Margaret CantrellRoss University School of Veterinary Medicine Class of 2014 firstname.lastname@example.org Competition coordinator – Sophie Russell
“Smokey” Cantrell12 October 2010SUBJECTIVESmokey is an 8 YO spayed female domestic short hair feline weighing 3.86 kg. The owner reported that the pethad not been eating well for about 2 weeks and has been lethargic for several days. The owner was unsure if thepet had been drinking water, as the dish is shared between the pet and two dogs. The owner also reported thatto the best of his knowledge, the pet has had no vomiting or diarrhea. Upon presentation, the pet wasdepressed, icterus was noted at the ears, nose, sclera, and mucous membranes, and the hair coat was unkempt.OBJECTIVEThe pet was presented for evaluation of anorexia and lethargy. Temperature was 100.5ᵒF and weight was notedto be 3.86 kg. Smokey is not on any medications, including flea/tick/heartworm prevention. The onlyabnormality noted on physical examination was icterus. Neurologic examination revealed that all cranial nervesare intact, and no neurologic abnormalities were noted. In-house biochemistry revealed a slightly elevatedblood glucose (149 mg/dL, normal 70-130 mg/dL), elevated ALP (358 U/I, normal 0-90 U/I), and low BUN (9.8mg/dL, normal 15.0-32.0 mg/dL). Values for creatinine, ALT, and total protein were within normal limits.ASSESSMENTBased on clinical presentation and biochemical analysis, a differential list of hepatic lipidosis, hemolytic anemia,and Haemobartonella felis was made. To help minimize the differential list, additional blood work was sent to anoutside lab for a complete blood count and smear. These tests revealed a stress leukogram, thrombocytosis, andslightly decreased hemoglobin (9.3 g/dL, normal 9.5-15 g/dL). An increased RDW was also noted on CBC (27.4%,normal 14.0-18.5%), but on microscopic examination, it was found that both WBC and RBC morphology werenormal. The blood smear did not demonstrate H. felis organisms, but because ALT is not significantly increased,along with the presence of both icterus and anemia, H. felis is the primary differential for this case.PLANDue to poor condition on presentation, it was recommended that the pet remain at the clinic for observation for2-3 days. Though the pet was not noted to be dehydrated, 200 mL of LRS was administered subcutaneously onthe day of presentation as a precautionary measure. Additionally, 0.75 mL of Baytril and 0.5 mL of prednisonewere given to control the suspected hematological disorders. When the pet was released to the owner 3 dayslater (on 15 October 2010), prescriptions for doxycycline (25 mg/mL) and prednisone (8 mg/mL) were filled andsent home, with 1 mL of each to be administered twice each day for one week, at which time the pet will needto return for a recheck.22 October 2010SUBJECTIVERecheck appointment. Owner reports that the pet is still not eating well, and that it has been difficult to
administer medication to the pet, and as a result, there have been several missed doses over the past week. Thepet is still very icteric and coat is unkempt, though hydration status appears to be normal.OBJECTIVEPhysical examination revealed that icterus is still present and appears to have worsened. Weight was noted tohave decreased since the last visit, and is now 3.64 kg. Temperature was recorded at 101.7ᵒF. In-housechemistry and PCV were done. ALP has increased since presentation (594 U/I, normal 0-90 U/I), and ALT is alsoslightly elevated (101 U/I, normal 0-85 U/I), and BUN has further decreased (7.6 mg/dL, normal 15.0-32.0mg/dL). PCV has dropped since the last visit (from 26.9% to 24.8%, normal 25.0-45.0%), though it is only slightlybelow the range. Values for blood glucose, total protein, and creatinine were all within normal limits. CBCrevealed lymphocytopenia (1.0 x 103/µL, normal 1.8-7.0 x 103/µL), monocytosis (1.7 x 103/µL, normal 0.2-1.0 x103/µL), and mild granulocytosis (13.1 x 103/µL, normal 2.8-13.0 x 103/µL), in addition to an increased RDWa(38.5 fl, normal 20.0-35.0 fl) and RDW% (26.0%, normal 14.0-18.5%). Platelet count is improved since last visit,and is now within normal limits.ASSESSMENTClinical signs appear to have worsened since the last visit. Additionally, an insignificant increase in ALT alongsidecontinuing icterus and anemia continues to support a tentative diagnosis of H. felis. Hepatic lipidosis can beruled out due to the absence of a significant increase in ALT.PLANThough thrombocytosis has resolved, other abnormalities in blood work and worsening icterus indicate that thepet still needs to continue treatment. Differential list still includes hepatic lipidosis, hemolytic anemia, and H.felis, though hemobartonellosis is more strongly suspected. The pet was given ¾ mL Depo-medrol IM and wassent home with 22.7 mg Baytril, to be given SID for 7 days. The owner was instructed to keep a close eye on thepet, and to encourage the pet to eat. Recheck in one week is recommended, at which time another CBC will bedone.29 October 2010SUBJECTIVERecheck appointment. Owner reports some improvement since last visit, stating that the pet has been eating,though only a few bites each day. Owner also stated that the pet has not been hiding as much, and no doses ofmedication have been missed since the last visit.OBJECTIVEOn physical examination, icterus was noted to still be present, though it does appear to have improved since thelast visit. Weight has continued to decrease, and is now 3.30 kg. Temperature was recorded at 99.6ᵒF, and PCVhas increased since last visit (24.8% to 27.1%, normal 25.0-45.0%). In-house CBC was done, and noted acontinued mild lymphocytopenia (1.7 x 103/µL, normal 1.8-7.0 x 103/µL), monocytosis (1.9 x 103/µL, normal 0.2-1.0 x 103/µL), and increased RDW% (23.4%, normal 14.0-18.5%). All other values were within normal limits.ASSESSMENTContinuing resolution of clinical signs suggest that the animal is recovering. Of concern, however, is continued
weight loss, which will need to be monitored closely in the coming weeks. Icterus, though still present, seems tobe resolving. This, in conjunction with an increased PCV since the last visit, strongly suggests that the patient’scondition is improving.PLANBecause icterus has not yet resolved, treatment will be continued. The pet was given ¾ mL Depo-medrol IM, andwas sent home with instructions to be given 22.7 mg Baytril to be given SID for 14 days, at which time the petshould return for a reassessment. Because weight has continued to decrease, the owner was instructed toencourage the pet to eat, and to notify the clinic with any further concerns.12 November 2010SUBJECTIVERecheck appointment. Owner reports that the pet has been eating some since the last visit, and that there havebeen no issues in administering medication. Additionally, icterus appears to be resolving.OBJECTIVEPhysical examination revealed that icterus is present, though appears to be less noticeable than at the previousvisit. The pet’s weight was recorded at 3.30 kg (same as last visit). In-house CBC revealed a continued mildlymphocytopenia (1.7 x 103/µL, normal 1.8-7.0 x 103/µL) and monocytosis that has increased since the last visit(from 1.9 x 103/µL to 2.3 x 103/µL, normal 0.2-1.0 x 103/µL). Likewise, RDW% has increased since the last visit(from 23.4% to 24.3%, normal 14.0-18.5%). Anemia is continuing to resolve, with PCV recorded at 27.5% at thisvisit, compared to 27.1% at the prior visit (normal 25.0-45.0%).ASSESSMENTRecovery appears to be progressing smoothly, as anemia and icterus are resolving, and weight has beenmaintained over the past two weeks. Lymphocytopenia and monocytosis may be attributed to the suspectedhaemobartonellosis.PLANThough resolving, the continued presence of icterus necessitates continuing treatment. As such, the owner wasinstructed to continue giving 22.7 mg Baytril SID for 14 days, at which time the pet should return for a recheck.29 November 2010SUBJECTIVERecheck appointment. Owner reports that the pet appears to be feeling better, as evidenced by fractiousbehavior, which owner states is normal for the pet. Owner also reports that the pet has been “ravenouslyhungry” since the last visit.OBJECTIVEPhysical exam revealed that icterus is almost completely resolved. PCV was noted to have improved since thelast visit, increasing from 27.5% to 29.3% (normal 25.0-45.0%). CBC also revealed a continuing mildlymphocytosis (1.4 x 103/µL, normal 1.8-7.0 x 103/µL), increased RDW% (24.5%, normal 14.0-18.5%), as well as
thrombocytosis (570 x 103/µL, normal 200-500 x 103/µL) and slightly decreased MPV (7.7 fl, normal 8.0-12.0 fl).Additionally, the pet has lost weight since the last visit, and was noted to be 3.18 kg.ASSESSMENTIcterus has almost completely resolved and PCV has risen to an acceptable level, and as a result, it would appearthat the haemobartonellosis has resolved. However, based on the new discovery of a ravenous appetite couplewith continued weight loss, it is possible that the pet has developed either steroid-induced appetite stimulation(as a consequence of Depo-medrol administration) or has hyperthyroidism. A T4 panel was sent to an outsidelaboratory to rule out hyperthyroidism. T4 was found to be within normal limits at 1.3 µg/dL (normal 0.8-4.7µg/dL).PLANBecause the haemobartonellosis appears to have resolved, Depo-medrol injections are no longer necessary, andthe owner was told to discontinue use of Baytril. Based on the normal T4 value, it may be said that the pet is nota hyperthyroid patient, but it cannot be ruled out indefinitely. If the pet does, in fact, have hyperthyroidism, thenormal value could be due to euthyroid sick syndrome, or the pet could be in the early stages of thehyperthyroidism. In order to confirm, further testing (i.e., evaluation of free T4 or a T3 suppression test) wouldneed to be performed in several weeks, once we can be fairly certain that there are no interfering factorspresent. At this time, owner declined such tests. A recheck in 3-4 weeks, at which time a PCV should be obtainedto determine if all hematological values have returned to normal.
FAX ONLY THE FRONT OF THIS CLAIM FORM. NO COVER SHEET REQUIRED. CLAIM FORM CHECKLIST ✓ ❑ I entered in my policy number, pet information and my contact information. ❑ This claim form includes only one pet. ❑ My veterinarian helped me complete Section 2 with the diagnosis(es), treatment date and the name of the hospital/clinic. ❑ I included all of my itemized and legible receipts/invoices. ❑ My pets name and policy number are clearly identified on each receipt/invoice. ❑ I added up all my eligible receipts and entered the Total Amount Submitted. ❑ I signed and dated this claim form. (My veterinarian is not required to sign this form.) ❑ I submitted this claim form and all supporting receipts/invoices to the VPI Claims Department. I understand that claim forms that are incomplete or missing itemized and legible supporting receipts/invoices may be delayed. ❑ I kept a back-up copy of all documentation submitted for my records. ❑ If medical records are requested to process this claim, I understand that it is my responsibility to provide them to VPI. Two ways to submit your claim: Fax 714-989-5600 – OR – VPI Claims Department, PO Box 2344, Brea, CA 92822 If FAXING your claim, DO NOT MAIL IT IN. Duplicate claims submission may delay processing.Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or otherperson files an application for insurance or statement of claim containing any materially false informationor conceals for the purpose of misleading, information concerning any fact material thereto commits afraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties.Not applicable in Nebraska, Oregon and Vermont.
VPI® MAJOR MEDICAL PLAN BENEFIT SCHEDULE SECTIONS USED FOR CALCULATION OF CLAIM REIMBURSEMENT A B Primary SecondaryCode Diagnosis Allowance AllowanceINFECTIOUS (Virus, Bacteria, & Fungus) Conditions2008 Haemobartonella (Mycoplasmosis) $350 | $140ENDOCRINOLOGY Conditions2921 Hyperthyroidism $720 | $290
INVOICE 2921 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 A 2008 AINELIGIBLE Invoice total: $470.00
CLAIM CALCULATION BASED ON INVOICE AND BENEFIT ALLOWANCES VPI® Major Eligible veterinary Eligible Conditions Veterinary Fees Annual deductible Medical Plan fees1 Amount Benefit Allowance Haemobartonella $42000 -$10000 $31700 $35000 $31700 (Mycoplasmosis) Hyperthyroidism $5000 $5000 $72000 $5000 Invoice total: $47000 Total reimbursement: $36700Reimbursed fees: $367 00Fees paid out-of-pocket: $10300Fees incurred without insurance: $470 001 $300 boarding fees are ineligible for coverage; $42000 veterinary fees - $10000 deductible - $300 ineligible fees = $31700eligible veterinary fees