Patient History for Safia - 01/04/2017 to 04/06/2017

Transcription

1 Mrs Holland 315 Abbey Road Popley 4 Basingstoke Hampshire RG24 9EH Ref: Bk Basingstoke Companion Care Hatch Warren Retail Park, Wallop Drive, Basingstoke, Hampshire, RG22 4TT VAT: Clinic: basingstoke@companioncare.co. uk Patient History for Safia - 01/04/2017 to 04/06/2017 Breed: Rhodesian Ridgeback Species: Dog Sex: Female (Spayed) DOB: 13/05/2007 Age: 10 yrs 1 mths Current : Colour: Weaten Brindle Microchip: /04/2017 Ref: Mafalda Santos 44.4 kgs Body Condition Score Heart Rate 92 bpm Temperature 38.4 C Mucous Membrane Colour Pink Pain Score 5 (1-10) Reason: Cystitis? Appointment Notes: PuPd, bloody U+, reduced appetite q24hrs ke History: OR yesterday was passing more urine than usual, asking to go outdoors more frequently and passing small amounts all times, squanting everywhere and haematuria noticed. Also drinking more than usual, reduced appetite on dry diet but still eating well chicken/beef. Examination: Alert on presentation but tense as expected in that breed with strangers. Muzzled as precaution for the CE. Hydrated, good BCS, very good for age. CE all vital parameters wnl, no hm/arrhythmia or abno sounds detected. CRT not performed. Tender on abdo palp, ++ middle abdomen, no abno masses palpated but not 04/06/ :19:53 Page 1

2 easy exam as large dog. Vulva clea and mm pink. Ocular mm pink. Lnn nad. Eyes, ears, nostrils clean. Disc symptoms of acute cystitis present but can not rule out possible causes without further investigations. Advised general PU/PD with urinanalysis as a starting point. Plan-Diagnostic: Start ab course in cons room and one off inj of meloxicam given today. Uripet dispensed to collect urine sample on Monday and to bring to us until 6pm (PLEASE ADD URINE SAMPLE TO PU/PD IDDEXX PROFILE) To wait for blood results over the week, O made aware may have delays but to call us back next week if no phone call received. Depending on blood results and Safia improv, advise can be made to have further complementary exams as US/XRAYS/urine culture/etc /04/ :03:11 RME: Laboratory External - Resolved - 03/04/2017 Consultation: Sick/Trauma Polyuria/Polydipsia (Idexx) GER1I Laboratory Fee External: Clinical Pathology Nisamox 500mg per tablet (100) 2 Metacam Inj 0.5% (20ml) per ml 1.78 Noroclav (50ml) per ml 3.50 Consumables Uripet Ref: Kate Ashworth Urine sample brought in /04/ :35:09 RL2: 10:30 Tried to contact O twice with laboratory results,not possible to leave a message /04/ :34:22 RL2: 04/06/ :19:53 Page 2

3 Contacted O with laboratory results, A/V to continue with ATB and R/c when finishes ATBcourse. R/c Before if concerned. Safia's improved on ATB. Bright, DUDE NAD 03/05/ kgs Reason: Has Been Sick Over Last Two Days Appointment Notes: ejc Ok'd by SP History: since two days not eating much ( eaten small amount chk/rice last night ) was sick few times last one earl;y this morning. Not eaten today. Produced normal but small amount faeces Is drinking water and holding it down Is a scavenger Examination: needed to be muzzled for exam Mm pink moist crt, 2 sec Chest ok Abd not painful altthough difficult to palpate much as large abdomen and quite tense Plan: on first instance adv starving 24 hours but leave water down From tomorrow small amounts bland food Cerenia inj + Clamoxyl LA given here To go home with zantac for 3 days R/c in next hours INI 27/05/2017 Consultation: Health Assessment (next due in 6 months) Cerenia Inj per ml 4.30 Clamoxyl LA (100ml) per ml 4.30 Zantac Syrup (15mg/ml) (300ml) per ml kgs Respiration Rate 12 brpm Heart Rate 54 bpm Temperature 37.8 C Mucous Membrane Colour Pink Capillary Refill Time < 2 sec 04/06/ :19:53 Page 3

4 Reason: Poss Urine Inf + Dia Appointment Notes: rl History: o feels dog has gone down hill recently Lethargic, not wanting to walk as much Still eating well, drinking no more than 2 l a day Yesterday had watery diarrhoea and leaked urine, not straining to urinate though Examination: Dog QAR here Oral exam : mm pink moist crt < 2sec HR 54 regular but Bradycardic? Abd ok T 37.8 Also noticed mild thinning of the hairs on the flank Plan: discussed options with o Repeat comprehensive BT (o declined as was done recenlty ) Just do TSH /T4 Treat the acute diarrhea with AB and prokolin INI then would benefit from further investigation 31/05/2017 Consultation: Health Assessment (next due in 6 months) Canine TSH and Total T4 (Idexx) CTSH Laboratory Fee External: Clinical Pathology Metrobactin 500mg Per Tablet (250) Protexin Pro Kolin 30ml syringe 2.00 Reason: VET Results On File Appointment Notes: cb Called the and explained result low T4 but normal TSH. As advised by pathologist advised to run Free T4 to rule out hypothyroidism. O happy for it to be done. Price of test given Called idexx to go ahead with test FRee T4 also low indicating Hypothyroidism Called o with results will do trial on Thyforon and r/c in 1 month 04/06/ :19:53 Page 4

5 Called idexx to discuss results and spoke a to internal medicine specialist Who suggested that despite Ft4 and Total t4 are low Tsh in on low normal, She suggested to repeat Free T4 by equilibrium dialysis in 4 weeks to rule out non thyroidal illness. Called o Suggested 1, we have checked full BT 2 months ago, could repeat to se if any change in an effort to diagnose non thyroidal illness, o declined for now 2 trial on Thyforon, but o will have to commit to life long treatment and monitoring. O happy to continue with this plan 3 further diagnostisc like xray, scan - o will consider this if Safia not better /06/ :12:43 RME: Laboratory External - Resolved - Free T4 by immunoassay (Idexx) AVT4 Thyforon flavoured 400mcg per tablet (250) /06/2017 Ref: Jose Messa Reason: JM To Call Appointment Notes: pls read notes, O wants to know if it would be a good idea going to anderson moores, would like another vets opinion Owner came in tonight. Discussed BT results and suggested treatment by SP. O wondering if would be a good idea to be referred. I agreed it would be a good idea to investigate further so happy to do. Discussed possible cost involved in an internal medical case (from 2K to 4k initially) O rather not be referred at this point.. Will start tx as suggested by SP after all Will ring SP on Tuesday with progress report 04/06/ :19:53 Page 5