medicalhistory - free animal doctor€¦ · test results ref.range unit toxoplasmosis-igm negative

MEDICAL HISTORY14-Mar-2019 to 30-Apr-2019

Client Patient

Edward Seguin (32916)C: Edward: (760) 851-9638

Marisa (59349)FelineSiamese Mix

15y 1m (13-Mar-2004)TriFemale / Spayed - 4.79 kg (15-Mar-2019)

Most recent visit date: 14-Mar-2019Microchip No.: n/aRabies tag ID / date : n/a

Patient Alerts: n/a

Current medical overview: as of 10-May-2019

Service Reminders Due Date

Fel Rabies ReviewFel Panleukopenia 12-Sep-2016Fel Leukemia ReviewFel Dental Cleaning ReviewFel Heartworm RX ReviewPhysical Exam 12-Sep-2019Fecal Exam ReviewFel Flea Prevention ReviewFel Respiratory Virus 12-Sep-2016

Weight by Age Wt. Record date

15y 4.79 kg 10.56 lb 15-Mar-2019

Active Concerns Established

Vestibular disease 14-Mar-2019

Inactive Concerns Established

n/a

Resolved Concerns (since 14-Mar-2019) Established Resolved

n/a

Medications (since 30-Apr-2018) Amount Disp. Date

n/a

VCA Rancho Mirage Animal Hospital71-075 Highway 111, Rancho Mirage , CA 92270 | (760) 346-6103

Exported by: Kimberly Strum on 10-May-2019 1 of 4

Outpatient visit (14-Mar-2019 to 14-Mar-2019)

Appointment Type: Wellness Provider: Forney DVM, Michael Sex / age / weight: Female - Spayed / 15y / 4.79 kg (15-Mar-2019)

Concerns (Problem List)

Active• Vestibular disease (14-Mar-2019)

14-Mar-201914:24

Exam Forney DVM, Michael

Assisted by: Amelia.Bass

VITALSTemp (F) HR RR SBP CRT MM color Pain ([0-4]) BCS (/9)

14:24 101.1 180 -- -- < 2 Pink -- 6

PATIENT HISTORYGeneral findings Client comment - Pet presented for a head tilt to the left. Owner noted that it started on

Tuesday and he took her to Desert Dunes. They gave her a Depomedrol injection and she hassince gotten worse. Owner would like a second opinion. E/D okay. No V/D. On no meds.

Diet history Diet, specify food - 9 Lives DryFriskies Pate

EXAM FINDINGS

Whole body Attitude Bright; Alert; Aggressive - Patient hissing, growling, and opening mouthto bite during PE

Hydration Normal hydration - Adequate skin turgor

Head Head neurologicfunction

Circling to the left; Horizontal nystagmus - Fast phase to the right(away from the left)

Eyes Iris Iris atrophy - Mild OUConjunctiva No erythemaCornea Clear corneaLens No cataractVision Visual responses - Unable to obtain menace OS, present OD; however

patient not easy to evaluateRetina Fundic exam - Briefly tried to obtain fundic exam with indirect

ophthalmoscope lens - possible retinal lesions OS

Ears External ear canal No debris - No debris or abnormalities noted externally; did not evaluatewith otoscope due to patient temperament

Mouth Oral cavity No masses - No masses or ulcers appreciated

Thorax Heart No heart murmur - No murmur, regular rhythm, strong symmetricalpulses

All lung fields Breath sounds present - Normal bronchovesicular sounds all 4 quadrants

Abdomen Abdominal palpation Palpation non-diagnostic, tense patient

Integument General findings No alopecia; No crusts; No ectoparasites; No pruritusHair coat Healthy hair coat - Clean & intact

Musculoskeletal Ambulation Weight bearing - Bears weight all 4 limbs but circles primarily to left

ASSESSMENTS

Vestibular disease• DDX: central vestibular (e.g. neoplasia, infectious, inflammatory) vs. peripheral (e.g. infectious, polyp, idiopathic) vs.

other

Client: Edward Seguin (32916) Patient: Marisa (59349)MEDICAL HISTORY: 14-Mar-2019 to 30-Apr-2019

*Documents are available as separate attachments or files.VCA Rancho Mirage Animal Hospital

71-075 Highway 111, Rancho Mirage , CA 92270 | (760) 346-61032 of 4

14-Mar-201914:24

Exam Forney DVM, Michael

Assisted by: Amelia.Bass• Owner reports no exposure to medications, indoor only cat, has had her since a kitten• Given lack of nausea, vomiting and inappetance and possible ocular changes, suspicious for central vestibular

disease, however cannot rule out peripheral• Recommend testing for infectious diseases (e.g. toxoplasma, cryptococcus)• Recommend bloodwork to rule out systemic disease• Consider medications for nausea as needed• Consider referral to neurologist• Discussed with owner that if idiopathic, will likely resolve with time, however, other etiologies will likely progress

PLANS

Vestibular disease• Blood drawn for serum testing for infectious antigen testing (toxo, crypto, FIV, FeLV) - will call with results• Owner declined CBC/CHEM today• Owner declined Cerenia today - okay to fill or come in for injectable if patient shows signs of nausea• Gave owner contact information for Veterinary Neurology Center for referral to Dr. Hansen

14-Mar-2019 Order items

• Exam/Consultation Well Patient [1.1]: 1.00 each• FeLV FIV FCV Tox Cryp [161.29]: 1.00 test• Complete and Confirmed [609.9]: 1.00 each

Documents*

14-Mar-2019 • Seguin-Marisa__2019-05-10_Seguin,Marisa(Desert Dunes AH Med. Rec.).pdf

Diagnostic report

15-Mar-2019 FeLV FIV FCV Tox Cryp SA270 Forney DVM, Michael

11:08 Source: Antech | Order item: FeLV FIV FCV Tox Cryp SA270 [161.29]Sample collected: 11:22 15-Mar-2019 | Submitted: 15-Mar-2019 | Reported: 15-Mar-2019Lab reference: IRBE89497717

Test Results Ref. range Unit

FeLV Antigen (ELISA)

FELV (ELISA) NegativeFIV Antibody

FIV ANTIBODY NegativeIf recent infection cannot be excluded, retesting >60 days after last exposure is recommended.

Feline Coronavirus Titer

FCV AT 1:400 <1:400 <1:400FCV AT 1:1600 Negative

A positive FCV titer indicates exposure to a coronavirus. It does notdifferentiate between FIP, feline enteric coronavirus exposure, orvaccination. Diagnosis of FIP should be based on history, physicalexamination, and other laboratory findings.

Cryptococcal Antigen

CRYPTOCOCCAL ANTIGEN NegativeToxoplasma Ab - IgG/IgM

TOXOPLASMOSIS - IGG Negative <1:64




Test Results Ref. range UnitTOXOPLASMOSIS - IGM Negative <1:64Comment n/a

Documents*

18-Mar-2019 • Seguin-Marisa__2019-05-10_Seguin,Marisa (Vet Neurology Report 3.18.19).pdf

22-Apr-2019 • Seguin-Marisa__2019-05-10_Seguin, Marisa (Advanced Vet Care Center Report 4.20.19).pdf

30-Apr-2019 • Seguin-Marisa__2019-05-10_Seguin,Marisa (VOC report 4.25.19).pdf


