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Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

8/28/2017 TC

VD

MAH Client Communication - TENTATIVE - RECORDS REQUEST

Maricopa Animal Hospital

19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

8/28/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

Client Communication

Time: 5p

Discussion: O called and requested records be sent to jasonprado@live.com. O said they will be in TX for the next couple of months so she is going to find a vet there. Pending DVM approval.

Initials: vj

8/29/17 8:40a Approved per Dr. Larson. Emailed and received okay. vj

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

Maricopa Animal Hospital

Page

1 of 19

Date: 8/29/2017 8:38 AM

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

8/11/2017 C

KL

MAH Client Communication - FINAL 08/11/2017 - Labwork

Maricopa Animal Hospital

19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

8/11/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

2 PM- LMOM for owner to call us back to let us know how Lucy is doing and to make sure they got our message last week. I'm hoping some of the loose stool is starting to clear on the proviable, but call and let us know. Called number 832-231-5124. KL

-411pm- O cb and said that he got our message. P seems to be doing better and gaining weight back. E/d OK, no D+ and has good energy. Let O know thats good. I will give the doctor the update and if she has any additional questions, will give him a cb on Monday. O said OK, thank you. JW.

8/8/2017 C

KL

MAH Client Communication - FINAL 08/08/2017

Maricopa Animal Hospital

19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

8/8/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

5:30 PM-- Called 832-231-5124 - rang twice and no answer and no machine. Will try again tomorrow. KL

8/5/2017 C

KL

MAH Client Communication - FINAL 08/06/2017

Maricopa Animal Hospital 19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

8/5/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

2 PM- Called owner on 8322315124- LMOM for owner to call back Monday to go over results of labwork- things are looking better, but there are still some abnormalities- her liver enzymes are back to normal but her she does still have some anemia. Would like to see how she is doing, if the proviable is helping with the stool any yet, etc. Please call back Monday. KL

8/4/2017 L

MK

Chemistry results from IDEXX Reference Laboratory Requisition

 

ID: 106020421

Posted

Result

30 ug/L

Final

 

Test

Reference Range

SPEC cPL

0 - 200

Ascn: 7901224406

 

8/4/2017 L

MK

Hematology results from IDEXX Reference Laboratory Requisition ID: 106020421

Posted

Final

Test

Result

Reference Range

BASO

0.1 %

EOS

6.7 %

HCT

35.9 % L

38.3 - 56.5

HGB

12.2 g/dL L

13.4 - 20.7

LYMPHS

28.2 %

MCH

25.0 pg

21.9 - 26.1

MCHC

34.0 g/dL

32.6 - 39.2

MCV

74 fL

59 - 76

MONOS

9.7 %

NEUT SEG

55.3 %

PLATELETS

539 K/uL H

143 - 448

RBC

4.88 M/uL L

5.39 - 8.70

RETIC CNT

0.8 %

WBC

17.7 K/uL H

4.9 - 17.6

ABS BASO

18 /uL

0 - 100

ABS EOS

1186 /uL

70 - 1490

ABS LYMPHS

4991 /uL H

1060 - 4950

ABS MONOS

1717 /uL H

130 - 1150

ABS NEUTS

9788 /uL

2940 - 12670

ABS RET

39 K/uL

10 - 110

Ascn: 7901224406 RE: 3180 RETICULOCYTE COMMENT RETICULOCYTE COMMENT A reticulocyte count of greater than 110 K/uL of blood is considered evidence of bone marrow response to an increased peripheral demand. Depending on the degree of anemia, a reticulocyte count <110

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

 

K/uL may indicate an inadequate bone marrow response. Serial monitoring of the erythrogram and reticulocyte count may be useful to evaluate bone marrow responsiveness over time.

The following chart may be used as a guideline to determine appropriateness of regenerative response.

Degree of bone marrow response (K/uL):

Mild 110-150 Moderate 150-300 Marked >300 RE: 3034 REMARKS REMARKS SLIDE REVIEWED MICROSCOPICALLY.

8/4/2017 L

MK

Chemistry results from IDEXX Reference Laboratory Requisition

ID: 106020421

Posted

Final

Test ALB ALKP ALT ANION GAP AST BICARB BUN/UREA Ca Chloride CHOL CREA DBIL GGT GLU IBIL PHOS Potassium TBIL TP TRIG Sodium

Result 2.9 g/dL 128 U/L 90 U/L 17 mmol/L 29 U/L 20 mmol/L 24 mg/dL 9.9 mg/dL 119 mmol/L 104 mg/dL L 1.2 mg/dL <0.1 mg/dL 2 U/L 88 mg/dL 0.0 mg/dL 4.9 mg/dL 5.0 mmol/L 0.1 mg/dL 6.1 g/dL 33 mg/dL 151 mmol/L

Reference Range 2.7 - 3.9 5 - 160 18 - 121 11 - 26 16 - 55 13 - 27 9 - 31 8.4 - 11.8 108 - 119 131 - 345 0.5 - 1.5 0.0 - 0.1 0 - 13 63 - 114 0.0 - 0.2 2.5 - 6.1 4.0 - 5.4 0.0 - 0.3 5.5 - 7.5 20 - 150 142 - 152

A/G Ratio

0.9

0.7 - 1.5

B/C Ratio

20.0

Na/K Ratio

30

28 - 37

GLOB CK

3.2 g/dL 217 U/L H

2.4 - 4.0 10 - 200

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

 

Patient:

Lucy (8601)

   

Phone:

(832) 231-5124

 

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

 

Color:

Sable

   

Date Type

Staff

History

 

SDMA

12 ug/dL

0 - 14

 

Ascn: 7901224406 RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values.

 

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.

8/4/2017 L

MK

UA/Microscopy results from IDEXX Reference Laboratory Requisition ID: 106020421

Posted

 

Final

Test

Result

Reference Range

BACTERIA

NONE SEEN

BILIRUBIN

NEGATIVE

BLOOD

NEGATIVE

CASTS

NONE SEEN

CLARITY

Clear

COLOR

Dark Yellow

CRYSTALS

SEE NOTES

EPI CELL

RARE (0-1)

GLUCOSE

NEGATIVE

KETONES

NEGATIVE

MUCUS

NONE SEEN

PH

6.0

PROTEIN

NEGATIVE

RBC

0-2 HPF

SP GRAVITY

1.041

UROB

NORMAL

WBC

0-2 HPF

0

- 5

Ascn: 7901224406 RE: 900 COLLECTION METHOD CYSTOCENTESIS

OCCASIONAL AMMONIUM MG PHOSPHATE (0-1)/HPF Protein test is performed and confirmed by the sulfosalicylic acid test.

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

8/3/2017 C

MK

Quick Recheck - FINAL 08/03/2017

Recheck

_Here for recheck. She is doing better, she has gained weight. No v/d or c/s. E/d is normal and energy level

is back to normal. She is still on the Denamarin and she finished the Clavamox. Soft formed stools, flatulent, mm-pale/tacky, BCS 3/9_

Recommendations

Discussed soft stool and flatulence may be results of bacterial imbalance due to abx or original illness not resolved. Adult screen with spec cPL to Idexx - will call with results Consider testing for addisons, cobalmin/folate?, and consider need for prescription diet after bldwk review, but would not expect addisons to change liver function per bile acids results. Recommend ultrasound if bldwk values not improved or resolved.

Tgh with Proviable as directed - see rx

tech initials: ja

Doctor: Monica Kimber, DVM

8/3/2017

P

MK

1.00 bottle of Proviable DC Caps 80 Cap Btl (1407) Rx #: 73019 Exp. 12/31/18 0 Of 0 Refills Filled by: JA Give 1 capsule by mouth once daily. Seems to be doing a bit better. O is running late. mf Reason for Visit: Recheck Date Patient Checked Out: 08/03/17 Practice 0 Aug 3, 2017 04:22 PM Staff: KL

8/3/2017

CK

KL

8/3/2017 V

KL

 

------------------------------

Weight

: 15.40 pounds

8/3/2017 T

JW

Image: Estimate Callback - Callback Reminder (CBACK) ---- Note from Jamie N. Wells on 7/28/2017 at 09:48:38 ---- Called to check in on P. O says seems to be doing a bit better, is putting on weight again. Let O know about recheck, O scheduled for Wednesday.

7/28/2017

CB

SW

7/18/2017 C

SW

MAH Client Communication - FINAL 07/19/2017

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

Maricopa Animal Hospital

19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

7/18/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

How is P doing? Ps lepto test came back negative which is really good. The bile acids were moderately elevated which is consistent with some liver dysfunction but not bad enough to be a shunt. Would need ultrasound to confirm that, can refer to imaging specialist for that. If P is doing good/seems to be improving, recommend continuing on medication and rechecking in 2 weeks. SW

4:10pm Called and lmom stating above info. Asked O to give us a call back to let us know they got our message. ja

7/14/2017 T

MF

Image: Estimate/Admissions

7/14/2017

P

SW

1.00 bottle of Denamarin 225mg Chew Tabs (1403) Rx #: 72459 Exp. 02/28/19 0 Of 0 Refills Filled by: FR Give 1/2 tablet by mouth every 24 hours.

7/14/2017

P

SW

Give on an empty stomach 1 hour before a meal. 30.00 tablet of Clavamox 62.5 mg tablets (OM015) Rx #: 72458 Exp. 06/30/18 0 Of 0 Refills Filled by: FR Give 1 1/5 tablets by mouth every 12 hours till gone.

Give on a full stomach

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

7/14/2017 C

SW

MAH Client Communication - FINAL 07/15/2017

Maricopa Animal Hospital

19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

7/14/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

Client Communication

Here for a consultation, & drop off for bile acids testing.

Time: 10:00

Discussed with O about Ps bloodwork. Repeated previous client communication discussion of recommendations

1. Bile acids test. Explained that this is a liver function test and will help us rule in/out if P has an underlying genetic

condition called a liver shunt. Since P is younger, this is a possibility, but not very high chance.

2. Referral to imaging specialist in Gilbert for ultrasound. Recommend this to help get better idea of what exactly is going

on in liver.

3. Recommend starting on abx and liver protectant (Denamarin), in order to treat any possible infection. Would recommend

doing this no matter what follow-up diagnostics want to pursue.

4. Lastly would recommend checking for disease called leptospirosis. It affects the liver and is bad because it can actually

be transmitted to humans so we would be checking for it just to be safe.

O asked where would recommend starting cost-wise. Recommend abx and denamarin, then bile acids test. Explained concern for leptospirosis, would be good to have that test done as well since it is a human health hazard. Depending on the answers from the followup diagnostics, may need to pursue further imaging at specialist. O would like to do bile acids and lepto PCR today. P has been fasted for 12 hrs.

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

Discussion: Bile acids pre- drawn at 10:35 am, also drew blood for the Leptospira real PCR test- told owner it takes 1-3 days for results to come back- will call when they come in. Feed Science Diet Low Fat I/D Post bile acids drawn at 12:35 pm- Idexx pending- will call owner with results TGH- Clavamox & Denamarin- See Rx Also let O know that valley fever titer was negative.

Initials: FR

7/14/2017

CK

SW

Reason for Visit: Consultation

7/14/2017 V

SW

Date Patient Checked Out: 07/14/17 Practice 0 Jul 14, 2017 09:48 AM Staff: SW

 

------------------------------

Weight

: 13.20 pounds

7/14/2017 L

SW

Chemistry results from IDEXX Reference Laboratory Requisition

ID: 105701419 Test BILE ACIDS BILE ACPP

Posted

Result 54.3 umol/L H 25.1 umol/L H

Ascn: 7901201846

Final Reference Range 0.0 - 6.9 0.0 - 14.9

TUBE ORDER AND LABELED DRAW TIMES RECHECKED RESULT VERIFIED BY REPEAT ANALYSIS Elevated pre or post-prandial bile acids are suggestive of decreased liver function, but do not indicate the nature of the abnormality or whether the problem is reversible or permanent. Normal bile acids do not rule out the presence of hepatic disease. Mild elevations (15-30) may also be seen with extrahepatic diseases (e.g. small intestinal bacterial overgrowth (SIBO), hyperadrenocorticism, etc.) If clinical signs and other diagnostic findings are suggestive of primary liver disease, consider additional diagnostics to further evaluate the liver, including repeat bile acids panel in 2 to 4 weeks. Moderate to severe elevations (>30) are consistent with hepatic dysfunction, but cannot discriminate specific liver diseases or the

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

 

relative severity of liver disease. Additional diagnostics (e.g. ultrasound and/or liver biopsy) are recommended to further classify the disease process. Note: If the serum bilirubin concentration is elevated or the animal is icteric, there is little additional diagnostic value in performing a bile acids test. RESULT VERIFIED BY REPEAT ANALYSIS

7/14/2017 L

SW

Miscellaneous results from IDEXX Reference Laboratory Requisition ID: 105701419

Posted

Final

Test

Result

Reference Range

LEPTO BLD

NEGATIVE

LEPTO UR

NEGATIVE

Ascn: 7901201846

A POSITIVE LEPTOSPIRA RESULT indicates that DNA from

pathogenic Leptospira was detected in the sample(s) submitted. In animals with clinical signs this supports infection. Acute infection causes anorexia, fever, lethargy with laboratory parameters indicating organ injury in kidney, muscle, pancreas, and/or liver. Leptospira positive urine samples have to be considered a source of infection for other animals and humans.

A NEGATIVE LEPTOSPIRA RESULT indicates that Leptospira DNA

was not detected in the sample(s) submitted. However, a negative PCR result may be caused by the numbers of organisms being below the limit of detection, decreased numbers of organisms following treatment or chronic carrier state, or the occurence of new strain variations.

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

7/13/2017 C

VD

EMAIL SENT - CLOSED 07/20/2017

EMAIL SENT

Sent over discussion notes from Dr. Woods. vj

7/13/2017 C

SW

MAH Client Communication - FINAL 07/13/2017

Maricopa Animal Hospital

19950 N. John Wayne Pkwy P.O. Box 129

Maricopa, AZ

85139

(520) 568-2224

Client Communication

7/13/2017

Client ID:

4591

Patient ID:

8601

Client

Jason Prado

Name:

Lucy

Name:

Address:

20261 N. Herbert Ave.,

Species:

Canine - Corgi

Maricopa, AZ 85138

Sex:

Female

Telephone:

(832) 231-5124

Color:

Sable

 

Markings:

Birth Date:

8/10/2016

Client Communication

Time:

10:31am

Discussion:

Called and tto about Ps bloodwork resutls. Explained that Dr Larson is out of town and so I will be taking over Ps case for

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

her. Went over elevations in liver enzymes and anemia. Explained that we are worried about Ps liver, possibly an infection. Couple options for next steps,

1. Bile acids test. Explained that this is a liver function test and will help us rule in/out if P has an underlying genetic

condition called a liver shunt. Since P is younger, this is a possibility, but not very high chance.

2. Referral to imaging specialist in Gilbert for ultrasound. Recommend this to help get better idea of what exactly is going

on in liver.

3. Recommend starting on abx and liver protectant (Denamarin), in order to treat any possible infection. Would recommend

doing this no matter what follow-up diagnostics want to pursue.

4. Lastly would recommend checking for disease called leptospirosis. It affects the liver and is bad because it can actually

be transmitted to humans so we would be checking for it just to be safe. O asked if these could be done in one test. Let O know we could add on the Lepto to the bloodwork already sent to the lab, but the bile acids are a separate test. We fast them for 12 hrs, then take a sample, then feed them, then four hours later take another sample. This helps evaluate if the liver is able to clear the byproducts of food breakdown and assess the liver function. O asked if we could email him this and then if he could come down with P and go over it and decide what to do. Told O that was fine, can definitely do that. Email: jasonprado@live.com Scheduled for consultation tomorrow at 9: 45 am

Initials: SW

7/12/2017 L

KL

SNAP Assays results from IDEXX VetLab In-clinic

 
 

Laboratory Requisition ID: 5724

Final

Test

Result

Posted Reference Range

HW =

Negative

Lyme =

Negative

AP_spp =

Negative

EC-EE =

Negative

7/12/2017 T

VD

Image: Estimate 15.00 mL of Panacur 100mg/ml (AP025) Rx #: 72393 Exp. 10/31/18 0 Of 0 Refills Filled by: ML Give three (3) mls by mouth once (1) a day for 5 days.

 

7/12/2017

P

KL

7/12/2017 C

KL

SOAP new - FINAL 07/14/2017

 

SUBJECTIVE/HISTORY

Here for exam. Owner said that he has noticed wt loss with in the last 3 weeks. Owner went out of town and came

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

back and noticed the difference. Still e/d-good, no v/c/s. A little bit of soft stool. They did change her diet, its still puppy food. Decrease in energy. Is current on vx through vet in CA, owner didnt bring paperwork. Owner said that he doesnt think she had a stool check done. Had a heat cycle in Diet: blue buffalo puppy

Current Medications/Supplements: none

Vx Hx: current on vx through vet in CA-owner didnt bring paperwork.

Attitude: _QAR_

OBJECTIVE/EXAM

Technician's initials: {ML}

T: 101.4

P: 160 R: pant.

MM: pink

CRT: <2

BCS: _4/9_

Oral: wnl Ophthalmic: wnl Otoscopic: wnl Coat/Skin: wnl Respiratory: wnl Cardiovascular: wnl Abdominal: wnl M/S: wnl Neuro: wnl Lymph nodes: wnl Other:

ASSESSMENT

_Weight loss/slight lethargy- intestinal parasites, bacterial, fungal, viral, rickettsial, renal, open_

Prognosis: fair-good

PLAN

Discussed with owner that overall pet does seem a bit more relaxed than typical corgi pup. And if she has been losing a bit of weight there are concerns. Is possible she could have intestinal parasites- asked owner if her stools are loose- per owner they are occassionally a little loose but they recently changed her diet so think it is from that. Recommend checking a fecal and checking bloodwork. Discussed VF, TF, intestinal parasites, or other possible causes of weight loss. HW4DX- negative all four Fecal and cocci profile to Idexx- will call with results. Recommend going ahead and doing a dewormer for pet even if fecal comes back negative. TGH with panacur as directed. See Follow up: _pending labwork _

Doctor: Kelly Larson, DVM

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

7/12/2017

CK

KL

LMOM to confirm appt. Reason for Visit: Appointment

 

7/12/2017 V

KL

Date Patient Checked Out: 07/12/17 Practice 0 Jul 12, 2017 01:53 PM Staff: KL

 

------------------------------

Weight

: 13.00 pounds

7/12/2017 L

KL

Hematology results from IDEXX Reference Laboratory Requisition ID: 105665235

Posted

Final

Test

Result

Reference Range

BASO

0.1 %

EOS

13.9 %

HCT

37.6 % L

38.3 - 56.5

HGB

12.5 g/dL L

13.4 - 20.7

LYMPHS

31.0 %

MCH

24.8 pg

21.9 - 26.1

MCHC

33.2 g/dL

32.6 - 39.2

MCV

74 fL

59 - 76

MONOS

5.5 %

NEUT SEG

49.5 %

PLATELETS

354 K/uL

143 - 448

RBC

5.05 M/uL L

5.39 - 8.70

RETIC CNT

0.9 %

WBC

14.8 K/uL

4.9 - 17.6

ABS BASO

15 /uL

0 - 100

ABS EOS

2057 /uL H

70 - 1490

ABS LYMPHS

4588 /uL

1060 - 4950

ABS MONOS

814 /uL

130 - 1150

ABS NEUTS

7326 /uL

2940 - 12670

ABS RET

45 K/uL

10 - 110

Ascn: 7901201384 RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on

chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. Ascn: 7901201384 RE: 3034 REMARKS REMARKS SLIDE REVIEWED MICROSCOPICALLY. REACTIVE LYMPHOCYTES PRESENT

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

7/12/2017 L

KL

Chemistry results from IDEXX Reference Laboratory Requisition

ID: 105665235

Posted

Final

Test ALB ALKP ALT AMYL ANION GAP AST BICARB BUN/UREA Ca Chloride CHOL CREA DBIL GGT GLU IBIL LIPA PHOS Potassium TBIL TP Sodium

Result 3.1 g/dL 229 U/L H 794 U/L H 421 U/L 13 mmol/L 40 U/L 22 mmol/L 9 mg/dL 10.5 mg/dL 111 mmol/L 104 mg/dL L 0.7 mg/dL 0.1 mg/dL 5 U/L 100 mg/dL 0.1 mg/dL 84 U/L L 5.2 mg/dL 4.8 mmol/L 0.2 mg/dL 5.6 g/dL 141 mmol/L L

Reference Range 2.7 - 3.9 5 - 160 18 - 121 337 - 1469 11 - 26 16 - 55 13 - 27 9 - 31 8.4 - 11.8 108 - 119 131 - 345 0.5 - 1.5 0.0 - 0.1 0 - 13 63 - 114 0.0 - 0.2 138 - 755 2.5 - 6.1 4.0 - 5.4 0.0 - 0.3 5.5 - 7.5 142 - 152

A/G Ratio

1.2

0.7 - 1.5

B/C Ratio

12.9

Na/K Ratio

29

28 - 37

GLOB CK SDMA

2.5 g/dL 116 U/L 19 ug/dL H

2.4 - 4.0 10 - 200 0 - 14

Ascn: 7901201384 RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. Ascn: 7901201384 RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values.

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

 

SDMA IS INCREASED AND CREATININE IS WITHIN THE REFERENCE INTERVAL. IDEXX SDMA Test is a more reliable indicator of kidney function than creatinine because SDMA detects declining kidney function earlier and is not impacted by muscle mass. Creatinine can miss early function loss and be falsely decreased in patients with poor muscle mass. SDMA increases in acute and active injury as well as chronic kidney disease. A complete urinalysis should be performed to evaluate for inappropriate specific gravity, proteinuria and other evidence of kidney disease. If SDMA is 15-19 ug/dL and there is other evidence of kidney disease, action should be taken. If SDMA is 15-19 ug/dL with no other evidence of disease, recheck in 2-4 weeks. If SDMA &#8805;20 ug/dL or is persistently 15-19 ug/dL, regardless of whether there is other evidence of kidney disease, action should be taken. For information on recommended actions visit:

www.idexx.com/SDMAalgorithm Note: In puppies, SDMA reference interval is 0-16 ug/dL. SDMA reference interval studies are underway for kittens and Greyhounds, and results should be interpreted in light of other findings.

7/12/2017 L

KL

Endocrinology results from IDEXX Reference

Laboratory Requisition ID:

105665235

Posted

Final

Test

Result

Reference Range

T4

2.3 ug/dL

1.0 - 4.0

Ascn: 7901201384 RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. Ascn: 7901201384

Interpretive ranges:

<1.0

1.0-4.0 Normal

Low

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

 

>4.0 High 2.1-5.4 Therapeutic Dogs with no clinical signs of hypothyroidism and results within the normal reference range are likely euthyroid. Dogs with low

T4

concentrations may be hypothyroid or euthyroid sick . Occasionally, hypothyroid dogs can have T4 concentrations that are low normal. Dogs with clinical signs of hypothyroidism and low or low normal

T4

concentrations may be evaluated further by submission of free T4 and canine TSH. A high T4 concentration in a clinically normal dog is likely variation of normal; however elevations may occur secondary to thyroid autoantibodies or rarely thyroid neoplasia. For dogs on thyroid supplement, acceptable 4-6 hour post pill total T4 concentrations generally fall within the higher end or slightly above the reference range.

7/12/2017 L

KL

Immunology results from IDEXX Reference Laboratory Requisition ID: 105665235

Posted

Final

 

Test

Result

Reference Range

COCCI IGG

NEGATIVE

COCCI IGM

NEGATIVE

IMMUN DIFF

NOT INDICATED

Ascn: 7901201384 RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. Ascn: 7901201384

7/12/2017 L

KL

Microbiology results from IDEXX Reference Laboratory Requisition ID: 105665235

Posted

Final

 

Test

Result

Reference Range

OVA&PARA Ascn: 7901201384

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs

 

Patient History Report

 

Client:

Prado, Jason (4591)

Patient:

Lucy (8601)

Phone:

(832) 231-5124

Species:

Canine

Breed:

Corgi

Address:

20261 N. Herbert Ave.,

Age:

12 Mos. 2 Wks. 5 Days

Sex:

Female

 

Maricopa, AZ 85138

Color:

Sable

   

Date Type

Staff

History

RE: 281 HEMOLYSIS INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. RE: 282 LIPEMIA INDEX N Index of N, 1+, 2+ exhibits no significant effect on chemistry values. Ascn: 7901201384

OVA & PARASITES NO OVA OR PARASITES SEEN In cases of acute or chronic diarrhea in addition to a fecal floatation and antigen testing for ova and parasites consider testing for viral, bacterial and protozoal infectious agents using RealPCR (canine diarrhea panel: test code 2625; feline diarrhea panel: test code 2627).

B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs