Please see his medical records below. Some of the formatting got lost in the scanning
Emergency Pet Clinic, INC 8503 Broadway Suite 105 San Antonio, TX 78217 (210) 822-2873
CLIENT DISCHARGE INSTRUCTIONS
Referring Veterinary Hospital:
No Regular Veterinarian Chosen At This Time Client Information:
LaTrenda (#60186)
Patient Information:
Rodney (#207827)
Bull Terrier, Brown/White male intac tAge: 6 months
Discharge Instructions: -DIAGNOSIS:
Parvoviral gastroenteritis with the complication of facial and muzzle swelling from allergic reaction to medications vs an occult infection which we have not been able to diagnose.
CASE SUMMARY:
We provided aggressive intravenous fluid therapy, broad-spectrum antibiotic therapy, nutritional support, anti-emetic drugs to control vomiting, and drugs to reduce stomach acid production.
We have recently added antihistamines, steroids and discontinued the previous medications given by injection in case these caused the reaction. The swelling of the facial area had occurred prior to the administration of the Fresh Frozen Plasma (FFP).
Rodney has improved and is stable for discharge.
MEDICATIONS:
Antibiotic: TribrissenlDitrim Suspension 48mg/ml -- give 4 mls by mouth every 12 hours for 10 days. Next dose is due at 10 PM tonight.
Rx: Panacur 15ml: Give 5cc orally every 24 hrs for three days. The first dose was given yesterday at so the next dose will be due at 8 PM tonight. This must be repeated in three weeks so be sure and have this done at your veterinarian's clinic.
Antacids: Pepcid AC (Famotidine 10 mg tablets)-- give 1/2 tablet every 12 hours for 10 days. The last dose was given at 1 PM this afternoon.
FOOD AND WATER:
Offer boiled chicken breast that is skinless and boneless and unseasoned with boiled white rice every 3-4 hours during the day for the next 2-3 days. If no vomiting is noted and your pet continues to improve, gradually mix in a premium puppy food over the following 2-3 days before going to a normal feeding routine.
Offer fresh water at all times, however, make sure that Rodney does not over-drink at anyone time.
ACTIVITY/EXERCISE:
Restrict activity for the next 7 days. Do not allow loose running or active play. Supervise walks outside to ensure Rodney doesn't eat grass or other items.
SPECIAL CARE INSTRUCTIONS:
The diarrhea will take several days to completely resolve. Daily, the feces should be firmer and you should not notice blood or loose stools. Continued vaccinations are important, as your pet remains at risk for infection with other common viruses.
If you have other puppies or unvaccinated dogs in the house, we recommend you have them examined by your veterinarian. We recommend you disinfect any toys, feed bowls, and the premises with a dilute bleach solution (1 part bleach to 30 parts water) to kill the virus.
Flies are major carriers of Parvovirus which can last up to 1 year in the environment by landing on feces and spreading the virus which can be shed for up to 3 weeks after Rodney retwrning home. Thus, immediately pick up the stool and bag and discard to limit the spread of Parvovirus.
RECHECK INSTRUCTIONS:
We have examined and treated your pet on an emergency basis only. This is not a substitute for the care provided by your family veterinarian.
Rodney should be dewormed and vaccinated as per your regular veterinarian in the next 5-7 days as per his clinical course. Please contact your regular veterinarian and schedule follow-up care.
EMERGENCY CARE INSTRUCTIONS: Seek immediate veterinary care if any of the following clinical signs are noted: vomiting, diarrhea that is not improving daily or persists more than 3 days, inappetance, weakness or collapse. Rodney's facial and muzzle swelling should improve daily--if this is not occurring, or if the swelling becomes painful or shows signs of infection--redness, pain, discharge, then recheck promptly.
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Emergency Pet Clinic, INC 8503 Broadway Suite 105 San Antonio, TX 78217 (210) 822-2873
MEDICAL RECORD
Referring Veterinary Hospital:
No Regular Veterinarian Chosen At This Time Client Information:
LaTrenda I1U k (#60186) • ~t
:::zr i i !39
home (£ I d F15,work
6 months
Patient Information:
Rodney (#207827)
Bull Terrier, Brown/White male intactAge:
6-10-2009 7:31 PM - Presenting Complaint I Emergency Pet Clinic Staff Patient presented to EPC Broadway at 07:29 PM on Wednesday, June 10, 2009.
shocky, bleeding rectally, urinating on self. found at 3Vaccination Status: Not Current
Food Allergies: None
Medication Allergies: None
Current on Heartworm Preventative: Not Current Currently on any Medications: No
Preexisting Medical Problems: No
CPR instructions: Perform CPR
Other Comments:
on side of road
6-10-20097:44 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC
Hematology Data (ILe) (June 10,200907:44 PM)
32-55 (%)
I
4.7-8.5 (MflJL)
I
10.3-18 (OiDL)
I
60-77 (FL)
I
14.7-17.9 (%)
I
30-37.5 (OiDL)
18.5-30 (PO)
I
175-500 (KflJL)
I
Test Result
V\I!3C (-) 0.65
LYM (=) 0.44
MONO (=) 0.07
NEU (=) 0.12
Eosinophils (=) 0.02
BASO (=) 0.01
LYM% (=) 67
MONO% (=) 11.1
NEU% (=) 18.3
EOS% (=) 2.9
BASO% (=) 0.7
HCT (=) 42.7
RBC (=) 5.95
HOB (*) 15.9
RETIC (=) 7.7
RETIC% (=) 0.1
MCV (=) 71.7
ROW(=) 16
MCHC (=) 37.3
MCH (=) 26.74
PLT(=) 264
MPV (=) 9.96
PCT (=) 0.3
PDW(=) 18.9
Hgb sheath timing variability.
FI(lq
l l l l l
Normal Ranqs
5.5-16.9 (KflJL) 0.5-4.9 (KflJL) 0.3-2 (KflJL) 3-12 (KflJL) 0.1-1.49 (KflJL)
0-0.1 (KflJL)
In d i cater
I I I
I I
II I
I I
I I
6-10-20097:46 PM - History I Greg Lisciandro, DVM, DABVP, DACVECC --Temp: 105.1
HR: 200
RR: 40
WT: 9.2 kg ; •• c.otrc.c,\
Found on side of road, spoke to who said treat pet knowing no guarantees, that will
spend 500$ immediately, that will be 800$ ball park figure overnight, still needs 3-5 days, probably closer to 5 days with approx 85% chance of survival, very shocky at this time and needs aggressive resuscitation efforts as top RIO is Parvo. Said will get back to us, approves and left credit card with receptionist.
6-10-20097:49 PM - Physical Examination I Greg Lisciandro, DVM, DABVP, DACVECC
--Appearance: recumbent and poorly responsive, obtund to stuporous
--Body condition score: 4-5 (live fleas)/9
--Eyes Ears Nose and Throat: drooling
--Cardiovascular: 200 with barley palpable pulses
--Mucus membrane color: light pink
--CRT: < 1.5 sec
--Respiratory: clear to harsh
--Gastrointestinal: soft to tenses, ropy GI loops, has Parvo D pouring out from anus
--Digital Rectal exam: NE
--Musculoskeletal: recumbent--see above, BCS
--Neuro:see above
--Urol: No significant findings
--Integ:see MS/BCS
--Repro: MI
--Lymph: No significant findings
--Hydration Status: 5-7% dry
6-10-20097:50 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC
i-STAT, Parvo Cite, ALB, Fecal.,l ••
Parvo Cite: positive ~U~ - Ie «'\ <
6-10-2009 7:50 PM~ Assessment I Gre Lisciandro DVM DABVP DACVECC
---Approx 3 month MI I found on side of road approx 1 hour ago, recumbent, brought in by good
Samaritan and ~ £who accepted financial responsibility as noted above in History.
Parvo Cite positive c."",
Severe leukopenia with normal PCV and ALB on admission High fever
Collapse and hypovolemic shock Mild metabolic acidosis Hypoglycemia
Bloody D
6-10-20097:52 PM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC ---STAT bolus 300 ml LRS within first hour, 2/3 in first 15 minutes, then to 60 ml/hr then according to clinical course, HES bolus 45 ml then to 8 mllhr, Na Ampicillin 200 mg IV q 8 hours, Baytril 95 mg IV slow q 24 hours, NPO, Famotidine 5 mg SQ. NPO, soft E Collar.
6-10-20097:56 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Glucose: 35 mg/dL (60 - 115)
BUN: 37 mg/dL (10 - 26)
Sodium: 135 mmol/L (142 - 150)
Potassium: 3.4 mmol/L (3.4 - 4.9)
Chloride: 104 mmol/L (106 - 127)
TC02: 18 mmol/L (17 - 25)
Anion Gap: 18 mmol/L (8 - 25)
HCT: 43% (35 - 50%)
Hb: 14.6 g/dl (12 - 17)
pH: 7.364 (7.35 - 7.45) venous pC02: 30.3 (35 - 38)
HC03: 17.3 mmol/L (15 - 23) BE: -8 mmol/L (-4 to 0)
PCV: 46 %
TS: 6.0 g/dL plasma clear
ALB:2.6g/dl
6-10-20098:00 PM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC --Bolused 50% dextrose diluted 10 ml IV approx 10-15 minutes ago as soon as got i-STAT.
6-10-20099:24 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC --In sternal and looking around in cage, responded favorably to shock therapy.
6-10-20099:36 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC --Call La Trenda and left mesage re-iterating as discussed above regarding cost of care, ave stay in hosp, that responded favorably to our efforts, call to let us know got message and what plan is in the morning.
La Trenda called back approx 30 minutes later and updated and elects to keep Rodney (his given name) here for continued care--may have benefactors call and pay for care by credit card over the phone.
\no~ co.'~
6-10-20099:42 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Fecal Direct: Cocci ++, Rods ++
Fecal Float: Negative
6-11-20095:29 AM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Glucose: 120 mg/dL (60 - 115)
BUN: 10mg/dL (10-26)
Sodium: 136 mmoliL (142 - 150)
Potassium: 4.2 mmoliL (3.4 - 4.9)
Chloride: 112 mrnol/l, (106"- 127)
TC02: 19 mmol/L (17 - 25)
Anion Gap: 10 mmol/L (8 - 25)
HCT: 27% (35 - 50%)
Hb: 9.2 g/dl (12 - 17)
pH: 7.327 (7.35 - 7.45) venous pC02: 34.3 (35 - 38)
HC03: 18.0 mmol/L (15 - 23) BE: -8 mmol/L (-4 to 0)
PCV: 34 %
TS: 4.2 g/dL
6-11-2009 7:08 AM - Progress Notes I Susan Leonard, DVM
--Rodney is quiet, lethargic. MM pink. CRT < 2sec. Abdomen is palpable but uncomfortable with nausea response. Hydration is improved, but still assess at 5-7% dehydration. We have continued IV fluids and supportive care as planned by Dr Lisciandro.
6-11-2009 7:09 AM - Treatment I Susan Leonard, DVM --3am: 200mg Na ampicillin IV
6-11-2009 9:28 AM - Physical Examination I James McLean, DVM Presentation: Extremely depressed but responsive when spoken to.
EENT: WNL. No ocular or nasal discharge bilaterally.
CV: WNL. NR/R. No murmurs. Strong pulses.
MM: Pink.
CRT: < 2 sec.
Resp: WNL. No harsh sounds or crackles bilaterally.
GI: NSF on abdominal palpation. No pain. Hypersalivation (nausea). Regurgitated a bit when abdomen was palpated.
Digital Rectal exam: WNL. MIS: WNL.
Body condition score: 2.5-3/9.
Neuro: WNL. No neurologic signs other than depression. Urol: No palpable bladder. No pain.
Integ: WNL.
Repro: WNL. Intact. Lymph: WNL.
Hydration Status: Approx. 5% dehydrated. Additional Information:
6-11-20099:40 AM - Progress Notes I James McLean, DVM Rodney had some bloody diarrhea.
6-11-2009 4: 14 PM - Progress Notes I James McLean, DVM Rodney vomited. His mental status has not changed.
6-11-2009 5:06 PM - Progress Notes I James McLean, DVM Rodney had bloody diarrhea.
6-11-20096:53 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC
Hematology Data (ILC) (June 11,2009 06 :53 PM)
Test
Result
Flaq
Normal Ranqe
Indicator
I/IiBC (*)
0.57
L
5.5-16.9 (KI\,JL)
I
I
I
LYM (=)
0.45
L
0.5-4.9 (KI\,JL)
I
I
MONO (=)
0.08
L
0.3-2 (KI\,JL)
II
I
NEU C*)
0.03
L
3-12 (f{I\,JL)
I
I
I
Eosinophils (*)
0.01
L
0.1-1.49 (KI\,JL)
I
I
BASO (=)
0
0-0.1 (KI\,JL)
I
LYM% (*)
79.5
I
MONO% (')
13.8
I
NEU% (*)
5.4
I
EOS% (0)
1.3
I
BASO% (0)
0
I
HCT C=)
33.4
32-55 C%)
II
I
I
RBC (=)
4.64
L
4.7-8.5 (MI\,JL)
I
HGB CO)
12
10.3-18 (GiDL)
I
I
RETIC (=)
9.7
I
RETIC% (=)
0.2
I
MCV (=)
72.1
60-77 (FL)
I
I
RDW(=)
16
14.7-17.9 (%)
I
I
MCHC (=)
35.8
30-37.5 (GiDL)
I
I
MCH (=)
25.83
1 8.5-30 CPG)
I
I
PL T C=)
141
L
175-500 (KI\,JL)
II
I
MPV (=)
10.6
I
I
PCT (=)
0.1
I
I
PDW(=)
20.5
I
I
Differential algorithm issues. Confirm with blood film.
Hgb sheath timing variability.
6-11-20097:03 PM - Physical Examination I Greg Lisciandro, DVM, DABVP, DACVECC
--Appearance: O-subdued
--Body condition score: no change/9
--Eyes Ears Nose and Throat: drooling slightly
--Cardiovascular: 132 no murmur and PSS to fair and synch
--Mucus membrane color: Pink
--CRT: < 1.5 sec
--Respiratory: slight harsh
--Gastrointestinal: soft, ropy loops
--Digital Rectal exam: NE, has watery bloody D dripping form perineal area
--Musculoskeletal: ambuatry but prefers to lie in sternal, Ive right front day #2, OK
--Neuro:see above
--Urol: No significant findings
--Integ:see MS, fleas and ticks, repeated Frontline
--Repro: No significant findings
--Lymph: No Significant findings
--Hydration Status: Normal
6-11-20097:04 PM - Treatment! Greg Lisciandro, DVM, DABVP, DACVECC --Applied Frontline for fleas and ticks, reduced fluid rate at 9am to 35 mllhr, HES continues at 8 ml/hr.
6-11-20097:39 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC ALB: 1.6 g/dL (2.1 - 3.6)
?
6-11-20097:46 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Glucose: 116 mg/dL (60 - 115)
BUN: 7 mg/dL (10 - 26)
Sodium: 134 mmol/L (142 - 150) Potassium: 3.9 mmollL (3.4 - 4.9) Chloride: 111 mmol/L (106 - 127) TC02: 17 mmol/L (17 - 25)
Anion Gap: 11 mmol/L (S - 25) HCT: 2S% (35 - 50%)
Hb: 9.5 g/dl (12 - 17)
pH: 7.3S5 (7.35 - 7.45) venous pC02: 27.2 (35 - 3S)
HC03: 16.6 mmol/L (15 - 23) BE: -S mmol/L (-4 to 0)
PCV: 32 %
TS: 4.0 and clear g/dL
6-11-20099:18 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC --Depressed but stable, has had some V and bloody D past 2 hours, continuing with same plan.
6-11-2009 9:20 PM - Assessment I Greg Lisciandro, DVM, DABVP, DACVECC -----Approx 3 month MI Bull Terrier found on side of road approx 1 hour ago, recumbent, brought in by good Samaritan and contacted La Trenda who accepted financial responsibility as noted above in History.
Parvo Cite positive
Severe leukopenia--persists with little change at 24-hours post-admission High fever--resolving, low grade fever low 103 range through the day Collapse and hypovolemic shock-resolved--remains depressed
Mild metabolic acidosis--persistent
Hypoglycemia-resolved and has 5% dextrose in fluids
Bloody D--more watery
Vomiting intermittently
Normal ALB on admission, now hypo ALB at 1.6 R/O dilutional as well as GI loss Fleas and ticks--treated with Frontline
Mild non-regenerative anemia (PCV: 30%)--R/O from dilution vs GI loss vs both
Will taper back fluids and continue HES 24-hour CRI at S mllhr
Weight has increased from 9.2 kg to 10 kg --need to watch for over hydration/edema especially with low ALB (1.6)--no signs at this time.
6-11-200910:57 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC
--Little change in status, remains depressed but stable.
6-11-2009 11 :57 PM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC --Na Ampicillin 200 mg IV q S hours (11 am-7pm-3am), Baytril (day 3) 95 mg IV slow q 24 hours, Famotidine 5 mg SQ q 12 hours (11 am-11 pm), HES at S ml/hr, LRS with 5% dextrose and 20 meqKCLlL at 35 ml/hr, i-STAT, ALB, CBC q 24 hours in evenings if stable.
6-12-20093:00 AM - Treatment I Susan Leonard, DVM
--200mg Na ampicillin IV and continuing IV LRS 5% dextrose with 20meq KCLlliter at 35mllhr and hetastarch at Sml/hr.
6-12-2009 4:56 AM - Progress Notes I Susan Leonard, DVM
--Rodney is quiet, but responsive. MM pink. CRT< 2sec. Hydration is much improved over the past 24 hr ( adequate at this time). No vomiting since Spm last night. Still passing diarrhea but not as much as 24 hrs ago. Abdomen is softer, less painful with no regurgitaion when palpated at this time. Fever remains low level.
We are continuing fluid therapies, antibiotics, H2 blockers and supportive carel monitoring as previously outlined.
6-12-20097:55 AM - Progress Notes I Susan Leonard, DVM
--Rodney's owner called and was updated for ongoing care. Rodney is improved and fever is continuing to drop. Owner will call and check on Rodney later today.
6-12-20099:39 AM - Physical Examination I James McLean, DVM Presentation: Depressed but much more responsive than yesterday.
EENT: WNL. No ocular or nasal discharge bilaterally.
CV: WNL. NR/R. No murmurs. Strong pulses.
MM: Pink.
CRT: < 2 sec.
Resp: WNL. No harsh sounds or crackles bilaterally. GI: Mild pain on abdominal palpation.
Digital Rectal exam: WNL.
MIS: WNL.
Body condition score: 3.5/9.
Neuro: WNL. No neurologic signs other than depression. Urol: No palpable bladder. No pain.
Integ: WNL.
Repro: WNL. Intact. Lymph: WNL.
Hydration Status: Normal. Additional Information:
6-12-200910:54 AM - Treatment I James McLean, DVM IV was replaced.
6-12-2009 3:46 PM - Progress Notes I James McLean, DVM Rodney has had about three bouts of bloody diarrhea but as has not vomited.
6-12-20097:18 PM - Diagnostic I James McLean, DVM
Hematology Data (ILC) (June 12,200907:18 PM)
Test
Result
Flaq
Normal Ranqe
Indicator
I/IIBC n
0.38
L
5.5-16.9 (f
I
I
I
LYM (=)
0.22
L
0.5-4.9 CKf\JL)
I
I
MONO C=)
0.12
L
0.3-2 CKf\JL)
II
I
NEU CO)
0.04
L
3-12 CKf\JL)
I
I
I
Eosinophils n
0.01
L
0.1-1.49 (f
I
BASO (=)
0
0-0.1 (f
I
LYM% CO)
57.4
MONO%(,,)
31.5
NEU% (*)
9.3
EOS% CO)
1.9
B.A,SO% CO)
0
HCT (=)
32.5
32-55 C%)
RBC C=)
4..45
L
4.7-8.5 CMf\JL)
I
HGB C=)
10.7
1 0.3-18 CGIDL)
RETIC (=)
11.4
RETIC% (=)
0.3
MCV C=)
73.1
60-77 (FL)
I
RDW(=)
16.1
14.7-17.9 C%)
I
MCHC C=)
32.8
30-37.5 CGIDL)
I
MCH (=)
23.98
18.5-30 (PG)
I
PL T C=)
48
L
175-500 (Kf\JL)
I
MPV C=)
14.53
PCT (=)
0.1
PDW(=)
22.9
Differential algorithm issues. Confirm with blood film.
6-12-20097:32 PM - Diagnostic I James McLean, DVM
IIJ
Test
Albumin (=)
Albumin (June 12,200907:32 PM)
Result Haq Normal Ranqe Indicator
1.3 L 2.1 -3.6 CGIDL) '--"1'--'--______ '-----'
PCV: 34% TS: 4.0g/dl Clear
6-12-20098:05 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Glucose: 100 mg/dL (60 - 115)
BUN: 4mg/dL (10-26)
Sodium: 135 mmol/L (142 - 150) Potassium: 3.6 mmol/L (3.4 - 4.9) Chloride: 108 mmol/L (106 - 127) TC02: 19 mmol/L (17 - 25)
Anion Gap: 12 mmol/L (8 - 25) HCT: 28% (35 - 50%)
Hb: 9.5 g/dl (12 - 17)
pH: 7.403 (7.35 - 7.45) venous pC02: 29.1 (35 - 38)
HC03: 18.2 mmol/L (15 - 23) BE: -7 mmol/L (-4 to 0)
=cv. 34 %
TS: 4.0 and clear g/dL
6-12-2009 11 :07 PM Assessment I Gre Lisciandro DVM DABVP DACVECC -------Approx 3 month MI ~found on side of road approx 1 hour ago, recumbent, brought in by good Samaritan and contacte~ who accepted financial responsibility as noted above in History.
Parvo Cite positive
Severe leukopenia--persists with little change at 48-hours post-admission
High fever--intermittent 103 range through the day yesterday, 104 spike today
Collapse and hypovolemic shock-resolved--remains depressed
Mild metabolic acidosis--resolved
Hypoglycemia-resolved and has 5% dextrose in fluids
Bloody D--more watery
Vomiting intermittently--none past 12 plus hours
Normal ALB on admission, now hypo ALB at 1.3 (was 1.6 yesterday) RIO dilutional as well as GI loss Fleas and ticks--treated with Frontline
Mild non-regenerative anemia (PCV: 30%)--R/O from dilution vs GI loss vs both--today has normal PCV at 34%
Weight today: 9.9 kg (was 9.2 kg on admission and 10.1 kg last night)
6-12-200911:10 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC
--Remains subdued to depressed but stable, since no V > 12 hours consider NE tube as per client authorization--called La Trenda and she approved NE tube and added cost
6-13-200912:07 AM - Diagnostic I Greg Lisciandro. DVM. DABVP, DACVECC Nutritional calculations:
Patient's body weight: 9.7 kg Patient RER: 361.00 kcal/day
Calorie content of diet to be used: 1 kcal/mL Number of feedings per day, if not CRI:
Amount (mL) in can of diet to be fed:
Ounces per can of selected diet:
Amount of selected diet to feed daily: 361.0 mL
Amount of selected diet to feed per feeding, if bolus fed: 0.0 mL Amount of selected diet to provide per hour, if fed as CRI: 15.0 mLlhr Ounces to feed per feeding if bolus fed: 0.00
6-13-200912:08 AM - Physical Examination I Greg Lisciandro. DVM. DABVP. DACVECC
--Appearance: subdued
--Body condition score: no change/9
--Eyes Ears Nose and Throat: no change, E Collar applied since placing NE tube
--Cardiovascular: 132 no murmur and PSS
--Mucus membrane color: Pink
--CRT: < 1.5 see
--Respiratory: clear
--Gastrointestinal: ropy Glloops with no pain
--Digital Rectal exam: NE
--Musculoskeletal: stained perineal area form watery brown D
--Neuro:see above
--Urol: No significant findings
--Integ:see MS
--Repro: no change
--Lymph: No significant findings
--Hydration Status: Normal
6-13-200912:08 AM - Treatment I Greg Lisciandro, DVM, DABVP. DACVECC --Added 1.5 mg/kg/day of Metoclopramide CRI and placed a 5 French red rubber tube and started bolus feeding of CliniCare every other hour of 8 ml.
Could not place 8 French red rubber tube as very irritating to dog due to size of tube--did not tolerate the diameter.
Summary Treatment through past 18 hours:
Normosol R with 20 meqKCLlL at 35 mllhr, HES at 8 mllhr, Na Ampicillin q 8 hours as previous, Baytril q 24 hours as previous, Famotidine SO q 12 hours as previous--needs deworming empirically once eating ( vs at EPC).
Started bolus feeding through NE tube today as well as added Metoclopramide CRI
6-13-200912:48 AM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC CXR lateral confirmed placement of tube in esophagus
6-13-2009 5:54 AM - Progress Notes I Susan Leonard, DVM
--Rodney is quiet, lethargic but responsive. MM pink. CRT < 2sec. Dehydration estimated at 5-6% as skin turgor is increased since 24 hr ago. Abdomen is soft and palpable but with soft moan on palpation. Diarrhea is continuing ( bloody watery diarrhea).
We had begun scheduled NE feedings at 1am (8ml clinicare every 2 hrs) but Rodney vomited at 3am so that feeding was cancelled.
We did restart the feedings at 5am and he has kept down the feeding so far. We are continuing treatment plan per Dr Lisciandro's instructions at this time.
6-13-20091:19 PM - Progress Notes I Enrique Carlo, DVM --Vomited ++, Trickle feeding Discontinued until 7pm.
6-13-2009 1 :23 PM - Physical Examination I Enrique Carlo, DVM --Appearance: Lethargic, alert.
--Body condition score: 4/9
--Eyes Ears Nose and Throat: No significant findings
--Cardiovascular: NMA, strong femoral pulses
--Mucus membrane color: Pink
--CRT: < 1.5 sec
--Respiratory: No significant findings
--Gastrointestinal: Soft, non-painful. Regurgitad during palpation
--Digital Rectal exam:
--Musculoskeletal: amb x 4
--Neuro: No significant findings
--Urol: No significant findings, full bladder
--Integ: No significant findings
--Repro: No significant findings
--Lymph: No significant findings
--Hydration Status: Normal
6-13-2009 1 :27 PM - Treatment I Enrique Carlo, DVM
---NaAmpiciliin 200 mg IV due at 9am. Administered 12pm. Continue @ 8pm, 4am.
-Baytril 95 mg IV slow/dilute @ 5pm
-Famotidine 5 mg SO scheduled @ 9am, administered at 12pm. Next due at 12am.
-Continue HES 8 mLlhr
-Continue LRS/5% dextrose @ 35 mLlhr (with KCI 20 mEq/L)
6-13-2009 7:01 PM - Diagnostic I Enrique Carlo, DVM
l~
Hematology Data (ILC) (June 13,200907:01 PM)
Test
Result
Flaq
Normal Ranqe
Indicator
iflJEC (-)
1.16
l
5.5-16.9 (K!\JL)
I
I
I
L YM (=)
0.43
l
0.5-4.9 (K!\JL)
I
I
MONO (=)
0.35
0.3-2 (K!\JL)
I
I
NEU (=)
0.2
l
3-12 (K!\JL)
I
I
Eosinophils (=)
0.19
0.1-1.49 (K!\JL)
II
BASO (=)
0
0-0.1 (K!\JL)
LYM% (=)
36.7
MONO% (=)
30.4
NEU% (=)
16.8
EOS% (=)
16
BASO% (=)
0
HCT (=)
30.9
l
32-55 (%)
RBC (=)
4.29
l
4.7 -8.5 (M!\JL)
II
HGB (=)
10.2
l
10.3-18 (GJDL)
RETIC (=)
8
RETIC% (=)
0.2
MCV (=)
71.9
60-77 (FL)
I
RDW (=)
16.2
14.7-17.9 (%)
I
MCHC (=)
33
30-37.5 (GJDL)
I
MCH (=)
23.76
18.5-30 (PG)
I
PL T (=)
79
l
175-500 (K!\JL)
I
MPV (=)
12.18
PCT (=)
0.1
PDW (=)
20.8
6-13-20097:14 PM - Diagnostic I Enrique Carlo, DVM
IJ
Test
Albumin (=)
Albumin (June 13,200907:14 PM)
Result Flaq Normal Ranqe Indicator
1.1 L 2.1-3.6 (GIDL) LI •. I_L- ________ LI_--'
6-13-20097:19 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Glucose: 121 mg/dL (60 - 115)
BUN: 4 mg/dL (10 - 26)
Sodium: 137 mmol/L (142 - 150) Potassium: 3.8 mmol/L (3.4 - 4.9) Chloride: 110 mmol/L (106 - 127) TC02: 20 mmol/L (17 - 25)
Anion Gap: 11 mmol/L (8 - 25) HCT: 25% (35 - 50%)
Hb: 8.5 g/dl (12 - 17)
pH: 7.369 (7.35 - 7.45) venous pC02: 33.4 (35 - 38)
HC03: 19.3 mmol/L (15 - 23) BE: -6 mmol/L (-4 to 0)
PCV: 30 %
TS: 3.6 g/dL
Plasma = clear
6-13-2009 10:04 PM - Physical Examination I Susan Leonard, DVM --Appearance: Depressed by responsive
--Body condition score: 3//9
--Eyes Ears Nose and Throat: Nasoesophageal tube in place.
--Cardiovascular: No significant findings- pulse quality is good
--Mucus membrane color:Light Pink
--CRT: < 1.5 sec
--Respiratory: No significant findings
--Gastrointestinal: Abdomen is soft, palpable, slightly pot bellied. Patient is doing some drooling and
appears to be nauseous and has regurgitated/ vomited thru the day. --Digital Rectal exam: NE
--Musculoskeletal: No significant findings
--Neuro:depressed/ lethargic
--Urol: No significant findings
--Integ: IV catheter in Left cephalic v.
--Repro: No significant findings
--Lymph: No significant findings
--Hydration Status: estimated 5-7% dehydration
6-13-2009 10:08 PM - Assessment I Susan Leonard. DVM --Young puppy with parvo enteritis
Persistent nausea has prevented successful NE feeding. Hypoalbuminemia (now 1.1 mg/dl down from 1.324 hr ago) Persistent neutropenia but with slight improvement noted in 24 hrs.
We will add additional antiemetic care and increase the IV fluid rate to replace presistent losses.
The slight increase in the WBC may indicate potential that Rodney may be about to rebound/ go into recovery phase.
Prognosis is still guarded to fair at this time
6-13-200910:11 PM - Treatment I Susan Leonard. DVM --Na ampicillin 200mg IV q 8 hr ( 9am/5pm/1 am)
Baytril 95mg diluted IV q 24hr ( 5pm)
Famotidine 5mg q 12 hr ( 9am/9pm)
Cerenia 1.0ml SQ q 24 hr PRN (1 Opm tonight then 9pm thereafter)
LRS with 5% dextrose/liter and 20 meq KCLlliter at 50ml/hr for next Bhr Hetastarch 8ml/hr
ISTAT CBC ALB q 24hr (7pm)
Discontinue trickle feeding until no longer nauseous.
6-14-20094:17 AM - Progress Notes I Susan Leonard. DVM
--Rodney has continued to have regurgitation when trying to feed thru NE tube. We have cancelled feedings thru the rest of the night.
Rodney is quiet, lethargic, but better hydrated at this time. He is still passing very concentrated yellow urine and still has blood on rectal exam. He has not passed any diarrhea so far over night. MM pink. CRT < 2sec. Abdomen is still tense but palpable with no mass effects.
We are continuing medications as previously outlined.
6-14-20098:04 AM - Treatment I Enrique Carlo. DVM
--Crystalloids ran out -New bag Crystalloids made(with KCI 20 mEq/L + Reglan 3.4 mLlL Continue at 50 mLlhr.
6-14-20099:31 AM - Diagnostic I Susan Leonard. DVM Glucose: 111 mg/dL (60 - 115)
BUN: 6 mg/dL (10 - 26)
Sodium: 139 mmol/L (142 - 150) Potassium: 4.2 mmol/L (3.4 - 4.9) Chloride: 110 mmol/L (106 - 127) TC02: 22 mmol/L (17 - 25)
Anion Gap: 13 mmol/L (8 - 25)
HCT: 24% (35 - 50%) Hb: 8.2 g/dl (12 - 17)
pH: 7.357 (7.35 - 7.45) venous pC02: 38.0 (35 - 38)
HC03: 21.3 mmol/L (15 - 23) BE: -4 mmol/L (-4 to 0)
PCV: 28 %
TS: 2.1 g/dL
6-14-20092:44 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC --Small amount D, stable
6-14-20093:41 PM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC --Decreased fluid rate to 35 ml/hr, if continues GER and normal WBC--remove NE tube this evening.
Updated owner by phone approx 10 minutes ago.
6-14-20093:44 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC --Updated La Trenda will be rechecking labwork later today, will remove NE tube likely.
6-14-20095:38 PM - Physical Examination I Greg Lisciandro, DVM, DABVP, DACVECC
--Appearance: quiet, depressed
--Body condition score: no change 4/9
--Eyes Ears Nose and Throat: negative oral, soft E Collar, just removed NE tube
--Cardiovascular: 132 no murmur
--Mucus membrane color: pink
--CRT: < 1.5 see
--Respiratory: clear
--Gastrointestinal: abdomen benign
--Digital Rectal exam: NE
--Musculoskeletal: ambulatory x 4, IVC in front leg OK
-Neuro: see above
-Urol: No significant findings
--Integ: see MS, some ventral edema underside of neck, ventral cervical area, soft non-painful, no other
signs of SO edema
--Repro: MI 2 scrotal testicles
--Lymph: No significant findings
--Hydration Status: 5% dry to hydrated
6-14-20095:40 PM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC --Cancelled NE tubes earlier and removed NE tube at this time, replace as needed. Continuing plan as previous.
6-14-20096:28 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC Glucose: 102 mg/dL (60 - 115)
BUN: 7 mg/dL (10 - 26)
Sodium: 141 mmol/L (142 - 150) Potassium: 4.2 mmol/L (3.4 - 4.9) Chloride: 111 mmol/L (106 - 127) TC02: 21 mmol/L (17 - 25)
Anion Gap: 14 mmol/L (8 - 25) HCT: 24% (35 - 50%)
Hb: 8.2 g/dl (12 - 17)
pH: 7.365 (7.35 - 7.45) venous pC02: 35.8 (35 - 38)
HC03: 20.4 mmol/L (15 - 23) BE: -4 mmol/L (-4 to 0)
PCV: 30 %
TS: 2.0 g/dL
/4-
Plasma: clear
6-14-20097:34 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC
Hematology Data (Ile) (June 14,200907:34 PM)
Test
Result
Flag
Normal Range
Indicator
V\lBC (=)
3.8
L
5.5-16.9 (KflJL)
II
LYM (=)
0.42
L
0.5-4.9 (f
I
MONO (=)
0.19
L
0.3-2 (KflJL)
•
NEU (=)
3.01
3-12 (KflJL)
I
Eosinophils (=)
0.16
0.1-1.49 (KflJL)
BASO (=)
0.02
0-0.1 (KiJL)
I
LYM% (=)
11
MONO% (=)
5.1
NEU% (=)
79.2
EOS% (=)
4.1
BASO% (=)
0.6
HCT (=)
28.7
L
32-55 (%)
I
RBC (=)
3.96
L
4.7-8.5 (MflJL)
I
HGB (*)
10.6
1 0.3-18 (GiDL)
RETIC (=)
12.4
RETIC% (=)
0.3
MCV (=)
72.4
60-77 (FL)
I
ROW (=)
16.5
14.7-17.9 (%)
I
MCHC (=)
37.1
30-37.5 (GiDL)
II
MCH (=)
26.82
18.5-30 (PG)
I
I
PL T (=)
110
L
175-500 (KflJL)
I
I
MPV (=)
9.84
I
PCT (=)
0.1
I
POW(=)
18.8
I
Hgb sheath timing variability.
6-14-20097:56 PM - Diagnostic I Greg Lisciandro, DVM, DABVP, DACVECC
Test
Albumin (-)
Albumin (June 14,200907:56 PM)
Result Flag Normal Range Indicator
0.6 L 2.1-3.6 (GiDL) •.. 1_----'- ______ 1'-----'
6-14-20098:14 PM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC --Decreased crystalloids to 15 ml/hr and continuing HES at 8 ml/hr (as has some peripheral underside of neck--hypo ALB--WBC has rebounded and is in recovery phase of Parvo, normal PMN count)
6-15-200912:02 AM - Treatment I Greg Lisciandro, DVM, DABVP, DACVECC --Pre-treated Diphenhydramine earlier 25 mg IV, given 152 ml of FFP over 4 hours, discontinued other fluids, at this time no sign of reaction, Q-depressed as previous, stable.
6-15-20091:05 AM - Assessment! Greg Lisciandro, DVM, DABVP, DACVECC --As previously described. Improving WBC with now normal Neutrophil count. Discontinue Baytril as not septic, no fever spikes. Now clinical for hypo ALB so recieved FFP 152 ml for ALB support and repeat another 130 ml beginning at 3am.
Hypo ALB
Severe leukopenia, resolving
GER persist and on Metoclopramide CRI, Famotidine, Cerenia prn
Food trial later today. In recovery phase of the disease.
6-15-2009 4:54 AM - Progress Notes I Susan Leonard, DVM
--Rodney is quiet, lethargic but responsive. The facial edema is most pronounce on the left side of face. Rodney experience discomfort when mouth was opened but no specific lesions were found. MM pink. CRT < 2sec. Heart and lungs auscult wnl. Abdomen is non painful.
We have continued the FFP transfusion and are continuing care as previously outlined.
6-15-20094:54 AM - Treatment I Susan Leonard, DVM --Replaced IV catheter due to infiltration above catheter.
6-15-2009 9:24 AM - Physical Examination I David Bristol, DVM --Appearance: Quiet;' attentive
--Body condition score: 5/9/9
--Eyes Ears Nose and Throat: severe facial swelling with pain; lips thickened and painful when lifted up.
--Cardiovascular: normal heart sounds; good quality femoral pulse
--Mucus membrane color: pink to injected/ inflamed
--CRT: < 1.5 sec
--Respiratory: lungs clear all fields
--Gastrointestinal: soft, non painful;
--Digital Rectal exam: not done
--Musculoskeletal: No significant findings
--Neuro:slight depression due to painful face
--Urol: No significant findings
--lnteg:New IVC right cephalic
--Repro: No significant findings
--Lymph: No significant findings
--Hydration Status: Normal
6-15-20099:29 AM - Diagnostic I David Bristol, DVM
17
Hematology Data (Ile) (June 15,200909:29 AM)
Test Result Flau Normal Ranqe Indicator
VVBC (-) 13.13 5.5-16.9 (Kf\.JL) I I
LYM (=) 0.72 0.5-4.9 (Kf\.JL) ~=;~I=========~===~
MONO (=) 0.28 L 0.3-2 (Kf\.JL)
NEU (=) 11.78 3-12 (f{f\.JL)
Eosinophils (=) 0.31 0.1-1.49 (Kr~L)
BASO (=) 0.03 0-0.1 (Kf\.JL)
LYM% (=) 5.5
MONO% (=) 2.2
NEU% (=) 89.7
EOS% (=) 2.4
B,8,SO% (=) 0.3
HCT (=) 27.1
RBC (=) 3.75
HGB (*) 9.9
RETIC (=) 16.3
RETIC% (=) 0.4
Mev (=) 72.2
ROW(=) 16.6
MCHC (=) 36.7
MCH (=) 26.5
PL T (=) 147
MPV (=) 11.74
rcr (=) 0.2
PDW(=) 21
Hgb sheath timing variability.
L L L
32-55 (%) 4.7-8.5 (Mf\.JL) 10.3-18 (GIDL)
L
60-77 (FL) 14.7-17.9 (%) 30-37.5 (GIDL) 18.5-30 (PG) 1 75-500 (Kf\.JL)
I
I
II
I I
I
I
I
II
I
II
pcv: 26% ts: 2.8 g/dl
6-15-20099:34 AM - Progress Notes I David Bristol, DVM --Sniffs at food as though wants to eat but too painful to open mouth.
6-15-2009 10:46 AM - Assessment I David Bristol, DVM
--Rodney has not had regurge since 7 pm Sunday. No diarrhea since 12 pm Sunday.
His WBC/Neutrophils now wnr range with high norm neutrophils at 11.78 K
Rodney has facial swelling with swollen thickened lips.
This was noted around 8 pm. The swelling now is painful and preventing Rodney from eating. Appears to be allergic reaction. Swelling was noted prior to FFP transfusion. RO reaction to antibiotic vs unknown at this time.
Plan: Benedryl sc, pain meds. Since WBC is normal now if no response to the pain meds and benedryl will give low dose Dex SP.
6-15-200910:52 AM - Progress Notes I David Bristol, DVM
--Despite Diphenhydramine lips still swollen and painful although not as painful as at 9am. Has since had Buprenex. Will go a head with Dex SP 2 mg diluted and given slowly.
6-15-2009 10:59 AM - Treatment I David Bristol, DVM --Continue IV fluids and tx protocol as established by Dr. Lisciandro
10 am Diphenhydramine 22 mg sc
10 am Buprenex 0.156 mg 1M
11 am: Dexamethasone 2 mg diluted 1:3 and given slow IV for continued facial swelling and pain.
6-15-2009 12:00 PM - Progress Notes I David Bristol. DVM --11 am: bloody diarrhea blow oout.
6-15-2009 3:00 PM - Progress Notes I David Bristol. DVM --facial swelling present but is down from this am.
No interest in food yet.
6-15-2009 4:45 PM - Progress Notes I David Bristol. DVM --grooming OAR
6-15-20095:00 PM - Progress Notes I David Bristol. DVM
--still no interest in food. Gave 6 nil AD by syringe for a food trial test to see if could hold down food.
6-15-20096:06 PM - Treatment I Greg Lisciandro. DVM. DABVP. DACVECC -Discontmued all injectable drugs and changed to TMP 200 mg PO q 12 hours as this could be an allergic reaction.
Added Prednisone 2.5 mg PO this evening and RX Prednisone 5 mg 1/4 tab q 12 hours for 2 days then 1/4 tab q 24 hours for 3 days.
Needs Strongid PO will add--2am.
Continuing food trial and then fluid taper if continues to eat well.
RX Prednisone 5 mg 1/4 tab q 12 hours for 2 days then 1/4 tab q 24 hours for 3 days. RX Tribrissen Suspension 50 mg/ml give 200 mg (4ml) q 12 hours for 10 days.
6-15-2009 7:04 PM - Progress Notes I David Bristol. DVM --No vomiting thus far. has held down the food given.
6-15-2009 8:06 PM - Diagnostic I David Bristol. DVM Glucose: 79 mg/dL (60 - 115)
BUN: 4 mg/dL (10 - 26)
Sodium: 136 mmol/L (142 - 150) Potassium: 4.0 mmol/L (3.4 - 4.9) Chloride: 108 mmol/L (106 - 127) TC02: 20 mmol/L (17 - 25)
Anion Gap: 14 mmol/L (8 - 25) HCT: 23% (35 - 50%)
Hb: 7.8 g/dl (12 -17)
pH: 7.336 (7.35 - 7.45) venous pC02: 34.9 (35 - 38)
HC03: 18.7 mmol/L (15 - 23) BE: -7 mmol/L (-4 to 0)
PCV: 27 %
TS: 3.2 g/dL plasma clear
6-15-20098:13 PM - Diagnostic I Greg Lisciandro. DVM. DABVP. DACVECC
Test
Albumin (-)
Albumin (June 15,200908:13 PM)
Result Flau Normal Ranqe Indicator
1.1 l 2.1-3.6 (GIDL) LI .•. I_-L-_________ ---'--_---'
6-15-20098:42 PM - Physical Examination I Greg Lisciandro, DVM, DABVP, DACVECC
--Appearance: subdued and depressed
--Body condition score: no change/9
--Eyes Ears Nose and Throat: negative oral, muzzle symmetrically swollen and non-painful angioedema,
cannot find any abscess, draining tract and extends tomb ventral mandible, the LN in region are not enlarged like in puppy strangles nor painful
--Cardiovascular: 124 no murmur
--Mucus membrane color: Pink
--CRT: < 1.5 sec
--Respiratory: clear
--Gastrointestinal: soft
--Digital Rectal exam: NE
--Musculoskeletal: ambulatory x4, no other swelling other than EENT
--Neuro:see above
--Urol: No significant findings
--Integ:see MS
--Repro: No significant findings
--Lymph: No significant findings
--Hydration Status: Normal
6-15-20098:51 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC --Ate AD ravenously after I examined Rodney.
6-16-200912:07 AM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC
--Has eaten x 2, D earlier in day and fever, resolved since. LaTrenda called and SNIPSA may take Rodney. Told her looked him over closely and may be allergic reaction and treating for immune-mediated reason for the facial/muzzle swelling.
If continues to eat will deworm with Strongid and set up with antibiotic, Benadryl, and short Prednisone taper. Owner appreciated the update.
6-16-20093:12 AM - Progress Notes I Susan Leonard, DVM
--Rodney is quiet, alert and responsive. MM pink. CRT< 2sec. Heart and Lungs auscult wnl. Pulse quality is good Abdomen is non painful. Hydration is good. No vomiting but still having occasional large bouts of red fetid diarrhea.
Facial swelling has improved and has moved ventrally since this morning. We are continuing medications and IV fluids at 15ml/hr and hetastarch at 8ml/hr.
6-16-20098:34 AM - Progress Notes I Susan Leonard, DVM
--Rodney refluxed when food was offered this morning. We are schedule for oral medications, but due to reflux will give injectable ranitidine and then try to give oral medications in one hr.
6-16-20098:41 AM - Treatment I Susan Leonard, DVM
--9am: 19m9 ranitidine 1M, Increased IV fluid rate to 30ml/hr with LRS 5% dextrose with 20meq/KCI and 3.4ml reglanlliter.
6-16-20093:10 PM - Physical Examination I Michael Lagutchik, DVM, DACVECC --Appearance: alert and responsive; slightly lethargic
--Body condition score: 2/9
--Eyes Ears Nose and Throat: normal menace and PLRs au; ears, nose, and throat are normal
--Cardiovascular: NSR with SSP; HR 108
--Mucus membrane color: Pink
--CRT: < 1.5 sec
--Respiratory: eupneic at rest at 12/min; lung sounds are clear bilatlall quads
--Gastrointestinal: soft, but slightly distended and some discomfort noted on palp; no mass effect to suggest intussusception; no organomegaly
--Digital Rectal exam: not performed; last feces passed per record was watery brown diarrhea (2+)
--Musculoskeletal: ambulatory but marked emaciation and slightly weak
--Neuro:normal mentation/LOC
--Urol:urinary bladder small
--Integ:patent R ceph cath present
--Repro: intact male; testes not fully descended
--Lymph: No significant findings
--Hydration Status: normal skin turgor; MM moist; CRT normal = normal
6-16-2009 3:27 PM - Assessment I Michael Lagutchik, DVM, DACVECC --Signalment: 6 M intact male bull terrier
Summary: Hospitalization day #7; parvoviral gastroenteritis in stray dog complicated by severe emaciation, shock on admission, profound neutropenia, hypoalbuminemia, hypoglycemia, persistent bloody diarrhea, persistent vomiting and now reflux, development of anemia and thrombocytopenia, and apparent allergic reaction with signficant facial edema. Neutropenia, hypoglycemia, shock, and fever have resolved; apparent angioedema has nearly cleared; remains markedly hypoalbuminemic, diarrhea is tapering but persists, vomiting has resolved but reflux persists - is now tapering and pet is eating without regurg/reflux. Pt will eat and at last feeding at 1500 hrs did not vomit or regurgitate.
Ox: Parvoviral gastroenteritis, severe
Problem list:
*persistent reflux/regurgitation -- r/o 2/2 gastroparesis despite prokinetic use *hypoalbuminemia -- 1.1 last check yesterday
*anemia, mild for puppy - 26% last recheck yesterday
*thrombocytopenia, mild -- 147 last recheck yesterday
*persistent diarrhea but without blood
*mild hyponatremia -- 136 last recheck yesterday *mixed acidosis, mild -- 7.336 last recheck yesterday *emaciation 2/2 stray
At this point, pt is improving but gradually. An outstanding balance of -$3000 exists and it is not clear who is covering the bill or when last estimate was generated and discussed with Ms Walker and/or SNIPSA or _. Will transfer case to Dr Lisciandro for continued care at 1800 hrs.
6-16-2009 3:35 PM - Treatment I Michael Lagutchik, DVM, DACVECC --Revised treatment plan thru 0800 hrs Wednesday:
*Food and water -- offer chicken breast meat and/or 1 tbs I/O canned diet q4h; water available always
*Fluid therapy -- continue LRS with 5% dextrose and 20 mEq/L KCI at decreased rate of 30 mLlh (-1.5 M); continue HES at 8 mLlh
*Anti-emetic -- continue metoclopramide 1.5 mg/kg/day CRI
*Prokinetic therapy -- added ranitidine 19 mg im q24h in addition to metoclopramide CRI
*Abx therapy -- continue trimethoprim-sulfamethoxazole 192 mg po q12h
*Gastric acid suppression therapy -- continue famotidine 5 mg po q24h
*Anti-inflammatory therapy -- continue prednisone 1.25 mg po q12h
*Antihistamine therapy -- continue diphenhydramine 25 mg po q12h
6-16-20094:10 PM - Progress Notes I Michael Lagutchik, DVM, DACVECC
--CE: Ms Walker called and I updated her that pt is stable, quiet but alert, and that diarrhea is tapering. Also advised that pet ate about 1 hr ago and has not vomited or regurgitated since, which is promising. Asked that she call back 1800-2400 hrs to speak with Dr Lisciandro about plans and billing issues.
6-16-20095:13 PM - Progress Notes I Michael Lagutchik, DVM, DACVECC
--Ms Maria Thomas with SNIPSA arrived to photograph pt. I called Ms Walker and she gave permission for this and confirmed that she had discussed this with SNIPSA yesterday. Ms Thomas took several photos to aid in adoption of pet.
6-16-20096:30 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC
--Called LaTrenda and informed her SNIPSA was here and she was aware as we called for her l&\ L_~ authorization. Rodney is doing very well and eating with occasionally bouts of GER and,diarrhea,. \~.l. 'fV ~V
swelling nearly non-existent on muzzle area which is great news. ~.. ~\\\\ W ~ ~ 1 (t')
She is trying to get Rodney moved to another facility and appreciates our efforts. We should have him ~ 0 ~IJl
off IVF and on only oral medications by tomorrow if continues to do well. Ms Walker spoke with our ~~I~r "n
receptionist (TP) and paid her balance. \J I"
6-16-200910:33 PM - Progress Notes I Greg Lisciandro, DVM, DABVP, DACVECC
--Rodney had a little GER and will make feedings q 6 hours overnight when resume.
6-16-200911:59 PM - Discharge Instructions I Greg Lisciandro, DVM, DABVP, DACVECC
-DIAGNOSIS:
Parvoviral gastroenteritis with the complication of facial and muzzle swelling from allergic reaction to medications vs an occult infection which we have not been able to diagnose.
CASE SUMMARY:
We provided aggressive intravenous fluid therapy, broad-spectrum antibiotic therapy, nutritional support, anti-emetic drugs to control vomiting, and drugs to reduce stomach acid production.
We have recently added antihistamines, steroids and discontinued the previous medications given by injection in case these caused the reaction. The swelling of the facial area had occurred prior to the administration of the Fresh Frozen Plasma (FFP).
Rodney has improved and is stable for discharge.
MEDICATIONS:
Antibiotic: Tribrissen/Ditrim Suspension 48mg/ml -- give 4 mls by mouth every 12 hours for 10 days. Next dose is due at 10 PM tonight.
Rx: Panacur 15ml: Give 5cc orally every 24 hrs for three days. The first dose was given yesterday at so the next dose will be due at 8 PM tonight. This must be repeated in three weeks so be sure and have this done at your veterinarian's clinic.
Antacids: Pepcid AC (Famotidine 10 mg tablets)-- give 1/2 tablet every 12 hours for 10 days. The last dose was given at 1 PM this afternoon.
FOOD AND WATER:
Offer boiled chicken breast that is skinless and boneless and unseasoned with boiled white rice every 3-4 hours during the day for the next 2-3 days. If no vomiting is noted and your pet continues to improve, gradually mix in a premium puppy food over the following 2-3 days before going to a normal feeding routine.
Offer fresh water at all times, however, make sure that Rodney does not over-drink at anyone time.
ACTIVITY/EXERCISE:
Restrict activity for the next 7 days. Do not allow loose running or active play. Supervise walks outside to ensure Rodney doesn't eat grass or other items.
SPECIAL CARE INSTRUCTIONS:
The diarrhea will take several days to completely resolve. Daily, the feces should be firmer and you should not notice blood or loose stools. Continued vaccinations are important, as your pet remains at risk for infection with other common viruses.
If you have other puppies or unvaccinated dogs in the house, we recommend you have them examined by your veterinarian. We recommend you disinfect any toys, feed bowls, and the premises with a dilute bleach solution (1 part bleach to 30 parts water) to kill the virus.
Flies are major carriers of Parvovirus which can last up to 1 year in the environment by landing on feces and spreading the virus which can be shed for up to 3 weeks after Rodney returning home. Thus, immediately pick up the stool and bag and discard to limit the spread of Parvovirus.
RECHECK INSTRUCTIONS:
We have examined and treated your pet on an emergency basis only. This is not a substitute for the care provided by your family veterinarian.
Rodney should be dewormed and vaccinated as per your regular veterinarian in the next 5-7 days as per his clinical course. Please contact your regular veterinarian and schedule follow-up care.
EMERGENCY CARE INSTRUCTIONS: Seek immediate veterinary care if any of the following clinical signs are noted: vomiting, diarrhea that is not improving daily or persists more than 3 days, inappetance, weakness or collapse. Rodney's facial and muzzle swelling should improve daily--if this is not occurring, or if the swelling becomes painful or shows signs of infection--redness, pain, discharge, then recheck promptly.
6-17-20092:58 AM - Progress Notes I Susan Leonard, DVM
--Rodney is brighter, alert and had an excellent appetite. He ate boiled chicken very well. However, he had a a large volume bloody fetid diarrhea episode and then vomited up the chicken. We are continuing IV fluids and will try to continue oral medications overnight.
6-17-20095:58 AM - Progress Notes I Susan Leonard, DVM
--Rodney is alert and friendly. He vomited up another small amount of food. We will continue IV fluids and hetastarch, repeat IV ranitidine this morning in place of the oral famotidine and then continue slower feedings thru the day.
6-17-20099:52 AM - Physical Examination I James McLean, DVM Presentation: Alert and responsive. Stood up straight away when I went into parvo ward. EENT: WNL. No ocular or nasal discharge bilaterally.
CV: WNL. NR/R. No murmurs.
MM: Pink.
CRT: < 2 sec.
Resp: WNL. No harsh sounds or crackles bilaterally.
GI: Mild pain on mid abdominal palpation. Mild hypersalivation. Digital Rectal exam: Not performed.
MIS: Large amount of muscle loss.
Body condition score: 3/9.
Neuro: WNL. No neurologic signs. Urol: Very large, non painful bladder. Integ: WNL.
Repro: Testicles are not fully descended. Lymph: WNL.
Hydration Status: Appears well hydrated at this time.
Additional Information: Patent IV cephalic catheter in right limb.
6-17-200912:59 PM - Progress Notes I James McLean, DVM Gave 1 Tbs I/O. Rodney ate it very well.
6-17 -2009 4:43 PM - Progress Notes I James McLean, DVM
Rodney has been doing very well. He has not had any vomiting or diarrhea. He is on his fluids and appears to be very comfortable.
6-17-20095:37 PM - Physical Examination I William Gibson, DVM --Appearance: Bright, Alert and Responsive
--Body condition score: 2.5/9
--Eyes Ears Nose and Throat: No significant findings
--Cardiovascular: No significant findings
--Mucus membrane color: Pink
--CRT: < 1.5 sec
--Respiratory: No significant findings
--Gastrointestinal: Belly soft and NSL noted on palpation
--Digital Rectal exam:
--Musculoskeletal: Emaciated
--Neuro: No significant findings
--Ural: No significant findings
--Integ: No significant findings
--Repro: Intact male
--Lymph: No significant findings
--Hydration Status: Normal
6-17-20095:51 PM - Assessment I William Gibson, DVM Rodney is a six month old intact male Bull Terrier.
Clinical concerns:
* Reflux I regurgitation - Resolved, he last vomited at 5am * Hypoalbuminemia - Last checked June 15, was 1.1 mg/dl
* Anemia - Last checked June 15, was 26%, he is light pink to pink today * Mild thrombocytopenia - Last checked June 15
* Diarrhea - Resolved, last bout was at 3am
* Hyponatremia - Last checked June 15
* Mixed acidosis - Last checked June 15
* Emaciated - Persisting, is eating today
Plan:
* IV fluids
* IV Hetastarch
* Discontinue Prednisone * Oral Tribrissen
* IV Ranitidine
* Rx Panacur (suggested by Dr Greg Lisciandro)
* Send him home is he continues to eat and stayed asymptomatic
6-17-20095:56 PM - Treatment I William Gibson, DVM Rx: Panacur 15ml (5cc PO q 24 hrs x 3).
6-17-20096:51 PM - Progress Notes I William Gibson, DVM Offered him 10 and he ate well.
6-17-20097:01 PM - Diagnostic I William Gibson, DVM Nutritional calculations:
Patient's body weight: 9.5 kg Patient RER: 355.00 kcal/day
Calorie content of diet to be used: 1.311 kcal/mL (Canned 10) Number of feedings per day, if not CRI: 6
Amount (mL) in can of diet to be fed: 370
Ounces per can of selected diet: 13
Amount of selected diet to feed daily: 270.8 mL
Amount of selected diet to feed per feeding, if bolus fed: 45.1 mL Amount of selected diet to provide per hour, if fed as CRI: 11.3 mUhr Ounces to feed per feeding if bolus fed: 1.58
6-17-20098:33 PM - Progress Notes I William Gibson, DVM
Owner called for update. Rodney is doing well, no vomiting or diarrhea and eating well. If he has a good night he will be ready to go home in the morning. The owner said she will need time tomorrow to find a home for Rodney. We let her know she will need to find a day-clinic to board Rodney. Waynette went over today's estimate and owner approved it.
6-17-20099:13 PM - Progress Notes I William Gibson, DVM He vomited.
6-17-20099:16 PM - Treatment I William Gibson, DVM 5mg Anzemet IV q 24 hrs
6-18-2009 12:04 AM - Progress Notes I William Gibson, DVM Resting quietly receiving his fluids and HES, no more vomiting.
6-18-2009 1 :02 AM - Physical Examination I Christina Jung, DVM --Appearance: Quiet, alert, responsive
--Body condition score: 3.5/9
--Eyes Ears Nose and Throat: Pupils equal and reactive. No ocular or nasal discharge present.
--Cardiovascular: Normal heart sounds; regular pulses and normal rhythm
--Mucus membrane color: Pink
--CRT: < 1.5 sec
--Respiratory: Normal breath sounds bilaterally
--Gastrointestinal: Abdomen relaxed on palpation
--Digital Rectal exam:
--Musculoskeletal: Bearing weight well on all limbs
--Neuro: No significant findings
--Urol: No significant findings
--Integ:i.v. catheter present in right cephalic vein. Slight amount of puffiness present above the catheter.
Catheter appears comfortable. --Repro: intact- testicles descended
--Lymph: No significant findings
--Hydration Status: Normal
6-18-2009 1 :24 AM - Progress Notes I Christina Jung, DVM --Rodney was fed a meatball of ild at 1 a.m. He ate well and so far has kept it down.
6-18-2009 3:45 AM - Progress Notes I Christina Jung, DVM --Curled up sleeping.
6-18-2009 7:23 AM - Progress Notes I Christina Jung, DVM --Rodney is resting quietly. He ate ild well again at 7 a.m.
6-18-2009 8:24 AM - Physical Examination I James McLean, DVM Presentation: BAR. Very active. Biting at cage bars.
EENT: WNL. No ocular or nasal discharge bilaterally.
CV: WNL. NR/R. No murmurs.
MM: Pink.
CRT: < 2 sec.
Resp: WNL. No harsh sounds or crackles bilaterally. GI: NSF on abdominal palpation. No pain.
Digital Rectal exam: Not performed.
MIS: Muscle loss.
Body condition score: 3/9.
Neuro: WNL. No neurologic signs.
Urol: Moderately sized non painful bladder. Integ: WNL.
Repro: WNL. Intact.
Lymph: WNL.
Hydration Status: Appears well hydrated at this time.
Additional Information: Placed hard E-collar to keep him from chewing on bars.
6-18-2009 9:04 AM - Progress Notes I James McLean, DVM Vomited large amount of watered down food.
6-18-200910:54 AM - Treatment I James McLean, DVM Treatment plan for today:
Wean off fluids.
Continue with oral medication.
Continue feeding (unless vomiting becomes an issue). Discharge when 0 is able to pick up.
6-18-2009 11 :41 AM - Treatment I James McLean, DVM Decreased fluid rate from 15 ml/hr to 10 ml/hr.
6-18-2009 12:12 PM - Progress Notes I James McLean, DVM Catheter blown.
Did not replace.
Will start on 5 mg Famotidine PO SID.
6-18-2009 12:15 PM - Diagnostic I James McLean, DVM
Hematology Data (ILC) (June 18,200912:15 PM)
Test
Result
Fla~l
Normal Range
Indicator
V\l8C CO)
0.1
l
5.5-16.9 CKf\.JL)
I
I
I
I
I
LYM C=)
0.04
l
0.5-4.9 Cf
I
II
I
I
MONO C=)
0
l
0.3-2 CKf\.JL)
I
II
I
I
NEU CO)
0.01
l
2-12 CKf\.JL)
I
II
I
I
Eosinophils CO)
0
l
0.1-1.49 CKf\.JL)
I
I
I
I
BASO C=)
0
0-0.1 CKf\.JL)
I
I
LYM% CO)
72
I
I
MONO%(*)
0
I
NEU% (*)
24
I
EOS% CO)
0
I
BASO% C*)
4
I
HCT (-)
0
l
37-55 (%)
I
RBC CO)
0.25
l
5.5-8.5 (Mf\.JL)
HGB (-)
0
l
12-18 CGJDL)
RETIC CO)
0
RETIC% CO)
0
MCY C-)
0
l
60-77 (FL)
RDW(-)
0
l
14.7-17.9 C%)
MCHC C-)
0
L
30-37.5 CGiDL)
MCH (-)
0
l
18.5-30 (PG)
PL T (*)
19
l
175-500 (Kf\.JL)
I
I
MPY C-)
0
I
I
PCT (-)
0
I
I
PD'W C-)
0
I
I
6-18-2009 12: 17 PM - Assessment I James McLean, DVM
Rodney is a six month old intact male dog that has been being treated for Parvovirus since 6-10-09. Overall, he has been responding well to treatment. He is eating well and will occasionally vomit but he does not vomit after every feeding or after water consumption.
Clinical concerns:
Vomiting
Hypoalbuminemia - June 18, was 1.2 mg/dl Anemia - Last checked June 18, was 21 % Mild thrombocytopenia -
Diarrhea - None since 3 AM 6-17-09. Hyponatremia - Last checked June 18 Emaciation - he is eating well.
Plan:
Discontinue IV fluids and Hetastarch. Oral Medications.
Food and water.
Send him home if he continues to eat and stays asymptomatic.
6-18-2009 12:25 PM - Diagnostic I James McLean, DVM
Test
Albumin (=)
Albumin (June 18,200912:25 PM)
Result Haq Normal Ranqe Indicator
1.2 L 2.3-4 (GIDL) LI ..• I_....I....- _____ -'-I _--'
6-18-2009 12:30 PM - Diagnostic I James McLean, DVM Glucose: 97 mg/dL (60 - 115)
BUN: 8 mg/dL (10 - 26)
Sodium: 139 mmol/L (142 - 150) Potassium: 4.6 mmol/L (3.4 - 4.9) Chloride: 110 mmol/L (106 - 127) TC02: 24 mmol/L (17 - 25)
Anion Gap: 11 mmol/L (8 - 25) HCT: 21 % (35 - 50%)
Hb: 7.1 g/dl (12 - 17)
pH: 7.460 (7.35 - 7.45) venous pC02: 31.8 (35 - 38)
HC03: 22.7 mmol/L (15 - 23) BE: -1 mmol/L (-4 to 0)
PCV: 22 %
TS: 3.8
Hematocrit plasma: clear g/dL
6-18-2009 1: 15 PM - Progress Notes I James McLean, DVM o called to say they will be here to pick up Rodney at about 2 PM today.
6-18-2009 1 :34 PM - Progress Notes I James McLean, DVM o here to pick up Rodney.
6-18-2009 1 :34 PM - Diagnostic I James McLean, DVM
Hematology Data (Ile) (June 18,200901 :34 PM)
Test Result Flag Normal Range Indicator
t/\J8C (-) 43.53 H 5.5-16.9 (KIj..JL) I •
L YM (=) 4.45 0.5-4.9 (KIj..JL) II I
MONO (*) 3.73 H 0.3-2 (KIj..JL) •
NEU (*) 34.95 H 2-12 (f{Ij..JL)
Eosinophils (=) 0.34 0.1-1.49 (KIj..JL) ::===~I====;;;:=;::::~
B,ll,SO (=) 0.01 0-0.1 O{Ij..JL) I
L YM% (=) 10.2
MONO% (*) 8.6
NEU% (') 80.3
EOS% (=) 0.8
BASO% (=) 0.2
HCT (=) 23.4 L 37 -55 (%) :::I~=!========!===:::;
RBC (=) 3.22 L 5.5-8.5 (MIj..JL) ~I~=!========!===:::;
HGB (') 9 L 12-'18 (GIDL) I
RETIC(=) 14.5 ~=~======I~~
RETIC% (=) 0.5 I
MCV (=) 12.6 60-77 (FL) I I
ROW(=) 11 14.7-17.9 (%) I I
MCHC (=) 38.7 If 30-37.5 (GIDL) II
MCH (=) 28.12 18.5-30 (PG) I 'I
PL T (=) 438 175-500 (KIj..JL) I I
MPV (=) 9.28 I
PCT (=) 0.4 I
POW(=) 19 I
Differential algorithm issues. Confirm with blood film.
Hgb sheath timing variability.
