains  gravity dependent sludge

Right Kidney:  mild decrease in corticomedullary distinction

Left Kidney:  smaller has less defined architecture compared to the right kidney

Urinary Bladder:  Normal

Right Adrenal:  Normal

Left Adrenal:  Normal

Stomach:  Normal

Small Intestine:  Normal

Lymph nodes:  Normal

Peritoneum:  Normal

Spleen:  Normal. There is a large 6 x 6cm complex mass caudal and lateral to the left kidney. Most likely a splenic mass

Colon:  Normal

Pancreas:  Normal
Impression:

Chronic renal disease

Gall bladder sludge

R/O  steroids hepatopathy vs much less likely infiltrative liver disease

R/O Splenic mass: HSA vs other sarcomas or benign splenic tumor vs LSA

Antech ID:130261

Lab:

Antech Diagnostics

1111 Marcus Avenue

Lake Success, NY 11042

Reported: 02/12/09 12:13 PM

Received: 02/11/09

Reference No. NYCA02923531

Cytology

Microscopic Description: 5 slides, left mandibular LN, 8 yr old ridgeback with hx of lymphoma in remission

The smears are thin and cellular with lymphoid cells dispersed on an unstained background. The lymphoid population is heterogeneous, composed mainly of lymphocytes and includes some plasma cells and

lymphoblasts. Lymphoblasts are less than 10% of total lymphoid cells.

Microscopic Findings: Normal or reactive lymph node, no detectable lymphoma infiltrate

Comment: The cytologic pattern is consistent with aspiration of a normal sized lymph node or one enlarged by lymphoid hyperplasia in an immune response.

Julia Blue, DVM, PhD, Diplomate ACVP

Entered by Linda L.

Reference No. NYCA02923541

Cytology

Microscopic Description: 4 slides, splenic mass, 8 yr old ridgeback with hx of lymphoma in remission

The largest smear contains partilcles of red pulp stroma that are heavily loaded with hemosiderin, and blood that is moderately cellular with splenic lymphoid cells. Most of the cells are lymphocytes. Plasma cells and lymphoblasts are present but in low numbers. The other smears are smaller and composed of blood with a

few lymphoid cells and macrophages. None of the smears show an increase in lymphoblasts, or any unusual cells.

Microscopic Findings: Normal splenic stroma and cells

Comment: There is no evidence of lymphoma or other form of neoplasia. The mass is probably hyerplastic nodule or hematoma.

Julia Blue, DVM, PhD, Diplomate ACVP

Entered by Linda L.

- 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

______________________________________________________________________

January 08, 2009

RADIOLOGIST ASSESSMENT (11:08 am MAN Wendy Gwin, DVM DACVR/nyc)

01/08/09 PENDING REVIEW BY DR. GWIN

Right lateral, left lateral and ventrodorsal projections of the thorax as well as lateral and ventrodorsal projections of the abdomen are available.

Thorax

Findings: An endotracheal tube is in place, with its distal aspect at the level of C6-7. The cardiovascular structures are within normal limits for size. Mild pulmonary osseous metaplasia is present. A moderate diffuse interstitial pulmonary pattern is present and is most severe caudodorsally. Pulmonary underinflation is noted on all projections. The cardiac silhouette is shifted into the left hemithorax. Ill-defined soft tissue opacity is noted within the cranioventral mediastinum, dorsal to the 1st through 3rd sternebra. Moderate ventral spondylosis deformans is present within the cranial thoracic spine.

Impression: Probable mild sternal lymphadenopathy. Pulmonary parenchymal changes are likely influenced by intubation and hypoinflation during the exam; however, pulmonary disease secondary to the historically described lymphoma cannot be ruled out. Degenerative changes, thoracic spine.

Abdomen

Findings: The liver and spleen are moderately enlarged. Abdominal serosal detail is mildly decreased. The urinary bladder is minimally distended. A small amount of amorphous mineral gastric content is present. Moderate ventral spondylosis deformans is present at L2-3. Mild ventral deviation of the colon is noted at L6-7; however, colonic feces is present. An ill-defined, approximately 10.70 cm rounded mass effect is identified within the caudodorsal abdomen, caudal to the left kidney and dorsal to the spleen and small intestine.

Impression: Hepatosplenomegaly. Decreased abdominal serosal detail, possibly due to the mass effect exerted by the liver and spleen; however, concurrent mesenteric lymphadenopathy and peritoneal effusion cannot be ruled out. Probable left caudal intra-abdominal mass, possibly originating from mesenteric lymph node or small intestine. Possible mild lymphadenopathy. Artifactual changes due to gravity-dependence of feces within the colon is also considered. Degenerative changes, cranial lumbar spine.

WG/ljj

t: 01/11/09

TPR (1:27 pm MAN Tim Rocha, DVM DACVIM (Oncology)/nyc)

Temperature = 100.9

Pulse= 120

Respiratory Rate= 20

Weight: 45.000 kg, 99.00 lb, 1.27 m2

WRITTEN COMMUNICATION (2:14 pm MAN Tim Rocha, DVM DACVIM (Oncology)/nyc)

Date: 01-08-09

NYCVS IN-HOUSE

ULTRASOUND CONSULTATION

Client Last Name: Monteiro Patient Name: “Tanzi” N(#18415)

Species: Canine Breed: Rhodesian Ridgeback

Age: 7 year Sex: Male

NYCVS Clinician: Tim Rocha, DVM DACVIM

____________________________________________________________________________

Requested Exam: Abdomen

____________________________________________________________________________

Reason For Exam: LSA staging

____________________________________________________________________________

Ultrasonographer Additional Comments:

____________________________________________________________________________

Radiologist Preliminary Findings:

EMERGENCY DRUG CALCULATIONS (3:09 pm MAN Tim Rocha, DVM DACVIM (Oncology)/nyc)

Weight: 45.000 kg, 99.00 lb, 1.27 m2

Epinephrine (1:1000) 0.45ml

Atropine (0.54mg/ml) 4.50ml

Lidocaine (20mg/ml) 4.50ml

Bicarb (1mEq/ml) 45.00ml

Calcium (100mg/ml) 22.50ml

Magnesium (4mEq/ml) 2.25ml

Vasopressin (20 units/ml) 1.80ml

Amiodarone (50mg/ml) 4.50ml

Naloxone (0.4mg/ml) 4.50ml

Flumazenil (0.1mg/ml) 9.00ml

External defibrillation 90 to 450 Joules

Internal defibrillation 9 to 45 Joules

Source: J Vet Emerg Crit Care 2003; 13(1): 13-23

PRESENTING COMPLAINT (3:14 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

01-08-09: lymphoma

HISTORY (3:22 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

Tanzi, a 7.5 year old intact male Rhodesian Ridgeback, was referred to the NYC-VS Oncology service for lymphoma. The owners noticed a lump on Tanzi’s neck, and brought him in to see Dr. Paoloni, who found generalized lymphadenopathy on physical examination. Lymph node aspirates confirmed lymphoma. In-house chemistry showed mildly elevated ALT (142 and 153U/L, repeated test) and mildly elevated GGT (14U/L); CBC was within normal limits, but some medium sized lymphoblasts were seen on smear evaluation. Tanzi is currently on cephalexin. He has been doing well at home, with no vomiting, diarrhea, inappetance, weight loss, lethargy, coughing, sneezing or change in body weight appreciated.

SS

PHYSICAL EXAMINATION (3:35 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

BAR.

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

PLN: Multilobulated 4 cm diam mandibs

Prescaps 5 cm diam

NP axillaries

Inguinals 2 cm diam, fatty

Popliteals 3 cm diam

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

ABD: Nonpainful on palpation, markedly enlarged spleen.

UG: Intact male, testes smooth and symmetrical.

MSI: BCS = 5/9, well muscled.

Rectal: Normal fecal material, small anal sacs, sublumbar LN nonpalpable. Symmetrically enlarged smooth prostate, median raphe appreciable.

SS modified by TR

DIAGNOSIS (3:35 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

LSA, high grade, probable stage IVa: PLNs, spleen, liver, lungs

bone marrow result pending

DIAGNOSTICS (3:36 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

Urinalysis Antech - pending

AUS - see below

2 view thoracic radiographs - enlarged parasternal lymph nodes, diffuse interstitial pattern suggestive of lymphoma infiltration into the lungs

2 view abdominal radiographs - significant splenomegaly and hepatomegaly, enlarged sublumbar LN

bone marrow aspirate Antech - pending

TREATMENT (3:36 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

butorphanol 1mg/lb = 10mg IV

propofol 6mg/kg = 270mg IV

Elspar 400 IU/kg = 18,000IU SQ

prednisone 2mg/kg = 80mg SQ

Tanzi has received his first dose of chemotherapy today. He will be receiving a multi-drug chemotherapy regimen called the “CHOP protocol”, which requires weekly chemotherapy injections for the first 8 weeks, and then biweekly injections for the next 8 weeks, for a total 6 month treatment time. If Tanzi goes into complete clinical remission and stays in remission for the next 4 weeks, we can discuss full-body radiation therapy as an adjunctive treatment to chemotherapy at that time.

We discussed the following treatment options:

1) No treatment. Average prognosis 1-2 months.

2) Prednisolone (steroids). Average prognosis 2 months.

3) CHOP chemotherapy. Average prognosis 12 months. We discussed the best-, worst-, and average-possible outcomes with this type of chemotherapy. We also discussed the cost, schedule of treatments and side effects.

4) CHOP chemotherapy + half-body radiation therapy. This experimental therapy has shown increased prognosis of 2-3 years, average.

5) Bone marrow transplant at NC State University. This is experimental. Prognosis unknown.

DISCHARGE INSTRUCTIONS (3:52 pm MAN Tim Rocha, DVM DACVIM (Oncology)/ko)

You should also be given chemotherapy information sheets. If you have any questions after reading them, please ask any member of the Oncology service.

Please make an appointment for Tanzi’s next dose of chemotherapy for Tuesday, January 13 at our Queens practice location. Dr. Karen Oberthaler will be taking care of Tanzi next week, and I will be out in Queens the following week.

ULTRASONOGRAPHY (5:59 pm MAN Lisa Ireland, DVM DACVIM/nyc)

ABDOMINAL ULTRASOUND REPORT

Liver: Significantly enlarged, very hyperechoic and mildly mottled.

Gallbladder: Contains a small amount of hyperechoic debris

Right Kidney: Difficult to image - partially obscured by gas - visible portion appears normal.

Left Kidney: Normal architecture, shape and size (long axis 6.4 cm).

Urinary Bladder: Normal

Right Adrenal: Obscured by gas.

Left Adrenal: Difficult to positively identify among the enlarged lymph nodes.

Stomach: Contains obscuring gas with normal wall thickness (0.39 cm) and retained visible wall layering.

Small Intestine: Normal (total wall thickness 0.2 cm).

Lymph nodes: There are numerous enlarged peritoneal lymph nodes (1.3 - 4.23 cm lengths).

Reproductive: The prostate is partially obscured, but appears enlarged (app. 5 cm sagittal width) with a normal echotexture.

Spleen: Extremely enlarged, hyperechoic, very mottled.

There is a solid, mottled mass effect located towards the head of the spleen (6.1 x 6.6 cm).

Colon: Normal

Pancreas: no lesions seen

Other: There is sublumbar lymphadenopathy (app. 1.3 x 2.7 cm)

Impression:

r/o: Lymphoma infiltration of liver, spleen, peritoneal/sublumbar lymph nodes

Splenic mass r/o: lymphoma vs other neoplasia vs hematoma

Prostatomegaly - r/o: BPH vs infiltrative disease

WRITTEN COMMUNICATION (7:05 pm MAN Lisa Ireland, DVM DACVIM/nyc)

Date: 01-08-09

NYCVS IN-HOUSE

RADIOGRAPHIC CONSULTATION

Client Last Name: Monteiro Patient Name: “Tanzi” N(#18415)

Species: Canine Breed: Rhodesian Ridgeback

Age: 7 year Sex: Male

NYCVS Clinician: Tim Rocha, DVM DACVIM

____________________________________________________________________________

Reason For Exam: LSA staging

Other:

_____________________________________________________________________________

Radiologist Preliminary Findings:

MEDICATION (7:13 pm MAN Tim Rocha, DVM DACVIM (Oncology)/nyc)

PREDNISOLONE, 20MG #66

(01-08-09 MAN Tim Rocha, DVM DACVIM (Oncology))

Rx: START TOMORROW. Give 4 tabs by mouth once daily for 6 days, then 3 tabs for 7 days, then 2 tabs for 7 days, then 1 tab for 7 days.

Refills: 0

Begin this medication __TOMORROW, FRIDAY, 1/9/9__.

WRITTEN COMMUNICATION (7:21 pm MAN Tim Rocha, DVM DACVIM (Oncology)/nyc)

DISCHARGE ORDERS for “Tanzi”

January 08, 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:

You should also be given chemotherapy information sheets. If you have any questions after reading them, please ask any member of the Oncology service.

Please make an appointment for Tanzi’s next dose of chemotherapy for Tuesday, January 13 at our Queens practice location. Dr. Karen Oberthaler will be taking care of Tanzi next week, and I will be out in Queens the following week.

Diagnostics:

Urinalysis Antech - pending

AUS - see below

2 view thoracic radiographs - enlarged parasternal lymph nodes, diffuse interstitial pattern suggestive of lymphoma infiltration into the lungs

2 view abdominal radiographs - significant splenomegaly and hepatomegaly, enlarged sublumbar LN

bone marrow aspirate Antech - pending

Treatment:

butorphanol 1mg/lb = 10mg IV

propofol 6mg/kg = 270mg IV

Elspar 400 IU/kg = 18,000IU SQ

prednisone 2mg/kg = 80mg SQ

Tanzi has received his first dose of chemotherapy today. He will be receiving a multi-drug chemotherapy regimen called the “CHOP protocol”, which requires weekly chemotherapy injections for the first 8 weeks, and then biweekly injections for the next 8 weeks, for a total 6 month treatment time. If Tanzi goes into complete clinical remission and stays in remission for the next 4 weeks, we can discuss full-body radiation therapy as an adjunctive treatment to chemotherapy at that time.

We discussed the following treatment options:

1) No treatment. Average prognosis 1-2 months.

2) Prednisolone (steroids). Average prognosis 2 months.

3) CHOP chemotherapy. Average prognosis 12 months. We discussed the best-, worst-, and average-possible outcomes with this type of chemotherapy. We also discussed the cost, schedule of treatments and side effects.

4) CHOP chemotherapy + half-body radiation therapy. This experimental therapy has shown increased prognosis of 2-3 years, average.

Diagnosis:

LSA, high grade, probable stage IVa: PLNs, spleen, liver, lungs

bone marrow result pending

Medications:

PREDNISOLONE, 20MG #66

(01-08-09 MAN Tim Rocha, DVM DACVIM (Oncology))

Rx: START TOMORROW. Give 4 tabs by mouth once daily for 6 days, then 3 tabs for 7 days, then 2 tabs for 7 days, then 1 tab for 7 days.

Refills: 0

Begin this medication __TOMORROW, FRIDAY, 1/9/9__.

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 (7:21 pm MAN Tim Rocha, DVM DACVIM (Oncology)/nyc)

January 08, 2009

Dr. Teresa Paoloni

Veterinary Care Unlimited

8409 Rockaway Blvd.

Ozone Park, NY 11416

Fax: (718) 296-1266

Dear Dr. Paoloni:

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

Reason for Visit 01-08-09: lymphoma

Diagnosis:

LSA, high grade, probable stage IVa: PLNs, spleen, liver, lungs

bone marrow result pending

Diagnostics:

Urinalysis Antech - pending

AUS - see below

2 view thoracic radiographs - enlarged parasternal lymph nodes, diffuse interstitial pattern suggestive of lymphoma infiltration into the lungs

2 view abdominal radiographs - significant splenomegaly and hepatomegaly, enlarged sublumbar LN

bone marrow aspirate Antech - pending

Treatment:

butorphanol 1mg/lb = 10mg IV

propofol 6mg/kg = 270mg IV

Elspar 400 IU/kg = 18,000IU SQ

prednisone 2mg/kg = 80mg SQ

Tanzi has received his first dose of chemotherapy today. He will be receiving a multi-drug chemotherapy regimen called the “CHOP protocol”, which requires weekly chemotherapy injections for the first 8 weeks, and then biweekly injections for the next 8 weeks, for a total 6 month treatment time. If Tanzi goes into complete clinical remission and stays in remission for the next 4 weeks, we can discuss full-body radiation therapy as an adjunctive treatment to chemotherapy at that time.

We discussed the following treatment options:

1) No treatment. Average prognosis 1-2 months.

2) Prednisolone (steroids). Average prognosis 2 months.

3) CHOP chemotherapy. Average prognosis 12 months. We discussed the best-, worst-, and average-possible outcomes with this type of chemotherapy. We also discussed the cost, schedule of treatments and side effects.

4) CHOP chemotherapy + half-body radiation therapy. This experimental therapy has shown increased prognosis of 2-3 years, average.

Medications: PREDNISOLONE, 20MG #66

(01-08-09 MAN Tim Rocha, DVM DACVIM (Oncology))

Rx: START TOMORROW. Give 4 tabs by mouth once daily for 6 days, then 3 tabs for 7 days, then 2 tabs for 7 days, then 1 tab for 7 days.

Refills: 0

Begin this medication __TOMORROW, FRIDAY, 1/9/9__.

Discharge Instructions: You should also be given chemotherapy information sheets. If you have any questions after reading them, please ask any member of the Oncology service.

Please make an appointment for Tanzi’s next dose of chemotherapy for Tuesday, January 13 at our Queens practice location. Dr. Karen Oberthaler will be taking care of Tanzi next week, and I will be out in Queens 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

January 09, 2009

LABORATORY (6:24 am MAN Non-DVM/nyc)

ANTECH DIAGNOSTICS

1111 Marcus Avenue Lake Success NY 11042 Phone: 800-872-1001

NYC Veterinary Specialists Client # 180244

410 W 55th St Chart # 18415

New York, NY 10019

Tel: 212-767-0099

Fax: 212-767-0098

Accession No. Doctor Owner Pet Name Received

NYAA45323662 ROCHA MONTEIRO TANZI 01/09/2009

Species Breed Sex Pet Age Reported

Canine Rhodesian Ridgeback M 7Y 01/09/2009 02:11 AM

Test Requested Results Reference Range Units

URINALYSIS

pH 7.5 (HIGH) 5.5-7.0

Specific Gravity 1.050 1.015-1.050

Appearance Cloudy *Clear

Color Amber

Protein Neg Neg

Glucose Neg Neg

Ketone Neg Neg

Bilirubin 1+ Neg To 1+

Blood Neg Neg

WBC 0-3 0-3 HPF

RBC 0-3 0-3 HPF

Bacteria None None HPF

Epithelia Rare None-Few HPF

Renal Epithelia Cells None None-Rare HPF

Transitional Epithelia Cells None None-Rare HPF

Triple Phosphate Crystals None HPF

Amorphous Phosphates None HPF

Calcium Phosphate Crystals None HPF

Calcium Carbonate Crystals None HPF

Ammonium Biurate Crystals None HPF

Amorphous Urate None HPF

Calcium Oxalate Crystals None HPF

Uric Acid Crystals None HPF

Mucous None None-2+ STRANDS/HPF

Hyaline Casts None Seen 0-3 LPF

Granular Casts None Seen LPF

RBC Casts None Seen LPF

Waxy Casts None Seen

WBC Casts None Seen LPF

Budding Yeast None None HPF

Oval Fat Body None None HPF

Entered by Doris

January 10, 2009

LABORATORY (2:16 am MAN Non-DVM/nyc)

ANTECH DIAGNOSTICS

1111 Marcus Avenue Lake Success NY 11042 Phone: 800-872-1001

NYC Veterinary Specialists Client # 180244

410 W 55th St Chart # 18415

New York, NY 10019

Tel: 212-767-0099

Fax: 212-767-0098

Accession No. Doctor Owner Pet Name Received

NYCA02781202 ROCHA MONTEIRO TANZI 01/09/2009

Species Breed Sex Pet Age Reported

Canine Rhodesian Ridgeback M 7Y 01/09/2009 05:43 PM

Test Requested Results Reference Range Units

BONE MARROW CYTOLOGY

Bone Marrow

SOURCE: Five slides prepared from aspiration of the bone marrow are

examined.

DESCRIPTION:

The preparations are characterized by several small marrow spicules on

a background of peripheral blood. Cellularity of the preparations

appears to be normal. Megakaryocytes are present in normal numbers, a

majority of which appear to be mature. The myeloid series is complete

with orderly maturation. The erythroid series is complete with

orderly maturation, and a small amount of polychromasia is seen.

Scattered lymphocytes and macrophages are identified. No infectious

agents are observed.

MICROSCOPIC FINDINGS: NO CYTOLOGICAL EVIDENCE OF DISEASE.

COMMENTS:

The marrow appears to be of normal cellularity, and the erythroid and

myeloid series are complete with orderly maturation. No evidence of

dysplasia or neoplasia is identified, and the preparations appear to

be cytologically normal. A current CBC must be submitted when

submitting bone marrow aspirates or biopsy to allow for the most

accurate interpretation of the sample submitted.

REVIEWED BY:

Leo J. McSherry, DVM, Diplomate ACVP

800-872-1001, ext. 3998

pad

REPORT NOTES:

R ILIAC CREST

-KennyG-

January 13, 2009

LABORATORY (9:31 am MAN Alexis Smith, DVM/que)

PRESENTING COMPLAINT (9:54 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

scheduled chemotherapy

HISTORY (9:55 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

doing great!

TPR (9:55 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

Temperature = 100.3

Pulse= 150

Respiratory Rate= 42

PHYSICAL EXAMINATION (9:57 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

BAR.

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 = 5/9, well muscled.

DIAGNOSIS (9:57 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

LSA, high grade, stage IVa: PLNs, spleen, liver

DIAGNOSTICS (9:57 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

in house CBC

TREATMENT (9:58 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

vincristine 0.82mg IV

MEDICATION (9:58 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

Continue tapering his prednisolone as directed.

RECHECK (9:58 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

in 1 week for continued chemotherapy

DISCHARGE INSTRUCTIONS (9:59 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

Everything went very well today. Tanzi received vincristine chemotherapy. Please schedule Tanzi’s next chemotherapy appointment for 1 week from now.

TPR (10:03 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

Weight: 40.300 kg, 88.66 lb, 1.18 m2

WRITTEN COMMUNICATION (10:07 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

DISCHARGE ORDERS for “Tanzi”

January 13, 2009

SEEN BY: Karen Oberthaler, VMD DACVIM (Oncology)

REFERRING VETERINARIAN: Dr. Teresa Paoloni

REFERRING CLINIC: Veterinary Care Unlimited

OWNER: Charles Monteiro

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

Diagnosis: LSA, high grade, stage IVa: PLNs, spleen, liver

Medications: Continue tapering his prednisolone as directed.

Schedule Re-exam: in 1 week for continued chemotherapy

Discharge Instructions:

Everything went very well today. Tanzi received vincristine chemotherapy. Please schedule Tanzi’s next chemotherapy appointment for 1 week from now.

Please don’t hesitate to call if you have any questions or concerns regarding Tanzi’s progress at home.

________________________________________

Karen Oberthaler VMD Timothy A Rocha DVM

ACVIM Oncology ACVIM Oncology

WRITTEN COMMUNICATION (10:08 am QUE Karen Oberthaler, VMD DACVIM (Onc)/que)

January 13, 2009

Dr. Teresa Paoloni

Veterinary Care Unlimited

8409 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.

Diagnosis: LSA, high grade, stage IVa: PLNs, spleen, liver

Physical Exam:

BAR.

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 = 5/9, well muscled.

Diagnostics: in house CBC

Treatment: vincristine 0.82mg IV

Comments: I am enclosing a copy of the discharge instructions given to the client. 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,

_____________________________________________

Karen Oberthaler, VMD

ACVIM Oncology

January 16, 2009

TREATMENT (11:37 pm MAN Karen Oberthaler, VMD DACVIM (Onc)/db)

(01-16-09 11:37 PM MAN Karen Oberthaler, VMD DACVIM (Onc))

IV Catheter:

IV Fluids:

Gastroprotectants:

Antiemetics:

Antibiotics:

Pain Medication:

Blood Products:

Sedation / anesthesia:

Special (insulin, lasix, steroids, oxygen, etc …):

Procedures:

Nursing Care:

EMERGENCY DRUG CALCULATIONS (11:37 pm MAN Karen Oberthaler, VMD DACVIM (Onc)/db)

Weight: 40.300 kg, 88.66 lb, 1.18 m2

Epinephrine (1:1000) 0.40ml

Atropine (0.54mg/ml) 4.03ml

Lidocaine (20mg/ml) 4.03ml

Bicarb (1mEq/ml) 40.30ml

Calcium (100mg/ml) 20.15ml

Magnesium (4mEq/ml) 2.01ml

Vasopressin (20 units/ml) 1.61ml

Amiodarone (50mg/ml) 4.03ml

Naloxone (0.4mg/ml) 4.03ml

Flumazenil (0.1mg/ml) 8.06ml

External defibrillation 81 to 403 Joules

Internal defibrillation 8 to 40 Joules

Source: J Vet Emerg Crit Care 2003; 13(1): 13-23

CASE SUMMARY (11:37 pm MAN Karen Oberthaler, VMD DACVIM (Onc)/db)

PROGRESS REPORT (01-16-09 11:37 PM MAN Karen Oberthaler, VMD DACVIM (Onc)):

PRESENTING COMPLAINT (1:45 pm QUE Amy Zalcman, DVM/que)

01-18-09 01:45 PM: Possible haematochezia

HISTORY (2:14 pm QUE Amy Zalcman, DVM/que)

See prior history.

Tanzi received Vincristine on January 13. He has been having loose stool since Friday. The owners swtiched him to boiled chicken and rice and removed broccoli from his diet.

He has been active and eating well.

TPR (2:14 pm QUE Amy Zalcman, DVM/que)

Temperature = 100.9

Pulse= 120

Respiratory Rate= 30

Weight: 40.300 kg, 88.66 lb, 1.18 m2

PHYSICAL EXAMINATION (3:01 pm QUE Amy Zalcman, DVM/que)

(01-18-09 02:14 PM QUE Amy Zalcman, DVM)

Appearance: Quiet, alert, responsive. BCS 4/9

Integument: No overt ectoparasites. Appropriate haircoat

Eyes: Lenticular sclerosis OU.

Ears: Unremarkable. Deep ear canal and tympanum-not fully visualized AU.

Nose: Unremarkable.

Oral Cavity: Pink mucous membranes, crt < 2 secs, tacky, deciduous dentition.

Lymph Nodes: Unremarkable.

Heart / Lungs: Heart sounds are appropriate, no obvious murmurs or arrhythmias. Femoral pedal pulses adequate. No pulse deficits. Auscultation of all lung fields unremarkable.

Musculoskeletal: Ambulatory x 4. Limited exam does not reveal swellings or lameness.

Abdomen: Soft, non-painful. No overt masses or foreign bodies palpated.

Urogenital: Small bladder, intact male; prominent prostate smooth. Retroperitoneal palpation unremarkable.

Neurologic: Appropriate mentation. Complete exam is not performed.

Rectal: No mucus, scant stool, scant hematochezia. Yellow liquid

PROBLEM (3:24 pm QUE Amy Zalcman, DVM/que)

Diarrhea

Vocalisation

Ongoing treatment for LSA

DIFFERENTIAL DIAGNOSIS (3:24 pm QUE Amy Zalcman, DVM/que)

Diarrhea

Vocalisation

Ongoing treatment for LSAConsider chemotherapeutic side effect versus dietary change versus other

RECOMMENDATIONS (4:13 pm QUE Amy Zalcman, DVM/que)

(01-18-09 03:24 PM QUE Amy Zalcman, DVM)

Tanzi was assessed promtply upon presentation to the hospital. The owner was informed of physical exam findings following historical review. We discussed differentials and diagnostic options (CBC). The importance of identifying septicemia early in chemotherapy patients. The owners elect outpatient Flagyl.

DISCHARGE INSTRUCTIONS (4:27 pm QUE Amy Zalcman, DVM/que)

Monitor:

Watch for depression, weakness, lethargy or other GI signs such as vomiting and diarrhea.

Medications:

Flagyl (Metronidazole): This medication has neurologic side effects that may result in depression, wobbly gait (ataxia) or seizure. If you observe these signs stop the medication and consult a veterinarian immediately.

Follow up:

Please call Dr. Rocha tomorrow at 212-767-0099 with a phone update.

MEDICATION (4:28 pm QUE Amy Zalcman, DVM/que)

METRONIDAZOLE, 500mg #20

(01-18-09 QUE Amy Zalcman, DVM)

Rx: Give 1 tablet(s) every 12 hours until gone.

KEEP OUT OF REACH OF CHILDREN

Refills: 0

Begin this medication ____________.

WRITTEN COMMUNICATION (4:30 pm QUE Amy Zalcman, DVM/que)

- NYC Veterinary Specialists - Queens -

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

Date: 01-18-09

Patient: “Tanzi” (#18415), 7 year old male Rhodesian Ridgeback

Owner: Charles Monteiro (#16826) P:

Referring Doctor: Teresa Paoloni, Veterinary Care Unlimited P: (718) 296-7700 F: (718) 296-1266

Seen By: QUE Amy Zalcman, DVM

________________________________________________________________________________

EMERGENCY SERVICE

*** Discharge Report ***

Reason for visit: 01-18-09 01:45 PM: Possible haematochezia

History: See prior history.

Tanzi received Vincristine on January 13. He has been having loose stool since Friday. The owners switched him to boiled chicken and rice and removed broccoli from his diet.

He has been active and eating well.

Physical Examination:

Temperature = 100.9

Pulse= 120

Respiratory Rate= 30

Weight: 40.300 kg, 88.66 lb, 1.18 m2

(01-18-09 02:14 PM QUE Amy Zalcman, DVM)

Appearance: Quiet, alert, responsive. BCS 4/9

Integument: No overt ectoparasites. Appropriate haircoat

Eyes: Lenticular sclerosis OU.

Ears: Unremarkable. Deep ear canal and tympanum-not fully visualized AU.

Nose: Unremarkable.

Oral Cavity: Pink mucous membranes, crt < 2 secs, tacky, deciduous dentition.

Lymph Nodes: Unremarkable.

Heart / Lungs: Heart sounds are appropriate, no obvious murmurs or arrhythmias. Femoral pedal pulses adequate. No pulse deficits. Auscultation of all lung fields unremarkable.

Musculoskeletal: Ambulatory x 4. Limited exam does not reveal swellings or lameness.

Abdomen: Soft, non-painful. No overt masses or foreign bodies palpated.

Urogenital: Small bladder, intact male; prominent prostate smooth. Retroperitoneal palpation unremarkable.

Neurologic: Appropriate mentation. Complete exam is not performed.

Rectal: No mucus, scant stool, scant hematochezia. Yellow liquid

Problem list:

Diarrhea

Vocalisation

Ongoing treatment for LSA

Differential Diagnosis:

Diarrhea

Vocalisation

Ongoing treatment for LSA

Consider chemotherapeutic side effect versus dietary change versus other

Recommendations:

(01-18-09 03:24 PM QUE Amy Zalcman, DVM)

Tanzi was assessed promptly upon presentation to the hospital. The owner was informed of physical exam findings following historical review. We discussed differentials and diagnostic options (CBC). The importance of identifying septicemia early in chemotherapy patients. The owners elect outpatient Flagyl.

Medication:

METRONIDAZOLE, 500mg #20

(01-18-09 QUE Amy Zalcman, DVM)

Rx: Give 1 tablet(s) every 12 hours until gone.

KEEP OUT OF REACH OF CHILDREN

Refills: 0

Discharge Instructions:

Monitor:

Watch for depression, weakness, lethargy or other GI signs such as vomiting and diarrhea.

Medications:

Flagyl (Metronidazole): This medication has neurologic side effects that may result in depression, wobbly gait (ataxia) or seizure. If you observe these signs stop the medication and consult a veterinarian immediately.

Follow up:

Please call Dr. Rocha tomorrow at 212-767-0099 with a phone update.

Yours truly,

______________________________________

QUE Amy Zalcman, DVM

January 20, 2009

LABORATORY (10:04 am MAN Alexis Smith, DVM/nyc)

PRESENTING COMPLAINT (10:20 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

01-20-09: Chemo

TPR (10:22 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

Temperature =

Pulse= 100

Respiratory Rate= 30

Weight: 42.800 kg, 94.16 lb, 1.22 m2

HISTORY (10:22 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

Diarrhea has resolved as of last night/this AM.

Eating well and very active.

Has had several drops of bloody discharge from penis, but not while urinating. No hematuria.

MEDS: metronidazole

PHYSICAL EXAMINATION (10:24 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. No blood or palpable abnormalities of penis or prepuce.

MSI: BCS = 5/9, well muscled.

RECTAL:

DIAGNOSIS (10:25 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

LSA, high grade, stage IVa: PLNs, spleen, liver

Suspect prostatitis

Diarrhea–resolving?/resolved?

DIAGNOSTICS (10:26 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

CBC in-house

Already on metronidazole, so not submitting urine culture/sensitivity.

Echocardiogram to be performed next Tuesday, in prep. for doxorubicin due in 2 weeks.

TREATMENT (10:30 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

CYCLOPHOSPHAMIDE–305 MG IV

LASIX–94 MG IV

MEDICATION (10:32 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

CLAVAMOX PILL, 375mg #28

(01-20-09 QUE Tim Rocha, DVM DACVIM (Oncology))

Rx: Give 2 tablets by mouth every 12 hours, for 7 days. Give with food.

Refills: 0

DISCHARGE INSTRUCTIONS (10:34 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

Everything went fine today.

Please start the antibiotic today.

Next week, Tanzi is scheduled for both chemotherapy and the echocardiogram. Please try to arrive by 9 AM.

WRITTEN COMMUNICATION (10:35 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

DISCHARGE ORDERS for “Tanzi”

January 20, 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.

Please start the antibiotic today.

Next week, Tanzi is scheduled for both chemotherapy and the echocardiogram. Please try to arrive by 9 AM.

Diagnostics:

CBC in-house

Already on metronidazole, so not submitting urine culture/sensitivity.

Echocardiogram to be performed next Tuesday, in prep. for doxorubicin due in 2 weeks.

Treatment:

CYCLOPHOSPHAMIDE–305 MG IV

LASIX–94 MG IV

Diagnosis:

LSA, high grade, stage IVa: PLNs, spleen, liver

Suspect prostatitis

Diarrhea–resolving?/resolved?

Medications:

CLAVAMOX PILL, 375mg #28

(01-20-09 QUE Tim Rocha, DVM DACVIM (Oncology))

Rx: Give 2 tablets by mouth every 12 hours, for 7 days. Give with food.

Refills: 0

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 (10:36 am QUE Tim Rocha, DVM DACVIM (Oncology)/que)

January 20, 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 01-20-09: Chemo

Diagnosis:

LSA, high grade, stage IVa: PLNs, spleen, liver

Suspect prostatitis

Diarrhea–resolving?/resolved?

Diagnostics:

CBC in-house

Already on metronidazole, so not submitting urine culture/sensitivity.

Echocardiogram to be performed next Tuesday, in prep. for doxorubicin due in 2 weeks.

Treatment:

CYCLOPHOSPHAMIDE–305 MG IV

LASIX–94 MG IV

Medications: CLAVAMOX PILL, 375mg #28

(01-20-09 QUE Tim Rocha, DVM DACVIM (Oncology))

Rx: Give 2 tablets by mouth every 12 hours, for 7 days. Give with food.

Refills: 0

Discharge Instructions: Everything went fine today.

Please start the antibiotic today.

Next week, Tanzi is scheduled for both chemotherapy and the echocardiogram. Please try to arrive by 9 AM.

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

ECHOCARDIOGRAM

: DVM, DACVIM (Cardiology)/nyc)

Date of Exam: Jan 28, 2009

2D/M-mode: Normal LAD, normal LV dimensions and function, normal valves, papillary muscles appear to have a hypoechoic region

Doppler: no flow disturbances seen

Assessment: These findings are consistent with an essentially normal echo. The significance of the hypoechoic areas of the papillary muscles is not clear at this time, but no discrete pathology is evident.

Recommendations/Treatment: OK for adria