Texas Equine Hospital South State Highway 6 Bryan TX (979) /16/2017

Transcription

1 CLIENT INFORMATION: Name: Michelle Gilbert Address: 1897 Fickey Rd Bryan, TX Phone: H: (832) W: ( ) - ext: PATIENT INFORMATION Name: Sex: Birthday : ID Color Cinderella F 04/28/2011 U Palomino Spouse: Species: Breed: Age: Rabies Tag: Weight: Equine Quarterhorse 6 years and 1 month old 0 lbs. PATIENT CHART MEDICAL HISTORY: 02/14/2014 Stoudt Hx: Horse presented for lameness exam; was working and came up lame Exam: Baseline: sound baseline and after flexion; horse likely took a bad step Diagnosis: none Treatment: none 04/01/2014 Stoudt Hx: Fever for 3 days, no fever last 2 days. Imaging: Endoscope- Mild amount of purulent discharge in trachea. Treatment: Will begin a course of uniprim. 04/02/2014 Stoudt HX: owner called and stated horse was dragging leg Exam: LR leg - dragging leg - stifle was "locked" (upward patellar fixation); after working approximately 20 minutes, stifle was unlocked - owner will bring to blister tomorrow Diagnosis: left upward patellar fixation Treatment: none at this time 04/03/2014 Stoudt Page 1 of 8

2 Hx: Exam: Mare locked L stifle yesterday; 3cc iodine/almond oil was injected over medial patellar ligament Diagnosis: left upward patellar fixation Treatment: see above 07/01/2014 Stoudt Hx: Found lame RF 6/29/14 Exam: Baseline - 3.5/5 RF -> PDN RF -> no change -> RF coffin block -> no change -> RF abaxial -> no change Diagnosis: open Treatment: will hospitalize and begin lameness exam tomorrow 07/01/2014 Honnas Cinderella is BAR this morning. She has a good appetite and multiple piles of normal manure in her pen. She is moving well at a walk in the pen. Plan: Lameness Work up 07/02/2014 Stoudt Hx: Exam: Lameness has improved about 50% over the last two days -> LL shows moderate RF lameness -> PDN RF -> no change -> abaxial RF -> no change Diagnosis: open Treatment: spoke with owner and because of the improvement in lameness owner elected to give Bute; will give 1g Bute BID for 4-5 days and regroup Page 2 of 8

3 07/02/2014 Honnas Cinderella is BAR with a great appetite and multiple piles of normal manure in her pen. She is moving well at a walk in the pen. Plan: Lameness Work up 07/09/2014 Honnas Cinderella is BAR this morning. She has a healthy appetite and multiple piles of normal manure in her pen. She is moving well at a walk in the pen. Plan: Lameness Work up 07/11/2014 Stoudt HX: Exam: owner requested bilateral medial patellar fenestration Diagnosis: left upward patellar fixation Treatment: bilateral medial patellar ligaments were fenestrated 07/21/2014 Stoudt HX: both stifles were fenestrated 2 weeks ago. EXAM: We elected to inject stifles post fenestration TREATMENT: inj MFT joints 50mg gent 20mg legend 5mg kenalog -10 cc Bute give IV 11/17/2014 Stoudt Page 3 of 8

4 Medical Records HX - 07/11/14 - Fenestrate patellar ligaments Exam - Baseline - Sound Treatment - None - Will not blister stifles until needed or if needed again 12/07/2014 Lawson Colic Note Observation: Horse has been lethargic, laying down more than usual in lateral. Owner gave 1000# dose banamine PO about 11:30. Just came back from first big barrel race. 12:45: BAR, HR: 52 (anxious) mm: pink/moist, CRT <2sec T: GI sounds positive in all four quadrants strong. NG Tube: No net reflux. Gave 1/2 gallon mineral oil and 1/2 gal water with electrolytes via NG tube. Rectal: very pliable impaction palpable just left of midline, at fingertips. Otherwise NSF. Normal manure in rectum. Kept for monitoring over the day. 3:30pm: passed 1 pile normal moist manure-> slightly depressed/quiet 5:20pm: Gave ~5L water via NG tube. Plan: give 10cc banamine IV at 9pm 7:00pm: HR: 36. GI sounds positive in all four quadrants. 1 new pile of manure. Stills sedated from NG tube. 9:00pm: Gave 10cc banamine IV. 1 new pile of manure. BAR, HR: 36 GI sounds positive in all four quadrants. 2:00am: laying down, looked at belly. Got up on own. BAR when standing, passed 1 new pile of manure. HR: 40, GI sounds positive in all four quadrants 5:15am: Was down in lateral, laying quietly since about 4:15. Got up on own. HR: 36. GI sounds positive in all four quadrants. 1 new pile of manure 12/08/2014 Honnas Cinderella is BAR this morning. HR 36, GI sounds are positive in all 4 quadrants. There are multiple piles of oily manure in her stall. She has a good appetite for the small amounts offered. Plan: continue to monitor for signs of discomfort, attitude, appetite and manure production 12/08/2014 Lawson Colic Note 7:15am: HR: 36, RR: 16, T: 99.7, MM; pink/moist, CRT <2sec. BAR, no ocular or nasal discharge bilaterally. Thoracic ausculation WNL. DPs WNL x4, no signs of lameness. Three piles of well formed manure, oil present, adequate water Page 4 of 8

5 consumption overnight. GI sounds positive in all four quadrants. PCV: 36%, TP: 6.6 g/dl 8:00am: Rectal exam: Large colon impaction no longer palpable- NSF 9:00am: Great appetite 12pm: Laying quietly in sternal, 1 pile manure Feeding Schedule Handful Senior Pellets at 9am, 11am, 1pm 12/23/2014 Stoudt Hx: owner requests stifles to be injected Exam: none Diagnosis: none Treatment: Inj. MFTJs w/ 50mg Gent, 20mg Legend, 5mg Kenalog 12/24/2014 Lawson Colic Note Hx: Quieter than usual today. Decreased appetite tonight and laying down more than usual Observation/Treatment: 5:30pm presentation - Temp HR 50, anxious/nervous. GI: (+) x4. MM - pink, moist. CRT < 2 sec. Bright, no overt signs of pain. Rectal - many fecal balls in small colon; otherwise NSF. NG tube - no net reflux. Gave 1/2 gallon MO and H2O w/ electrolytes. Gave 10cc Banamine IV; kept for overnight observation. 8:40pm - passed a pile normal manure. 10pm - passed another large pile normal manure. HR 36. Great GI sounds all four quadrants. Standing quiet. 12am - BAR, comfortable, passed another pile. 2am - passed another large pile of manure. 6am - HR 36, GI sounds are good and strong all four quadrants. standing comfortably 12/25/2014 Lawson Colic Note Hx: Observation/Treatment: 7:00am - Temp HR 38. RR 10. MM - bright pink, moist. CRT < 2 sec. BAR. Passed five piles manure overnight. Drank 1/3 bucket H2O. Walking uncomfortably in stall. Thoracic auscultation WNL. Eyes and nostrils clean. GI: (inc) x4. DPs WNL x4. No oil on perineum yet, or seen in manure. Passed additional pile normal manure this am. Gastroscopy - mucosa along margoplicatus appears thin. Otherwise NSF 01/05/2015 Stoudt Page 5 of 8

6 Hx: Locked up L stifle over the weekend Exam: Baseline - sound baseline and after flexion. L stifle locking intermittently -> sore to palpation of stifle Diagnosis: Intermittently locking L stifle Treatment: Need to warm up well prior to running, need to walk in straight line/large circle for mintues daily w/ rider, needs weight on back. Recommend Cavalettis, backing up, "walking up" hill work helps; recommend horse remains turned out 24/7 01/11/2015 Stoudt Daily observations 1/10-11 Cinderella was BAR over the weekend, with an excellent appetite and adequate water consumption. She passed multiple piles of manure daily. It was normally formed except for Saturday night, when she passed multiple piles of loose, cow pie manure. Her temperature remained normal and she was bright. She did not show any signs of lameness and walked well in the stall. She was seen laying down several times, but was bright and comfortable, without any signs of pain or discomfort. Plan: Hospitalized for lameness work-up and observation Medications: 1. 1 scoop omeprazole PO SID mth 01/12/2015 Honnas Cinderella is BAR this morning. She has a good appetite and multiple piles of normal manure in her stall. All 4 soft ride boots are in place. She shows no lameness or discomfort this morning. Plan: Monitor for discomfort - lameness exam Medications: 1) Omeprazole 1 scoop PO SID PM 01/12/2015 Stoudt Hx: Exam: Based on masseuse/psychic interpretations - will try injecting neck Page 6 of 8

7 Imaging: owner requested radiographs of hocks, stifles and back Hocks: WNL Back: WNL Stifles: mild remodelling proximal left medial tibia Diagnosis: none Treatment: Injected neck in 3 areas (pinpoints) w/ 40mg Depo 02/16/2015 Stoudt Exam: Baseline - Sound baseline & after flexions Treatment: None 03/02/2015 Stoudt Hx: 2/16/15 - sound baseline Exam: Baseline - 3/5 RF -> PDN RF -> sound; pulled RF shoe prior to arrival; VERY sensitive to back palpation Imaging: None Diagnosis: Sore RF foot -> suspected due to pulled shoe. Sore back Treatment: Inj. back w/ 2.5ml Depo, 16ml P Block. 2g Bute IV 03/18/2015 Stoudt Hx: Today - front foot lameness Exam: Baseline - 3/5 RF -> PDN RF -> sound Imaging: RADS - WNL Diagnosis: RF palmar heel pain Treatment: Inj. RF navicular bursa w/ 50mg Gent, 20mg Depo. 2g Bute IV 04/02/2015 Symm Exam: Got into cattle feed. BAR Page 7 of 8

8 Treatment: 1 gallon mineral oil per NG tube 06/29/2015 Stoudt Hx: History of RF lameness Presenting complaint: Recheck RF Exam: Sound baseline and after flexions Diagnosis: none Treatment: owner spoke about potentially selling the mare For any questions on Cinderella's health, please call the clinic. Page 8 of 8