Veterinary Externship Skill 2

DISCHARGE SUMMARY Provider: Dr. Eliza O'Callaghan Patient: Walter Date Generated: May 15, 2025 Small Door Gramercy

380 Second Ave New York, NY 10010 (212) 933-9044

OWNER

Jordana Hochman 1-(917) 767-2942 [email protected]

PATIENT

Walter | 9.1 YO | Male (Neutered) | Terrier Mix | 24.8 kg Patient ID: 349477239 | Canine DOB: Apr 04, 2016 | Color: Black Tan And Brown Microchip: 982000407806373 Allergies: None Recorded

EXAM with Dr. Eliza O'Callaghan SMALL DOOR GRAMERCY March 27, 2025 at 8:46 am

DISCHARGE INSTRUCTIONS

Date: March 27, 2025

Walter underwent a partial pinnectomy of the left ear and the amputation of digits 3 and 4 of his right forelimb today due to the presence of a mast cell tumor and its progression into the webbing between the digits. The affected tissue from both the limb and the ear has been sent for histopathology. The biopsy for the digits is a complex biopsy, which typically takes 14 days, while the biopsy for the ear mass typically takes 7-10 business days. A bandage was placed over the surgical sites on both the paw and the ear, and he received appropriate pain management during the procedure.

Anesthesia & Recovery Because Walter was under general anesthesia today, he may be sleepy for the remainder of the day. Special care must be taken to prevent falls, running into objects, or exposure to extreme temperatures. His appetite may be slightly reduced tonight, but he should return to normal eating and drinking habits by tomorrow.

Bandage Care Bandages were placed over both Walter’s paw and ear surgical sites. Paw Bandage & Medi-Paw Cover: • Walter is going home with a Medi-Paw protective boot over his bandaged paw. The Medi-Paw is designed to keep the bandage clean and dry while he walks outside. It is water-resistant and helps prevent debris from contaminating the bandage. When taking Walter outside, ensure the Medi-Paw is securely in place. Once back indoors, remove the Medi-Paw to allow airflow and prevent moisture buildup inside. Please

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 1 of 14

monitor the bandage at least 2-3 times per day. If the bandage becomes soiled, wet, loose, or has a foul odor, please contact us. If the bandage is removed and cannot be replaced immediately, ensure Walter wears an Elizabethan collar (e-collar) to prevent licking or chewing at the surgical site. • Walter’s paw bandage will need to be changed at Small Door West Village on Saturday, March 29, 2025, followed by another change on Friday, April 4, 2025. Dr. O’Callaghan will be available on April 4 to reassess the healing process and determine the next steps. Ear Bandage: • The bandage on Walter’s ear is primarily for initial protection and may naturally fall off before his Saturday, March 29, 2025, bandage change at Small Door West Village. If the bandage has not fallen off by then, it can remain on until it does. No additional ear bandaging will be necessary after it falls off.

Ear Care Walter’s partial pinnectomy involved the removal of approximately one-third of his left ear pinna. The surgical site was closed skin sutures that we may remove or let dissolve; it depends on how it heals. Some minor swelling or bruising may be noted over the next few days. Monitor for signs of excessive redness, discharge, or discomfort, and prevent Walter from scratching or rubbing at his ear. He must wear an e-collar at all times until suture removal in approximately 14 days.

Adapting to Digit Amputation Walter may take some time to adjust to walking without two digits on his right forelimb. Initially, you may notice some unsteadiness or reluctance to bear full weight on the limb. This is normal, and most dogs adapt very well over time. He may naturally shift his weight or modify his gait as he gets used to the change. Short, controlled leash walks on non-slip surfaces can help him regain confidence and balance. If he appears consistently painful or reluctant to use the limb, please let us know so we can reassess his comfort and healing progress.

Medications 1) Carprofen 100mg – Give 1/2 tablet by mouth every 12 hours for 7 days, starting tomorrow morning (March 28, 2025). This is a non-steroidal anti-inflammatory medication for pain relief. Discontinue if vomiting, diarrhea, or dark/tarry stools are noted. 2) Clavamox (previously prescribed) – Continue as directed, starting tomorrow morning (March 28, 2025). 3) Diphenhydramine (previously prescribed) – Continue as directed, starting tomorrow morning (March 28, 2025). 4) Famotidine (previously prescribed) – Continue as directed, starting tomorrow morning (March 28, 2025). 5) Gabapentin (previously prescribed) – Continue as needed for additional pain relief, starting tonight (March 27, 2025). 6) Trazodone (previously prescribed) – Continue as needed to help keep Walter calm, starting tonight (March 27, 2025). 7) Vetoryl (previously prescribed) – If he is interested in eating tonight, you may administer his Vetoryl. If he does not eat, start Vetoryl again in the morning.

Follow-Up Plan • Bandage changes: Saturday, March 29, 2025, at Small Door West Village, followed by another change on Friday, April 4, 2025.

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 2 of 14

• Suture removal: Approximately 14 days post-surgery. • Monitor for signs of infection or complications, including excessive swelling, discharge, bleeding, or Walter excessively licking or chewing at the surgical sites. • If you have any concerns about the bandage or incision sites before the scheduled follow-up, please contact us. • We will follow up once histopathology results are available.

Thank you for entrusting us with Walter’s care.

Talk soon, Dr. Eliza O'Callaghan, DVM (she/her) Managing Veterinarian | Small Door Veterinary – Gramercy & West Village � West Village: (212) 300-9893 | � Gramercy: (212) 300-9891 www.smalldoorvet.com

If you need to schedule an appointment, you may use the Small Door app or email [email protected]. In  the event of an emergency, please reach out to us through the Small Door Urgent chat function on our app or  contact your nearest emergency veterinary clinic.

LAB RESULTS - Ordered by Dr. Eliza O'Callaghan

PATHOLOGY (as of Mar 31, 2025)

TEST RESULT REFERENCE RANGE/COMMENTS

Note from Laboratory Your biopsy sample has been re- ceived and requires additional fix- ation prior to processing. Please expect a delay of 1 to 6 days for your results.

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Biopsy Source: SKINSQ_MASS -

Biopsy Type: EXCISIONAL -

Clinical History: 2cm soft fixed pink cutaneous mass L convex ear pinna. Mast cell tumor on FNA.

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Pathologist's Report INTERPRETATION: Pinna mast cell tumor low grade 2 Mitotic count (per 2.37 sq mm): 1 Histologic tumor-free margins: clear; the nearest peripheral mar- gin is 8.5 mm Vascular invasion: not observed

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Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 3 of 14

COMMENTS: Mast cell tumors (MCTs) are among the most common neoplasms in the dog. They can occur in var- ious organ systems but the cu- taneous and subcutaneous loca- tions are the most common. Cu- taneous MCTs (CMCTs) are lo- cated within the dermis with or without extension into the un- derlying subcutis whereas subcu- taneous MCTs (SCMCTs) are con- fined to the subcutis with no der- mal involvement. Historically CM- CTs have been graded according to the Patnaik scale (grade I II and III) but the more recently de- veloped two-tiered (low grade or high grade) Kiupel system has been shown to provide increased in- ter-observer consistency and over- all superior prognostic informa- tion. IDEXX pathologists apply both grading systems to all CMCTs.

Grade: The neoplastic process present in this specimen is grade II (Patnaik system) and low grade (Ki- upel system). Grade II CMCTs (Pat- naik system) are morphologically moderately well-differentiated and 47 percent of dogs with this type of neoplasm survived the study pe- riod of 1500 days (Patnaik et al. 1984). Dogs with low grade CMC- Ts (Kiupel system) had a median survival time of over 2 years and only 5 percent of patients died due to MCT-associated disease while 20 percent developed additional MCTs (Kiupel et al. 2011).

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 4 of 14

Mitotic count (MC; number of mi- totic figures per 10 high power fields): Previously known as mitot- ic index MC has been found to be an indicator of prognosis. According to the Kiupel system a MC of less than 7 is associated with increased survival time (median survival of over 2 years compared to 4 mon- ths in case of CMCTs with a MC of 7 or more). In a different study the MC alone was a strong predic- tor of overall survival for dogs with CMCTs regardless of Patnaik grade: dogs with a MC of 5 or less had a median survival time of 70 months while dogs with a MC of more than 5 had a median survival of 2 mon- ths (Romansik 2007).

Surgical margins: While the width of tumor free margins that would consistently prevent recurrence could not be determined studies have suggested that taking 2 cm macroscopically measured skin margins and deep margins of one facial plane at surgery will result in complete excision of low grade MCTs measuring less than 4 cm in diameter (Fulcher et al. 2006). In another study grade I and II MCTs (Patnaik system) excised with microscopic lateral margins of at least 1 cm and a deep margin of at least 4 mm did not recur giv- en that the deep margins included the panniculus muscle or the un- derlying fascia or in their absence the superficial layer of the mus- culature (Schultheiss 2011). A third study showed that 96 percent of low grade (Kiupel system) CMC-

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 5 of 14

Ts did not recur even though 29 percent of these tumors were ex- cised with microscopic margins of 3 mm or less (Donnelly et al. 2015).

Prognostic panels: CMCTs can dis- play a wide variety of biologi- cal behavior and the small sub- set (estimated at 5 to 20 percent) of CMCTs that are morphological- ly well-differentiated but exhib- it a more aggressive biologic be- havior cannot be identified based on morphology alone. In some cases valuable prognostic informa- tion and therapeutic guidance may be obtained by performing sup- plementary testing collectively re- ferred to as MCT Prognostic Pan- els (MCT-PP). These panels include evaluation of cellular proliferation indices (Ki-67 AgNOR Ag67) KIT pattern; and/or presence/absence of c-kit mutations. A more compre- hensive description and ordering information of these tests can be found in the most recent edition of the Mast Cell Tumor Diagnostic Up- date available at the following ad- dress: www.idexx.com/mct. Please note that if a panel is requested on more than one tissue/mass this will be charged per site.

Additional information: Despite the vast amount of knowledge on canine CMCTs there is no single test or measurable feature that could unequivocally establish the prog- nosis of CMCTs and patients should be evaluated on a case-by-case basis taking into account all fac- tors including patient information

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 6 of 14

clinical history anatomic location microscopic features supplemen- tary testing results and results of staging (Sledge et al. 2016; Kiupel 2017).

References: Please refer to the IDEXX Diagnostic Update for Can- ine Mast Cell Tumors (2017) for the complete list of references cited in this report: www.idexx.com/mct.

Internal Interpretation ID: IXD1.2

(For lab use only: Mast Cell Tumor Prognostic Panel 1 US code 3375 Canada code MCTPP; please use block a)

HISTOPATHOLOGIC DESCRIP- TION: Haired skin from pinna. Ele- vating the epidermis infiltrating the dermis extending into the subcutis there is a moderately to densely cellular well demar- cated and unencapsulated neo- plastic mass composed of round cells forming sheets supported by a fine fibrovascular stroma. These cells contain abundant fine basophilic granules (well granu- lated mast cells).The nuclei are round with finely stippled chro- matin with 1 small eosinophilic nu- cleolus. There is mild anisocytosis and anisokaryosis. The neoplastic cells are infiltrated by a small to moderate number of eosinophils. There are no significant number of karyomegalic cells or multinucle- ated cells.

PATHOLOGIST:

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 7 of 14

Genevieve Remmers DVM Diplomate American College of Veterinary Pathologists

HOW TO CONTACT ME: E-mail (preferred): [email protected] Phone (direct): ext. 52151

Veterinarians: To contact the pathologist regarding this report please either use email or call Cus- tomer Support and dial the exten- sion shown above. If the pathol- ogist is unavailable call Customer Support and request to speak to the Pathologist on Duty. Please ref- erence patient accession number 2315732126.

Pet owners: Please contact your veterinarian for advice to adhere to the legal veterinary-client-patient relationship.

This pathology report may not be published via any distribution channel (including social media) without the pathologist's express permission.

LAB RESULTS - Ordered by Dr. Eliza O'Callaghan

PATHOLOGY (as of Apr 08, 2025)

TEST RESULT REFERENCE RANGE/COMMENTS

Biopsy Source: DIGIT -

Biopsy Type: EXCISIONAL -

Clinical History: 1.3cm firm raised ulcerated mass w/ surrounding inflamma- tion along medial aspect of digit 4

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Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 8 of 14

and invading the webbing of digit 3. On FNA and cytology this was a Mast Cell Tumor. Removed BOTH digits in an attempt to get clean margins.

Pathologist's Report INTERPRETATION: Cutaneous mast cell tumor grade III (Patnaik) high grade (Kiupel) Mitotic count (per 2.37 sq mm): 9 Histologic tumor-free margins: Neoplastic cells are 16 mm from the proximal skin margin 21 mm from the interdigital margin (gross- ly) and 23 mm from the proximal bone margin (grossly) Vascular invasion: Not observed

COMMENTS: Histological examination of this mass is consistent with a grade III / high grade cutaneous mast cell tumor. Mast cell tumors (MCTs) are among the most common neo- plasms in the dog. They can oc- cur in various organ systems but the cutaneous and subcutaneous locations are the most common. Cutaneous MCTs (CMCTs) are lo- cated within the dermis with or without extension into the un- derlying subcutis whereas subcu- taneous MCTs (SCMCTs) are con- fined to the subcutis with no der- mal involvement. Historically CMC- Ts have been graded according to the Patnaik scale (grade I II and III) but the more recently developed two-tiered (low grade / high grade) Kiupel system has been shown to provide increased inter-observ- er consistency and overall superior prognostic information. In addition it has been proposed that combin-

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Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 9 of 14

ing these two grading systems fur- ther refines our ability to discrimi- nate between Patnaik grade 2 CM- CTs (i.e. grade II / high grade vs grade II / low grade) that are more or less likely to have an aggres- sive clinical behavior respectively (Berlato et al. 2021). As such IDEXX pathologists apply both grading systems to all CMCTs.

Grading: The neoplastic process present in this specimen is grade III (Patnaik system) / high grade (Kiu- pel system). Grade III CMCTs (Pat- naik system) are morphologically poorly-differentiated and only 6% of dogs with this type of neoplasm survived the study period of 1500 days (Patnaik et al. 1984). Dogs with high grade CMCTs (Kiupel sys- tem) had a median survival time of less than 4 months and 90% of patients died due to MCT-asso- ciated disease while 70% devel- oped additional MCTs (Kiupel et al. 2011 Sledge et al. 2016). Overall the prognosis for grade III / high grade CMCTs is guarded to poor with 67 – 75% of dogs succumbing to tumor-related death and medi- an survival times of 3 – 6 months. Risk of metastasis for this specific group (i.e. grade III / high grade) of CMCTs has been reported as 46% for regional lymph nodes and 21% for distant sites.

Mitotic count (MC; number of mi- totic figures per 10 high power fields): MC has been found to be an indicator of prognosis. According to the Kiupel system a MC of less

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 10 of 14

than 7 is associated with increased survival time (median survival of over 2 years compared to 4 mon- ths in case of CMCTs with a MC of 7 or more). In a different study the MC alone was a strong predic- tor of overall survival for dogs with CMCTs regardless of Patnaik grade: dogs with a MC of 5 or less had a median survival time of 70 months while dogs with a MC of more than 5 had a median survival of 2 mon- ths (Romansik 2007).

Surgical margins: While the width of tumor free margins that would consistently prevent recurrence could not be determined rec- ommendations for high grade MCTs have included macroscopi- cally measured lateral margins of at least 3 cm and deep margins of one fascial plane. However one study showed that 36% of high grade (Kiupel system) CMCTs re- cur locally despite histologically tumor-free margins (Donnelly et al. 2015).

Prognostic panels: PCR analysis for mutations in exon 8 and exon 11 of the cKIT gene performed on the already submitted paraf- fin embedded tissue specimens may offer additional therapeu- tic information as improved clini- cal response with tyrosine kinase inhibiting compounds has been shown in dogs with MCTs demon- strating ITD mutations in exon 11 of ckit. A more comprehensive de- scription and ordering informa- tion of these tests can be found

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 11 of 14

in the most recent edition of the Mast Cell Tumor Diagnostic Update available at the following address: www.idexx.com/mct.

** Please note that if a panel is requested on more than one tis- sue/mass this will be charged per site. **

Additional information: Despite the vast amount of knowledge on canine CMCTs there is no single test or measurable feature that could unequivocally establish the prog- nosis of CMCTs and patients should be evaluated on a case-by-case basis taking into account all factors including patient information clin- ical history anatomic location mi- croscopic features MCT-PP results and results of staging (Sledge et al. 2016; Kiupel 2017).

References: Please refer to the IDEXX Diagnostic Update for Can- ine Mast Cell Tumors (2017) for the complete list of references cited in this report: www.idexx.com/mct.

Internal interpretation ID: IXD1.4

(For lab use only: Mast Cell Tumor Prognostic Panel 3 US code 3374 Canada code MCTPCR; please use block C for mass [1])

HISTOPATHOLOGIC DESCRIP- TION: Right forelimb: The specimen is characterized by a poorly demar- cated and unencapsulated prolif- eration of neoplastic round cel- ls. These cells form solid sheets

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between the collagen bundles of the superficial and deep dermis extending into the subcutis. The neoplastic cells have distinct cell borders amphophilic cytoplasm with variable amounts of ba- sophilic cytoplasmic granules and a round centralized nucleus which contains vesicular chromatin and an indistinct nucleolus. There is mild to moderate anisocytosis and anisokaryosis. Eosinophils are present throughout the mass.

PATHOLOGIST: Gary Lee BVMS PhD Diplomate American College of Veterinary Pathologists

HOW TO CONTACT ME: Email (preferred): [email protected] Phone (direct): Ext: 72543

Please note that I am based in Aus- tralia and may be difficult to reach by phone due to time zone differ- ences. Email is the preferred mode of communication.

Veterinarians: To contact the pathologist regarding this report please either use email or call Cus- tomer Support and dial the exten- sion shown above. If the pathol- ogist is unavailable call Customer Support and request to speak to the Pathologist on Duty. Please ref- erence patient accession number 2315732092.

Pet owners: Please contact your veterinarian for advice to adhere to the legal veterinary-client-patient

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 13 of 14

relationship.

This pathology report may not be published via any distribution channel (including social media) without the pathologist's express permission.

Dr. Eliza O'Callaghan

Owner: Jordana Hochman | Patient: Walter | Species: Canine | Breed: Terrier Mix | Page: 14 of 14