7/01/2018

[DVM Intake] DVM Intake Exam Estimated age: 8y Microchip noted on Intake?N Microchip Number (If Applicable): History : owner surrender Subjective:bar Observed Behavior – friendly, but sensitive right ear, allows all other handling, a bit “mouthy” but in a more curious, friendly way, gets easily overstimulated Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T = P = wnl R = wnl BCS 5/9 EENT: Eyes clear, otitis ou, w/ chronic, no nasal or ocular discharge noted Oral Exam: mild staining, overall good condition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: mn MSI: Ambulatory x 4, skin free of parasites, no masses noted,large abrasion caudal to od from scratching, tail gland hyperplasia and alopecia, nose reddened from likely rubbing against cage as not observed yesterday, feet x 4 mild erythema CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: ne Assessment: 8 yr mn large mixed breed chronic otitis and secondary pyoderma caudal ad from pruritis Prognosis: good to excellent Plan:tomorrow sedate to more fully evaluate ear and clean abrasion caudal to ad. Apply claro May need chronic tx of ad or dietary modification in long term SURGERY: na

8/01/2018

sedated w/ d/t to examine and clean ear. A lot of mucoid debris au but worse ad w/ abrasion caudal ad. Claro applied au Feet red x 4 from salt outdoors.

14/01/2018

Progress exam-recheck ears, paws reported to be irritated. History : owner surrender 1/7. 1/8 claro applied for otitis externa and feet irritated from salt outside. Subjective: BARH. No csvd. Ears have erythema and mild yellow crusty debris AU. Likely has chronic otitis. Objective BCS 5/9 EENT: Eyes clear, erythema to pinna with mild to moderate yellow crusty debris AU, scabbed area behind right ear where he had been scratching but does not appear active, no nasal or ocular discharge noted PLN: No enlargements noted H/L: Eupneic, normal RR/RE ABD: Non painful, no masses palpated U/G: MN MSI: Ambulatory x 4, skin free of parasites, no masses noted, no lameness or sensitivity noted on feet CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: Hx otitis externa Feet red from salt Prognosis: Good but may need longterm management Plan: CTM while at BACC Start tresaderm AU BID x14d until 1/28 Recheck 1/28

16/01/2018

Progress exam-paws bleeding History : owner surrender 1/7. 1/8 claro applied for otitis externa and feet irritated from salt outside. Subjective: BARH. No csvd. Feet noted to be bleeding again today after walk outside. Good appetite and energy. Objective BCS 5/9 EENT: Eyes clear, erythema to pinna, no nasal or ocular discharge noted PLN: No enlargements noted H/L: Eupneic, normal RR/RE MSI: Ambulatory x 4, skin free of parasites, no masses noted, several raw areas interdigitally with active bleeding CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: Hx otitis externa Irritated paw pads likely from salt outside Prognosis: Good but may need longterm management for otitis Plan: CTM while at BACC Continue tresaderm AU BID until 1/28 Recheck ears 1/28 Start rimadyl 4.4mg/kg PO SID x3d until 1/18 Recheck paws 1/18

18/01/2018

Progress exam-paws bleeding History : owner surrender 1/7. 1/8 claro applied for otitis externa and feet irritated from salt outside. 1/16-given rimadyl for salt irritation on feet Subjective: BARH. No csvd. Feet are much improved. Coughing a little on the leash but not in the cage. Objective P=wnl R=wnl BCS 5/9 EENT: Eyes clear, erythema on pinna but clean au, no nasal or ocular discharge noted PLN: No enlargements noted H/L: NMA, RR, Lungs C&E ABD: SNP, NMP MSI: Ambulatory x 4, skin free of parasites, no masses noted, several raw areas interdigitally that have much improved-no bleeding or d/c CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: Hx otitis externa Irritated paw pads likely from salt outside-improved Prognosis: Good but may need longterm management for otitis Plan: CTM while at BACC Continue tresaderm AU BID until 1/28 Recheck ears 1/28 Extend rimadyl 4.4mg/kg PO SID x2d until 1/20

21/01/2018

Progress exam History : owner surrender 1/7. 1/8 claro applied for otitis externa and feet irritated from salt outside. 1/16-started on rimadyl for salt irritation on feet Subjective: BARH. No csvd. Noted to be sneezing on rounds board but not noted on cage exam. Feet do not seem to be bothering him in the cage. Objective BCS 5/9 EENT: Eyes clear, no nasal or ocular discharge noted H/L: Eupneic, normal RR/RE MSI: Ambulatory x 4 CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: Hx otitis externa Irritated paw pads likely from salt outside-improved Prognosis: Good but may need longterm management for otitis Plan: CTM while at BACC Continue tresaderm AU BID until 1/28 Recheck ears 1/28 Extend rimadyl 4.4mg/kg PO SID until 1/23 Add chlorhex soaks SID for all 4 feet Monitor for CIRDC

22/01/2018

Progress exam History: owner surrender 1/7. 1/8 claro applied for otitis externa and feet irritated from salt outside. 1/16-started on rimadyl for salt irritation on feet Subjective: BARH. No cvd. Noted to be sneezing on rounds board for 3 days and noted in cage as well today. Eating well. Objective BCS 5/9 EENT: Eyes clear, no ocular discharge noted, mild serous nasal d/c H/L: Eupneic, normal RR/RE, sneezing MSI: Ambulatory x 4 CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: CIRDC Hx otitis externa Irritated paw pads likely from salt outside-improved Prognosis: Good but may need longterm management for otitis Plan: CTM while at BACC Continue tresaderm AU BID until 1/28 Recheck ears 1/28 Continue rimadyl 4.4mg/kg PO SID until 1/23 Continue chlorhex soaks SID for all 4 feet Start doxycycline 10mg/kg PO SID x14d until 2/5 Move to iso Recheck day 7

Details on my behavior are…