MEDICAL HISTORY. 25-Jan-2017 to 27-Jan VCA Central Animal Hospital 281 North Central Avenue, Upland, CA (909)

Transcription

1 VCA Central Animal Hospital 281 North Central Avenue, Upland, CA (909) MEDICAL HISTORY to 27-Jan-2017 Client Timothy C Saunders (42916) C: Timothy C: (626) Patient Kodiak Tokota (67949) Canine Retriever, Labrador 9y 10m (20-May-2007) Black Male / Intact lb () Most recent visit date: Microchip No.: Rabies tag ID / date : Patient Alerts: Current medical overview: as of 28-Mar-2017 Current Wellness Reminders K9 Rabies K9 Distemper K9 Bordetella K9 Heartworm Test K9 Parvo K9 Dental Cleaning K9 Heartworm RX Physical Exam Fecal Exam K9 Flea Prevention Due Date 04-Oct Nov Nov Jan Oct-2007 Medications (since 27-Jan-2016) Amount Disp. Date Give 2 to 3 tablets by mouth every 8 to 12 hours as needed for coughing. Tech: DS Dr.Check: Maximum 24hr dose: 9 Tablets Doxycycline Monohydrate 100mg Caps cap Give 3 tablets orally every 12 hours for 14 days. Techs: DS/ Weight by Age Wt. Record date 9y 8m kg 128 lb Active Concerns Inactive Concerns Established Established Resolved Concerns (since ) Established Resolved Medications (since 27-Jan-2016) Amount Disp. Date Amoxicillin (gen) 400mg Tab tab Give 3 tablets by mouth every 12 hours for 14 days. Call Dr. Johnson with update status report on Monday (1/30) or Tuesday (1/31). Techs: DS/ Enrofloxacin (gen) 136mg Tab tab Give 2 & 1/4 tablets by mouth every 12 hours for 14 days. Techs: DS/ Hydrocodone/Homa 5mg/1.5mg tab Exported by: Vanessa Roberts on 28-Mar of 3

2 Client: Timothy C Saunders (42916) Patient: Kodiak Tokota (67949) MEDICAL HISTORY: to 27-Jan-2017 Outpatient visit ( to ) Appointment Type: Breathing/ing/Sneezing Provider: Sex / age / weight: Male - Intact / 9y 8m / 128 lb () Concerns (Problem List) Active () 07:05 Exam VITALS Assisted by: Angela.Acuna, Carl.Bennington Temp (F) HR RR SBP CRT MM color Pain (0-10) BCS (1-9) 07: CLIENT INTERVIEW Presenting concerns Medication history Digestive Urinary ing - O said P has been coughing for the last 4 weeks and doesn't seem to be getting any better. P tends to vomit out liquid. O said he was at another pet hospital 2-3 weeks ago and got medication, but P doesn't seem to be getting any better. Eating/drinking, urinating/defecating normally, P is on Amoxicillin. CB Flea control - Product name and dosing frequency; Heartworm preventative No vomiting/diarrhea - Normal appetite no problems - No problems with urinary system EXAM FINDINGS Whole body Over Overweight - Overweight - BCS 7-8/9 Attitude Hydration Alert - Attitude - alert/responsive Hydration normal - Hydration - WNL Eyes Lens Nuclear sclerosis - Early nuclear sclerosis OU Thorax All lung fields Harsh airway sounds - Slightly harsh, dry pulmonary sounds - dog intermittently panting ; Some dry coughing when handled Abdomen Abdominal palpation Doughy - Doughy palpating abdomen - difficult to assess abdominal organs due to weight Behavioral General findings alert/responsive Cardiovascular General findings no murmur noted Integument General findings no skin lesions Lymphatic system General findings lymph nodes within normal limits Musculoskeletal General findings no musculoskeletal problems Gait Stiff gait - Slightly stiff gait Nervous system General findings no nervous system problems Reproductive General findings no reproductive problems Respiratory General findings no problems with urinary system - No problem with respiratory system Urinary General findings no problem with urinary system ASSESSMENTS R/O: Infectious (ITB? Other?) ; Airway disease/bronchitis? Neoplasia? Other? 2. Overweight - Dietary? Hypothyroid? Other? * Documents are available as separate attachments or files. ** Lab results/procedure reports (if included in export) are located at the end of this document. VCA Central Animal Hospital 281 North Central Avenue, Upland, CA (909) of 3

3 Client: Timothy C Saunders (42916) Patient: Kodiak Tokota (67949) MEDICAL HISTORY: to 27-Jan-2017 Exam 07:05 Assisted by: Angela.Acuna, Carl.Bennington PLANS Order items Documents* Radiographs (with AIS) - Generalized increased interstitial pattern in lung fields ; Cardiac size WNL ; Tracheal lumen WNL ; Moderate amount gas/air in GI tract ; Small to moderate feces ; Increased prostate size ; Full bladder. - RTJ Canine PCR Respiratory Fast Panel ( ) Thyroid Profile 2 (161.79) Rx: - Amoxitabs 400 mg - 3 tabs po q 12 hours for 14 days (# 84) - Baytril 136 mg - 2 & 1/4 tabs po q 12 hours for 14 days (# 63) - Doxycycline 100 mg - 3 tabs po q 12 hours for 14 days (# 84) - Hydrocodone 5 mg tabs po q 8-12 hours prn for coughing (# 80) Log Dr. check C.I.: - Call Dr. Johnson with update status report on Monday (1/30) or Tuesday (1/31) Exam/Consultation Medical Condition [1.2]: 1.00 each Radiograph Thorax [21.394]: 1.00 proc AIS Radiology Interpretation [ ]: 1.00 proc Respiratory Test [ ]: 1.00 test Thyroid Profile 2 [161.79]: 1.00 test Amoxicillin (gen) 400mg Tab [301.16]: tab - Give 3 tablets by mouth every 12 hours for 14 days. Call Dr. Johnson with update status report on Monday (1/30) or Tuesday (1/31). Techs: DS/. Refills: 0. Exp: 01-Feb Enrofloxacin (gen) 136mg Tab [ ]: tab - Give 2 & 1/4 tablets by mouth every 12 hours for 14 days. Techs: DS/. Refills: 0. Exp: 01-Jul Hydrocodone/Homa 5mg/1.5mg [309.61]: tab - Give 2 to 3 tablets by mouth every 8 to 12 hours as needed for coughing. Tech: DS Dr.Check: Maximum 24hr dose: 9 Tablets. Refills: 0. Exp: 01-Jul Doxycycline Monohydrate 100mg Caps [ ]: cap - Give 3 tablets orally every 12 hours for 14 days. Techs: DS/. Refills: 0. Exp: 01-May Saunders-Kodiak Tokota _AIS Reports.pdf Lab results** 27-Jan :56 27-Jan :14 K9 Respiratory PCR T995 Source: Antech Submitted: Reported: 27-Jan-2017 Thyroid Profile 2 SA370 Source: Antech Submitted: Reported: 27-Jan-2017 * Documents are available as separate attachments or files. ** Lab results/procedure reports (if included in export) are located at the end of this document. VCA Central Animal Hospital 281 North Central Avenue, Upland, CA (909) of 3

4 Patient Info: Name: Kodiak Tokota Chart No: Owner: Saunders Timothy C Doctor: Johnson Dvm, Richard T Species: Canine Breed: Labrador Retriever Age: 10Y Sex: M Hospital: Lab: VCA Central Animal Hosp ANTECH Diagnostics A Cowan Avenue 281 N Central Ave Irvine, CA Upland, CA Reported: 01/28/17 05:45 Antech ID: Received: 01/25/17 Accession No Doctor Owner PetName IRBE Johnson Dvm, Richard T Saunders Timothy C Kodiak Tokota Test Results Adult Reference Range Fastpanel PCR Canine Respiratory Panel Canine Influenza (H3N8) NEGATIVE Canine Adenovirus type 2 NEGATIVE Canine Herpesvirus NEGATIVE Canine Parainfluenza Virus NEGATIVE Canine resp. coronavirus NEGATIVE Influenze H1N1 (swine flu) NEGATIVE Influenza H5N1 (avian flu) NEGATIVE Canine Distemper NEGATIVE Bordetella bronchiseptica NEGATIVE Mycoplasma cynos POSITIVE Nucleic acids of Mycoplasma cynos were amplified from the specimen provided which proves the presence of the organism. If clinical signs compatible with M. cynos infection are present, this organism should be considered as the likely cause of clinical signs. Healthy dogs can be colonized by Mycoplasma cynos and so positive test results do not prove the clinical syndrome is caused by Mycoplasma cynos. There are other Mycoplasma spp. that may be primary pathogen and so use of this PCR assay does not exclude all organisms in this group. Strep. zooepidemicus NEGATIVE Comment Nucleic acids from organisms reported as negative were not amplified from the specimen provided. This suggests that these organisms are not associated with the clinical signs of disease or the organisms were cleared by immune responses prior to sample collection. This PCR system includes a control assay that determines whether the sample submitted was adequate for testing. Page 1 of 1 FINAL 3/28/2017 8:40:53 AM

5 Patient Info: Name: Kodiak Tokota Chart No: Owner: Saunders Timothy C Doctor: Johnson Dvm, Richard T Species: Canine Breed: Labrador Retriever Age: 10Y Sex: M Hospital: Lab: VCA Central Animal Hosp ANTECH Diagnostics A Cowan Avenue 281 N Central Ave Irvine, CA Upland, CA Reported: 01/27/17 01:25 Antech ID: Received: 01/25/17 Accession No Doctor Owner PetName IRBE Johnson Dvm, Richard T Saunders Timothy C Kodiak Tokota Test Results Adult Reference Range Total T4 T4 1.6 ug/dl Free T4 (Equilibrium Dialysis) Free T4 Equilibrium Dialysis 21.5 pmol/l 8-40 Page 1 of 1 FINAL 3/28/2017 8:40:53 AM