Age: 14 Houston TX 77007

Transcription

1 Patient Medical History HEIGHTS HOSPITAL FOR ANIMALS Bernie Rogers Patient: JACK DOB: 08/26/ Courtlandt St. Species: FELINE Age: 14 Houston TX Breed: Domestic Shorthair Sex: MN Color: Black Tag: Acc. No: 362 Doctor: Dr. Clint Duncan Weight: 7.75 Phone: (713) (832) Warning: Jack gets verys sick from vxs Chronological Weight: 01/31/ /09/ /13/ History Line Items: [Code, Description, Qty, Dr, Date] Log: Call log Dr: Dr. Clint Duncan Log Date: 02/20/2013 Called and discussed p/ w/ o/ - hasn't V+ since they started the medication, I rec trying once a day for a week and then try every other day, let uis know if V+ starts again. Still ravenous, suspect related to pred. Log: how is v+ and pred Dr: Heights Hospital for Animals Log Date: 02/19/2013 call back: LMOM and LM for Dr. d to check in. Jm Log: Medical Notes Dr: Dr. Clint Duncan Log Date: 02/07/2013 approved an rx for prednisilone 5mg flav chews through VFC, adv 1 bid and will callback to see if helping w/ V+ and weight loss. Rx is under Debbie Morris Log: CHEM 27 Test Dr: Log Date: 02/01/2013 Test Date: 02/01/2013 Test Time: 8:52 AM ALK. PHOSPHATAS = 10 U/L 0-62 ALT (SGPT) = 43 U/L AST (SGOT) = 26 U/L 5-55 CK = 108 U/L GGT = 0 U/L 0-6 AMYLASE = 813 U/L LIPASE = 134 U/L ALBUMIN = 3.3 g/dl TOTAL PROTEIN = 7.1 g/dl GLOBULIN = 3.8 g/dl TOTAL BILIRUBIN = 0.1 mg/dl DIRECT BILIRUBIN = 0.0 mg/dl BUN = 27 mg/dl CREATININE = 1.6 mg/dl CHOLESTEROL = 140 mg/dl GLUCOSE = 94 mg/dl CALCIUM = 9.4 mg/dl PHOSPHORUS = 4.6 mg/dl TCO2 (BICARBONAT = 16 meq/l CHLORIDE = 125 meq/l POTASSIUM = 4.0 meq/l Printed March 24, 2014 at 2:11 PM Continued Page 1

2 SODIUM = 154 meq/l A/G RATIO = 0.9 H B/C RATIO = 16.9 INDIRECT BILIRUBI = 0.1 mg/dl NA/K RATIO = 39 HEMOLYSIS INDEX = + Index of N,+,++ exhibits no significant effect on chemistry values. LIPEMIA INDEX = N Index of N,+,++ exhibits no significant effect on chemistry values. ANION GAP = 17 meq/l Log: T4 Test Dr: Log Date: 02/01/2013 Test Date: 02/01/2013 Test Time: 8:52 AM T4 = 1.2 ug/dl Interpretive ranges: <0.8 Subnormal 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 ( ). Log: CBC STANDARD Test Dr: Log Date: 02/01/2013 Test Date: 02/01/2013 Test Time: 7:40 AM WBC = 6.0 K/uL RBC = 7.78 M/uL HGB = 12.5 g/dl HCT = 33.0 % MCV = 42 fl MCH = 16.1 pg MCHC = 37.8 g/dl H NRBC /100 WBC 0-2 % RETICULOCYTE = 0.1 % RETICULOCYTE = 8 K/uL 3-50 RETICULOCYTE CO Printed March 24, 2014 at 2:11 PM Continued Page 2

3 NEUTROPHIL SEG = 51.3 % NEUTROPHIL BAND % 0-3 LYMPHOCYTES = 19.0 % L MONOCYTES = 3.7 % 1-4 EOSINOPHIL = 23.5 % H 2-12 BASOPHIL = 2.5 % H 0-1 METAMYELOCYTES % MYELOCYTE % PROMYELOCYTE % UNCLASSIFIED AUTO PLATELET = 231 K/uL POLYCHROMASIA ANISOCYTOSIS POIKILOCYTOSIS HEINZ BODIES PLATELET COMME REMARKS = SLIDE REVIEWED MICROSCOPICALLY. ABSOLUTE NEUTR = 3078 /ul ABSOLUTE NEUTR /ul ABSOLUTE LYMPH = 1140 /ul L ABSOLUTE MONOC = 222 /ul ABSOLUTE EOSINO = 1410 /ul ABSOLUTE BASOP = 150 /ul H ABSOLUTE METAM /ul ABSOLUTE MYELO /ul ABSOLUTE PROMY /ul ABSOLUTE UNCLAS /ul Log: Call log Dr: Dr. Clint Duncan Log Date: 02/01/2013 Called and adv o/ of results - everything fairly normal. Rec US to evaluate IBD or lymphoma, declined due to expense for now. Offered trying pred to see if helps, would like to try that first. Adv o/ to go to VFC and order 5mg Prednisolone tablets, will try 1 tab bid to start and then decrease if it is helping. Log: URINALYSIS ADD-ON Test Dr: Log Date: 02/01/2013 Test Date: 02/01/2013 Test Time: 8:55 AM COLLECTION METH = CYSTOCENTESIS COLOR = YELLOW CLARITY = CLOUDY SPECIFIC GRAVITY = GLUCOSE BILIRUBIN KETONES BLOOD PH = 6.5 PROTEIN WBC = 0-2 HPF 0-5 RBC = 0-2 HPF 0-5 Printed March 24, 2014 at 2:11 PM Continued Page 3

4 BACTERIA EPI CELL MUCUS CASTS CRYSTALS OTHER UROBILINOGEN = RARE (0-1) HPF = NONE SEEN = NORMAL Log: RETICULOCYTE PANEL Test Dr: Log Date: 02/01/2013 Test Date: 02/01/2013 Test Time: 7:40 AM % RETICULOCYTE = 0.1 % RETICULOCYTE = 8 K/uL 3-50 RETICULOCYTE CO PICT ov sign in /31/2013 IDXUA Urinalysis-IDEXX 1.00 Dr. Clint Duncan 01/31/2013 SA120 SA120 lab referred 1.00 Dr. Clint Duncan 01/31/2013 OV Examination/Consultation 1.00 Dr. Clint Duncan 01/31/2013 Log: ov Dr: Dr. Clint Duncan Log Date: 01/31/2013 Subjective: Hx: p/ had been V+ alot so o/ started feeding him smaller more frequent meals and that improved greatly. Now p/ is ravenous, can't get enough and is still loosing weight. No pu/pd, might be urinating more smaller piles, stools look normal. V+ 2-3 small puddles yesterday. Objective: Temperature Heart Rate 164 Resp. Rate 28 MM/CRT p+m,<2 Hydration nml Attitude bar Pulse strong OTHER grade 2.5 teeth General appearance Eyes Ears Integumentary Musculoskeletal Anomalies noted bcs 4/9, lost another pound Circulatory Respiratory Digestive Anomalies noted possible intestinal thickening but no obv masses Genitourinary Neural system Lymph nodes Mucous membrane Other abnormality Assessment: Plan: Discussed w/ o/ - highly rec bloodwork and UA as a start, consider US pending the results. Went Printed March 24, 2014 at 2:11 PM Continued Page 4

5 over numerous possible causes for PP and wt loss SA 120-pending, noticed during blood pull that it only seemed to trickle out of the jugular and medial saphenous looked small as well. Ua-pending Printed March 24, 2014 at 2:11 PM End of Report Page 5