Vet AI Scribe for Referral & Specialty Hospitals

Tilly

Thursday, October 15, 2026 at 10:30 AM

Internal Medicine — Consultation Report

Referring veterinarian: Dr. Sam Whitaker, Maple Grove Veterinary Clinic
Reason for referral: Chronic intermittent diarrhea and weight loss with hypoalbuminemia.

History

Summarized from the referral records (3 PDFs) and today's conversation with the owner.

• 7-year-old spayed female Yorkshire terrier.
• Intermittent small-bowel diarrhea since June 2026.
• Weight 3.4 kg in March 2026; 2.9 kg on October 2.
• July: Fenbendazole 50 mg/kg PO q24h for 5 days; no improvement.
• August: Course of metronidazole; stools improved briefly, relapse within two weeks.
• September: Hydrolyzed protein diet for three weeks; stools somewhat firmer, appetite reduced.
• Bloodwork, October 2: Albumin 1.7 g/dL (2.5–4.0), globulin 2.1 g/dL (2.3–5.2), cholesterol 96 mg/dL (110–320); liver enzymes within reference intervals.
• Urinalysis, October 2: USG 1.030; protein negative on dipstick.
• Cobalamin: 190 ng/L (251–908). Folate: 11.6 µg/L (7.7–24.4).
• Owner noticed her abdomen looking rounder over the past week.

Physical Exam

• Weight: 2.9 kg; body condition 3/9; moderate muscle loss.
• Temperature: 101.2°F · Heart rate: 120 bpm · Respiratory rate: 28 breaths/min
• Abdomen: Mild fluid wave; non-painful; small intestinal loops feel mildly thickened.
• No peripheral edema. No murmur; lungs clear.

Diagnostics Today

• Abdominal ultrasound: Diffuse hyperechoic mucosal striations in the jejunum; jejunal wall 3.8 mm with normal layering. Mildly enlarged mesenteric lymph nodes (largest 5 mm). Small volume of anechoic free fluid. Liver, spleen and kidneys unremarkable.
• Urine protein:creatinine ratio: 0.1.
• Bile acids, pre/post: 4 / 12 µmol/L.

Assessment

1. Protein-losing enteropathy — panhypoproteinemia, low cholesterol and low cobalamin with ultrasound changes consistent with lymphangiectasia. Renal and hepatic causes of hypoalbuminemia excluded.
2. Underlying cause — lymphangiectasia, chronic inflammatory enteropathy, or intestinal lymphoma (less likely with normal wall layering, but not excluded).
3. Hypocobalaminemia.
4. Mild ascites secondary to hypoalbuminemia.

Plan

• Gastroduodenoscopy and ileoscopy with biopsies on Tuesday, October 20, once the owner has approved the estimate.
• Diet: Ultra-low-fat diet from today, changed over 3 days.
• Cyanocobalamin: 250 µg SC once weekly for 6 weeks, first dose given today.
• Clopidogrel: 2 mg/kg PO q24h (compounded), as thromboprophylaxis.
• Decision on immunosuppressive treatment after histopathology.
• Recheck weight and albumin at the endoscopy appointment.

Letter to the Referring Veterinarian

Dear Dr. Whitaker,

Thank you for referring Tilly. Her low albumin, cholesterol and cobalamin with a normal urine protein:creatinine ratio and bile acids point to a protein-losing enteropathy, and the ultrasound changes suggest lymphangiectasia. We have started an ultra-low-fat diet, cobalamin injections and clopidogrel, and endoscopic biopsies are planned for October 20. We will send you the histopathology results and our treatment recommendations as soon as they are available, and would be glad for the weekly cobalamin injections to continue with you after the first two doses here.

Kind regards,
Dr. Nadia Rourke, DVM, DACVIM (SAIM)