Complete Pet Care Animal Hospital at Heritage

Transcription

1 Complete Pet Care Animal Hospital at Heritage 941 Gateway Commons Circle Wake Forest, NC Patient Chart Printed: at 4:09p CLIENT INFORMATION Name Amy Gant (588) Address 625 Walters Dr Wake Forest, NC Phone PATIENT INFORMATION Name Linny Species Feline Sex Female, Spayed Breed Domestic Shorthair Deceased Age ID Rabies Color Black Weight lbs Reminded (none) Codes D Reminders for: Linny Last done Senior Wellness HEALTH HISTORY SUMMARY Date Diagnosis OBSTRUCTION* GI PERFORATION* VOMITING SNEEZING DIETARY INDISCRETION INFLAMMATORY BOWEL DISEASE possible, beginning stages Linny's weight history (in lbs) MEDICAL HISTORY TC CCD Client Communication RT: at 4:09p: attempted to call owner to discuss intestinal histopathology results after speaking with pathologists but was unable to leave voic . Will call again later. RT RT FNOTE$ By: AO, Individual Cremation w/ lock h faithful friends called RT IDXREQ IDEXX LabREXX Requisition #

2 Date: , Time: 4:09p Page: 2 Age: 11y Biopsy results are consistent with extensive necrohemorrhagic and neutrophilic enteritis. Although not definitive, the change suggest underlying acute bacterial insult and/or enterotoxin secretion ultimately resulting in intestinal disease and then subsequent erosions. Dr. Ryan Thames/lr STD BIOPSY w/ DESC :25a PATHOLOGIST REP SOURCE/HISTORY: Sections of jejunum and cecum colon submitted for investigation of any underlying disease. Additional clinical history was provided and has been reviewed by the pathologist. The history has been summarized from the requisition form as follows: During surgery for possible obstruction two focal areas of perforation, 5-6 sections moderately thickened, diffuse fibrotic adhesions sloughing of mucosal lining, suspected perforation, hair and firm fecal material in colon, patient euthanized on table MICROSCOPIC DESCRIPTION: Jejunum, cecum and colon: In all sections, the villous mucosa is extensively pale eosinophilic with a marked loss of cellular detail but partial maintenance of tissue architecture. In affected regions, there is frequent dropout of crypts the remnants of which comprised sloughed, degenerate cellular debris and fibrin. In these regions, there is marked lamina proprial hemorrhage and congestion of small caliber blood vessels. Blood and lymphatic vessels within lamina propria and submucosa are often occluded by fibrin thrombi. In some sections, there are marked lamina proprial and superficial submucosal infiltrates of viable and degenerate neutrophils, dense basophilic cellular debris, hemorrhage, fibrin and variably sized scattered rafts of superficial lining coccobacilli. Throughout the subserosal connective tissue, there are numerous, multifocal to coalescing regions of hemorrhage and congestion of small caliber blood vasculature. MICROSCOPIC INTERPRETATION: Jejunum, cecum, colon: Enterocolitis, necrosuppurative, hemorrhagic, fibrinous, with segmental superficial coccobacilli, extensive, marked, acute COMMENTS: Histopathological examination of the submitted segments revealed extensive necrohemorrhagic and neutrophilic enteritis. Although not definitive, the changes suggest underlying acute bacterial insult and/or enterotoxin secretion. Clostridium perfringens overgrowth, E. coli and Salmonella infection have been implicated in cases presenting with these histopathological lesions.no large bacilli are observed, but there are small clusters of coccobacilli. Neoplastic cells are not observed. Consultation with an internal medicine specialist regarding additional diagnostics may be of benefit in this case. Consultation with an internal medicine specialist can be obtained by calling PATHOLOGIST: Kimberly Cavender, DVM Diplomate, American College of Veterinary Pathologists Direct: , option 0, x Kimberly-Cavender@idexx.comThank you for submitting your pathology sample to our service. If you have any questions regarding this case, do not hesitate to contact us directly at the number(s) listed above.

3 Date: , Time: 4:09p Page: RT RX2701 Biopsy - Micro Desc - 1 Site - Standard TC CC Client Communication AO: at 9:57a: waiting for O to call back to okay cremation RT ZO1165 OBSTRUCTION* GI ZP3438 EUTHCI INDIVIDUAL CREMATION PERFORATION* Individual Cremation w/ lock hair & PP EUTH Euthanasia Items used: BEUTH Beuthanasia D 100ml 2.00 ANESM Pulse Oximeter/Anesthetic Monitoring 0 ANESG Anesthesia (General) 10 SURG Surgery 10 CD Controlled Drugs Items used: CD002 Propofol 200mg/20 ml 2.20 HOSPD Hospitalization FLIV Fluids, Intravenous FLSET Fluid Set-up Items used: LINEMACR IV Line 106 Inch Piggyback 1.00 XRAY1 Radiograph RADINT Radiographic Interpretation 0 ER Medical Progress Exam Age: 11y Weight: Temp: Respiration: Pulse: CRT: <2 secs. SUBJECTIVE SECTION Presents for recheck. Patient is not doing well. She was seen on Saturday here and then an emergency hospital. Radiographs were taken here and showed a moderate amount of stool in the colon. There is also gas distention around what appeared to be the cecocolic junction. An enema was performed and it appeared that the fecal material was moving through and the gas was also settling and moving through as well, however, patient has continued to not eat and seems very lethargic today. She was prescribed Gabapentin at the emergency hospital. Patient is QAR/depressed. Mucous membranes are light pink. There is consistent pain on palpation of her abdomen, especially her mid dorsal abdomen. Radiographs today look very similar to those taken Saturday afternoon before discharge. It does not look like her intestines have moved much at all. There also appears to be a moderate gas/fluid distention in her gastric lumen which was confirmed on ultrasound. The decision was made to take patient to surgery. An IV catheter was placed. Administered 0.54 ml Cerenia IV and 1.1 ml Cefazolin IV. Anesthesia was induced with propofol and maintained on isoflurane gas throughout the procedure. Patient was place in dorsal recumbency. Ventral abdomen was surgically clipped and prepped. A ventral midline incision was made. There was a large area of compromised intestines in her mid jejunum, about a inch section. The intestines were inflamed, very dark, purple in nature. There were two small areas on each end of that section that had mesentery adhesions and were necrotic appearing in nature. The area of her cecocolic junction was also very dark, discolored in nature and had an area of necrosis on the anti-mesenteric border. There is about a 5-6 inch area distal to the compromised area of jejunum that is thickened and inflamed though not discolored. The color is still pink in nature but compared to the proximal jejunum,

4 Date: , Time: 4:09p Page: 4 the mucosa there was extremely thickened and had the appearance of beginning to be compromised. The stomach was very fluid filled on manual examination during exploratory. Liver grossly appearing bright orange/yellow in nature, consistent with hepatic lipidosis. No foreign material noted in the intestinal tract. There was very firm material noted in the distal colon. It is pliable and was consistent with fecal material. There is a small amount of thick abdominal fluid present with a somewhat purulent nature. Suspect underlying sepsis. Talked to the owner over the phone during the procedure. Given the lack of true foreign material in the GI tract and the findings of the overall intestines, suspect general illius secondary to underlying intestinal disease which then resulted in the fecal material being potentially lodged in the intestines. Discussed resection and anastomosis of the small intestines and then a jejunal ileocolic resection and anastomosis of the jejunum. Also discussed recovery and rehabilitation for the owner and overall poor prognosis. Owner elects euthanasia. Patient was euthanized on the surgery table with 2.0 ml Beuthanasia solution. The intestinal contents were then incised. Fecal material was noted in the distal colon. It was very firm and clay-like. There were large amounts of what appear to be patient's own hair. The cecum was incised and found to be necrotic on the inside of the cecum. ASSESSMENT SECTION DIAGNOSES PERFORATION* OBSTRUCTION* GI PLAN SECTION NOTES Will submit compromised section of intestines for biopsy/histopathology. Patient's remains were submitted for individual cremation. Dr. Ryan Thames/lr RT ZV8459 VOMITING IDXREQ IDEXX LabREXX Requisition # CHEM 25 w/ SDMA :12a ALP U/L ALT U/L AST U/L CREATINE KINASE U/L GGT U/L ALBUMIN g/dl TOTAL PROTEIN g/dl GLOBULIN g/dl TOTAL BILIRUBIN < mg/dl BILIRUBIN CONJUG mg/dl BUN mg/dl CREATININE mg/dl CHOLESTEROL mg/dl GLUCOSE 183 H mg/dl CALCIUM mg/dl PHOSPHORUS 6.4 H mg/dl TCO2 (BICARBONA mmol/l CHLORIDE mmol/l POTASSIUM mmol/l SODIUM mmol/l

5 Date: , Time: 4:09p Page: 5 ALB/GLOB RATIO BUN/CREATININE R 18.1 BILIRUBIN UNCONJ mg/dl NA/K RATIO HEMOLYSIS INDEX 3+ Index of 3+ may decrease ALP and GGT by 25-50%, and increase AST by 25-50%. LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. ANION GAP mmol/l SDMA ug/dl BOTH SDMA AND CREATININE ARE WITHIN THE REFERENCE INTERVAL which indicates kidney function is likely good. Evaluate a complete urinalysis and confirm there is no other evidence of kidney disease. T :12a T ug/dl Interpretive ranges: <0.8 Subnormal Normal Grey zone in old or symptomatic cats >4.7 Consistent with hyperthyroidism Cats with subnormal T4 values are almost exclusively euthyroid sick or overtreated for their hyperthyroidism. Older cats with consistent clinical signs and T4 values in the grey zone may have early hyperthyroidism or a concurrent non-thyroidal illness. Hyperthyroidism may be confirmed in these cats by adding on a free T4 or by performing a T3 suppression test. Following treatment with methimazole, T4 values will generally fall within the lower end of the reference range ( ). CBC COMPREHENSIVE :12a WBC 23.5 H K/uL RBC M/uL HGB g/dl HCT % MCV fl MCH pg MCHC g/dl % RETICULOCYTE 0.1 % RETICULOCYTE K/uL % NEUTROPHIL 94.4 % % LYMPHOCYTE 3.7 % % MONOCYTE 1.4 % % EOSINOPHIL 0.5 % % BASOPHIL 0.0 % PLATELET K/uL REMARKS SLIDE REVIEWED MICROSCOPICALLY. WBC AND RBC MORPHOLOGY APPEARS NORMAL. NEUTROPHIL H /ul LYMPHOCYTE /ul MONOCYTE /ul EOSINOPHIL /ul

6 Date: , Time: 4:09p Page: 6 BASOPHIL /ul URINALYSIS :12a COLLECTION METHCYSTOCENTESIS COLOR RED CLARITY TURBID SPECIFIC GRAVITY GLUCOSE 1+ (250 mg/dl) BILIRUBIN NEGATIVE KETONES TRACE BLOOD 3+ PH 6.5 PROTEIN 3+ ( mg/dl) Protein test is performed and confirmed by the sulfosalicylic acid test. WBC HPF RBC HPF BACTERIA MODERATE RODS 9-40/HPF Reporting of bacteria morphology has been added to your urinalysis results if indicated. Rods and cocci are reported if present, with suspect bacteria confirmed by Wright's stain. Accurate identification and determination of antibiotic susceptibility requires culture. For additional guidance on the diagnosis and management of urinary tract infections, please see EPI CELL RARE (0-1) MUCUS NONE SEEN CASTS NONE SEEN CRYSTALS NONE SEEN UROBILINOGEN NORMAL CARDIOPET probnp - FELINE :12a CARDIOPET probn 151 H pmol/l Cardiopet probnp pmol/L Abnormal. NT-proBNP concentration is compatible with increased stretch and stress on the myocardium. To obtain the most accurate information regarding cardiac structure and function, echocardiography is recommended. However, if respiratory signs are present, they are unlikely to be secondary to heart failure, and thoracic radiographs should be considered to evaluate for other causes of clinical signs. Additional blood tests (e.g., CBC, biochemical profile, T4) and systemic blood pressure are recommended because cats with hyperthyroidism, hypertension or severe azotemia may have increased NT-proBNP. Please note: Complete interpretive comments for all concentrations of Cardiopet probnp are available in the online directory of services RT XRAY1 Radiograph 2 RADINT Radiographic Interpretation 0 FID/C5 Feline I/D 5.5oz Can-Pate 6 FFORTI Feline FortiFlora Give 1 packet by mouth (apply on food) daily for 14 days. ENEMA Enema Items used: FTUBE8 Catheter/Feeding Tube 8 Fr. x CERNINJ Cerenia 10mg/ml 0.50 ES Examination, Diagnostic Age: 11y Weight: Temp: Respiration: Pulse: CRT: <2 secs. BCS: 3.00

7 Date: , Time: 4:09p Page: 7 SUBJECTIVE SECTION Presents for not eating or drinking. Patient vomited a little bit foam last night and this morning. She has multiple cats and is unsure if she has been eating but believes she ate yesterday. Patient seems to be meowing a little bit. Owner notes patient is a chronic over-groomer. Owner notes their other cat was euthanized yesterday for suspected possible FIP infection. Mucous membranes are pink. No other abnormalities found on PE. Administered an enema of 10 ml of Lactulose which produced several very firm fecal balls with the patient's own hair mixed in consistent with a hairball or trichobezor. Repeated lateral abdominal radiograph which showed the remaining fecal material appeared to be moving and the gas distention appeared to be subsiding and moving through the intestines as well. Findings at this time are not consistent with an obstruction. Physical Exam Abdomen No pain on abdominal palpation. There is some firm stool present in the colon. X-rays show what appears to be a moderate amount of firm fecal material within the colon. There is also some gas distention at what appears to be the cecocolic junction. ASSESSMENT SECTION NOTES PLAN SECTION Differentials are possible constipation, possible obstruction, possible underlying intestinal disease. DIAGNOSES VOMITING NOTES Submitted wellness panel, results pending. Administered 0.50 ml Cerenia injection subq. Dispensed Florti Flora and canned I/D. If patient continues to vomit or does not do well, recommend immediate recheck. Dr. Ryan Thames/lr Attachments\588\Linny\2018_04_30_11_39_06.pdf RT RX2774 Feline Wellness Panel RT ZS8819 SNEEZING ER Medical Progress Exam Age: 11y Weight: Temp: Respiration: Pulse: CRT: <2 secs. BCS: 4.00 SUBJECTIVE SECTION Presents for a little sneezing and possible swollen tongue. Patient is eating better and was started on HP diet. She had a Depomedrol injection about two weeks ago. Mucous membranes are pink. PE is WNL.

8 Date: , Time: 4:09p Page: 8 Physical Exam Oral Cavity Grade 2. Tongue appears normal. No ulcers or swelling noted. No overt signs of stomatitis or gingivitis. Nose and Throat Patient has very mild nasal congestion. No signs of nasal discharge at this time. ASSESSMENT SECTION PLAN SECTION DIAGNOSES SNEEZING NOTES Discussed the use of Chlorpheniramine or Benedryl. Owner will try. Will hold off on antibiotics in case the situation becomes worse. Dr. Ryan Thames/lr Attachments\588\Linny\2018_01_24_09_49_28.pdf TC GIFT Courtesy Gift TC FU Follow Up Phone Call KG: at 10:58a: lmom checking on p (vomiting after eating) BL ZB9999 DIETARY INDISCRETION IBD INFLAMMATORY BOWEL DISEASE possible, beginning stages TC IVDFHP7 Feline Hydrolyzed Protein HP 7.7lb Bag BL DEPOINJ Depomedrol injectable 20mg/ml USFAST Ultrasound - Focused ES Examination, Diagnostic Age: 11y Weight: Temp: Respiration: Pulse: CRT: <2 secs. BCS: 4.00 SUBJECTIVE SECTION Presents for vomiting after eating. It has been happening almost every day for the past 2-3 weeks since the owner changed food. It was a Royal Canin food and Royal Canin switched the formula. Patient is BAR. Mucous membranes are pink. No other abnormalities found on PE. Physical Exam Oral Cavity Grade 2. Abdomen

9 Date: , Time: 4:09p Page: 9 Abdomen palpates benignly. No overt organomegaly or masses appreciated. No evidence of foreign body and no pain on palpation. Focused ultrasound was performed looking at the GI tract and stomach. No obvious masses there. No thickening of the GI tract. ASSESSMENT SECTION PLAN SECTION DIAGNOSES INFLAMMATORY BOWEL DISEASE possible, beginning stages NOTES DIETARY INDISCRETION Owner to start patient of hypoallergenic food by Royal Canin. Administered 1.0 ml Depomedrol injection subq. Owner can start adding in treats and food in approximately 2-3 months. Recheck in one month. Dr. Beth Livesey/lr Attachments\588\Linny\2018_01_10_08_09_16.pdf TC CC Client Communication RT: at 8:49a: TTO regarding blood work, no significant abnormalities. Owner states that Linny is doing okay, has good appetite but still seems to be having some difficulty eating. owner to continue to monitor over the next few days RT IDXREQ IDEXX LabREXX Requisition # Age: 10y Bloodwork looks good, no significant abnormalities noted. Will call owner with results. Dr. Ryan Thames/lr CHEM 25 w/ SDMA :11p ALP U/L ALT U/L AST U/L CREATINE KINASE U/L GGT U/L ALBUMIN g/dl TOTAL PROTEIN g/dl GLOBULIN g/dl TOTAL BILIRUBIN mg/dl BILIRUBIN CONJUG mg/dl BUN mg/dl CREATININE mg/dl CHOLESTEROL mg/dl GLUCOSE mg/dl CALCIUM mg/dl PHOSPHORUS mg/dl TCO2 (BICARBONA mmol/l

10 Date: , Time: 4:09p Page: 10 CHLORIDE mmol/l POTASSIUM mmol/l SODIUM mmol/l ALB/GLOB RATIO BUN/CREATININE R 16.9 BILIRUBIN UNCONJ mg/dl NA/K RATIO HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. ANION GAP mmol/l SDMA ug/dl BOTH SDMA AND CREATININE ARE WITHIN THE REFERENCE INTERVAL which indicates kidney function is likely good. If SDMA and/or creatinine is at the upper end of the reference interval, early kidney disease cannot be ruled out. Evaluate a complete urinalysis to confirm there is no other evidence of kidney disease. T :11p T ug/dl Interpretive ranges: <0.8 Subnormal Normal Grey zone in old or symptomatic cats >4.7 Consistent with hyperthyroidism Cats with subnormal T4 values are almost exclusively euthyroid sick or overtreated for their hyperthyroidism. Older cats with consistent clinical signs and T4 values in the grey zone may have early hyperthyroidism or a concurrent non-thyroidal illness. Hyperthyroidism may be confirmed in these cats by adding on a free T4 or by performing a T3 suppression test. Following treatment with methimazole, T4 values will generally fall within the lower end of the reference range ( ). CBC COMPREHENSIVE :11p WBC K/uL RBC M/uL HGB g/dl HCT % MCV fl MCH pg MCHC g/dl % RETICULOCYTE 0.2 % RETICULOCYTE K/uL % NEUTROPHIL 59.5 % % LYMPHOCYTE 26.2 % % MONOCYTE 2.5 % % EOSINOPHIL 11.8 % % BASOPHIL 0.0 % PLATELET K/uL REMARKS SLIDE REVIEWED MICROSCOPICALLY. WBC AND RBC MORPHOLOGY APPEARS NORMAL.

11 Date: , Time: 4:09p Page: 11 PLATELET CLUMPS SEEN ON SLIDE. PLATELET COUNT AND BLOOD FILM ESTIMATE MAY BE FALSELY DECREASED. NEUTROPHIL /ul LYMPHOCYTE /ul MONOCYTE /ul EOSINOPHIL /ul BASOPHIL /ul URINALYSIS :11p COLLECTION METHCYSTOCENTESIS COLOR DARK YELLOW CLARITY CLOUDY SPECIFIC GRAVITY GLUCOSE NEGATIVE BILIRUBIN NEGATIVE KETONES NEGATIVE BLOOD NEGATIVE PH 6.5 PROTEIN TRACE Protein test is performed and confirmed by the sulfosalicylic acid test. WBC HPF RBC NONE SEEN HPF BACTERIA NONE SEEN EPI CELL NONE SEEN MUCUS NONE SEEN CASTS NONE SEEN CRYSTALS NONE SEEN UROBILINOGEN NORMAL CARDIOPET probnp - FELINE :11p CARDIOPET probnp pmol/l Cardiopet probnp <100pmol/L Normal. NT-proBNP concentration is not compatible with increased stretch and stress on the myocardium. Clinically significant heart disease is unlikely at this time. Please note: Complete interpretive comments for all concentrations of Cardiopet probnp are available in the online directory of services RT RX2774 Feline Wellness Panel DEPOINJ Depomedrol injectable 20mg/ml 0.50 CONVENI Convenia Cefovecin Na 80mg/lb 200lb/10ml 0.60 FP09PY2 Free Initial Exam (FIRST TIME PATIENTS) ES Examination, Diagnostic Age: 10y SUBJECTIVE SECTION Presents for swollen tongue, drooling, unable to eat, but has appetite. Attachments\588\Linny\0803.pdf