[DVM Intake] DVM Intake Exam Estimated age:2-3y Microchip noted on Intake? n History : stray Subjective:severe facial edema, dependent in chin jowls area. OD bloody sclera. Obvious wound in area of right ear consistent with bite wound Observed Behavior -winces when face touched, allows exam, some small wags Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T = P =60 R =wnl BCS 5/9 EENT: blood in sclera OD, ears clean, no nasal or ocular discharge noted Oral Exam: clean teeth, unable to fully examine mouth due to pain level PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male x2 MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: infected bite wounds, edema Prognosis:good Plan:needs sedated wound exam, cleaning and drain placement rx 250 mg clavamox and carprofen 75 mg/day SURGERY: Okay for surgery

Hx: Bite wounds. Pt anesthetized for wound cleaning and drain placement – see LVT exam for anesthetic details. -Left maxillary I1 is missing; I2 is fractured at the root and attached just by a small amount of gingiva. -There is a small full-thickness laceration in the gingiva above I2. -There are two small puncture wounds on the left lower lip in the region of the premolars; one puncture is 5 mm with some purulent discharge and about a 2 cm pocket extending to the other puncture wound, which is slightly smaller. -Left ear pinna has a large divot missing, and the skin is fully healed as if this injury is very old -Moderate erythema and bruising on the ventral neck, but no wounds noted. -Right ear: bloody and dirty discharge inside the canal, and a 1 cm laceration on the medial aspect of the pinna. -The right side of the face is covered with many small horizontal linear lacerations (2-12 mm long), some superficial, some partial thickness and some full-thickness. There is purulent discharge from one full-thickness laceration in the center of the cheek, with a pocket extending 2-3 cm ventrally. -There is a moderate amount of soft edema ventral to the chin/neck The cheek laceration with purulent discharge was flushed with dilute chlorhexidine solution, and a 1/2″ Penrose drain was placed with entrance and exit dorsal and ventral to the original wound. The drain was tacked in place with 2-0 Monocryl, and the wound was closed with 2-0 Monocryl in a single stitch. The fractured incisor was removed, and the alveolar socket was explored and the root removed. The flap and socket were closed with a simple continuous line using 4-0 Monocryl. The laceration on the medial aspect of the right ear was closed with a single stitch of 4-0 Monocryl. PLAN: Continue Clavamox and Rimadyl as scheduled. Remove drain in 2-5 days. 1088

Pt not eating. Administered one dose of ampicillin 1.3 ml IM – okay to start Clavamox tomorrow morning. 1088

Hx: Bite wounds – drain placed in right side of face yesterday. S: Alert in kennel, standing and wagging tail. Flinches when touched but then allows all handling – sweet boy! O: BAR-H, BCS 3/9, MMs pink and moist, CRT <2 sec EENT: OU scleral hemorrhage dorsally. No discharge OU, nose, AU. PLNs: Not significantly enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Amb x4. Bruising on ventral neck and axillary region is greatly reduced today. Dependent edema is improved – still present but not hanging as low as yesterday. There is bruising on the right side of the face, but there is no pain or erythema around the bite wounds or drain entrance/exit wounds. Mild serosanguinous and slightly crusty discharge around the drain. UG: Male intact, testicles soft and symmetrical. Neuro: Alert and appropriate, no sign neurological deficiencies A: Bite wounds, drain placed – healing well Short-term prognosis: Good P: 1. Cleaned the drain site and the right side of the face with chlorhexidine scrub during the exam 2. Continue Rimadyl and Clavamox 3. Okay to move out of Medical 4. Monitor drain, plan to remove in 2-3 days 5. Place e-collar if pt is traumatizing the drain 1088

Recheck wound/drain on right side of face: S/O: BARH – no c/s no nasal d/c – wound healing well, only mild serosanguineous discharge present w/minimal swelling – seems comfortable – drain pulled and wound was cleaned P: cont. with current med tx

Recheck bite wounds, drain removed on 12/1 S/O -BAR, very energetic and friendly! -bite wounds along R side of face and under chin healing well; mild edematous swelling under chin but resolving -no nasal discharge or sneezing -eupnic A Bite wounds-healing well P CWCT prognosis: excellent

S/O: BAR, jumping on kennel bars Neck wounds look great! No swelling or discharge. Mild serous nasal discharge and sniffling. A: CIRDC P: Move to isolation, start doxycycline 175 mg PO SID x14 days. 1088

To whom it may concern- Saturn 14873 is an approximately 2-3 year old male intact medium-sized dog who presented to ACC in the evening on 11/28/17 with wounds on the right side of his face. A veterinarian’s exam on the following day showed severe swelling and edema in the ventral neck, as well as many puncture wounds around the right ear. Saturn was sedated for a closer exam and wound cleaning, and the wounds were small and deep, and consistent with bite wounds. After a drain was placed and a week of antibiotics, Saturn is doing much better and the wounds are healing very well. However, Saturn did develop CIRDC on 12/5/17. If you have any questions, please don’t hesitate to call.