9/6/2019

DVM Intake Exam Estimated age: Estimated 1-3 years old based on dentition and overall appearance Microchip noted on Intake? Scanned negative History : Got into fight with other household dog this evening. Brought in by police. Subjective: Alert, in very small carrier, staring at me and growling Observed Behavior - Pt was sedated for exam - 0.7 ml Dexdomitor IM and 0.6 ml butorphanol IM. Additional 0.2 ml Dexdomitor given during wound cleaning. Evidence of Cruelty seen - None Evidence of Trauma seen - Bite wounds to neck Objective Sedated. BCS 4/9. MMs pink. EENT: Eyes clear, both ears completely filled with black waxy discharge - AS additionally has clotted blood on the inside of the pinna. Small excoriations inside AS pinna. No nasal discharge. Small partial-thickness puncture wound (< 1 cm) to the left lower lip, near the lateral commissure. Large full-thickness puncture wound (1.5 cm) caudal to the left ear, with strands of fascia exposed. Three small partial-thickness puncture wounds (<1 cm) above, cranially and caudally to the large puncture wound. One small partial-thickness puncture wound (<1 cm) ventral/caudal to the large puncture wound. All punctures have mild bloody discharge. There is red-purple bruising surrounding all punctures, and a moderate amount of edema is collecting under the chin, ventral and rostral to the wounds. Oral Exam: Muzzled. Incisors and canines are clean. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, no coughing or sneezing ABD: Non painful, no masses palpated, not distended U/G: Male intact, testicles small, soft and symmetrical. MSI: Four superficial parallel linear excoriations on dorsal spine. Severe, severe generalized alopecia, greasy discharge, lichenification and hyperpigmentation over entire body - worst on ventral abd/inguinal region (including scrotum), on left flank just cranial to left hind leg, and on dorsal neck between the shoulder blades. Long nails. Small stature. Ambulatory x 4, skin free of parasites. No masses noted. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Normal externally Assessment: 1. Bite wounds to face, scratches to back - from another dog 2. Severe alopecia, hyperpigmentation and lichenification - R/O severe allergies 3. Cretinous stature - R/O maldigestion/malabsorption vs. other Prognosis: Fair Plan: 1. Sedation for wound clipping, cleaning and flushing, as well as ear cleaning, nail trimming and overall sponge-bath 2. Skin scrape to rule out Demodex 3. Rimadyl 50 mg/ml 2 ml SQ 4. Rimadyl 100 mg PO SID x5 days starting tomorrow 5. Clavamox 375 mg PO BID x10 days 6. Diphenhydramine 75 mg PO BID x21 days 7. Recommend Malaseb bathing three times weekly 8. Feed z/d only - recommend continuing limited ingredient diet trial for 8+ weeks 9. Recommend intradermal skin testing to determine a recipe for allergy shots 10. CBC/chemistry SURGERY: Temporary waiver due to severe allergies 1088

9/6/2019

SO: Hx of bite wounds to neck BAR in kennel baring teeth when talked to in kennel visual exam only due to behavior wounds do not appear excessively swollen or discharging excessively A: bite wounds on treatment P: continue current treatment plan

9/6/2019

CBC/Chem nsa on CBC Chemistry BUN 48 (7-27) r/o dehydration no other significant abnormalities on chemistry

9/12/2019

HX: visual- left side of face seems to have a little purulent discharge consider sedation and examination

9/15/2019

Hx: check ventral neck area QAR eating eent- moist discharge and alopecia on left side of neck and moderate swelling A) consider drain placement

9/18/2019

Hx: Bite wounds to neck, noted to be swollen with discharge on 9/15. Antibiotics finished on 9/14. S: Curled up on bed, does not get up today O: -Caudal dorsum is moist, alopecic, erythematous/hyperpigmented -Most of dorsum is very flaky, alopecic -Ventral left side of neck appears to have moist discharge, but it is difficult to see from outside the kennel A: Concern for neck infection or abscess P: Hands-on exam 1088

9/19/2019

SO Recheck bite wounds to neck. P was sedated for examination skin -- multiple bite wounds along left side of neck. There is a 0.25cm full thickness puncture wound along the left dorsolateral neck with minimal thick serous discharge present. Wound along the ventral neck full thickness, approximately 2mm in diameter with mild purulent discharge present. generalized alopecia, lichenification and hyperkeratosis. Skin is especially affected along the ventral abdomen and inguinal regions, testicles. ears -- ears and surround fur have crusting stuck within fur. ears have heavy amount of brown to black exudate, AU with hyperkeratosis. A bite wounds severe generalized hyperkeratotis and alopecia otitis externa, chronic P sedated with dexdomitor 0.6ml, butorphanol 1ml IM flushed wound pockets with dilute chlorhexidine followed by copious amounts of sterile LRS lanced ventral neck wound to allow drainage; applied pressure for hemostasis convenia 2.4ml SQ one time carprofen 100mg tablet -- give 1 tablet PO q24h x 4 days antisedan 0.6ml IM for reversal skin scrape -- negative.

9/21/2019

HX: Neck wounds drained and flushed 2 days ago and Convenia given. S: Barking and snarling at cage door. O: EENT: mm pink, eyes clear, no nasal or ocular discharge Skin: Left jowl slightly thickened compared to right. No erythema or discharge noted. A: Wounds appear to be healing well and not bothering dog. Plan: Continue with Rimadyl for 2 more days. Recheck skin visually 7 days to determine if further intervention is needed.