Lumpectomy Check In Form – Butler Veterinary Associates and Emergency Center

Dog/Cat Lumpectomy Check In

Pre-surgical

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact #*
Date of Planned Surgery*
MM slash DD slash YYYY
Patient's Name*
First
History
Where does your pet spend most of his/her time?*
- Indoor
- Outdoor
- Indoor/Outdoor about equal
Has your pet ever had a seizure?*
- No
- Yes, if so, please describe
Tell us about you're pet's Seizure*

Date, time, nature of the event
Has your pet ever had a vaccine reaction?*
- No
- Yes, if so, please describe
Tell us about you're pet's vaccine reaction*

Date, time, nature of the event
Has your pet ever had an allergic reaction?*
- No
- Yes, if so, please describe
Tell us about you're pet's allergic reaction*

Date, time, nature of the event
Has your pet ever had surgery before?*
- No
- Yes, if so, please describe
Tell us about you're pet's surgery*

Date, time, nature of the event
Has your pet been Spayed or Neutered?*
- Yes, Neutered
- Yes, Spayed
- No, Male
- No, Female
Is there any chance that your pet has been bred or is pregnant?*
- No
- Yes
When was you're pet's heat?*
Was food withheld after 10 pm the night before?*
- No
- Yes
Are there any Medications that your pet is on routinely?*
- No
- Yes
do not include flea/tick or heartworm preventatives
Please list your pet's medications & dose/time last time given
Surgical Procedure
Which lump (s) are requested to be removed?
Are there any additional procedures?*
- No
- Yes, if so, please describe
Additional Procedures requested
Pre-surgical bloodwork is recommended on all patients going under anesthesia. Would you like bloodwork performed prior to surgery?*
- No
- Yes, is so, please let us know status [next question]
Has bloodwork been done?*
- No, still needs done prior to surgery
- Yes, already done
Would you like a Home Again microchip inserted today?*
- No
- Yes
Disclosures
Potential Complications of Anesthesia

Anesthesia is a vital part of your pet’s care, but it also comes with risks including blindness, deafness, brain damage, aspiration pneumonia and other potential problems (i.e. organ damage and death). Underlying conditions (kidney/liver disease, intestinal blockage, liver disease, trauma and internal bleeding, etc.) can increase the risks, but we closely monitor blood pressure, heart rate and respiratory rate and intervene when necessary to try to prevent any complications.

The following are rare potential complications that can arise with mass removal. Some of these complications are more or less likely depending on the type and location of the mass. Your doctor will discuss with you any particular concerns that are specific to your pet’s mass.

Infection

An incision is made through the skin and fat layers around and underneath the mass to remove it. This incision is closed with internal sutures (+/- external sutures). Excessive activity or licking at the incision can cause the incision to become infected and affect the integrity of the sutures, resulting in opening of the incision. An additional surgery may be necessary to correct an infected incision or dehiscence.

Incomplete Closure

Depending on the location and size of the mass, the incision may not be able to be closed completely depending on the amount of skin available and the size of the mass. The areas that are more risk of incomplete closure are the legs, tail and head (anywhere that the skin is tight prior to surgery). The larger the mass, the more skin that needs to be removed, increasing this risk. If we are unable to close the incision, a bandage will be placed and will need changed frequently (up to 3 times a week) while the skin closes over time.

Nerve Involvement

While many masses are just in the skin or fat layer beneath the skin, some can encapsulate the nerve. This will make resection of the mass impossible without removing part of the nerve. This may result in pain after surgery or inability to feel/move certain areas. The severity of the complications depends on the amount of nerve involvement and location of the mass. If we are suspicious of nerve involvement prior to surgery, the doctor will discuss this with you in more detail.

Vessel/Lymphatic Involvement

The location of the mass can give us a lot of insight prior to going to surgery if there is the possibility of large vessel involvement. Usually there is enough collateral circulation (blood coming from another direction) to sustain the tissues, but there is the possibility that if we have to ligate the vessels that the tissues in the surrounding area may die. If the lymphatic system is affected during the removal of the mass, swelling below the incision or towards the tail may occur. Usually this will resolve eventually but can take months.

Incomplete resection

Some masses have microscopic cellular projections that extend down into the muscle, around vessels or nerves, or extend further than the surgeon can see during surgery. Histopathology (biopsy) is always recommended after removal of a mass to definitively determine the type of mass and if complete resection was achieved. In cases where complete resection is not achieved, the biopsy report will guide recommendations for further treatment such as additional surgery, chemotherapy, or radiation.

If your pet requires hospitalization overnight:

Overnight Stay. Although there is not a doctor present from 10 p.m. to 8 a.m., there are trained staff to treat and monitor your pet overnight onsite. If any drastic changes occur, the emergency doctor will be called to discuss treatment and possibly return to the hospital.

Overnight communication. Our phones are turned off from 10 p.m. to 8 a.m. the next morning, Mon thru Friday and 4pm to 8am Saturday, Sunday, and holidays. No news is good news overnight. If here is an emergency that involves your pet, you will be called by the technician or the doctor depending on the circumstance. You will be provided with an update the following morning after the morning doctor examines your pet (usually between 8 and 10 a.m.).

Intravenous Fluids. Usually your pet is placed on IV fluids when in the hospital to treat dehydration or to provide a way to medicate your pet. In rare occurrences, too much fluid can be administered that can build up in the lungs causing difficulty breathing, but they are monitored closely to prevent complications caused by excess fluids.
Consent Section
Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency drugs, or other heroic interventions, I request the veterinarian(s) at this hospital pursue such medical care. Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $250 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I accept that if the hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, determine that there appears to be virtually no hope for medical success, they will cease further CPR procedures. I understand that despite the best efforts of the doctors and staff at this facility, even the most successful CPR that restores my pet’s life may not allow my pet to regain his/her normal mental and physical health and thus, may leave him/her as an invalid.
Histopathology*
- I approve to have the mass sent to a pathologist for evaluation to determine the type of mass and whether complete resection was achieved. I am aware that additional testing may be needed to determine the grade or subtype of mass removed (additional fees may apply, but would be discussed prior to ordering). Results will typically take 7-10 business days to return unless additional fixation is required.
- I decline having the mass sent off for histopathology, and I am aware that further treatment may not be able to be pursued. Additionally, I am aware that the mass could recur at the current location or spread elsewhere in the body.
Election #1 [Resuscitation ]*
- I Agree
- I Do Not Agree [DNR choice will appear)
Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency drugs, or other heroic interventions, I request the veterinarian(s) at this hospital pursue such medical care. Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $325 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I accept that if the hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, determine that there appears to be virtually no hope for medical success, they will cease further CPR procedures. I understand that despite the best efforts of the doctors and staff at this facility, even the most successful CPR that restores my pet’s life may not allow my pet to regain his/her normal mental and physical health and thus, may leave him/her as an invalid.
Election #2 [DNR]*
- I Agree
- I Do Not Agree
I elect NOT to have the medical team pursue any lifesaving procedures. No person shall attempt to resuscitate my pet should my pet’s heart stop and or breathing stop. DO NOT RESUSCITATE (DNR). Instead, I request that the attending veterinarian assist my pet in dying in a peaceful manner.
Signature of Owner or Agent*
In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours is provided at the discretion of the attending veterinarian, who is not present at the facility from 10 p.m. to 8 am. I am aware that there are other emergency facilities that have a veterinarian present at all times and have the option to transfer to one of these facilities. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.

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Dog/Cat Lumpectomy Check In

History

Surgical Procedure

Disclosures

Consent Section