Airport Animal Hospital 4259 Haines Rd Duluth, MN (218) Gracie

Transcription

1 Blais, Scott Acct Number: Address...: Phone...: Cell Phone...: Patient ID: Swan Lake Rd Saginaw, MN H: (218) W:( ) - ext: ( ) - Gracie Medical Alert: Sex...: FS DOB...: 07/01/2007 Species..: Feline Chronic Meds...: Chronic Cond...: Flea Prev Meds...: [FLEA] Frontline+ F Heartworm Meds.: Weight.: 6.6lbs. Age...: 9 years and 6 months old Breed...: Dom. Shorthair Date Due: Date Due: Problem History: Status: Date Opened: Date Closed: Number: Scott called and asked when we get a moment, he would like Gracie and Shadow's records e- mailed to him to have on hand. He almost had to take Gracie to e-clinic and felt having records of current labs would be benifical if either of them had to go in. His is crmfghtr@yahoo.com Thanks! DL Owner called and was wondering about possible prescription diets for Gracie? She is eating right now but will still lay down after eating. He was wondering with the pancreatitis if there were rx diets that the DVM recommended? BH 01/23/ /23/ Scott called with updates and questions for you on Gracie and Shadow and wanted to discuss Cerenia options. He said it was WAY too lengthy to leave as a message, despite me trying to pry info/exact questions out of him. He said they are ok he just has a lot to talk about. DL Spoke with owner. 01/20/ /20/2017 Shadow headed right to the food when she got home. He has given Gracie tap water and she is loving it. Thank you! /bla/mw Are both Shadow and Gracie doing well - normal activity and eating well? no further vomiting? mw 1/23/17 LMOM to call with an update /bla 01/20/2017 Service Lean Treat Feline 3.5oz QTY: /20/2017 Service Cerenia injection QTY: /20/2017 Service Cerenia 16 mg tab QTY: 1 Provider: Office Staff Page 1 of 8

2 01/20/2017 RX#: Cerenia 16 mg tab QTY: 1 Expires On: Give 1/4 tablet orally once daily until otherwise directed - next dose is due tomorrow 1/21/17 01/20/2017 Service Weight QTY: 1 fpl Abnormal SNAP 01/20/ :19 PM 01/20/2017 Service fpl SNAP Test QTY: /20/2017 SOAP Not eating S: Gracie has only eaten about a tbsp of baby food in the last couple days, she seems interested and will lick gravy off of wet food. They have been feeding both cats purina proplan canned and have seen some reviews on BBB about other cats getting sick on this food. No more vomiting, they are unsure of stools but no urine/stool accidents out of box, she is a little bit lethargic. For the last couple months after Gracie would eat she seemed uncomfortable. Gracie does go outside but hasn't in a while and she doesn't roam, just go out for a little bit with client. O: A: P: 01/20/ /20/2017 O called (Scott) Gracie has not eaten for 3 days, Shadow has not eaten for 5 days... They will sniff food and walk away. O said he has tried a variety of food options. He thinks they are drinking water. Gracie slight decrease in activity, Shadow's activity appears normal. O asked for recommendations. JM What type of foods has owner tried - canned, dry, baby food, lean chicken, favorite treat? He can try warming food to entice eating. If they have eaten nothing at all for 3-5 days, and he is unable to get them started with one of the above then they should be seen. mw 1/20/17 11:13 O has tried everything except baby food, and warming the food, they will lick the gravy out of the food but not eat it. Gracie did eat a teaspoon of food but she isn't feeling very well,he has tried 8 different cans of food. After Gracie eats she has to lay down for a bit on her side. If warming or babyfood doesn't work he will call to get them in. Gracie is a challange /bla/mw 01/18/2017 Service Convenia 80mg/mL injection QTY: 3.00 Page 2 of 8

3 Catalyst Dx,UA Analyzer,ProCyte Dx 01/18/ :09 PM GLU 226HIGH mg/dl BUN mg/dl CREA mg/dl BUN/CREA 23 PHOS 2.9LOW mg/dl CA mg/dl TP g/dl ALB g/dl GLOB g/dl ALB/GLOB 0.9 ALT U/L ALKP U/L GGT U/L TBIL mg/dl CHOL mg/dl Na mmol/l K 3.3LOW mmol/l Na/K 46 Cl mmol/l Osm Calc 306 mmol/kg ph 7 PRO 100 GLU neg KET 15 UBG 4 BIL neg BLD 10 RBC M/µL HCT % HGB g/dl MCV fl MCH pg MCHC g/dl RDW % %RETIC 0.1 % RETIC K/µL WBC Page 3 of 8

4 %NEU 89.5 %LYM 8.3 %MONO 1.4 %EOS 0.1 %BASO 0.7 NEU LYM 1.28 MONO 0.22 EOS 0.02 BASO 0.11 PLT K/µL 01/18/2017 Service Urinalysis In-hospital QTY: 1 01/18/2017 Service Blood Chemistry 15 Catalyst QTY: /18/2017 Service CBC ProCyte QTY: 1 01/18/2017 Service Blood Chemistry Lytes 4 QTY: /18/2017 Service Senior Wellness Exam QTY: 1 01/18/2017 Service Weight QTY: 1 01/18/2017 SOAP Vomited yesterday S: Last night Gracie ate both her food and Shadow's food and 1 hour later started vomiting (4-5x within 1.5 hours) then this morning was acting very lethargic. Gracie has been happy/healthy up until this incidence. Not up to date on vaccines. Will let Scott decide about that when he comes at 2pm. KM O: wt: A: P: 03/17/ /17/2016 How is Gracie doing - eyelid swelling resolved/improved? mw Called O for update, left message jm Page 4 of 8

5 03/18/ :15 pm O called back and said that the eye looks much better. Swelling is going down. Still not 100% better, but certainly headed in that direction. Thanked us for calling to check in. DC/mw 03/15/20 16 Dx Confirme d Tick Infestation 03/15/20 16 Dx Confirme d Eye Trauma 03/15/2016 Service Onsior 6 mg tablet QTY: /15/2016 RX#: Onsior 6 mg tablet QTY: 3.00 Expires On: Give 1 tablet orally once daily for 3 days - next dose is due tomorrow 3/16/16 03/15/2016 Service Convenia 80mg/mL injection QTY: /15/2016 Service Exam & Consultation Level 2 QTY: 1 03/15/2016 Service Weight QTY: 1 03/15/2016 SOAP Check bump - above left eye S: Noticed lump above left eye about 4-5 days ago, was just a small red scabby area at first, noticed it was very large yesterday. There is some purulent discharge noted, does not seem to bother gracie - no squinting/rubbing, eating/drinking normally, no vomiting/diarrhea, using litter box normally, activity level normal. O: Gracie's Physical Examination Body Weight: 6.9 lbs. Body Condition: Gracie's body condition and weight are normal. There is the desired narrowing thru the abdomen and into the hips and waist and the ribs and spine are readily palpable. Ears: Both the ear canals and ear pinnas are normal. Gracie's tympanic membranes (ear drum) are normal and she seems to hear fine. Eyes: The following abnormalities were seen in the eye(s): The left upper eyelid is swollen and erythematous. There is a deer tick protruding from the center of the lesion. Gracie's eye(s) appear otherwise normal as do the eyelids and associated structures. Gracie appears to have normal vision. GI/Abdominal Palpation: Gracie's abdominal palpation is normal; there are no appreciable hernias, masses, fluid buildup, or pain. Heart/Cardiovascular: Gracie's heart is normal. The heart sounds are clear with no appreciable murmurs or arrhythmias heard and pulses palpate normally. Page 5 of 8

6 Lungs/Trachea: Gracie's lungs sound normal with no fluid, crackles or wheezes. The trachea sounds and palpates normally as well. Lymph nodes/thyroid gland: Gracie's external lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormalities associated with the thyroid gland. Mouth/Teeth/Gums: Gracie's oral examination is normal. There is no evidence of tartar accumulation or changes to the enamel of the teeth. There is no visible evidence of gingivitis, periodontal disease, or mobile teeth. Musculoskeletal: Gracie's muscles are in good condition and skeleton and joints are normal. There is no visible lameness or palpable pain and/or reduced range of motion noted. Nervous System: Gracie's nervous system is normal. There are no observable defects in the peripheral nerve, spinal cord or brain function. Nose/Throat: Gracie's nose and throat are normal. Air flows freely through nostrils and there is no discharge noted. There are no difficulties with vocalizing or swallowing. Skin/Haircoat: Gracie's haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin. Urinary/Reproductive: Gracie's urogenital and reproductive organs examined are normal. Other: Removed tick with hemostat, cleaned area well and compressed Admin 25mg Convenia SQ A: Eyelid swelling secondary to tick attachment P: Dispensed Onsior - 1st dose given in exam room Rec updating vaccinations - Gracie is past due Rec apply warm/moist compress to eyelid for minutes, 2-3 times per day until swelling has resolved Recheck if worsens or does not resolve 08/05/2015 Note Called O w/fecal results Provider: Dr. Christine Requisition # Accession # Accession Comment fv FS FELINE E FECAL PANEL COMP 08/05/ :40 AM Page 6 of 8

7 Panel Name FECAL PANEL COMP OVA & PARASITESNO OVA OR PARASITES GIARDIA ELISA WHIPWORM ELISA HOOKWORM ELISA ROUNDWORM ELISA NEGATIVE NEGATIVE NEGATIVE NEGATIVE In cases of acute or chronic diarrhea in addition to a fecalfloatation and antigen testing for ova and parasites consider testing for viral, bacterial and protozoal infectious agents using RealPCR(canine diarrhea panel: test code 2625; feline diarrhea panel: testcode 2627). 08/04/2015 Service Fecal Panel Comprehensive (24639) QTY: 1 08/04/2015 Service Nail Trim QTY: 1 08/04/2015 Service Exam/Consultation Level 1 Wellness QTY: 1 Provider: Dr. Christine Provider: Dr. Christine Provider: Dr. Christine 08/04/2015 SOAP Lethargic/twitching Provider: Dr. Christine S: Gracie was lethargic for a couple days, seems more normal yesterday and today. Also noticed for the last couple weeks that she will be running than stop quick and start biting at herself and has a twitch near tail. Does got outdoors but only on leash with owner. Eating drinking normally, no vomiting/diarrhea, using litter box normally, no coughing/sneezing, not on any medication. O: A: P: 04/27/2012 Service Weight QTY: 1 04/27/2012 Cert Rabies Certificate 04/27/2012 Service PureVax RCCP & Rabies 1yr QTY: 1 04/27/2012 Service Wellness Exam/Consultation QTY: 1 07/08/2009 Converted [RXFOOD] IVET FELINE ADULT 3.5# 07/08/2009 Converted [FLEA] Frontline+ Feline 6ct 01/16/2009 Converted [RXF] Disp: Clavamox Drops 15cc Provider: Dr. Leslie Clapper-Rentz Provider: Dr. Leslie Clapper-Rentz Provider: Dr. Leslie Clapper-Rentz Provider: Office Provider: Office Page 7 of 8

8 01/16/2009 Converted [EXP] Exam/Consult-Level 2 01/16/2009 Converted [HOSP12] Hosp Care-Half Day 01/16/2009 Converted [SED] Sedation 01/16/2009 Converted [RXF] Disp: Buprenorphine 0.3 mg/m 01/16/2009 Converted [OEX] Oropharyngeal Foreign Body 01/16/2009 Converted [RAD1] Radiograph First 01/16/2009 Converted [RAD2] Radiograph Second 10/10/2008 Converted [RXL] Disp: Buprenorphine 0.3 mg/m 10/10/2008 Converted [NTC] Courtesy Nail Trim 10/10/2008 Converted [OHESPC] Spay Certificate for OHE 10/10/2008 Converted [FOHE] Feline Ovariohysterectomy 10/10/2008 Converted [IVFLU] IV Fluids-Elective Surgery 10/10/2008 Converted [OTC] E Collar 12cm (3M) 10/10/2008 Converted [PAINM] Narcotic analgesia (multi) 09/15/2008 Converted [EXPV] Wellness Exam/Consultation 09/15/2008 Converted [RCCP] Felocell 4 RCCP annual 08/18/2008 Converted [EXPV] Wellness Exam/Consultation 08/18/2008 Converted [==FEL] SQ MERIAL PUREVAX KV 08/18/2008 Converted [RCPFRT] PureVax RCCP(temp)+Rabies For any questions on Gracie's health, please call. Page 8 of 8