Vet AI Scribe for Reptile

Tank

Friday, August 22, 2025 at 11:30 AM

Subjective

Chief Complaint

Owner reports two weeks of straining in the water bowl, reduced appetite, and no observed urates or faeces in the past five days.

History

• 14-year-old female Russian tortoise (Testudo horsfieldii), owned 11 years.
• Housed indoors in a 4 ft by 2 ft table enclosure; coconut coir substrate.
• Diet: grocery greens (romaine, spring mix), occasional fruit; no calcium supplementation.
• UVB: compact coil bulb, last changed approximately one year ago.
• Soaked weekly; owner describes the urine as frequently gritty.
• Brumated once, three years ago. No known egg laying.

Objective

Vitals

• Weight: 1,180 g (down from 1,265 g eight months ago)
• Carapace length: 18.5 cm
• Enclosure temperature, owner report: 75°F cool side, 88°F basking

Physical Exam

• Mentation: Bright; strong withdrawal reflex
• Shell: Mild scute pyramiding; no softening; no shell rot
• Eyes and nares: Clear; no discharge
• Oral cavity: Pink; no plaques or petechiae
• Limbs: Good muscle tone; no swelling at the long bones
• Coelomic palpation, prefemoral fossae: Firm rounded mass palpable caudally, approximately 3 cm
• Cloaca: Mildly erythematous; no prolapse; urates absent
• Hydration: Sunken periocular tissue; moderate dehydration

Assessment

Primary Problem List

1. Cystic calculus — palpable firm coelomic mass, straining, absent urates
2. Moderate dehydration
3. Weight loss (6.7%)
4. Husbandry deficits — coil UVB, unsupplemented diet, marginal basking temperature
5. Scute pyramiding — chronic, consistent with the humidity and dietary history

Differentials

• Cystic calculus — most consistent with the findings
• Retained eggs or post-ovulatory follicular stasis
• Cloacal or colonic obstruction
• Neoplasia

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Plan

Diagnostics

• Whole-body radiographs: dorsoventral, craniocaudal and lateral projections
• CBC and plasma biochemistry including uric acid, calcium and phosphorus
• Ionised calcium where available

Treatment / Management

• Fluids: Warm-water soaks 20 minutes BID; 15 mL/kg isotonic fluids administered in the epicoelomic space
• Analgesia: Meloxicam 0.2 mg/kg SC q24h
• Surgical: If a calculus is confirmed and is too large for retrograde flushing, schedule cystotomy. Prefemoral approach preferred where the stone can be fragmented; plastron osteotomy reserved for larger calculi.
• Husbandry: Replace the coil UVB with a linear T5 HO 10.0 tube mounted 12-14 inches above the basking site; raise the basking surface to 95°F; dust food with calcium carbonate two to three times weekly; shift the diet toward high-fibre, low-oxalate weeds and grasses.

Follow-Up

• Radiographs reviewed the same day
• Surgical decision within 48 hours; patient stabilised with fluids in the interim
• Post-operative rechecks at 10 and 30 days
• Annual radiographs to monitor for recurrence

Client Communication:
Explained that bladder stones in tortoises form over years and that this one reflects long-term dehydration and diet rather than a sudden illness. Reviewed why a coil UVB bulb delivers far less usable output at distance than a linear tube, and why grocery greens alone do not supply the calcium-to-phosphorus ratio a tortoise needs. Owner shown how to assess urate consistency at each soak.

— Dr. Elena Vasquez, DVM