5/3/2019

DVM Intake Exam Estimated age: 3y Microchip noted on Intake? no Microchip Number (If Applicable): History : owner surrender, stated dealing for a long time with skin condition to no effect Subjective: BARH, good appetite, no elimination noted Observed Behavior - allowed handling, escalated to growling and trying to flee Evidence of Cruelty seen - no Evidence of Trauma seen - no Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: unremarkable adult dentition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female intact, no leakage or discharge MSI: Ambulatory x 4, no visible parasites, no masses noted, alopecia on neck and ventrum. area around neck severely excoriated with fresh bloody wounds. the ventrum has multiple miliary papules. Extreme pruritus along the ventral neck CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: visually normal Assessment dermatitis wound Prognosis: fair to good depending on response to treatment Plan: convenia SQ once simbadol 0.24mg/kg SQ SID until 5/5 benedryl 0.5mg/kg PO BID until 5/5 entederm topical BID until 5/5 medicated bath and tech intake tomorrow impression smear - mostly cocci e collar and vest SURGERY: temp waiver dermatitis

5/4/2019

History 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds from pruritis. Impression smear (sample from skin fold in neck) showed TNTC cocci Convenia given. Simbadol, benadryl, topical entederm. E-collar and vest. S/O: Scheduled for medicated bath today. BAR, purring and attention seeking at front of cage, eating and drinking very well, allows some handling but escalates to growling and swatting with moderate restraint. EENT: Eyes - mild dried discharge UO, ears - mild dark discharge AU, no nasal discharge noted Oral Exam: mm pink, CRT <2, mild tartar H/L: No overt murmur - purring and then growling Lungs clear, eupnic ABD: Non painful, no masses palpated MSI: Ambulatory x 4, BCS 4/9, alopecia and severe lichenification and erythema along neck and inguinal region. Pigmentation present inguinally. Ventral neck is moist with thick purulent discharge in skin folds. Secondary/self inflicted excorations-lacerations at lateral and ventral neck extending to sides of face. CNS: Mentation appropriate, no signs of neurologic abnormalities Assessment: Severe pyoderma, dermatitis - ro allergy (atopy vs food vs FBD) vs autoimmune vs other Secondary self inflicted excoriations and lacerations to neck Prognosis: Fair Plan: Sedate for medicated bath today CBC/Chem - machine not working, scheduled for tomorrow Continue simbadol 0.24 mg/kg SQ SID until 5/5 Continue benadryl 1 mg/kg *change to SQ injection* BID until 5/5 Continue topical entederm to neck BID until 5/5 Keep e-collar and shirt on to prevent scratching SURGERY: Temporary waiver due to pyoderma

5/5/2019

Progress exam Intake 5/3/19: Owner surrender. Noted severe dermatitis, pyoderma with secondary self inflicted wounds from pruritis. Impression smear (sample from skin fold in neck) showed TNTC cocci Convenia given. Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4: Received medicated bath Today, 5/5: progress exam Subjective: BARH, no coughing/sneezing/vomiting/diarrhea. Objective: P: WNL R: WNL BCS: 4/9 EENT: Ears and nares clear bilaterally, no discharge noted. Mild dark discharge OU, unchanged from prior exam, no blepharospasm. CV: No murmurs or arrhythmias, pulses strong and synchronous. RESP: Eupneic, no crackles/wheezes GI: Soft, nonpainful, no palpable masses. Growling when palpated, likely due to handling rather than pain. INT: Alopecia and severe lichenification and erythema along neck, caudal aspect of forelimbs, and inguinal regions. Superficial excoriations and lacerations present at lateral and ventral neck, unchanged from previous exam--no healing noted, appears to be irritated by e-collar placement. No discharge noted in skin folds today, skin on ventrum moist. E-collar and shirt in place. MS: Ambulatory x4, no pain on palpation of epaxials NEURO: Mentation appropriate, cranial nerves intact, no deficits noted. Assessment: -Severe pyoderma, dermatitis - ro allergy (atopy vs food vs FBD) vs autoimmune vs other -Secondary self inflicted excoriations and lacerations to neck (not healing) Prognosis: Fair Plan: -CBC/Chem - machine still not working, scheduled for tomorrow 5/6 -Extend simbadol 0.24 mg/kg SQ SID until 5/8 -Start gabapentin 20 mg/kg PO q12h indefinitely -Continue benadryl 1 mg/kg SQ BID until 5/5, then place back on oral benadryl 4 mg/kg PO q12h indefinitely -Continue topical entederm to neck BID until 5/5 -Remove e-collar, keep shirt on to prevent scratching. Consider applying neck bandage while under sedation for bath to prevent further excoriation -Continue medicated baths q72h, next one scheduled for 5/7 SURGERY: Temporary waiver due to pyoderma

5/5/2019

withheld oral benedryl due to inability to give an appropriate oral dose

5/6/2019

History 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds from pruritis. Impression smear (sample from skin fold in neck) showed TNTC cocci Convenia given. Simbadol, benadryl, topical entederm. E-collar and vest. 5/4 Medicated bath (under sedation). Benadryl switched from IM administration to SQ. Scheduled CBC/Chem but machine not working. 5/5 Extended simbadol, start gabapentin. Scheduled CBC/Chem because machine still not working. S/O: BAR, vocal and very seeking at front of cage, eating and drinking very well, allows light handling/cleaning of wounds EENT: Eyes clear, ears - mild dark discharge AU, no nasal discharge noted Oral Exam: mm pink, CRT <2, mild tartar H/L: No overt murmur - purring, Lungs clear, eupnic MSI: Ambulatory x 4, BCS 4/9, alopecia and severe lichenification along neck and inguinal region. Pigmentation present inguinally. Ventral neck is moist in areas with mild thick purulent discharge in skin folds. Erythema improved - resolved. Secondary/self inflicted excorations-lacerations at lateral and ventral neck extending to sides of face. CNS: Mentation appropriate, no signs of neurologic abnormalities Assessment: Severe pyoderma, dermatitis - ro allergy (atopy vs food vs FBD) vs autoimmune vs other Secondary self inflicted excoriations and lacerations to neck Prognosis: Fair Plan: CBC/Chem today Continue simbadol 0.24 mg/kg SQ SID until 5/8 Start cleaning neck with chlorhex BID x 5 days Continue gabapentin 20 mg/kg PO BID indefinitely Keep e-collar and shirt on to prevent scratching Medicated baths Q72 hours, next one scheduled for tomorrow

5/6/2019

CBC -Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), ro chronic dz/inflammation vs other -Severe leukocytosis 42.32 K/uL (2.87-17.02) -Severe neutrophilia 36.07 K/uL (2.3-10.29), bands suspected -Severe basophilia 1.38 K/uL (0.01-0.26) Chem -Low cholesterol <6 mg/dL (65-225) PLAN: Start cefpodoxime 10 mg/kg PO SID x 7 days

5/7/2019

History 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds from pruritis. Impression smear (sample from skin fold in neck) showed TNTC cocci Convenia given. Simbadol, benadryl, topical entederm. E-collar and vest. 5/4 Medicated bath (under sedation). Benadryl switched from IM administration to SQ. Scheduled CBC/Chem but machine not working. 5/5 Extended simbadol, start gabapentin. Scheduled CBC/Chem because machine still not working. 5/6 CBC suggestive of overwhelming infection/inflammation. Start cleaning neck with chlorhex, cefpodoxime. -CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) -CHEM: Low cholesterol <6 mg/dL (65-225) S/O: BAR, eating well, vocal and attention seeking at front of kennel. No v/d noted. EENT: Eyes clear, ears -mod dark discharge AU, no nasal or ocular discharge noted Oral Exam: mm pink, CRT <2 H/L: Difficult to auscult over purring - no overt murmur, Lungs clear, eupnic MSI: Ambulatory x 4, BCS 4/9, inguinal and axillar regions - lichenification, milliary/diffuse papules. Ventral neck extending to sides of face - brown discharge within skin folds, greasy, excoriations and superficial lacerations from scratching. CNS: Mentation appropriate Assessment: Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs autoimmune vs other Secondary self inflicted wounds to neck Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other Anemia - ro chronic dz vs neoplasia vs other Plan: Removed e-collar as it appeared to be rubbing and not preventing scratching, but approx 2 hours after removing there were fresh red sratches along ventral neck. Medicated bath Placed soft padded neck bandage with telfa against ventral neck. Change bandage SID and clean neck as necessary Continue Cefpodoxime 10 mg/kg PO SID until 5/13 Continue gabapentin 20 mg/kg PO BID indefinitely DC cleaning neck with chlorhex BID (will do SID during bandage change) Recheck CBC on 5/13

5/8/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/7-placed bandage around neck to prevent scratching. Subjective: BARH. No csvd. Eating and drinking well. Very friendly. Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: clean adult dentition PLN: No enlargements noted H/L: NSR, Grade 2/6 HM, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, no MGTs, no vulvar d/c MSI: Ambulatory x 4, no visible parasites, no masses noted, diffuse alopecia with plaques on ventrum and severe lichenification diffusely especially on neck and ventrum. There is purulent d/c on the ventral neck striking through bandage. not pruritic. CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: Grade 2/6 HM Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs autoimmune vs other Secondary self inflicted wounds to neck Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other Anemia - ro chronic dz vs neoplasia vs other Plan: Placed soft padded neck bandage with telfa and SSD against ventral neck. (changed current bandage) Continue Cefpodoxime 10 mg/kg PO SID until 5/13 Continue gabapentin 20 mg/kg PO BID indefinitely Recheck CBC on 5/13 Rec echocardiogram with placement Prognosis: Fair

5/9/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) Subjective: BARH. No csvd. Normal BM and U. Great appetite. Very friendly and affectionate. Soft padded bandage mostly shredded. Removed bandage and will try to let it dry out but if she is scratching excessively will need another bandage. Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: clean adult dentition PLN: No enlargements noted H/L: NSR, Grade 3/6 HM, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, no MGTs, no vulvar d/c MSI: Ambulatory x 4, no visible parasites, no masses noted, diffuse alopecia with plaques on ventrum and severe lichenification diffusely especially on neck and ventrum. There is purulent d/c on the ventral neck that has improved since yesterday but when cleaning skin with chlorhex there was some bleeding CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: Grade 3/6 HM Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs neoplasia vs autoimmune vs other Secondary self inflicted wounds to neck Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other Anemia - ro chronic dz vs neoplasia vs other Plan: Removed bandage and gently cleaned neck with chlorhex-if scratching will need new bandage Will need dermatology consult +/- biopsy +/- steroid trial Continue Cefpodoxime 10 mg/kg PO SID until 5/13 Continue gabapentin 20 mg/kg PO BID indefinitely Recheck CBC on 5/13 Rec echocardiogram with placement Prognosis: Fair to poor

5/10/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/7: Second medicated bath under sedation, placed neck bandage. 5/8: Grade 2/6 heart murmur ausculted 5/9: Neck bandage replaced with e-collar. Heart murmur noted to be grade 3/6. Today, 5/10: Progress exam Subjective: BARH, no coughing/sneezing/vomiting/diarrhea. Appetite excellent, e-collar in place. Objective: P: WNL R: WNL BCS: 5/9 OP: Mucous membranes pink and moist. CRT <2. EENT: Eyes, ears, and nares clear bilaterally, no discharge noted. PLN: Small/soft/symmetrical/nonpainful CV: Grade 3/6 murmur. No arrhythmias, pulses strong and synchronous. RESP: Eupneic, no crackles/wheezes GI: Soft, nonpainful, no palpable masses. UG: FI, no mammary gland tumors noted, no discharge INT: Severe diffuse alopecia with lichenification on whole body, worst at neck and ventrum. Crusted discharge on ventral neck, no actively bleeding wounds. Cleaned with chlorhexidine. Patient became very irritated during cleaning and started attempting to scratch at neck. MS: Ambulatory x4, no pain on palpation of epaxials NEURO: Mentation appropriate, cranial nerves intact, no deficits noted. Assessment: -Grade 3/6 HM -Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs neoplasia vs autoimmune vs other -Secondary self inflicted wounds to neck -Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other -Anemia - ro chronic dz vs neoplasia vs other Prognosis: Fair to poor Plan: -E-collar in place, appears to be leaving area alone -Recommend echocardiogram, dermatology consult +/- biopsy or steroid trial with placement -Continue cefpodoxime 10 mg/kg PO q24h until 5/13 -Continue gabapentin 20 mg/kg PO q12h indefinitely -Start applying SSD to ventral neck area q24h after cleaning with chlorhex x 3d until 5/13, then assess response -Recheck CBC on 5/13 -NH notified--requires further diagnostics and care for management of clinical signs.

5/11/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/7: Second medicated bath under sedation, placed neck bandage. 5/8: Grade 2/6 heart murmur ausculted 5/9: Neck bandage replaced with e-collar. Heart murmur noted to be grade 3/6. 5/10: Progress exam Subjective: BARH, no coughing/sneezing/vomiting/diarrhea. Appetite excellent, e-collar in place. Objective: P: WNL R: WNL BCS: 5/9 OP: Mucous membranes pink and moist. CRT <2. EENT: Eyes, ears, and nares clear bilaterally, no discharge noted. PLN: Small/soft/symmetrical/nonpainful CV: Grade 3/6 murmur, unchanged from previous exam. No arrhythmias, pulses strong and synchronous. RESP: Eupneic, no crackles/wheezes GI: Soft, nonpainful, no palpable masses. UG: FI, no mammary gland tumors noted, no discharge INT: Severe diffuse alopecia with lichenification on whole body, worst at neck and ventrum. Crusted discharge on ventral neck. Patient started scratching at neck and opened new wounds during cleaning, bleeding stopped quickly with pressure. MS: Ambulatory x4, no pain on palpation of epaxials NEURO: Mentation appropriate, cranial nerves intact, no deficits noted. Assessment: -Grade 3/6 HM -Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs neoplasia vs autoimmune vs other -Secondary self inflicted wounds to neck -Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other -Anemia - ro chronic dz vs neoplasia vs other Prognosis: Fair to poor Plan: -Replaced e-collar with smaller size--evaluate tomorrow if too small and irritating area -Placed bandages over hind paws to prevent further trauma to neck -Recommend echocardiogram, dermatology consult +/- biopsy or steroid trial with placement -Continue cefpodoxime 10 mg/kg PO q24h until 5/13 -Continue gabapentin 20 mg/kg PO q12h indefinitely -Continue applying SSD to ventral neck area q24h after cleaning with chlorhex x 3d until 5/13, then assess response -Recheck CBC on 5/13 -NH notified--requires further diagnostics and care for management of clinical signs. -Change hind foot bandages q3d or earlier if soiled

5/12/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/7: Second medicated bath under sedation, placed neck bandage. 5/8: Grade 2/6 heart murmur ausculted 5/9: Neck bandage replaced with e-collar. Heart murmur noted to be grade 3/6. 5/11: Bandage placed to dissuade itching SO: BARH, no csvd. Appetite excellent, e-collar in place. unremarkable elimination P: WNL R: WNL BCS: 5/9 EENT: Eyes clear. ears clean. no oc or nasal discharge noted. Oral: unremarkable adult dentition H/L: Grade 3/6 murmur, No arrhythmias, pulses strong and synchronous. Eupneic, no crackles/wheezes Abd: no palpable masses. UG: FI, no mammary gland tumors noted, no discharge MSI: Ambulatory x4, no pain on palpation of epaxials. Severe diffuse alopecia with lichenification on whole body, worst at neck and ventrum. Worst affected areas are dry and crusted with scabbing. NEURO: Mentation appropriate, cranial nerves intact, no deficits noted. A: Grade 3/6 HM Severe pyoderma and dermatitis Secondary self inflicted wounds to neck Severe leukocytosis + neutrophilia - historic Anemia - historic Prog: Fair P: Recommend echocardiogram, dermatology consult +/- biopsy or steroid trial with placement Continue cefpodoxime 10 mg/kg PO q24h until 5/13 gabapentin 20 mg/kg PO BID Continue applying SSD to ventral neck area q24h after cleaning with chlorhex until 5/13 Recheck CBC and hemocrit tomorrow NH notified--requires further diagnostics and care for management of clinical signs. Clean hind foot bandages - will change q3d (next one 5/13) or earlier if soiled

5/13/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/10-started on SSD and wound cleaning Subjective: BARH. No cvd but is sneezing with mild congestion. Eating well. Friendly but removing the bandages on her back legs was very painful for her and the bandages were covered in feces. Her skin is slowly improving but has a long way to go and may never be normal. Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no ocular discharge noted, mild serous nasal d/c. Oral Exam: clean adult dentition PLN: No enlargements noted H/L: NSR, Grade 1/6 HM, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, no MGTs, no vulvar d/c MSI: Ambulatory x 4, no visible parasites, no masses noted, diffuse alopecia with plaques on ventrum and severe lichenification diffusely especially on neck and ventrum. There are areas on her neck that are raw from scratching but overall seems improved CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: Grade 1/6 HM-improved Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs neoplasia vs autoimmune vs other Secondary self inflicted wounds to neck Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other Anemia - ro chronic dz vs neoplasia vs other URI Plan: E-collar changed, very dirty Removed soft padded bandages on back legs-were very dirty and tape was irritating to skin Will need dermatology consult +/- biopsy +/- steroid trial Extend Cefpodoxime 10 mg/kg PO SID until 5/20-may need longterm treatment Continue gabapentin 20 mg/kg PO BID indefinitely Extend SSD cream on neck until 5/20 Start doxycycline 10mg/kg PO SID x10d until 5/23 Recheck CBC when machine is functioning Rec echocardiogram with placement Prognosis: Fair to poor **ADDENDUM** 4:41pm-placed soft padded bandage and socks due to cat scratching herself until she was bleeding around her neck

5/14/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/7: Second medicated bath under sedation, placed neck bandage. 5/8: Grade 2/6 heart murmur ausculted 5/9: Heart murmur noted to be grade 3/6. 5/11: Hind limb bandages placed to dissuade itching Subjective: BARH, no coughing/vomiting/diarrhea. Marked serous nasal discharge and sneezing with congestion. Objective: P: WNL R: WNL BCS: 4/9 OP: Mucous membranes pink and moist. CRT <2. EENT: Eyes and ears clear bilaterally, no discharge noted. Marked serous discharge from nares and sneezing PLN: Small/soft/symmetrical/nonpainful CV: Grade II/VI murmur ausculted. No arrhythmias, pulses strong and synchronous. RESP: Eupneic, no crackles/wheezes GI: Soft, nonpainful, no palpable masses. UG: FI, no mammary gland tumors noted, no discharge INT: Severe diffuse alopecia with lichenification and crusting, particularly on ventrum and neck. Crusted self- inflicted wounds on neck, no fresh or bleeding wounds on exam today. MS: Ambulatory x4. Appears to be tolerating soft padded bandage and socks well, both bandages clean on exam today. NEURO: Mentation appropriate, cranial nerves intact, no deficits noted. CBC: Assessment: -Grade 1-2/6 HM -Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs neoplasia vs autoimmune vs other -Secondary self inflicted wounds to neck, appear to be improved with application of soft bandages to feet -Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other -Anemia - ro chronic dz vs neoplasia vs other -URI Prognosis: Fair to poor Plan: -Will need dermatology consult +/- biopsy +/- steroid trial -Continue Cefpodoxime 10 mg/kg PO SID until 5/20-may need longterm treatment -Continue gabapentin 20 mg/kg PO BID indefinitely -Continue SSD cream on neck until 5/20 -Continue doxycycline 10mg/kg PO SID x10d until 5/23 -Recheck CBC today if machine is functioning -Rec echocardiogram with placement

5/15/2019

Progress exam History: 5/3 os intake: severe dermatitis, pyoderma with secondary self inflicted wounds. Impression smear (sample from skin fold in neck) showed TMTC cocci. Convenia given and started on Simbadol, benadryl, topical entederm. E-collar and vest placed. 5/4 Medicated bath (under sedation). 5/5 Started gabapentin for shelter anxiety 5/6 Start cleaning neck with chlorhex, started on simplicef. CBC: Moderate regenerative anemia, Hct 23.2 % (30.3-52.3), Severe leukocytosis 42.32 K/uL (2.87-17.02), Severe neutrophilia 36.07 K/uL (2.3-10.29) + bands suspected, Severe basophilia 1.38 K/uL (0.01-0.26) CHEM: Low cholesterol <6 mg/dL (65-225) 5/10-started on SSD and wound cleaning 5/13-diagnosed with URI but accidentally did not start on doxy Subjective: BARH. Eating very well. Vomited once. Sneezing. Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, no ocular discharge noted, mild serous nasal d/c. Oral Exam: clean adult dentition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, no MGTs, no vulvar d/c MSI: Ambulatory x 4, no visible parasites, no masses noted, diffuse alopecia with plaques on ventrum and severe lichenification diffusely especially on neck and ventrum. There are areas on her neck that are raw from scratching, lots of crusting on whole body especially around face, soft padded bandages on HLs to keep from scratching-cdi CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: Grade 1/6 HM-not ausculted today Severe pyoderma, dermatitis - ro allergy (atopy v food v FBD) vs neoplasia vs autoimmune vs other Secondary self inflicted wounds to neck Severe leukocytosis + neutrophilia - ro diffuse pyoderma/dermatitis vs neoplasia vs other Anemia - ro chronic dz vs neoplasia vs other URI Plan: E-collar cleaned, scrubbed neck wounds with chlorhex Will need dermatology consult +/- biopsy +/- steroid trial Continue Cefpodoxime 10 mg/kg PO SID until 5/20-may need longterm treatment Continue gabapentin 20 mg/kg PO BID indefinitely Continue SSD cream on neck until 5/20 Start doxycycline 10mg/kg PO SID x10d until 5/25 (not started on 5/23) Rec echocardiogram with placement Prognosis: Fair to poor

Behavior upon intake: Grace allowed to be picked up and place in a carrier. No further handling was done as she was rushed to vet services.