dc66e42ec4
Categories now match folder names (15 canonical values). Types normalized to 25 canonical values per VAULT_MAP.md spec. Context-aware mapping: W-2s→tax-form, lease files→lease, vet records→vet, etc.
6.5 KiB
date, type, provider, location, total, source
| date | type | provider | location | total | source | ||
|---|---|---|---|---|---|---|---|
| 2021-11-08 | vet | VCA West Los Angeles Animal Hospital | Los Angeles, CA | $495.80 |
|
VCA West Los Angeles — Emergency Visit
Date: 2021-11-08 Type: Emergency*** Client: Erica Jiang (#214489) Patient: Argo (#369932) — Feline, Domestic Long Hair, Male Neutered, Brown And White Age: 6y (DOB: 11/08/2015) Weight: 5.00 kg
Active Concerns
- Anorexia (08-Nov-2021)
- Ptyalism (08-Nov-2021)
Exam — Dr. Olivia Thomas, DVM
Date: 08-Nov-2021, 09:30
Vitals
| Temp (F) | HR (/min) | RR (/min) | SBP (mmHg) | CRT (s) | MM color | Pain (0-4) | BCS (/9) | Wt (kg) |
|---|---|---|---|---|---|---|---|---|
| 102.5 | 180 | 40 | -- | < 2 | Pink | 0 | 6 | 5.00 |
Patient History
Argo presented to the ER for excessive drooling and anorexia. Owners stated that he started drooling yesterday. He ate well yesterday morning, but was not interested in food yesterday evening or this morning. He has otherwise been acting normal. The owners did not see him eat or lick at anything he shouldn't have. They have cat grass in the house that he has eaten for the past few years and have not had any reactions to. He also received a piece of shrimp yesterday, but that is also something he has had many times before. Owner said that he sneezed a lot two days ago, but has not sneezed since.
- Strictly indoors
- No other pets
- No vomiting or diarrhea
- Not up to date on vaccine (Last set 2 years ago)
Exam Findings
| System | Findings |
|---|---|
| Eyes | Clear and free of discharge OU. Pupillary light reflex intact OU. Menace response present OU. Palpebral reflex present OU. |
| Ears | No debris AU. Pinna clear of lesions or masses. |
| Mouth | Ptyalism; No signs of stomatitis or ulceration. |
| Abdomen | No masses, fluid wave, or organomegaly palpated. No pain on palpation. |
| Behavioral | BAR |
| Cardiovascular | No murmurs or arrhythmias auscultated. Femoral pulses synchronous and strong. |
| Integument | Coat is clean and full. No ectoparasites seen. No skin lesions noted. |
| Lymphatic system | Palpable lymph nodes are soft, smooth, and small. |
| Musculoskeletal | Ambulatory on all limbs. Gait is normal. No swellings or bruising seen. No crepitus felt. |
| Nervous system | No obvious deficits; full neurological exam not performed. |
| Respiratory | Eupneic. Normal bronchovesicular sounds in all lung fields. No wheezing or crackles on auscultation. No strider or stertor heard. |
Assessments
Ptyalism, Anorexia
Ptyalism rule-outs:
- Oral Cavity Disease: oral trauma, oral masses, severe periodontal disease, stomatitis (toxins, infectious, immune-mediated), glossitis, faucitis, foreign body
- Drugs/toxins
- Nausea
- Cranial nerves deficits
- Seizures
Anorexia rule-outs:
- Primary anorexia: rare
- Secondary anorexia associated with nausea: GI inflammatory disease, GI ileus, delayed gastric emptying, vestibular disease, Food eversion (due to pain, vomiting)
- Pseudo-anorexia: retrobulbar abscess, intraoral masses/foreign bodies, mandibular fractures/TMJ disease, periodontal disease, oropharyngeal dysphagia, esophageal disease, nasal disease
Plan
Diagnostics: EDD Adult Feline panel: results pending
Treatments: Cerenia 1 mg/kg inj
Plan: Administer anti-nausea medication and monitor at home. Run bloodwork to look for abnormalities.
Communication
Discussed physical exam finding and history with owners. It is likely that Argo's excessive drooling is due to some kind of irritation associated with his mouth. Could be caused by any material that Argo may have eaten or licked that would be irritation to the mucosa of the mouth. No signs of ulcers seen, but that doesn't mean he didn't get into something. Another reason he could be drooling is if he is nauseous, though since he is not vomiting, it seems less likely. Recommended bloodwork to make sure there are no abnormalities linked to clinical signs. Offered pain medication and anti-nausea medication. Owners declined pain medication but agreed to bloodwork and anti-nausea medication.
Order Items
- Emergency Exam [3.112]: 1.00 exam — $218.00
- EDD Adult Blood Panel w/ Heartworm & Urinalysis Fe [163.4]: 1.00 test — $266.15
Buprenorphine (gen) 0.3mg/mL/mL Oral [325.86](Declined)- Maropitant (Cerenia) 10mg/mL/mL [53.315] - Dose: 5 mg (Amt: 0.5 mL) — $11.65
Subtotal: $495.80 Courtesy Discount: -$34.95 Paid: $495.80 (MasterCard)
Diagnostic Report — 09-Nov-2021
Source: Antech | Lab reference: IRBF24644783 Sample collected: 07:46 09-Nov-2021
Adult Wellness Chemistry
| Test | Results | Ref. range | Unit |
|---|---|---|---|
| Total Protein | 8.2 | 5.2 - 8.8 | g/dL |
| Albumin | 3.9 | 2.5 - 3.9 | g/dL |
| Globulin | 4.3 | 2.3 - 5.3 | g/dL |
| Alb/Glob ratio | 0.9 | 0.35 - 1.5 | |
| ALT | 37 | 10 - 100 | IU/L |
| ALP | 32 | 6 - 102 | IU/L |
| BUN | 26 | 14 - 36 | mg/dL |
| Creatinine | 1.6 | 0.6 - 2.4 | mg/dL |
| BUN/CREAT RATIO | 16 | 4 - 33 | |
| Glucose | 148 | 64 - 170 | mg/dL |
| Potassium | 4.2 | 3.4 - 5.6 | mEq/L |
Complete Blood Count
| Test | Results | Ref. range | Unit |
|---|---|---|---|
| WBC | 10.1 | 3.5 - 16 | 10^3/uL |
| RBC | 8.3 | 5.92 - 9.93 | 10^12/L |
| HGB | 12.9 | 9.3 - 15.9 | g/dL |
| HCT | 39 | 29 - 48 | % |
| MCV | 47 | 37 - 61 | fL |
| MCH | 15.6 | 11 - 21 | pg |
| MCHC | 33 | 30 - 38 | g/dL |
| Platelet Count | 238 | 200 - 500 | 10^3/uL |
| Platelet Estimate | Adequate | ||
| Neutrophils | 81 | 35 - 75 | % |
| Bands | 0 | 0 - 3 | % |
| Lymphocytes | 14 | 20 - 45 | % |
| Monocytes | 3 | 1 - 4 | % |
| Eosinophils | 2 | 2 - 12 | % |
| Basophils | 0 | 0 - 1 | % |
| Absolute Neutrophils | 8181 | 2500 - 8500 | /uL |
| Absolute Lymphocytes | 1414 | 1200 - 8000 | /uL |
| Absolute Monocytes | 303 | 0 - 600 | /uL |
| Absolute Eosinophils | 202 | 0 - 1000 | /uL |
| Absolute Basophils | 0 | 0 - 150 | /uL |
Heartworm Antibody, Feline
HEARTWORM ANTIBODY: NEGATIVE
Urinalysis
No urine was received. Please submit a urine sample within 30 days.
Medical Overview (as of 20-Nov-2021)
Service Reminders: Multiple items marked "Review" (Rabies, Panleukopenia, Leukemia, FIP, Dental Cleaning, Heartworm RX, Physical Exam, Fecal Exam, Flea Prevention, Rattlesnake). Heartworm Test and Wellness Testing due 08-Nov-2022.
Weight: 5 kg / 11.02 lb (08-Nov-2021)