Signalment

• Age: 7 years
• Sex: female spayed
• Species: dog

Disease Notes

• Certainty: confirmed
• Final Status:

Treatment and Outcome

Problem Notes

• Atopic Dermatitis: Hi Steve,
  Hoping to get your advice on a skin case. I am limited because it is a telehealth client but am giving it my best.
  
  Subjective:
  Cleo has a history of CAD with a known poultry sensitivity as well. Her allergies present as fall seasonal typically late August through early November with pododermatitis (not particularly moist but rather erythema and dry skin with some hair loss and pruritus), focal miliary dermatitis on the bridge of the nose, occasional prurutic ears and perineum.
  
  Allergy testing revealed a significant tall grass allergy, some other weeds/trees, and also dust mite. The allergy symptoms started at 3 yo in the fall after she moved from NYC (where she was adopted) to Philly suburbs. She did allergy immunotherapy for about 9 months with minimal benefit and significant harm to bond with owner. She would hide under the bed for a day or two after the injections. Oral therapy was considered by Cleo hates her head and face being manipulated more than anything so this option would not actually be tolerated or better.
  Cytopoint helps some but not completely and during the time she was receiving these monthly injections she had clumps of hair fall out of her tail and perineum. This could have been associated with stress (telogen effluvium) but a side effect listed for Cytopoint (although not common at all) is hairloss. Could have been coincidental but cannot fully discount and association with Cytopoint. Owner would rather not use unless absolutely last resort.
  Owner does not want to use Apoquel unless last resort.
  Owner washes paws daily (or tries). The chlorhex wipes really work to reduce the erythema but seems to be painful for Cleo
  
  She repeatedly has had diarrhea if fed poultry based foods. She seems to tolerate a small amount but not full meals. Fortiflora (original) caused constipation and AG issues).
  
  Recent and prior labs have been normal. NuQ testing was normal as well.
  
  Diet:
  JFFD (rotates venison/sweet potato with cod/sweet potato and occasional beef/potato)
  very small amount of Holisitic Health Extension chicken and rice little bites kibble (has been fed this since a puppy)
  topper of bison liver freeze dried
  
  Nutritional and other supplements:
  beef bone broth with pumpkin, parsley, and turmeric
  Dog is Human multivitamin (beef liver flavor)
  omega 3 nordic naturals fish oil
  
  Medications:
  Credelio Quattro
  Visbiome (has not started yet)
  
  Objective:
  Wood constitution: IS very stubborn, friendly and social but can be bossy, can be irritable and grumpy.
  Appetite is normal. Thirst is normal (but she is a bit of a camel). Urination and stools are normal.
  No flatulence but she will belch a little after meals. No vomiting or signs of nausea.
  She sleeps good, does dream but doesn't seem excessive.
  Prefers COLD. Does not tolerate heat well.
  Raised in NYC with lots of noise but there are certain sounds that cause distress/fear/phobia. Beeping, fireworks, thunderstorms cause drooling, panic, and hiding. Thundershirt does seem to help a bit.
  
  She may be exhibiting orthopedic pain in the forelimbs- owner notes that she is reluctant to want to go out before bed (has to go down several flights of stairs) but then when outside she will have a big bowel movement (typically stands at the door and asks to go out for potty break but at night won't ask but goes when she is outside). Its possible she is anticipating pain going down the stairs that is overriding the need to defecate but once she gets moving, that stimulates a BM)
  
  Skin lesions are typically NOT moist but red and dry and itchy. Interdigital primarily. Scratches behind her ears and sometimes her tail and peri-anal region as well.
  
  Owner describes her tongue as not red but more on the lighter pink to lavendar side. somewhat dry (definitely not excess moisture).
  
  Assessment:
  Blood deficiency, Liver Qi Stagnation, Shao Yang disharmony; less likely to be Damp Heat but cannot rule out quite yet
  Seasonality suggestive of Shao Yang - Yang not able to return to interior. Heat in the upper body/heart leading to anxiety, head shy reactivity, heat trapped at the periphery; positive allergy testing
  Liver imbalance/blood deficiency- Wood constitution (stubbornness), light pink/lavendar tongue, pododermatitis, lesion locations- paws, peri-anal, AG; noise sensitivity, dreaming
  Stagnation- signs of arthritis, irritability
  Spleen Qi deficiency possible underlying cause- drooling with phobias, diarrhea with poultry, blood deficiency
  
  Plan:
  Chai Hu Si Wu Tang (Cessorex) to start
  considered Xiao Yao San but considering seasonality, I thought Cessorex was a better fit
  
  Discontinue: Dog is Human multivitamin, Holistic Health Extension chicken kibble, JFFD Venison and Beef recipes (may rotate these back in during later winter)
  Continue: JFFD cod/sweet potato, omega 3 supplement, bison topper (small amount)
  Begin Visbiome
  
  Am I on the right path here?
  Thanks!
  Jen