KORI – 22775

KORI – 22775

Intake Date : 3/13/18  Intake Type: Owner surrender

Medical Behavior: Green  Age: 9 years  Sex: Female

Weight: 18 lbs

DVM Intake Exam : Estimated age: reportedly 9 years old, age appears consistent with exam  Microchip noted on Intake?  Microchip Number (If Applicable):  History :dog has been urinating blood and owner is unable to afford further vet care  Subjective: QAR/BAR  Observed Behavior -a little shy at first but docile and friendly, warms up quickly  Evidence of Cruelty seen -no   Evidence of Trauma seen -no  Objective : BCS 5/9  EENT: OU-mild nuclear sclerosis (age related change), ears clean, no nasal or ocular discharge noted  Oral Exam:mm pk, moist; underbite; teeth have mild to moderate tartar, staining; appear to have been cleaned at some point  PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic  ABD: Non painful, no masses palpated  U/G: female, suspect spayed, possible palpable spay scar and mammae/vulva very small; hooded vulva with mod irritation-likely secondary to dirty, matted hair coat along hind end; bladder small and non painful, no large palpable bladder stones  MSI:
-mild chronic thickening of L stifle with slightly decreased ROM and mild internal rotation at hip; mild thigh muscle atrophy compared to RH but no lameness noted -moderate matting along rear and hind limbs CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal:grossly normal  Assessment : 1. Hematuria-r/o UTI vs bladder stones vs other  2. L stifle changes, suspect previous injury such as mild cruciate tear or luxating patellar that has resolved but caused mild arthritis  Prognosis:good  Plan:
-CBC/chem  -lateral abdominal rad  -clavamox 125 mg PO BID x 10 days  -carprofen 25 mg PO SID x 5 days  -shave hind end, sanitary clip/clean  SURGERY:suspect spayed

My medical notes are…

3/14/18 : Vet Notes:

Lateral abdominal radiograph-copious amount of ingesta in stomach, intestines appear slightly bunched with mild multifocal gas distension; bladder appears small-mid sized with no obvious radioopaque stones but possible congregation of crystalline debris (may be artifact secondary to overlapping intestines). A-no sign of obvious bladder stones, possible crystals forming  P : -recommend urinalysis with sediment  CBC-moderate neutrophilia (22.92), mild thrombocytosis  Chemistry-WNL  A : 1. Neutrophilia-r/o infection (UTI vs other)

3/15/18 Vet Notes:

Urinalysis shows significant proteinuria, hematuria, increased leukocytes and 1+ ketones; pH 8, BG 101  A : 1. Suspect UTI, ketones likely incidental and of no clinical significance.  h/o hematuria, radiographs showed possible congregration of crystals but no obvious bladder stones; started on clavamox and rimadyl  S/O : -BAR, very friendly and energetic, allows all handling  -great appetite  -mm pk, moist; CRT <2 sec  -no nasal discharge or sneezing  -OU: open and clear  -eupnic  -soft abdomen  -mild chronic changes to L stifle  A : 1. Hematuria-suspect UTI +/- concurrent crystalline debris  2. Geriatric  3. L stifle arthritis, mild  P : -continue clavamox/rimadyl  -if hematuria does not resolve, then consider switching to baytril +/- urine culture  -due to high pH of urine, if crystals are present in urine, they are likely to be struvite which occur in alkaline urine usually secondary to an infection; if persistent urinary signs are noted, then consider prescription urinary diet such as RC SO

 

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