Visit Info: Izzy's visit began at 1:27 PM 10/16/2016 Medical Authorizati Release Signed? Doctors Assisting or Csulting with Care: Dr. Sabrina Kordis Future appointment(s) scheduled for: 10/16/2016 at N Fort Worth TX, 11/11/2016 at N Fort Town Center TX *This is a preliminary report-invoice is still open and/or lab results have not yet been entered. Patient Informati 10/16/2016 Yes Name: Izzy Species: Canine Breed: Terrier, West Highland White Gender: Female (Spayed) Descripti: White Date of Birth: 7/3/2009 Weight: 21.20 Lbs/9.62 Kgs Microchip #: 981010001181721 Home Again/Merck Optimum Wellness Plan: Special Care Izzy has visited this Banfield Hospital 8 times. Izzy's first visit 7/3/2013 at this hospital Izzy's last visit 10/16/2016 at this hospital Preventive Care Given Due Date Preventive Care Given Due Date Heartworm Preventi 8/7/2014 2/3/2015 Heartworm Test 10/12/2016 10/12/2017 Flea Preventi 4/26/2014 5/26/2014 Lyme Test 10/12/2016 10/12/2017 Tick Preventi 4/26/2014 5/26/2014 Ehrlichia test 10/12/2016 10/12/2017 Mosquito Preventi 4/26/2014 5/26/2014 Anaplasma Test 10/12/2016 10/12/2017 Roundworms 10/12/2016 4/10/2017 Blood Cell Count 10/12/2016 10/12/2017 Hookworms 10/12/2016 4/10/2017 Serum Chemistries 10/12/2016 10/12/2017 Tapeworms 10/12/2016 4/10/2017 Differential Exam 10/12/2016 10/12/2017 Whipworms 10/12/2016 4/10/2017 Electrolytes 1/3/2014 1/3/2015 Rabies 8/13/2015 8/12/2018 Fecal Exam 10/12/2016 4/10/2017 DAPP 8/13/2015 8/12/2018 Urine Specific Gravity 10/12/2016 10/12/2017 Leptospirosis 10/12/2016 10/12/2017 Urine Strip Tests 10/12/2016 10/12/2017 Bordetella 10/12/2016 10/12/2017 Urine Sediment Exam 10/12/2016 10/12/2017 Dental Prophylaxis 1/3/2014 1/3/2015 Subjective Izzy was presented 10/16/2016 for: Injury-Lameness, also dia See 'Plan and Other Notes' secti for patient history documentati, if pertinent. Page 1 of 7
Objective Physical Exam Findings 10/16/2016 Exam was certified by Dr. Sabrina Kordis, DVM 10/16/2016 Temperature: 100.4º F - Within Normal Limits Heart Rate: 114/min - Within Normal Limits Respirati: 24/min - Within Normal Limits Capillary Refill Time: Under 2 Secds Normal or Not Selected Findings: Overall Cditi Coat and Skin Ocular Otic Oral/Nasal Respiratory Cardiovascular Abdominal Dehydrati Level - No Dehydrati Skin Lesis - Ne Nail - Normal Length Bulb/Cornea - Normal Eyelid - Normal Otoscopic Exam - Normal Pinna - Normal Tsils - Normal Lymph Node Size - Normal Nasal Discharge\Sneezing - Not Found Color of Gums - Normal Left Caudal Auscultati Percussi - Normal Left Cranial Auscultati Percussi - Normal Left Caudal Auscultati Brchovesicular Right Cranial Auscultati Brchovesicular Respiratory Character - Normal Pulse - Normal Stomach Palpati - Normal Abdominal Lymph Nodes - Normal Bladder Palpati - Normal Dewclaw - N existent/normal Length Cjunctiva - Normal Otic Exudate - Ne Pharyngeal - Normal Lymph Node Csistency - Normal Tgue - Normal Right Caudal Auscultati Percussi - Normal Right Cranial Auscultati Percussi - Normal Right Caudal Auscultati Brchovesicular Left Cranial Auscultati Brchovesicular Heart Murmur Grade - No Murmur Heart Rhythm - Normal Hepatic Palpati - Normal Abdominal General Impressi - Normal Spleen Palpati - Normal Page 2 of 7
Right Kidney Palpati - Normal Prostate / Uterus Palpati - Normal Left Kidney Palpati - Normal Urogenital Type of Discharge in Mammary Glands - Ne Mammary Glands - Normal Perineal Neurological Tail - Normal Perineum - Normal Neurological Observati - Normal Anal Glands - Normal Abnormal Findings: Overall Cditi Overall Cditi - Needs Improvement Body Cditi Score - Overweight Oral/Nasal Swelling/Inflammati of Gums - Found Tartar Teeth - Found Alignment of Bite - Over-shot Jaw Abdominal Gas Filled Loops in Intestines - Found Fluid Filled Loops in Intestines - Found Musculoskeletal Right Rear Leg - Lameness Pain and/or Musculoskeletal Lesi - Found Left Rear Leg - Lameness Pain and/or Musculoskeletal Lesi - Found Assessment Tentative Diagnosis Status Date Hospital Big Dog/Little Dog Trauma Cditi Resolved 10/16/2016 2065 N Fort Worth Colitis, Cservative Undergoing Therapy 10/16/2016 2065 N Fort Worth Collapsed Trachea, Acquired Stable/Persistent/Chric 10/16/2016 2065 N Fort Worth Cruciate Ligament Rupture Anterior Undergoing Therapy 10/16/2016 2065 N Fort Worth Dental Calculus Undergoing Therapy 10/16/2016 2065 N Fort Worth Gingivitis Undergoing Therapy 10/16/2016 2065 N Fort Worth Overbite Stable/Persistent/Chric 10/16/2016 2065 N Fort Worth Overweight Undergoing Therapy 10/16/2016 2065 N Fort Worth Patellar Luxati, Medical Undergoing Therapy 10/16/2016 2065 N Fort Worth Page 3 of 7
Pyoderma Cditi Resolved 10/16/2016 2065 N Fort Worth Tapeworm Cditi Resolved 10/16/2016 2065 N Fort Worth Wound, Animal Bite, Cservative Cditi Resolved 10/16/2016 2065 N Fort Worth Plan and Other Notes Prescribed and Administered Therapy for this visit/hospitalizati: (Reported by most recent date first) 10/16/2016 Physical Exam: Wellness Plan - Completed Medical Waste Disposal Fee - Completed Rectal Exam - Brief - Completed Metridazole 250mg Tablet - Completed Rimadyl 75mg Chewable Tablet - Completed Office Visit - Completed Exam - Lameness - Completed MRX RC Canine Gastrointestinal Low Fat - Completed Advita Canine Probiotic Powder (per packet) - Completed Additial Medical Notes documented for this visit/hospitalizati: (Reported by most recent date first) Date Type Note Doctor VT/VA CSC Hospital Patient: Izzy (Canine) Client: Prescripti Filled On: 10/16/2016 Prescripti #: 2065-12788311 Rx: Rimadyl 75mg Chewable Tablet Manufacturer: Instructis: Give 0.5 chewable tablets every 24 hours for 14 days Give with food. Give by mouth ly. Mitor for signs of intestinal upset (decreased appetite, vomiting, diarrhea). Providing Doctor: Sabrina Kordis Quantity: 7.00 Discard By: 4/16/2017 Number of Refills: 0 Refill Expirati Date: 4/16/2017 Page 4 of 7
Patient: Izzy (Canine) Client: Prescripti Filled On: 10/16/2016 Prescripti #: 2065-12788310 Rx: Advita Canine Probiotic Powder (per packet) Manufacturer: Instructis: Give 1 packet every 24 hours for 14 days Give with food. Give by mouth ly. Mitor for signs of intestinal upset (decreased appetite, vomiting, diarrhea). Providing Doctor: Sabrina Kordis Quantity: 14.00 Discard By: 4/16/2017 Number of Refills: 0 Refill Expirati Date: 4/16/2017 Patient: Izzy (Canine) Client: Prescripti Filled On: 10/16/2016 Prescripti #: 2065-12788307 Rx: Metridazole 250mg Tablet Manufacturer: Instructis: Give 0.5 tablets every 12 hours for 8 days Start tight. Give with food. Give by mouth ly. Mitor for signs of intestinal upset (decreased appetite, vomiting, diarrhea). Providing Doctor: Sabrina Kordis Quantity: 8.00 Discard By: 4/16/2017 Number of Refills: 0 Refill Expirati Date: 4/16/2017 Patient: Izzy (Canine) Client: Prescripti Filled On: 10/16/2016 Prescripti #: 2065-12788301 Rx: MRX RC Canine Gastrointestinal Low Fat Manufacturer: Instructis: Providing Doctor: Sabrina Kordis Quantity: 1.00 Discard By: N/A Number of Refills: N/A Refill Expirati Date: N/A Subjective Kordis, S. Anglin, L. 2065 N Fort P presented for acute set diarrhea and lameness. O reports diarrhea started last night, as well as the lameness. Objective Kordis, S. Anglin, L. 2065 N Fort Page 5 of 7
Weight:21.20lbs Attitude/Mentati: BAR Hydrati Status: euhydrated T:100.4 P: 114 R: 24 BCS: 4/5 CRT/MM: <2/pink and moist Coat/Skin: wnl Eyes: wnl Ears: wnl N/T: wnl Oral: 2/5; mild dc/ging; overbite H/L: wnl GI: gas and fluid bowel loops abdominal exam UG: wnl M/S: grade 3/5 lameness RR leg; (+) cranial drawer an awake examinati; grade 2/4 bilateral MPL Reproductive: wnl Perineal: wnl Neuro: wnl Assessment Kordis, S. Pirtle, J. Anglin, L. 2065 N Fort dental calculus gingivitis overbite overweight MPL Ruptured CCL colitis, cservative Plan(Notes) Kordis, S. Pirtle, J. Anglin, L. 2065 N Fort Page 6 of 7
PE. Rectal Exam Brief- mucus and fresh blood rectal exam Awake Orthopedic exam reveal grade 3/5 lameness RR leg, bilateral MPL and torn cruciate ligament RR leg. Referral to DVSC Rx: Rimadyl 75mg Chewable Tablet Manufacturer: Instructis: Give 0.5 chewable tablets every 24 hours for 14 days Rx: Advita Canine Probiotic Powder (per packet) Manufacturer: Instructis: Give 1 packet every 24 hours for 14 days Rx: MRX RC Canine Gastrointestinal Low Fat Manufacturer: Rx: Metridazole 250mg Tablet Manufacturer: Instructis: Give 0.5 tablets every 12 hours for 8 days 1 Prognosis: fair 2 Client Educati: see above; referral to DVSC surgical center in Grapevine for surgical repair of her CCL and MPL 3 Recheck: prn 4 Follow-Up Therapy: prn *********************************************************************** Home Care Instructis documented for this visit/hospitalizati: (Reported by most recent date first) Ne Therapy presented & declined by the client for this visit/ hospitalizati: Ne Therapy csidered but not medically necessary for this visit/hospitalizati: Intestinal Parasite Fecal Exam - Not Medically Necessary Giardia Test - Not Medically Necessary Fecal Sample Collecti - Not Medically Necessary Therapy postped by the client or doctor this visit/hospitalizati: Ne Page 7 of 7