Brasher Tiny Medical history 2016 01 26 to 2016 01 26 (PDF)

VCA Ashford Animal Hospital
12633 Whittington , Houston , TX 77077 | (281) 497-3917

MEDICAL HISTORY
26-Jan-2016 to 26-Jan-2016
Client

Patient

Virginia Brasher (5656)

Tiny (33437)

1y (25-Jan-2015)

C: Virginia: (281) 704-2280

Feline

Tabby, Silver

Domestic Medium Hair

Male / Neutered - 10 lb 3 oz (26-Jan-2016)

Most recent visit date:

26-Jan-2016

Microchip No.:

n/a

Rabies tag ID / date :

n/a

Patient Alerts: n/a

Current medical overview: as of 28-Jan-2016
Current Wellness Reminders

Due Date

Fel Rabies

Review

Fel Distemper

Review

Fel Leukemia

Review

Fel Dental Cleaning

Review

Fel Heartworm RX

Review

Physical Exam

27-Jan-2017

Fecal Exam

27-Jan-2017

Fel Flea Prevention

Review

Fel FIV

Review

Fel Respiratory Virus

Review

Weight by Age
1y

4.62 kg

Wt.

Record date

10.19 lb

26-Jan-2016

Active Concerns

Established

deceased

26-Jan-2016

Vomiting blood

26-Jan-2016

Inactive Concerns

Established

n/a
Resolved Concerns (since 26-Jan-2016)

Established

Resolved

Amount

Disp. Date

n/a
Medications (since 26-Jan-2015)
n/a

Exported by: Brittany Newton on 28-Jan-2016

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Client: Virginia Brasher (5656)

Patient: Tiny (33437)

MEDICAL HISTORY: 26-Jan-2016 to 26-Jan-2016
Outpatient visit (26-Jan-2016 to 27-Jan-2016)
Appointment Type: Wellness Provider: Slomer DVM, Sally Sex / age / weight: Male - Neutered / 1y / 10 lb 3 oz (26-Jan-2016)
Concerns (Problem List)
Active
• deceased (26-Jan-2016)
• Vomiting blood (26-Jan-2016)
26-Jan-2016 Exam

Slomer DVM, Sally

09:00

Assisted by: Betty.Wood1027, Eugene.Philyaw
VITALS

09:00

Temp (F)

HR

RR

SBP

CRT

MM color

Pain

BCS

100.9

160

30

--

--

Pale pink

0

5

CLIENT INTERVIEW
General findings

Coughing/sneezing - absent; Polyuria/polydipsia - absent; Vomiting/diarrhea - absent

Presenting concerns

Diarrhea - Started last night. red color in stool.; Vomiting - Started saturday

Appetite history

Decreased appetite - Not eating since weekend

Diet history

Diet, specify food - Was on blue buffalo and tried offering proplan sensitive stomach

Activity and exercise history

Activity level normal

EXAM FINDINGS
Whole body

General findings

Alert; Bright; Responsive

Hydration

Hydration normal - Normal skin turgor

In-house lab results

FeLV/FIV test - Negative

Head

General findings

nomal

Eyes

Cornea

Clear and bright

Lens

Cataract - absent

Vision

Visual tracking - Vision appears normal

Sclera

Clear and white

Ears

External ear canal

Debris - absent - AU

Mouth

Dental occlusion bite Occlusion, normal
Teeth

Tartar accumulation - absent

Neck

General findings

normal

Thorax

Heart

Arrhythmia - absent; Murmur - absent; Pulse deficits - absent - Strong
synchronous pulses

All lung fields

Normal bronchovesicular sounds

Thoracic limbs

General findings

normal

Abdomen

Abdominal palpation Unremarkable - No organomegaly, soft compliant abdomen, non-painful

Pelvic limbs

General findings

normal

Pelvic region

General findings

normal

Tail

General findings

normal

Behavioral

General findings

Lethargy; Quiet

Digestive

Vomitus

in exam room vomited bile with blood - Very large amount of bilious
fluid vomited up with large flecks of blood in it.

* Documents are available as separate attachments or files. ** Lab results are located at the end of this document, in the 'Lab results' section.

VCA Ashford Animal Hospital | 12633 Whittington , Houston , TX 77077 | (281) 497-3917

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Client: Virginia Brasher (5656)

Patient: Tiny (33437)

MEDICAL HISTORY: 26-Jan-2016 to 26-Jan-2016
26-Jan-2016 Exam

Slomer DVM, Sally

09:00

Assisted by: Betty.Wood1027, Eugene.Philyaw
also blood in stool
very dehydrated
Integument

General findings

Ectoparasites - absent - No evidence of fleas, ticks or mites

Lymphatic system

General findings

Lymphadenopathy - absent - All palpable peripheral lymph nodes are

Musculoskeletal

Gait

Normal gait

Reproductive

General findings

normal

Urinary

General findings

normal

normal in size and non-painful

ASSESSMENTS
deceased
Vomiting blood
PLANS
Vomiting blood

Rads--no sign of obstruction
started on IV fluids 25 ml/hr
metro 1 cc bid
cerenia 1/2 cc sub q
keep overnight on fluids
profile pending

Vomiting blood
26-Jan-2016

Died this morning

Order items
• Exam Medical Condition [1.2]: 1.00 each
• BestCare SeniorCatSA768 [163.106]: 1.00 test
• Fluid Set Up - Surgery [37.60]: 1.00 each
• Famotidine (gen) 10mgIH [54.50]: 1.00 tab
• Maropitant(Cerenia)10mg/ml/ml [53.315]: 1.00 ml
• Patient Care Injections [51.3]: 1.00 each

* Documents are available as separate attachments or files. ** Lab results are located at the end of this document, in the 'Lab results' section.

VCA Ashford Animal Hospital | 12633 Whittington , Houston , TX 77077 | (281) 497-3917

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