ASTOR – 29111

ASTOR – 29111

**NEEDS VET CARE ASAP**

Intake Date: 5/24/18; Intake Type: Stray

Medical Behavior: Green   Sex: Male   Age: 8 years

Weight: 66 lbs

DVM Intake Exam : Estimated age: 8 years  History : stray; trouble urinating per finder  Subjective:  Observed Behavior – friendly  Evidence of Cruelty seen – no  Evidence of Trauma seen – no  Objective : BCS 5/9  EENT: Eyes clear, AU-erythema, mild tan debris, no nasal or ocular discharge noted  Oral Exam: moderate dental calc  pLN: No enlargements noted  H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic  ABD: Enlarged bladder palpated, able to partially express bladder but not in a steady stream  U/G: MI, 2 descended testicles  MSI: Ambulatory x 4, skin free of parasites, approx. 0.5 cm pigmented mass ventral to left eye  CNS: Mentation appropriate – no signs of neurologic abnormalities  Rectal: no enlarged prostate felt, not painful  Assessment : difficulty urinating, enlarged bladder- R/O urolithiasis vs prostatitis vs BPH vs neoplasia vs other
cutaneous mass- R/O benign vs malignant  Prognosis: fair  Plan:  due to concern for partial obstruction, recommend radiographs as soon as possible and placing a urinary catheter if needed  Urinalysis strip (x)  recheck chemistry (x)  start enrofloxacin 272 mg PO SID in case of prostatitis  SURGERY:  Temporary waiver due to urinary tract disease

My medical notes are…

25-May-2018 Vet Notes: Urinalysis strip:  Urine specific gravity; 1.018  pH 7   LEU 100 Leu/microL  PRO 30  GLU neg  KET neg  UBG norm  BIL neg  BLD 250 Ery/microL  hematuria, pyuria- R/O urolithiasis vs urinary tract infection vs other

5-May-2018 Vet Notes: Bloodwork done by LVT on evening of 5/24/18:  CBC:   increased reticulocytes (324 K/microL)  slightly decreased eosinophils (0.07 K/microL)  Chemistry:  increased total calcium 913.7 mg/dL)- R/O R/O hypercalcemia of malignancy vs hypoadrenocorticism vs primary hyperparathyroidism vs nutritional secondary hyperparathyroidism vs osteolytic disease vs other  rest within normal limits

27-May-2018 Progress Exam Vet Notes:   Intake on 5/24- noted to be straining to urinate per finder, intake performed in SIACC 5/25  Urine specific gravity; 1.018  pH 7
LEU 100 Leu/microL  PRO 30  GLU neg  KET neg  UBG norm  BIL neg  BLD 250 Ery/microL  – Started Enrofloxacin 10 mg/kg PO SID

5/26
Lateral AXR shows many small bladder stones with several lodged in urethra at region of proximal aspect of os penis.
– Started on urinary S/o diet

S: BARH. No csvd. Small amount hematuria on bedding. Ate some food. Did urinate on own, but only small amounts. Expressed Bladder this morning- able to produce an intermittent stream and expressed large amount of urine until bladder become small and soft.

Assessment:
1. Urolithiasis- Multiple stones noted in bladder and 2-3 located just proximal to the os penis- partially obstructed. Concern for progression to full obstruction, development of a resistant UTI if stones persist and has to be catheterized multiple times, potential for damage to urethral lining if stones remain within urethra for a prolonged period of time
2- Dermatitis- suspect underlying allergies/atopy, but cannot r/o less likely causes such as parasites (scabies, demodex) vs immune-mediated skin disease vs neoplasia
3. Mass ventral to OS- suspect benign, but cannot r/o malignancy
4. Dental disease
5. Hypercalcemia- r/o if true hypercalcemia (need iCa) vs spurious.

Prognosis: Fair to good with prompt treatment

Plan:
Continue enrofloxacin
Monitor urination closely- palpate bladder and express if needed three times a day. If nothing coming out and bladder is large, inform DVM
Recommend immediate transfer to hospital for cystotomy +/- urethrotomy, urine culture and stone analysis. Recommend getting iCa to verify if calcemia is real.
Added Gabapentin 10mg/kg PO BID x 5 days- for discomfort/mild sedation

SURGERY: Temporary waiver due to urethral obstruction

 

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