Patient History Report

Transcription

1 6/1/2016 P NC None of RX Outside Pharmacy (8004) Rx #: Of 0 Refills Filled by: NB1 Heartgard Plus 12pk Blue 1-25lbs. Refills:0. SIG: Give 1 chew every 30 days. Tablet Must be chewed. Do not swallow whole. Faxed into 1-800PETMEDS. 4/29/2016 C C63 ** NWPC La Canada Records ** - FINAL 04/29/ Anesthetic Chart See Attachment 4/27/2016 T DCM Image: Miscellaneous 4/27/2016 T DCM Image: Abdomen 4/27/2016 C N29 ** SOAP Brief ** - FINAL 06/01/ Attempt at voided urohydropulsion bladder stones- not successful Check In Tech: CR Reason for Recheck Visit: Brief SOAP History: Cosmo presents for anesthetized voiding urohydropulsion of numerous small bladder stones. Sedation: Buprenorphine 0.15mg/ml 0.8ml IM Glycopyrolate 0.2mg/ml 0.6ml IM Acepromazine 10mg/ml 0.03ml IM Induction: 20g IVC R cephalic. Propofol IV to effect. Intubated 7.5mm ET tube and maintained under gas isoflurane anesthesia. Began LRS IVF at 120ml/hr. Stable throughout anesthesia. Unasyn 150mg/ml 1.6ml IV slow Rimadyl 50mg/ml 1ml SQ Procedure: Inserted sterile U-cath (8Fr red rubber), filled bladder 30-40ml sterile saline until taught but not too distended. Attempted in several Northwest Pet Clinic, Pllc Page 1 of 43 Date: 7/11/ :32 AM

2 positions (with re-filling of bladder each time) to express stones out of he bladder. (tried staff holding him in standing position, hanging caudal half of body over table edge, elevating cranial half, etc). Unsuccessful in getting stones to void. Post-procedure rad- all stones remain in bladder lumen. None present in urethra. Routine and uneventful recovery. Phoned owner, explained though I tried every position I could put Cosmo in, I was unable to express the stones via voiding hydropulsion. Owner understanding. Will continue to monitor for adverse clinical signs of stones (hematuria, UTI, obstruction) Scheduled discharge. BC Notes: 4/27/2016 C C30 NWPC Treatment Request - FINAL 04/27/2016 Patient Name: Cosmo ( Canine) Neutered Male Client # & Name: George & Patricia Hatfield Doctor: Brittney Carpenter, DVM Treatment Request ADMIT TIME: 09:06 WT: 25.2 pounds Temp: q hr HR: q hr RR:_ q hr BP: q hr Walk: q hr Labs: Chem 10 PCV/TP CBC CPL CPL1 Chem 17 (AZO) PT USG Parvo Systemic Screen BG q hrs PTT Urine Sediment FeLV/FIV STAT Panel 4 Dx Platelet Estimate Urine Dipstick (Ethylene Glycol) NSAID Panel Renal Panel Urine Culture HWT Snap Giardia Snap Fecal & Giardia Urine Drug Test Fluids: SQ Fluids ml IV Fluids IVC: Periph Central LRS Normosol-R Vetstarch Northwest Pet Clinic, Pllc Page 2 of 43 Date: 7/11/ :32 AM

3 Normasol 0.9% NaCl Blood Products 0.9% NaCl 2.5% Dextrose in 0.45% NaCl LRS D5W Other: Bolus: ml's Then ml/hr ***After Bolus add Additives*** Additives: Medications: Product Amount/Dose Route/Frequency Specifics Imaging: Thorax Limb Contrast Study Met Check Spine Fast Scan Abdomen Other Pelvis Other: 4/27/2016 V C30 Apr 27, :52 AM Staff: C Weight : pounds Northwest Pet Clinic, Pllc Page 3 of 43 Date: 7/11/ :32 AM

4 4/20/2016 C N53 ** NWPC La Canada Records ** - FINAL 04/20/ travel sheet See Attachment 4/20/2016 C N29 ** SOAP Brief ** - FINAL 04/20/ recurrent cystoliths ***ADDENDUM 4/20/2016 Brief SOAP Check In Tech: cr Reason for Recheck Visit: recheck radiographs 4/20/2016 9:46 AM Vital Sign C30 Weight 25.1 pounds BodyScor 3 - Optimal e5 Temp Pulse 90 Resp pant Dental 2 - Mild Muc Pink/Healthy Memb CRT <2 sec Hydration wnl History: Cosmo presents for recheck evaluation of radiographs. Doing well at home, currently feeding S/O diet mixed with homemade food. Follow up R lat abd rad: Recurrent tiny cystoliths (10-20 very tiny stones) that were not present 6months ago. Static hepatomegaly. Reviewed rads with owners, unfortunately stones have recurred despite owner's best attempt at keeping the urine acidic and dilute (owner checks ph and USG frequently). This is very common with CaOx stones. Options: attempt uro-retrohydropulsion to expel as many stones as possible vs monitor for stone growth or urinary obstruction and consider surgical intervention if it becomes indicated in the future. Owners elect to monitor for time being. Will observe closely for signs of urinary obstruction, recheck immediately if such develops. Otherwise plan to monitor stone number and size with continued abd rad q6m. Northwest Pet Clinic, Pllc Page 4 of 43 Date: 7/11/ :32 AM

5 BC Notes: ADDENDUM on 4/20/2016 at 15:01:47 from Brittney L. Carpenter, DVM Correction: Will need to verify with owner that he was targeting or noting a more commonly acidic ph for Cosmo's urine. A slightly alkaline ph is desired for CaOx stone prevention. BC 4/20/2016 T DCM Image: Abdomen 4/20/2016 T DCM Image: Miscellaneous 4/20/2016 C C30 NWPC Travel Sheet SICK/URGENT - FINAL 04/20/2016 Current Weight (pounds): 25.1 (Kg= ) Exams Code TP $ Treatments Code TP $ Radiographs Code TP $ Brief Recheck 1116 Activated Charcoal 6095 Radiographs 3 View 5501 Exam/Consult 1102 Anal Glands 6002 X-Ray Additional 5502 Follow Up Exam 1104 Cystocentesis 6006 X-Ray Follow Up 5503 Urgent Care 1002 Ear Cleaning & Meds 6056 X-Ray Single View 5505 Work in/walk in 1001 Emesis 6094 In-House Labs/DX Code TP $ Enema 6049 Ultrasound/Cardell Code TP $ Systemic Screen 4030 Fluid Therapy-up to 6021 Single Organ System USORGAN 250mL Dose Blood Glucose 4017 Fluid Therapy 6022 Fast Scan USEMERG mL Dose CPL Snap CPLSNAP Fluid Therapy 6023 U/S Guided Cysto USCYSTO mL Dose Cytology 4009 Cardell Monitoring CARDELL Ear/Skin Cytology 4010 Medications to go Home RX2GO Fecal & Giardia 3999 Laser Therapy Code TP $ FeLV/FIV Snap 4036 Eye Diagnostics Code TP $ Laser Bundle 6 pk LASER5 FNA + Cytology 2009 Eye Group GEYE Laser Single TX LASERST FNA w/o Cytology 2013 Fluorescein Stain 4006 Northwest Pet Clinic, Pllc Page 5 of 43 Date: 7/11/ :32 AM

6 FPL Snap FPL Schirmer Tear 4014 Euthanasia Code TP $ Giardia Snap 3998 Tonopen IOP 2003 Euthanasia 6039 HCT/TP 4024 Idexx Labs Code TP $ Regular Cremation Geuthc NSAID Panel 4032 Cocci Profile IL933 Special Cremation Geuths Parvo Snap 4016 Cocci S/T IL706 Groups Code TP $ PLT Count/Blood Smear 4015 Cytology IL605 Day 1 Hospitalization GH1 Doppler Blood Pressure 2011A Fecal + Giardia IL2463 Additional Day Hosp. GHADD Skin Scraping 4011 Feline ADR w/fpl IL2733 Blocked Cat A GBCA Urine Dipstick Medications Monitoing 4044 Sedate/Reverse GSED USG Senior Screen 30 Snakebite Out Patient GSR Urinalysis 4002 Total Health Plus IL75 Snakevite Hospitalization GR2 Dermatology Work Up SKIN UA + Culture MIC IL1394 Parvo Home TX GPVH Urinalysis 8 Parvo Hospitalization A GIPV Misc. Labs Code TP $ Major Trauma MT/COY U of A Cytology UAH106 Emergency Group GEMER Additional Diagnostics/TX: Rx's & Instructions/Food: 4/20/2016 V C30 Apr 20, :46 AM Staff: C Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : Pulse : 90 Respiration : pant Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 12/9/2015 C C63 ** Attach Registration Form ** - FINAL 12/09/2015 Northwest Pet Clinic, Pllc Page 6 of 43 Date: 7/11/ :32 AM

7 See Attachment 12/9/2015 C C30 ** SOAP K9 VX Ina/Oracle ** - FINAL 12/09/2015 Wellness/Vaccine SOAP Canine Check In Tech: cr Reason for Visit: Wellness/Vaccines 12/9/ :52 AM Vital Sign C30 Weight 24.3 pounds BodyScor 3 - Optimal e5 Temp 99.7 Pulse 140 Resp 50 Dental 2 - Mild Muc Pink/Healthy Memb CRT <2 sec Hydration wnl Testing Offered by Accepted by Declined by Annual Blood Screen cr Heartworm utd Dental cr S: PRESENTATION / COMPLAINT:vx History: Cosmo presents for vaccines. Doing well, no concerns. Medications: heartgard Prior Medical History: Northwest Pet Clinic, Pllc Page 7 of 43 Date: 7/11/ :32 AM

8 Prior Lab Results: S: (Subjective) BCS: 5/9 Attitude: BAR Eating/Drinking: normal Vomiting: no Current Diet: urinary diet Urinating: normal Coughing/Sneezing: no Environment: in/out Bowel Movements: normal Limping: no Other pets: no new Activity: normal Seizures: no HW/Flea-Tick: yes O: PHYSICAL EXAMINATION: BCS: 4/5 Wt= 24.3 Attitude: BAR, happy today Ear Eye Nose Throat Dental Grade Cardiovascular Lungs Integument Muscular/Skeletal Peripheral Lymph Nodes Abdominal Uro/Genital Neurological Rectal NAF Mild chronic waxyiness and lichenification of canals low grade 2, teeth look good for his age NSF - no murmurs Auscult clear and eupnic Hair coat not greasy today though is mild to moderately dandruffy and mildly pruritic (pedal response when back is scratched) Previous retained SQ suture and draining tract from lipoma removal has resolved. No lameness noted NAF Soft and non-painful NAF NAF N/E A: PROBLEM LIST / ASSESSMENT: One year post-cystotmy- no recurrence of stones Healthy, OK for vaccinations Mild to moderate pruritis, mild to mod dander: suspect seasonal allergy P: DIAGNOSIS / TREATMENT: Owner has apoquel prescribed by Washington DVM, okay to use this seasonally when pruritis is worst Northwest Pet Clinic, Pllc Page 8 of 43 Date: 7/11/ :32 AM

9 For skin- continue omega3 FA, try oatmeal shampoo followed by leave-on lotion BC Vaccine(s) Given Duration Site/SQ Manuf Serial Number Exp. Date DAPP LS Merial 45472B 21NOV16 DAP LS Pfizer A SEP16 Parvo LS Merial MAR16 Rabies 3y RS Merial NOV16 Bord Oral Oral Boehringer Ingelheim A 25FEB17 Bordetella Intra Scap Pfizer A409720A 9AUG17 Rattlesnake Red Rock SEP16 Lepto Merial 49006A 23MAR16 Lyme Boehringer Ingelheim A 10Mar16 12/9/2015 C C30 ** Rabies Certificate La Canada ** - FINAL 12/09/2015 RABIES CERTIFICATE Wednesday, December 9, 2015 Name: George & Patricia Pet's Name: Cosmo Hatfield Address: 5934 W. Ticson Species: Canine Estates Parkway Breed: Schnauzer, Miniature City: Tucson Sex: Neutered Male State: AZ Postal Code: Birth Date: 11/11/2008 Microchip #: Issued By: 52 Northwest Pet Clinic, Pllc Page 9 of 43 Date: 7/11/ :32 AM

10 Vaccine Manufacturer: Imrab3 Merial, Serial #18273 Exp: 22DEC16 Vaccine: Date Given: Date Due: Rabies 12/9/ /9/2018 This is to certify that the above described animal has been Rabies Vaccinated at Northwest Pet Clinic, Pllc. Doctor: Brittney Carpenter, DVM To obtain a license, call (or visit website for details) Pima Animal Care Center at Pinal County Animal Control /9/2015 C C30 NWPC Travel Sheet - WELLNESS - FINAL 12/09/2015 Client: George & Patricia Hatfield Patient: Cosmo Current Weight (Pounds): 24.3 Date: Wednesday, December 9, 2015 Doctor: Brittney Carpenter, DVM Exams Code TP $ Canine Vaccines Code TP $ Parasite Prevention Code TP $ Wellness Exam 1105 Bordetella INJ 1 year 1706 Heartgard Dewormer DWSP Wellness Exam SR 1115 Bordetella Oral 6M BORDOR6 Heartgard Blue 12M T372 Wellness 4 week WELL4 BORDORA Bordetella Oral 1 Year Heartgard Green 12M T373 Northwest Pet Clinic, Pllc Page 10 of 43 Date: 7/11/ :32 AM

11 Pet Adoption Exam 1120 DAPP 4wk V101 Heartgard Brown 12M T374 DAPP 1 Year V103 Nexgard 4-10# (3M) DAPP Extended V105 Nexgard 10-24# (3M) In-House Labs Code TP $ DAP Extended V106 Nexgard 24-60# (3M) FeLV/FIV Snap Test 4036 Parvo 20wk PARV18 Nexgard # (3M) FNA w/cytology 2009 Parvo Extended V108 FNA w/o Cytology 2013 Rabies 1 Year 1601 Dental Recommendations Grade 2 HWT ADOPTION 4022A Rabies 3 Year 1602 Home Care Discussed HWT 4022 TX Plan Provided Feline Vaccines Code TP $ FVRCP 2wk 1516 Diet Recommendations Idexx Labs Code TP $ FVRCP 4wk 1801 RCVD Maintenance Annual Blood Screen 4042 FVRCP 1 Year 1802 RCVD Dental Fecal & Giardia - Well 4001W FVRCP Extended 1810 Other Leukemia 4wk 1901 Treatments Code TP $ Leukemia 1 Year 1903 Rewards Program Code $ Anal Glands 6002 Rabies 1 Year 1606 Membership MEMBER Nail Trim 6001 Program MBEXAM Complimentary Exam Program B-Day NT MBNT Program Renewal MBREN Additional Diagnostics/TX: G 3 G 4 Rx's & Instructions/Food: 12/9/2015 V C30 Dec 9, :52 AM Staff: C Northwest Pet Clinic, Pllc Page 11 of 43 Date: 7/11/ :32 AM

12 Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : 99.7 Pulse : 140 Respiration : 50 Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 11/14/2015 P N None of RX Outside Pharmacy (8004) Rx #: Of 0 Refills Filled by: N98 RCVD Canned or Dry Urinary S/O - Canine. sig: Feed as instructed. Refills PRN. Faxed to Petsmart on Irvington (520) /26/2015 P N Tablet of Metronidazole 250 mg Tablet (O1039) Rx #: Exp. 07/31/16 0 Of 0 Refills Filled by: N53 Please administer 3/4 tablet by mouth every 12 hours. Please contact Dr. Carpenter if diarrhea does not clear up. 10/26/2015 P N Btl of TrizULTRA Plus Ketoconozole 12 oz (C1262) Rx #: Exp. 07/31/17 0 Of 0 Refills Filled by: N53 Please use to clean both ears after bathing or as needed for maintenance. 10/26/2015 T ADM Image: Abdomen 10/26/2015 C N29 ** SOAP ** - FINAL 10/27/ one year post cystotomy- free of stones; diarrhea Examination SOAP Check In Tech: cr Reason for Visit: follow up radiographs after cystotomy, diarrhea S: PRESENTATION / COMPLAINT: History: Cosmo presents for diarrhea of several days duration. No blood, frequent (Q2hr). No change in diet, per O has had bouts of diarrhea due to clostridium overgrowth in the past- always responds to metronidazole and fortiflora. Also in for recheck abdominal rads after cystotomy back in nov of 2014 in order to ensure there is no stone growth. Eating/Drinking: wnl Vomiting: no Current Diet: S/O and homemade diet Urinating: wnl Coughing/Sneezing: no Environment: in/out Bowel Movements: loose Limping: no Other pets: no new Activity: normal Seizures: no HW/Flea-Tick: yes Northwest Pet Clinic, Pllc Page 12 of 43 Date: 7/11/ :32 AM

13 10/26/2015 1:54 PM Vital Sign N29 Weight 24.4 pounds BodyScor 3 - Optimal e5 Temp 98.9 Pulse 100 Resp pant Dental 2 - Mild Muc Pink/Healthy Memb CRT <2 sec Hydration wnl Prior medical history: Medications: Fortiflora, heartgard/frontline plus. Triz+keto after bathing Prior Lab Results: O: PHYSICAL EXAMINATION: BCS: 3.5/5 Wt= 24.4 Attitude: BAR Ear Eye Nose Throat Dental Grade Cardiovascular Lungs Integument Muscular/Skeletal Peripheral Lymph Nodes Abdominal NAF Mild chronic waxyiness and lichenification of canals low grade 2, teeth look good for his age NSF - no murmurs Auscult clear and eupnic Mild greasy quality to haircoat (occurred after switching to nearly complete home-cooked diet) Had lipoma removed R caudal thx last month and has had small draining tract since then. Cranial end of incision very small region of thin skin with drop of cloudy serosanguinous fluid present when squeezed. Removed 2 retained SQ sutures from cranial end of incision near this dermal hole. No heat/pain/swelling of the surgical site. No lameness noted NAF Soft and non-painful Northwest Pet Clinic, Pllc Page 13 of 43 Date: 7/11/ :32 AM

14 Uro/Genital Neurological Rectal NAF NAF N/E A: PROBLEM LIST / ASSESSMENT: One year post-cystotmy- no recurrence of stones Diarrhea- acute onset, history of similar extremely metronidazole responsive diarrhea events in the past Retained SQ sutures with draining tracts- removed sutures and scrubbed with chlorhex. Advise owner continue daily chlorhex scrubs and close monitor. May need oral abx if tracts do not close up with removal of these SQ sutures. P: DIAGNOSIS / TREATMENT: Single Rlat abd rad: no uroliths noted. Slight hepatomegaly. Reviewed rads with owner- no recurrrence of uroliths! Continue diet plan as clearly it is working for Cosmo. For the diarrhea- will add in metronidazole as per owner, historically Cosmo has had "clostridial overgrowth", metronidazole responsive diarrhea episodes. Consider other diagnostics or treatments if metro/flortiflora not effective. Continue daily fortiflora until diarrhea resolved Dispense metronidazole Refilled TrizKeto Item Description Directions Quantity Metronidazole 250 mg Tablet Please administer 3/4 tablet by mouth every 12 hours. Please contact Dr. Carpenter if diarrhea does not clear up. TrizULTRA Plus Ketoconozole 12 oz Please use to clean both ears after bathing or as needed for maintenance Northwest Pet Clinic, Pllc Page 14 of 43 Date: 7/11/ :32 AM

15 BC 10/26/2015 C N29 NWPC Travel Sheet SICK/URGENT - FINAL 10/26/2015 Current Weight (pounds): 24.4 Exams Code TP $ Treatments Code TP $ Radiographs Code TP $ Brief Recheck 1116 Activated Charcoal 6095 Radiographs 3 View 5501 Exam/Consult 1102 Anal Glands 6002 X-Ray Additional 5502 Follow Up Exam 1104 Cystocentesis 6006 X-Ray Follow Up 5503 Urgent Care 1002 Ear Cleaning & Meds 6056 X-Ray Single View 5505 Work in/walk in 1001 Emesis 6094 In-House Labs/DX Code TP $ Enema 6049 Ultrasound/Cardell Code TP $ 4 DX Fluid Therapy-up to 6021 Single Organ System USORGAN 250mL Dose Blood Glucose 4017 Fluid Therapy 6022 Fast Scan USEMERG mL Dose CPLSNAP CPL Snap Fluid Therapy 6023 U/S Guided Cysto USCYSTO mL Dose Cytology 4009 Cardell Monitoring CARDELL Ear/Skin Cytology 4010 Fecal & Giardia 3999 Laser Therapy Code TP $ FeLV/FIV Snap 4036 Eye Diagnostics Code TP $ Laser Bundle 6 pk LASER5 FNA + Cytology 2009 Eye Group GEYE Laser Single TX LASERST FNA w/o Cytology 2013 Fluorescein Stain 4006 FPL Snap FPL Schirmer Tear 4014 Euthanasia Code TP $ Giardia Snap 3998 Tonopen IOP 2003 Euthanasia 6039 HCT/TP 4024 Idexx Labs Code TP $ Regular Cremation 6064 NSAID Panel 4032 Cocci Profile IL933 Special Cremation 6016 Parvo Snap 4016 Cocci S/T IL706 Groups Code TP $ PLT Count/Blood 4015 Cytology IL605 Day 1 Hospitalization GH1 Smear Systemic Screen 4030 Feline ADR w/fpl IL2733 Additional Day Hosp. GHADD Skin Scraping 4011 Medications 4044 Blocked Cat A GBCA Monitoring Urine Dipstick Senior Screen 30 Snakebite Out Patient GSR USG Total Health Plus IL75 Snakebite Hospitalization GR2 Northwest Pet Clinic, Pllc Page 15 of 43 Date: 7/11/ :32 AM

16 Urinalysis 4022 UA + Culture MIC IL1394 Parvo Home TX GPVH Dermatology Work Up SKIN Urinalysis 8 Parvo Hospitalization A GIPV Major Trauma MT/COY Misc. Labs Code TP $ Emergency Group GEMER U of A Cytology UAH106 Additional Diagnostics/TX: Rx's & Instructions/Food: 10/26/2015 V N29 Oct 26, :54 PM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : 98.9 Pulse : 100 Respiration : pant Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 5/28/2015 C N60 ** Outside Records ** - CLOSED 05/29/ Laventure Vet Center See Attachment 3/26/2015 P N None of RX Outside Pharmacy (8004) Rx #: Of 0 Refills Filled by: N39 Heartgard Plus 12Pk Blue 1-25# w/ 0 refills. Sig: 1 chew po q 30 days. Faxed back Northwest Pet Clinic, Pllc Page 16 of 43 Date: 7/11/ :32 AM

17 to PetMeds (p: /f: ) 2/22/2015 PB N29 Seborrhea Oleosa (Minor, Active) 2/22/2015 PB N29 Wellness exam (Minor, Active) 2/22/2015 C N51 ** Outside Records ** - FINAL 02/22/ Cosmo's home diet See Attachment 2/22/2015 C N29 ** SOAP ** - FINAL 02/22/ Checkup, anal glands, lipoma Examination SOAP Check In Tech: kg/mt Reason for Visit: Checkup, check lipoma and anal glands S: PRESENTATION / COMPLAINT: BAR, tolerant of exam History: Cosmo presents for a general checkup and to have his anal glands and lipoma examined. He is doing normally otherwise. Owner says that his specific gravity has been staying steady and he is getting a homemade diet along with his Urinary SO canned food. His treats are banana chips and beef jerky. Eating/Drinking: WNL Vomiting: No Current Diet: 1/3 Urinary SO moderate calorie canned food/ 2/3 homemade mix (see recipe) Urinating: WNL Coughing/Sneezing: No Environment: Indoor/outdoor Bowel Movements: WNL Limping: No Other pets: No Activity: WNL Seizures: No HW/Flea-Tick: No 2/22/2015 9:44 AM Vital Sign N29 Weight 25.4 pounds BodyScor 3 - Optimal e5 Temp 99.7 Pulse 100 Resp pant Dental 2 - Mild Muc Pink/Healthy Memb CRT <2 sec Northwest Pet Clinic, Pllc Page 17 of 43 Date: 7/11/ :32 AM

18 Hydration WNL Prior medical history: Problem Description Severity State Create Staff Create Date Modified Date Bladder Stone Major Chronic Brittney L. 11/12/2014 2/22/2015 Carpenter, DVM Lipoma Major Active Brittney L. 11/12/2014 2/22/2015 Carpenter, DVM Cystotomy Minor Active Brittney L. 11/18/2014 2/22/2015 Carpenter, DVM Calcium Oxalate Calculi/Urolith Major Resolved Brittney L. Carpenter, DVM 12/1/2014 2/22/2015 Medications: None currently Prior Lab Results: 1/8/15 WNL O: PHYSICAL EXAMINATION: BCS: 3.5/5 Wt= 25.4 Attitude: BAR T MM- Pink P- 100 CRT- <2 R- pant Hydration- WNL Ear Eye Nose Throat Dental Grade Cardiovascular Lungs Integument Muscular/Skeletal Peripheral Lymph Nodes Abdominal Uro/Genital Neurological Rectal Previous chronic otitis, some lichenification inner pinnae, mild ceruminous accumulation (owner maintains ears with routine cleaning with keto-based ear cleanser) 2, heaviest tartar max carnasials NSF - no murmurs Auscult clear and eupnic Haircoat generally mildly oily, mild dander- both worst along dorsum R lat thx: golf-ball sized lipoma, deeply attached and slight growth recent months No lameness noted NAF Soft and non-painful NAF NAF Anal sacs: both mildly to moderately full of watery material. Expressed easily. Northwest Pet Clinic, Pllc Page 18 of 43 Date: 7/11/ :32 AM

19 A: PROBLEM LIST / ASSESSMENT: Lipoma, Calcium Oxalate Calculi/Urolith (removed via cystotomy several months ago), Wellness exam Seborrhea Oleosa (mild)- developed this after switching him to 80% homemade diet (owner's attempt to prevent recurrence of CaOx stones- see many previous notes regarding this) P: DIAGNOSIS / TREATMENT: Owner interested in removing the lipoma- provided treatment plan. Recommended Seborrhea shampoo for skin, owner wishes to try OTC Head and Shoulder first. Continue diet as currently doing. Owner has had the diet analyzed via online sources and it appears complete. Owner also brought in sheet of at-home ph testing and USG testing. For the majority of time Cosmo's urine is alkaline and <1.020, so the diet seems to be accomplishing the desired results. Plan to recheck rads several times a year to monitor for stone recurrence. BC 2/22/2015 V N29 Feb 22, :44 AM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : 99.7 Pulse : 100 Respiration : pant Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : WNL 1/8/2015 L N73 Hematology results from IDEXX Reference Laboratory Requisition ID: Posted Final Test Result Reference Range HCT 49.4 % Northwest Pet Clinic, Pllc Page 19 of 43 Date: 7/11/ :32 AM

20 HGB 18.2 g/dl MCHC 36.8 g/dl WBC 12.5 K/uL LYMPHS 21.0 % MONOS 3.9 % EOS 2.2 % BASO 0.1 % RBC 7.26 M/uL MCV 68 fl MCH 25.1 pg NEUT SEG 72.8 % PLATELETS 458 K/uL H RETIC CNT 1.0 % ABS BASO 13 /ul ABS EOS 275 /ul ABS LYMPHS 2625 /ul ABS MONOS 488 /ul ABS NEUTS 9100 /ul ABS RET 73 K/uL Ascn: RE: 3034 REMARKS REMARKS WBC AND RBC MORPHOLOGY APPEARS NORMAL. SLIDE REVIEWED MICROSCOPICALLY. 1/8/2015 L N73 Chemistry results from IDEXX Reference Laboratory Requisition ID: Posted Final Test Result Reference Range ALB 3.7 g/dl ALKP 68 U/L ALT 33 U/L AMYL 657 U/L AST 28 U/L BUN/UREA 18 mg/dl 9-31 Ca 10.6 mg/dl Chloride 109 mmol/l CHOL 234 mg/dl CK 181 U/L CREA 0.9 mg/dl DBIL <0.1 mg/dl GGT 13 U/L 0-13 GLU 84 mg/dl LIPA 474 U/L PHOS 4.5 mg/dl Potassium 4.7 mmol/l Sodium 145 mmol/l TBIL 0.1 mg/dl TP 6.8 g/dl Northwest Pet Clinic, Pllc Page 20 of 43 Date: 7/11/ :32 AM

21 GLOB 3.1 g/dl ANION GAP 17 mmol/l BICARB 24 mmol/l IBIL 0.0 mg/dl A/G Ratio B/C Ratio 20.0 Na/K Ratio Ascn: RE: 281 HEMOLYSIS INDEX 4+ Index of 4+ may increase AST and CPK by 25-50%, and decrease ALP, GGT by >50%, and Total and Direct Bilirubin by 25-50%. RE: 282 LIPEMIA INDEX 3+ Index of 3+ may decrease Direct Bilirubin by 25-50%. 1/8/2015 L N73 Endocrinology results from IDEXX Reference Laboratory Requisition ID: Posted Final Test Result Reference Range T4 1.1 ug/dl Ascn: Interpretive ranges: <1.0 Low Normal >4.0 High Therapeutic Dogs with no clinical signs of hypothyroidism and results within the normal reference range are likely euthyroid. Dogs with low T4 concentrations may be hypothyroid or euthyroid sick. Occasionally, hypothyroid dogs can have T4 concentrations that are low normal. Dogs with clinical signs of hypothyroidism and low or low normal T4 concentrations may be evaluated further by submission of free T4 and canine TSH. A high T4 concentration in a clinically normal dog is likely variation of normal; however elevations may occur secondary to thyroid autoantibodies or rarely thyroid neoplasia. For dogs on thyroid supplement, acceptable 4-6 hour post pill total T4 concentrations generally fall within the higher end or slightly above the reference range. Northwest Pet Clinic, Pllc Page 21 of 43 Date: 7/11/ :32 AM

22 1/8/2015 C N73 ** Lab Message Results / Call ** - FINAL 01/14/ THP Lab Results/Call Date: Thursday, January 08, 2015 Time: 17:09 Pet: Cosmo Client: George & Patricia Hatfield Client ID: Primary Phone: (520) Team Member: csm Lab Results: Doctor: Alice E. Goodman, DVM Problems / Diagnosis: Lab Results: Test Result Reference Range Date/Time ALKP 68 U/L /8/2015 ALT 33 U/L /8/2015 AST 28 U/L /8/2015 CK 181 U/L /8/2015 GGT 13 U/L /8/2015 AMYL 657 U/L /8/2015 LIPA 474 U/L /8/2015 ALB 3.7 g/dl /8/2015 TP 6.8 g/dl /8/2015 GLOB 3.1 g/dl /8/2015 TBIL 0.1 mg/dl /8/2015 DBIL <0.1 mg/dl /8/2015 BUN/UREA 18 mg/dl /8/2015 CREA 0.9 mg/dl /8/2015 CHOL 234 mg/dl /8/2015 GLU 84 mg/dl /8/2015 Ca 10.6 mg/dl /8/2015 Northwest Pet Clinic, Pllc Page 22 of 43 Date: 7/11/ :32 AM

23 PHOS 4.5 mg/dl /8/2015 BICARB 24 mmol/l /8/2015 Chloride 109 mmol/l /8/2015 Potassium 4.7 mmol/l /8/2015 Sodium 145 mmol/l /8/2015 A/G Ratio /8/2015 B/C Ratio /8/2015 IBIL 0.0 mg/dl /8/2015 Na/K Ratio /8/2015 ANION GAP 17 mmol/l /8/2015 Test Result Reference Range Date/Time ABS BASO 13 /ul /8/2015 ABS EOS 275 /ul /8/2015 ABS LYMPHS 2625 /ul /8/2015 ABS MONOS 488 /ul /8/2015 ABS NEUTS 9100 /ul /8/2015 ABS RET 73 K/uL /8/2015 BASO 0.1 % 1/8/2015 EOS 2.2 % 1/8/2015 HCT 49.4 % /8/2015 HGB 18.2 g/dl /8/2015 LYMPHS 21.0 % 1/8/2015 MCH 25.1 pg /8/2015 MCHC 36.8 g/dl /8/2015 MCV 68 fl /8/2015 MONOS 3.9 % 1/8/2015 NEUT SEG 72.8 % 1/8/2015 PLATELETS 458 K/uL (H) /8/2015 RBC 7.26 M/uL /8/2015 RETIC CNT 1.0 % 1/8/2015 WBC 12.5 K/uL /8/2015 Test Result Reference Range Date/Time T4 1.1 ug/dl /8/2015 A: BW wnl P: Annual bw is wnl, great news. CC: Reported bw results to owner. (also contraindicated to give calcium citrate to him) Potassium citrate not recommended per Northwest Pet Clinic, Pllc Page 23 of 43 Date: 7/11/ :32 AM

24 nutritionist at UCDavis O is feeding the home-cooked diet-- 85% of calories from homemade food, 15% from urinary s/o. If all goes well, just due for recheck UA and abdom rads in 6 mos. AEG 1/8/2015 C N62 ** NWPC Ina/Oracle Records ** - CLOSED 01/09/ At home monitoring records See Attachment 1/8/2015 C N73 ** SOAP K9 VX ADD Ina/Oracle ** - FINAL 01/08/2015 Vaccine SOAP Canine Add-on Testing Offered by Accepted by Declined by Annual Blood Screen MT Mr and Mrs Hatfield Vaccine(s) Given Duration Site/SQ Manuf Serial Number Exp. Date DAPP extended LS Merial 45451B 24DEC15 1/8/2015 C N73 ** SOAP Follow-up ** - FINAL 01/13/2015 Follow-up SOAP Check In Tech: Mt Reason for Recheck Visit: Follow up radiographs Vital Sign Weight BodyScor e5 1/8/2015 9:51 AM N pounds 3 - Optimal Northwest Pet Clinic, Pllc Page 24 of 43 Date: 7/11/ :32 AM

25 Temp Pulse 130 Resp 50 Dental 2 - Mild Muc Pink/Healthy Memb CRT <2 sec Hydration wnl S: PRESENTATION / COMPLAINT: History: Cosmo presents for a follow up on radiographs and would also like to do vaccines and wellness included if appropriate. Prior medical history: Problem Description Severity State Create Staff Create Date Modified Date Bladder Stone Major Chronic Brittney L. 11/12/ /2/2014 Carpenter, DVM Lipoma Major Active Brittney L. 11/12/ /2/2014 Carpenter, DVM Cystotomy Minor Active Brittney L. Carpenter, DVM 11/18/ /2/2014 Eating/Drinking: normal Vomiting: none Current Diet: Urinating: normal Coughing/Sneezing: none Environment: in/out Bowel Movements: normal Limping: none Other pets: none Activity: normal Seizures: none HW/Flea-Tick: hwp Medications:none Prior Lab Results: 12/5/2014 Test Result Reference Range Date/Time SOURCE URINE-CYSTO 12/2/2014 STATUS FINAL 12/2/2014 Lab Comments: Ascn: F RU,ID MN CANINE NO GROWTH SO FAR RE: 5002 COMPLETED CULTURE RESULTS COMPLETED CULTURE RESULTS NO GROWTH O: PHYSICAL EXAMINATION: Northwest Pet Clinic, Pllc Page 25 of 43 Date: 7/11/ :32 AM

26 BCS: 3/5 Attitude: BAR Ear Eye Nose Throat Dental Grade Cardiovascular Lungs Integument Muscular/Skeletal Peripheral Lymph Nodes Abdominal Uro/Genital Neurological Rectal NAF 2 mild caudal calc NSF - no murmurs Auscult clear and eupnic incision site healed; lipoma right lateral thorax No lameness noted NAF Soft and non-painful NAF externally NAF N/E A: PROBLEM LIST / ASSESSMENT: Lipoma, Calcium Oxalate Calculi/Urolith ---removed via cystotomy P: DIAGNOSTICS / TREATMENT: Time for rads. Rec UA, o decl as they have been checking at home. Due for annual bw. 2-view rads: initially a pinpoint radio opaque dot was seen in the bladder where it overlapped with colon (pet was taken outside to defecate and poss radio-opaque area confirmed as fecal material) After BM, no bladder stones seen, no stones in kidneys/ureters/urethra Gave vacc, see add-on vax SOAP. O is feeding a little bit of S/o, but now also making a home-cooked diet the owner found online written by a lay-person. I strongly recommend not feeding this diet, I recommend if we feed home-cooked we must use a vet nutritionist, o tried calling UC Davis about nutrition but they require an exam, etc. I gave the owner websites for online vet nutrition consult--- petdiets.com, balanceit.com. Dr. Goodman Northwest Pet Clinic, Pllc Page 26 of 43 Date: 7/11/ :32 AM

27 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 T N67 Image: Abdomen 1/8/2015 V N73 Jan 8, :51 AM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : Pulse : 130 Respiration : 50 Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 12/5/2014 C N73 ** Lab Message Results / Call ** - FINAL Lab Results/Call Date: Friday, December 05, 2014 Time: 13:19 Pet: Cosmo Client: George & Patricia Hatfield Client ID: Primary Phone: (520) Team Member: RN Lab Results: Doctor: Alice E. Goodman, DVM Problems / Diagnosis: Lab Results: Northwest Pet Clinic, Pllc Page 27 of 43 Date: 7/11/ :32 AM

28 Test Result Reference Range Date/Time SOURCE URINE-CYSTO 12/2/2014 STATUS FINAL 12/2/2014 Lab Comments: Ascn: F RU,ID MN CANINE NO GROWTH SO FAR RE: 5002 COMPLETED CULTURE RESULTS COMPLETED CULTURE RESULTS NO GROWTH A: Urine culture final and negative P: (see other CSR notes, o was refunded for the culture) CC: 12/4/2014 C C61 ed O receipt from per O's request rc - FINAL ed O receipt from per O's request rc 12/2/2014 L N73 SNAP Assays results from IDEXX VetLab In-clinic Laboratory Requisition ID: 5767 Posted Final Test Result Reference Range HW = Negative 12/2/2014 C N73 ** SOAP K9 VX Ina/Oracle ** - FINAL 12/02/2014 Wellness/Vaccine SOAP Canine Check In Tech: gm Reason for Visit: Wellness/Vaccines Testing Offered by Accepted by Declined by Northwest Pet Clinic, Pllc Page 28 of 43 Date: 7/11/ :32 AM

29 Annual Blood Screen Heartworm Dental gm S: PRESENTATION / COMPLAINT: History: Cosmo presents for suture removal (cystotomy), also vaccines if healthy. O' declines bordatella vaccine. O' collected urine sample around noon today. Sample was cloudy and o' states has been cloudy fo ra few days. Urinating a good stream. No blood notes. Eating/drinking well. Suture site semms good. O' requested heartworm antigent test * O' requested records be sent to RDVM Fidalgo Animal Medical Center 3303 Commercial Ave, Anacortes, WA, Phone #(360) , Fax # to Dr. Beth.Scheenstra@fidalgovets.com or to famc@fidalgovets.com * Medications: completed antibiotics a week now Prior Medical History: Problem Description Severity State Create Staff Create Date Modified Date Bladder Stone Major Chronic Brittney L. 11/12/ /2/2014 Carpenter, DVM Lipoma Major Active Brittney L. 11/12/ /2/2014 Carpenter, DVM Cystotomy Minor Active Brittney L. Carpenter, DVM 11/18/ /2/2014 Prior Lab Results: S: (Subjective) BCS: 5/9 Attitude: BAR Eating/Drinking: wnl Vomiting: none Current Diet: urinary s/o Urinating: wnl Coughing/Sneezing: none Environment: indoor Bowel Movements: wnl Limping: none Other pets: 1 Activity: wnl Seizures: none HW/Flea-Tick: HG O: PHYSICAL EXAMINATION: BCS: 3/5 Wt= 25.6 Attitude:BAR Northwest Pet Clinic, Pllc Page 29 of 43 Date: 7/11/ :32 AM

30 T MM- Pink P-120 CRT- <2 R- 50 Hydration- WNL Ear Eye Nose Throat Dental Grade Cardiovascular Lungs Integument Muscular/Skeletal Peripheral Lymph Nodes Abdominal Uro/Genital Neurological Rectal NAF 2 mild caudal calc NSF - no murmurs Auscult clear and eupnic Mild inflammation around staples, but incision intact--pet has been licking; lipoma right lateral thorax No lameness noted NAF Soft and non-painful NAF externally; bladder appears wnl on brief u/s for cysto NAF N/E A: PROBLEM LIST / ASSESSMENT: Healthy, OK for vaccinations Bladder Stone--calcium oxalate on analysis Lipoma, Cystotomy recheck-- 2 wks post-op Mild staple reaction P: DIAGNOSIS / TREATMENT: Discussed stone analysis results, o is already giving Urinary S/o canned, rec giving S/O canned mod calorie since pet is a schnauzer. Rec canned exclusivley if feasible. Gave handout on treats that are safe to give with calcium oxalate formers. S/R performed. E-collar for at least 3 more days--do not lick incision. Discussed sediment from free-catch UA and rec culture d/t struvites, o approved. I'll call with results. (Free catch from 12pm today) Dipstick Leu,Nit, Blo, Ket, Bil, Glu= Negative Uro- 0.2 Pro- Trace Ph- 8.0 Sg (refractometer) Sedistain Struvite crystals seen 5-6 phf Sterile Cystocentisis Northwest Pet Clinic, Pllc Page 30 of 43 Date: 7/11/ :32 AM

31 Dipstick Leu, nit, pro, blo,ket,bil,glu= Negative Uro- 0.2 Ph- 6.5 Sg (refractometer) Sedistain Wbc ~ 1 phf seen * Urine culture and MIC sent to IDEXX, Gave o' copy of xray c.d.* Heartworm Antigen Test = Negative I'll call with urine culture results, offered abx while waiting, o decl, will wait on results. Need to recheck UA and abdom rads in 2 more weeks. Please call with any concerns. Vaccine(s) Given Duration Site/SQ Manuf Serial Number Exp. Date DAPP Extended LS Merial 45451A 24DEC15 Dr. Goodman 12/2/2014 V N73 Dec 2, :54 PM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : Pulse : 120 Respiration : 50 Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 12/2/2014 C N64 ** Specialty/Referral Record ** - FINAL 12/02/ Minnesota Urolith Center See Attachment 12/2/2014 L N29 Microbiology results from IDEXX Reference Laboratory Requisition ID: Posted Final Northwest Pet Clinic, Pllc Page 31 of 43 Date: 7/11/ :32 AM

32 Test Result Reference Range SOURCE URINE-CYSTO STATUS FINAL Ascn: F RU,ID MN CANINE NO GROWTH SO FAR RE: 5002 COMPLETED CULTURE RESULTS COMPLETED CULTURE RESULTS NO GROWTH 12/1/2014 PB N29 Calcium Oxalate Calculi/Urolith (Major) Resolved on Feb 22/ /26/2014 C N64 ** Specialty/Referral Record ** - FINAL 11/28/ Minnesota Urolith Center See Attachment 11/23/2014 C N64 ** SOAP Follow-up ** - FINAL 11/29/ Post-cystotomy Follow-up SOAP Check In Tech: cr Reason for Recheck Visit: recheck, follow up bladder sx 11/23/2014 2:47 PM Vital Sign N64 Weight 26.2 pounds BodyScor 3 - Optimal e5 Temp 99.7 Pulse 110 Resp 50 Dental 2 - Mild Muc Pink/Healthy Memb CRT <2 sec Hydration wnl S: PRESENTATION / COMPLAINT:follow up bladder sx History: Cosmo presents for follow up after his bladder surgery, has gotten much better over the last couple of days. Is still taking all Northwest Pet Clinic, Pllc Page 32 of 43 Date: 7/11/ :32 AM

33 of his meds, getting 1/2 a tramadol every pm before bed. Prior medical history:uroliths - 11/18/14 Bladder stone(s), anal glands, lipoma lower R flank, chronic otitis Eating/Drinking: normal Vomiting: no Current Diet: hamburger,chees e,pasta Urinating: blood present Coughing/Sneezing: no Environment: in/out Bowel Movements: normal Limping: no limp Other pets: no new Activity: normal Seizures: no HW/Flea-Tick: yes Medications: ITEM DESCRIPTION Clavamox 125 mg Tablet DIRECTIONS Please administer 1 tablet by mouth every 12 hours until gone. Tramadol 50mg Tablet 100ct Give 1/2 tab by mouth every 8-12 hours as needed for pain. May cause sedation. Next dose due tomorrow morning. Vetprofen 25 mg Caplet Please administer 1 caplet by mouth every 12 hours for pain / discomfort. Next dose due early tomorrow afternoon. Prior Lab Results: 11/18/14 SX Pre op Labs: very slight elevated ALT 102, mild thrombocytosis O: PHYSICAL EXAMINATION: BCS: 6/9 Attitude: BAR Ear Eye Nose Throat Dental Grade Cardiovascular Lungs Clear OU, Clean AU, no nasal discharge Gr2-3/4 NSF - no murmurs, no arrhythmias Auscult clear and eupnic Northwest Pet Clinic, Pllc Page 33 of 43 Date: 7/11/ :32 AM

34 Integument Muscular/Skeletal Peripheral Lymph Nodes Abdominal Uro/Genital Neurological Rectal Healthy coat and skin, mild erythema at caudal margin of abd incision No lameness noted NAF Soft and non-painful, no appetite Moderate hematuria- red tinged no clots or frank blood, no accidents, frequent urination- last 2 days have had increasing volumes and decreasing frequency NAF, mentally appropriate, normal activity at home, no reflex deficits N/E, normal BM per o A: PROBLEM LIST / ASSESSMENT: Cystotomy - post op P: DIAGNOSTICS / TREATMENT: Doing better- on track for this post-op period Ok to travel by car to NM for holidays Discussed option of considering Adequan to help repair protective GAG lining of bladder/reduce cystitis symptoms Advised to continue staying in contact if any ques/concerns -Elsa Swenson, DVM 11/23/2014 V N64 Nov 23, :47 PM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : 99.7 Pulse : 110 Respiration : 50 Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 11/21/2014 C N29 ** Lab Message Results / Call ** - FINAL 11/22/ Bacteriology Lab Results/Call Date: Friday, November 21, 2014 Time: 18:55 Northwest Pet Clinic, Pllc Page 34 of 43 Date: 7/11/ :32 AM

35 Pet: Cosmo Client: George & Patricia Hatfield Client ID: Primary Phone: (520) Team Member: SH Lab Results: Doctor: Brittney L. Carpenter, DVM Problems / Diagnosis: Urine culture negative. Dr. Goodman to relay results at recheck appt this afternoon as I am not in the office today. BC Lab Results: CBC: Chemistry: T4: UA: Rads: Other: A: P: CC: 11/19/2014 V N45 Nov 19, :56 AM Staff: N Weight : pounds 11/18/2014 P N Tablet of Clavamox 125 mg Tablet (O1090) Rx #: Exp. 08/31/15 0 Of 0 Refills Filled by: N7 Northwest Pet Clinic, Pllc Page 35 of 43 Date: 7/11/ :32 AM

36 Please administer 1 tablet by mouth every 12 hours until gone. 11/18/2014 P N Tablet of Tramadol 50 mg Tablet ( ) Rx #: Exp. 07/31/17 0 Of 0 Refills Filled by: N7 Give 1/2 tab by mouth every 8-12 hours as needed for pain. May cause sedation. Next dose due tomorrow morning. 11/18/2014 P N Caplet of Vetprofen 25 mg Caplet (O1237) Rx #: Exp. 12/31/15 0 Of 0 Refills Filled by: N7 Please administer 1 caplet by mouth every 12 hours for pain / discomfort. Next dose due early tomorrow afternoon. 11/18/2014 C N36 ** NWPC Ina/Oracle Records ** - FINAL 11/18/2014 See Attachment 11/18/2014 C N36 ** NWPC Ina/Oracle Records ** - FINAL 11/18/ ***ADDENDUM 11/18/2014 See Attachment ADDENDUM on 11/18/2014 at 18:33:08 from Lorenzo Quiroz Total Fluid Volume - 535mL 11/18/2014 T N36 Image: Abdomen 11/18/2014 T N36 Image: Miscellaneous 11/18/2014 T N36 Image: Miscellaneous 11/18/2014 T N36 Image: Abdomen 11/18/2014 T N36 Image: Abdomen 11/18/2014 T N36 Image: Abdomen 11/18/2014 T N36 Image: Abdomen 11/18/2014 T N36 Image: Abdomen 11/18/2014 C N29 ** SOAP Brief ** - FINAL 11/19/2014 Brief SOAP Check In Tech: EK Reason for Recheck Cystotomy, lipoma removal Northwest Pet Clinic, Pllc Page 36 of 43 Date: 7/11/ :32 AM

37 Visit: History: Cosmo presents for cystotomy and lipoma removal. Pre op Labs: very slight elevated ALT 102, mild thrombocytosis ECG: WNL Pre-op rads: Multiple very small radio opaque uroliths evident within bladder- in same exact location as seen on every other rad taken of this pet. Unknown for sure if this is one large incompletely mineralized or several small stones (If small stones- estimate 7-9 stones depending on which view is evaluated). No stones seen within urethra. Lipoma on R caudal ribs does not appear to have osseous invasion. Sedation: Buprenorphine 0.15mg/ml 0.8ml IM Glycopyrolate 0.2mg/ml 0.6ml IM Acepromazine 10mg/ml 0.03ml IM Induction: 20g IVC R cephalic. Propofol IV to effect. Intubated 7.5mm ET tube and maintained under gas isoflurane anesthesia. Began LRS IVF at 120ml/hr. Stable throughout anesthesia. Unasyn 150mg/ml 1.6ml IV slow Rimadyl 50mg/ml 1ml SQ Surgery: Passed 8Fr red rubber Ucath into urethra with no resistance, cath seemed reasonably snug. Emptied bladder via syringe. Ventral abd clipped and sterilely scrubbed. Draped. Ventral midline incision from several cm cranial to penis, extending to right of prepuce. Incised through SQ fat. Ligated caudal epigastric vein. Stab incision into linea, extended. Exteriorized bladder and placed saline moistened lap sponges. Placed stay sutures 3-0 monosorb into bladder apex. Stab incision with 11blade into dorsal apical bladder. Suctioned urine with Poole suction tip, extended cystotomy with metzenbaums. Palpated for stone(s), none felt. Could feel U-cath tip at urethral opening. Palpated mucosal region where stones sat- region is thickened with rough, dark red papilla-type growths that may be mineralized. Used sterile saline to lavage the urethra with 8Fr Ucath, moving it proximally and distally through the urethra, still did not palpate any stones. Had colleague evaluate the bladder with gloved finger, concurs cannot palpate any stones. Phoned owner- relayed that cannot actually find any stones, suspect the mineralizations that never moved on serial rads may actually be related to a mucosal bladder growth. Recommend obtain biopsy and submit for histopath. Owner approves, elects to wait on lipoma removal at this time. Used 15 blade to obtain partial thickness mucosal biopsy samples (4 in total) of the abnormal region. Submitted in formalin. Northwest Pet Clinic, Pllc Page 37 of 43 Date: 7/11/ :32 AM

38 Apposed bladder 3-0 monosorb simple continuous, with care not to penetrate through mucosa. Oversewn with Cushings continous inverting pattern. Infused 10ml sterile saline into bladder with indwelling Ucath, no leaking observed. Changed gloves and instruments. Lavaged caudal abd with 300ml sterile saline. Apposed linea 2-0 monosorb simple continuous, SQ 3-0 monosorb simple continuous, cruciates to skin 3-0 monosorb. Took a curiosity post-op film to see if the mineralizations were decreased after biopsy sample collection. Observed 7-8 small stones had slipped into proximal urethra. Stones present after all, need to go back in surgically. Re-induced and re-intubated 7mm ET tube. Resumed supportive care as prior, remained stable throughout entire procedure. Replaced Ucath with 10-Fr. Flushed stones back into bladder, confirmed presence of 7-8 stones within bladder lumen with repeat rad. Placed in dorsal recumbancy, re-scrubbed. Removed suture lines and re-entered the abd and bladder. Immediately able to palpate and remove 6 small stones. Used indwelling Ucath to flush 2 additional stones up into bladder. Removed total 8 stones. Copiously lavaged urethra in both directions with 10Fr Ucath, no additional stones discovered. Repeated closure to bladder and abd as above except used staples for skin instead of suture. Post op rads: confirmed complete removal of ALL stones, 8 in total. Routine recovery. Repeated buprenorphine 0.8ml SQ after extubation. Phoned owners- discussed the events following my last conversation, discovered there were actually stones that slipped into the urethra beyond where I could palpate and for some reason they did not flush up with the 8Fr Ucath. Had to re-enter the abd, able to switch out U-caths to a larger size, flush stones back into bladder and retrieve them from bladder lumen. Confirmed that post-op rads showed removal of ALL stones, 8 in total. Reviewed expectations for recovery post-op (hematuria, pollakiuria, etc for first few days). Owners elect to wait on mucosal biopsy, quite understanding of the situation. Scheduled courtesy follow up tomorrow to review rads with owner and check up on Cosmo. Plan: -owners have e-collar -dispense clavamox (will change or extend pending culture results), vetprofen, and tramadol -Urine culture (intra-op cysto) submitted to UofA -stones submitted to Minnesota for analysis -s/r in days -Select urinary diet, supplements, etc based upon stone analysis results. Discussed most important factors will be urine concentration (need it to be dilute) and target ph depending on stone type. Will check urine sample several weeks after making diet change -see discharge sheet Item Description Directions Quantity Clavamox 125 mg Tablet Please administer 1 tablet by mouth every 12 hours until gone Tramadol 50mg Tablet 100ct Give 1/2 tab by mouth every Northwest Pet Clinic, Pllc Page 38 of 43 Date: 7/11/ :32 AM

39 Vetprofen 25 mg Caplet BC 8-12 hours as needed for pain. May cause sedation. Next dose due tomorrow morning. Please administer 1 caplet by mouth every 12 hours for pain / discomfort. Next dose due early tomorrow afternoon /19/14 12pm Courtesy follow up: Cosmo is BAR, still tender in abd (not palpated) but doing well at home. Has urinated several times, smaller amounts with orange (slightly bloody) color but no obvious distress. Ate home cooked food well this am, seems comfortable when taking all pain meds. Incision line slightly edematous but clean and dry. Staples intact. Reviewed the rads with owners, explaining why the procedure became more complex than intended- owners especially understanding. Advised them no need to see Cosmo back again until s/r unless there are concerns, and to call me ANYTIME if they have questions or concerns. I or a colleague will call as soon as lab results become available. BC 11/18/2014 L N29 Chemistry results from IDEXX VetLab In-clinic Laboratory Requisition ID: 5668 Posted Final Test Result Reference Range ALB = 3.2 g/dl ALKP = 87 U/L ALT = 102 U/L H BUN/UREA = 17 mg/dl 7-27 CREA = 1.2 mg/dl GLU = 114 mg/dl TP = 7.1 g/dl GLOB = 3.9 g/dl ALB/GLOB = 0.8 BUN/CREA = 14 11/18/2014 L N29 Hematology results from IDEXX VetLab In-clinic Laboratory Requisition ID: 5668 Posted Final Test Result Reference Range HCT = 47.9 % HGB = 17.6 g/dl MCHC = 36.7 g/dl Northwest Pet Clinic, Pllc Page 39 of 43 Date: 7/11/ :32 AM

40 WBC = K/µL LYMPHS = 2.91 K/µL %LYMPHS = 25 % MONOS = 0.47 K/µL %MONOS = 4 % NEUT = 7.84 K/µL %NEUT = 67.3 % EOS = 0.41 K/µL %EOS = 3.5 % BASO = 0.02 K/µL %BASO = 0.2 % PLT = 524 K/µL H Retics = 50 K/µL %Retics = 0.7 % RBC = 7.24 M/µL MCV = 66.2 fl MCH = 24.3 pg RDW = 19.5 % MPV = 9.9 fl PDW = 12.4 fl PCT = 0.52 % H /18/2014 V N29 Nov 18, :31 AM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : 99.0 Pulse : 100 Respiration : 50 Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 11/18/2014 T N48 Image: Abdomen 11/18/2014 T N48 Image: Abdomen 11/18/2014 T N67 Image: Abdomen 11/18/2014 T N67 Image: Abdomen 11/18/2014 PB N29 Cystotomy (Minor, Active) 11/13/2014 C N03 ** Outside Records ** - CLOSED 11/15/ Fidalgo Animal Medical Center See Attachment Northwest Pet Clinic, Pllc Page 40 of 43 Date: 7/11/ :32 AM

41 11/12/2014 PB N29 Lipoma (Major, Active) 11/12/2014 PB N29 Bladder Stone (Major, Chronic) 11/12/2014 C N51 ** Outside Records ** - FINAL 11/12/ Ajo Veterinary Clinic records See Attachment 11/12/2014 C N8 ** Attach Registration Form ** - FINAL 11/12/2014 See Attachment 11/12/2014 V N29 Nov 12, :16 AM Staff: N Weight : pounds Body Score (1-5) : 3 - Optimal Temperature : 99.9 Pulse : 132 Respiration : 68 Dental Score : 2 - Mild MM : Pink/Healthy CRT : <2 sec Hydration : wnl 11/12/2014 T N15 Image: Cosmo Ajorads /12/2014 T N15 Image: 10/2/14 R lat abd 11/12/2014 C N29 ** SOAP ** - FINAL 11/12/ Consult for Cystotomy Examination SOAP Check In Tech: kg Reason for Visit: Consult for Cystotomy S: PRESENTATION / COMPLAINT: BAR, tolerant of exam History: Cosmo presents for a consult for a cystotomy. He began having symptoms back in 8/14 with a UTI and hematuria, which was treated with Augmentin. He continued with hematuria for about a month. He has been eating Urinary SO for the past 3 months and is doing well, showing no further symptoms. Serial rads taken in recent months have shown consistent bladder stone(s). Cosmo Northwest Pet Clinic, Pllc Page 41 of 43 Date: 7/11/ :32 AM