CHAMP aka GOOPY – 26244

CHAMP aka GOOPY – 26244

***RETURNED 06/06/18***

Intake Date: 6/06/18   Intake Type: Owner Surrender

Medical Behavior: Blue   Sex: Male   Age: 10 years

Weight: 50.2 lbs

DVM Intake Exam : History : Impounded on 4/26/18, then reclaimed on 5/1/18. Now owner surrender. During previous stay, noted to be thin and having diarrhea. Intake on 6/10, still noted to be thin and having dark brown liquid stools. On board, it was noted that he coughed with small amount of blood noted.
Bloodwork from 4/27/18
CBC:
decreased eosinophils (0.01)
rest within normal limits

Chemistry:
increased ALT (155)
rest within normal limits

6/11- Melena on rectal
Repeat Bloodwork
CBC: Moderate to severe anemia (Hct 15.7%) with mild regeneration (Retic 113.7K), Mild leukocytosis (21.69) with neutrophilia (17.53) and monocytosis (1.63)
Chem: Mild Hypoalbuminemia (2.0), Mild hypocholesterolemia
T4: 1.6
Three view Chest radiographs unremarkable

S: QAR to BARH. No csv. Spots of blood seen in cage. No diarrhea seen today on board or in cage. Eating well.

Objective
R = eupneic
BCS 3/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted

H/L: eupnic
ABD: Non painful, no masses palpated
U/G: intact male with two descended testicles, no discharge
MSI: Ambulatory x 4 though mildly weak in the hindlimbs, skin free of parasites, no masses noted, healthy hair coat, thin body condition
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally- rectal not performed today

PCV: 22%
Saline agglutination negative (micro and macro)
Blood Smear: No spherocytes seen, moderate anisocytosis/polychromasia seen

Assessment
1) Diarrhea/Melena- based on previous notes, age and body condition, suspect this is a chronic condition. Top differentials for chronic diarrhea in an older dog would be pancreatitis vs IBD/lymphoma vs systemic neoplasia. Addisons or renal/liver disease are also possible but considered less likely. Also cannot completely r/o an acute process (dietary indiscretion, stress, infectious). The presence of melena on rectal today is indicative of an upper GI bleed, likely secondary to a chronic GI condition.
2) Thin body condition/emaciated- suspect related to #1 and having a chronic condition such as IBD/lymphoma or neoplasia.
3) Anemia, regenerative- Given the presence of #1, high concern for GI bleed. Other causes for regenerative anemia, such as IMHA (primary v secondary to tick-bourne, neoplasia, vaccines or new medication) vs toxin (heavy metal, though no fb identified on radiographs vs less likely infectious (babesia- not common in this region) cannot be entirely ruled out.
4) Hypoalbuminemia -Given #1, suspect secondary to loss from chronic GI disease (protein-losing enteropathy or PLE), though a negative acute phase response is possible from excessive inflammation. Liver failure is possible (as cholesterol slightly low), though considered less likely as both values are only mildly low.

Prognosis: Guarded to poor

Plan:
Continue TID feedings with I/D, reweigh in one week
Continue Metronidazole 10mg/kg PO BID x 7 days
Continue Probiotic SID x 7 days
Continue famotidine 1 mg/kg PO BID x 7 days
Continue Sucralfate 1g PO BID x 7 days
Needs placement-ASAP

===================================================================

RTO 05/01/18

Intake Date: 4/26/18   Intake Type: Stray

Medical Behavior: Blue   Sex: Male   Age: 10 years

Weight: 54 lbs

DVM Intake Exam; Estimated age: 10 years; Microchip noted on Intake? scan negative; History : stray; Subjective: Observed Behavior – friendly initially but attempted to bite during rectal exam; Objective ; BCS 3-4/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted; Oral Exam: mild dental calc; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic; ABD: Non painful, liver feels enlarged and firm in left cranial abdomen; U/G: MI, 2 descended testicles; MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: limited exam but some blood on glove; Assessment; cranial organomegaly- R/O neoplasia vs other; underweight- R/O GI diseas vs liver disease vs other; bloody diarrhea- R/O GI disease vs other; Prognosis: guarded; Plan: CBC/chemistry tomorrow; SURGERY: Permanent waiver due to age

 

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