9/01/2018

Estimated age:10 Microchip noted on Intake? No microchip on found on intake – LVT placed microchip History :Processed by intake on November 8th. Lethargy, emaciated. Owner indicated that DJ had been sick for a week and noted that he had a rat during this time. Subjective: Emaciated (BCS 2/9), depressed, lethargic (non recumbent), dull, hydration status (marginal) Observed Behavior – Lethargic/Non-mobile in kennel but stood and moved once removed from the kennel for the Physical Examination (PE). Agitated – growled at handlers and veterinary staff. Allowed for physical examination after appropriate handling. Evidence of Cruelty seen – Signs of emaciation Evidence of Trauma seen – none Objective P = 120 R = 30 BCS = 2/9 Weight 52 lb/24 kg EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Mucous membranes tachy, pink/white, Teeth: moderate periodontitis and calculus with severe wearing of incisors PLN: Sub-mandibular lymph nodes enlarged H/L: NSR, NMA, CRT = 1, clear, eupnic ABD: Non painful, no masses palpated, mildly distended U/G: Male Intact, testicles S/D MSI: Lethargy/weakness, severe edema of distal hind-limbs, skin free of parasites, no masses noted, dull hair coat CNS: Mentation Dull – no signs of neurologic abnormalities. Knuckling reflex: Normal Assessment Clinical signs: anemia, emaciation, lethargy, hind-limb edema, submandibular lyphm node enlargement DDX: Rodenticide toxicity, Neoplasia, Infectious (e.g. leptospirosis, ehrlichia, CAV), Chronic Kidney Disease, Immune mediated disease PCV: 18% TP: 6 Blood glucose – 193 Cytology – target cells, howell jolly bodies, basophilic stiplling Prognosis: Poor Plan: Treatment: 1) Intravenous fluid therapy (LRS) 1.5 X maintenance (50 x BWkg/24 * 1.5 = 75ml/hr) for 12 hours then maintenance (50 ml/hr) for 12hrs 2) Vit K Therapy – 1 mg/kg q 12hrs (25mg = 2.5 cc) until hematocrit levels stabilizes – After HCT stabilizes place on oral Vit K 1mg/kg q12 hrs PO 3) Continue doxycycline 10mg/kg BID 2 1/2 Tablets (100mg) BID for 14 days Diagnostics: 1) Abdominal radiographs Lateral and Ventral – sedation required: Propofol 5mg/kg to effect IV (125mg/12.5ml) and Torbugesic 0.2mg/kg IV (5mg/0.5ml) 2) Repeat HCT/TP Q24 hrs 3) Snap Dx4 test when available 4) CBC/Chem Panel when available 5) PT/PTT when available SURGERY: Temporary waiver due to emaciation and disease

10/01/2018

Abdominal Lateral and V/D x-rays performed -Lateral abdominal xrays – Small and large intestines filled with fecal matter. Ventral aspect revealed bone opacities in the small intestines. – Ventral Abdomen – Feces/gas filled large and small intestines. Poor abdominal contrast likely due to reduced abdominal fat secondary to emaciation. Cannot rule out abdominal effusion.

10/01/2018

Subjective: Observed Behavior – Mild improvement in energy levels from the day prior. Still lethargic/QAR. Good appetite. LVT indicated DJ had vomited food matter in the morning and his feces was firm. Objective T = 39 P = 120 R = 30 PLN: Submandibular lymph nodes enlarged ABD: Non painful, no masses palpated. Right side of abdomen mildly distended. MSI: Moderate Paresis. Ambulatory x 4. Distal hind-limb edema. CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment – Severe regenerative anemia, hypoproteinemia DDx: chronic disease (e.g. neoplasia, kidney disease), rodenticide toxicity, immune medicated disease, infectious (e.g. ehrlichia, lepto) Plan:Continue on current treatment plan Diagnostics: See CBC/Chem results from Idexx. Continue on current dx plan (i.e. PCV/TP q24hrs, urinanalysis) Recommended 1) Perform abdominalcentesis 2) Repeat abdominal x-rays or conduct an abdominal ultrasound 3) Aspirate sub-mandibular lymph nodes for cytology Prognosis: Fair SURGERY: Temporary waiver due to disease

10/01/2018

CBC Reduced HCT

10/01/2018

Subjective: Eating/drinking, vomited food matter in the morning, defecated dry fecal material Observed Behavior – Lethargic, QAR, lying down Objective T = 99 P = 120 R = 20 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted PLN: Enlarged sub-mandibular lymph nodes(bilateral) ABD: Non painful, mildly distended on the right side of the abdomen MSI: Severe Paresis, Ambulatory x 4 CNS: Mentation appropriate – no signs of neurological abnormalities Blood work: regenerative anemia, mild thrombocytosis, hypoproteinemia (hypoalbuminemia), mildly elevated SDMA Assessment: DDx: Neoplasia, Rodenticide toxicity, infectious (leptospirosis, ehrlichia, anaplasmosis), protein loosing enteropathy Blood work: Refer to blood work notes Summary: Moderate regenerative anemia, Moderate hypo-proteinenima, Mild thrombocytopenia Prognosis: Fair Plan: Continue on current treatment plan Recommended: 1) Abdomenocentisis right abdomen 2) PT/TTP 3) Thoracic radiographs (VD/L) and Repeat abdominal radiographs (lateral/VD) 4) FNA submandibular lymph nodes 5) Abdominal ultrasound SURGERY: Temporary waiver due to illness

10/01/2018

Objective: CBC Marked regenerated anemia and neutrophilia with a left shift – hematocrit (13.4) reticulocyctes (380) Marked increased in WBC'(32.4) Moderate Neutrophilia (28.836) with increased bands (649)(left shift) Mild Thrombocyctopenia (469) Biochemistry Mild Hyperglycemia (123) Mild SDMA elevation (16) Mild Hypocalcemia (7.5) Moderate hyproproteinemia (3.9) Hypoalbuminemia (1.5) Reduced A/G value (0.6) Mild Cholesteralemia (119) Mild CK elevation (344) USG: Unremarkable – 1030 Assessment: Ddx: 1) Neoplasia (non reg anemia, hypoprotenemia, neutrophilia) 2) Rodenticide toxicity (non regenerative anemia) 3) Protein losing nephropathy (Mild SDMA elevation) 4) Infectious (e.g. leptospirosis) Plan: Continue current treatment plan

11/01/2018

Subjective: Eating/drinking, Defecated normal stool. Still lethargic but mild improvement in energy levels as seen by his increase in growling. Observed Behavior – Lethargic, QAR Objective T = 101 P = 120 R = 20 Bounding femoral pulses MM: Pink/white PLN: Enlarged sub-mandibular lymph nodes(bilateral) ABD: Non painful, mildly distended on the right side of the abdomen MSI: Paresis, Ambulatory x 4. Distal hind-limb edema reduced CNS: Mentation appropriate – no signs of neurological abnormalities CBC: 1)Severely reduced HCT 2)Marked increase reticulocytes 3)Moderate neutrophilia and monocytosis 4)Thrombocytopenia Submandibular lymph node FN aspirate: High number of reticulocytes. Could not appreciate any increased or abnormal WBCs Idexx U/S: USG 1023 – no proteins in urine Abdomenocentisis right abdomen: Unremarkable – non productive (no fluid found) Prognosis: Poor Recommended: 1) Send out for PT/TTP 2) Coombs tests 3) Snap 4DX Screen 4) Thoracic radiographs (VD/L) and repeat abdominal radiographs (lateral/VD) 5) Abdominal ultrasound Assessment:I CBC – Regenerative anemia with an inflammatory response. Thrombocytopenia likely an artifact due to the lack of any clinical signs indicative of a coagulopathy (e.g. petechia) Tachycardia, paresis – secondary to anemia DDx: Primary IMHA, Neoplasia, Rodenticide toxicity, Secondary IMHA due to infection (leptospirosis, ehrilichia, babesia) Plan: Currently stable and comfortable. Continue on current treatment plan. Consider steroid treatment for IMHA if deterioration in condition. SURGERY: Temporary waiver due to illness

11/01/2018

Objective: CBC: 1)Marked decreased HCT (12.3) 2)Marked increase Reticulocytes (346.8) 3)Moderate neutrophilia (26) and monocytosis(2.26) 4)Thrombocytopenia (20) TP= 6 CBC – Regenerative anemia with an inflammatory response. Thrombocytopenia likely an artifact due to the lack of any clinical signs indicative of a coagulopathy (e.g. petechia) Submandibular lymph node FN aspirate: High number of reticulocytes. Could not appreciate any increased or abnormal WBCs Idexx U/S: USG 1023 – no proteins in urine Abdomenocentisis right abdomen: Non fluid present. Unremarkable Recommended: 1) Send out for PT/TTP 2) Coombs tests 3) Snap 4DX Screen 4) Thoracic radiographs (VD/L) and repeat abdominal radiographs (lateral/VD) 5) Abdominal ultrasound Assessment:I CBC – Regenerative anemia with an inflammatory response. Thrombocytopenia likely an artifact due to the lack of any clinical signs indicative of a coagulopathy (e.g. petechia) DDx: Primary IMHA, Neoplasia, Rodenticide toxicity, Secondary IMHA due to infection (leptospirosis, ehrilichia, babesia) Plan: Currently stable and comfortable. Continue on current treatment plan. Consider steroid treatment for IMHA if deterioration in condition. Prognosis: Poor SURGERY: Temporary waiver due to illness

12/01/2018

s/o: muzzled bar +++edema hind legs mucosal surfaces have no petechiae, urine look clear eating and drinking well a; open suspect imha over rodenticide , liver neoplasia possible too p: d/c fluids (even though edema has always been present) start 50mg prednisone per day (gave first dose) repeat bloodwork essentially unchanged: hct 12, elevated retics+++ idexx blood work from 2 days ago had spherocytes (rare) imha diagnosis is uncertain at this point but I would expect improvement if rodentide was involved. AUS recommended prognosis guarded/poor

14/01/2018

Severe, regenerative anemia and severely enlarged submandibular lymph nodes on presentation; started doxycycline initially and started on steroids yesterday for suspect IMHA S/O -BAR, more energetic today and behavior appears improved, allows gentle petting on the back without growling, wagging tail -ravenous appetite, noted to be significantly pu/pd -submandibular lymph nodes significantly smaller than previously, still prominent -mm pale pk, moist -no nasal discharge or sneezing -eupnic -abdomen soft and doughy -edema in distal hindlimbs almost resolved today! -ambulatory paraparesis, hindlimbs stiff with decreased weight bearing A 1. Severe anemia-suspect IMHA, r/o secondary to rickettsial disease vs idiopathic vs paraneoplastic 2. Lymphadenopathy-r/o rickettsial dz vs inflammatory secondary to immune mediated disease vs paraneoplastic 3. Hind limb edema-resolved; likely secondary to hypoproteinemia 4. Paraparesis P -continue current treatment -recommend AUS and monitoring CBC every 5-7 days initially -consider adding additional medications such as leflunomide, azathioprine or apoquel for suspected IMHA prognosis: guarded, IMHA can be managed but in many cases will relapse; underlying neoplasia cannot be ruled out

Dj growled at staff when approached, staff was unable to scan for a microchip or take picture on backdrop.