11/10/2025

[Spay/Neuter Waiver - Age] It is the policy of ACC not to perform surgery on any animal over the age of 8-10 years due to the higher risks incurred in a shelter setting. The veterinarian is hereby issuing a permanent spay/neuter waiver, from the spay/neuter requirements of the City of NY due to the estimated age of this animal. ACC does recommend you consult with your veterinarian to determine if surgical sterilization is appropriate.

11/10/2025

Subjective: DVM Intake Exam Name: Polar Animal ID: 241095 Species: Feline Estimated age: 9 years Microchip noted on Intake? Negative History: Agency; ACO impound. BAR MM pale pink, moist, CRT <2 sec Observed Behavior - Sedation needed for Intake Evidence of Cruelty seen - No Evidence of Trauma seen – No Evidence of Neglect- Yes Objective: P = 120 hr (sedated) R = 28 rr (sedated) BCS 5/9 Wt = 9.72 lbs EENT: Mild iris atrophy noted. An approximately one-inch area of thickened, mildly erythematous, alopecic skin is present on the bridge of the nose. Ears clean, no nasal or ocular discharge noted. Oral Exam: Moderate yellow enamel discoloration, most significant on the maxillary canines. Missing some maxillary and mandibular incisors. Minimal plaque on molars, no calculus observed. PLN: No enlargements noted H/L: NSR, no apparent murmur, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MI; mucopurulent discharge noted between the prepuce and scrotum. MSI: Ambulatory x 4. Significant urine staining is present on the entire ventrum, including all limbs and the perianal area. Urine scald is present on the ventral abdomen. There are raw, moist, erythematous, and mildly bleeding superficial abrasions on the paw pads of the right front second digit and the left front second digit. The nails are overgrown. Flea dirt was observed. Skin free of parasites, no masses noted, healthy hair coat otherwise. CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: Apparently healthy -Severe urine scald and dermatitis on ventrum, limbs, and perianal region -Superficial abrasions on front paw pads -Flea infestation -Alopecia on nasal bridge -Dental disease with missing incisors -Overgrown nails *ASSESSMENT, INCLUDING PROBLEM LIST WITH DIFFERENTIALS*: -*Urine scald and dermatitis*: Differentials include housing condition (unable to rest away from urine), urinary incontinence (neurogenic or non-neurogenic), urinary tract infection, or mobility issues preventing normal urination posture. -*Paw pad abrasions*: Differentials include chemical burn secondary to urine scald or trauma. -*Alopecia on nasal bridge*: Differentials include dermatophytosis, trauma, or allergic dermatitis. -*Hyperglycemia and Hypernatremia*: Stress-induced hyperglycemia is most likely, though diabetes mellitus cannot be ruled out. Hypernatremia suggests dehydration. -*Flea infestation*: Confirmed by presence of flea dirt. *NEW DIAGNOSTIC INFORMATION*: -*In-house CBC*: RDW 27.1% (mildly elevated), Lymphocytes 0.88 (mildly decreased); both considered clinically unremarkable. -*In-house Chemistry*: Glucose 210 mg/dL (elevated), Sodium 175 mEq/L (elevated), ALP <10 U/L (low). SDMA and Total T4 were within normal limits. -*Wood's lamp*: Negative for fluorescence on the nasal lesion. *REVISED ASSESSMENT WITH DIAGNOSTICS*: -*Urine scald dermatitis with secondary paw pad abrasions*: Confirmed. The underlying cause remains undetermined. -*Dehydration*: Suspected based on hypernatremia. -*Stress hyperglycemia*: Likely, given the clinical context. -*Flea infestation*: Confirmed. -*Nasal alopecia*: Dermatophytosis is less likely given the negative Wood's lamp result. *CONFIRMED DIAGNOSES*: -*Urine scald dermatitis* -*Paw pad abrasions* -*Flea infestation* -*Overgrown nails* -*Dehydration* *UNCERTAIN DIAGNOSES*: -*Etiology of urinary staining/incontinence* -*Stress hyperglycemia vs. Diabetes Mellitus* Prognosis: Fair Plan: Standard Intake Procedures: Rabies vaccine FVRCP vaccine FELV/FIV SNAP Pyrantel deworm Selamectin Microchip Wood's lamp: Negative Flea dirt noted; no Capstar administered as no live fleas were seen. Nail trim Sedation protocol: Initial sedation with 0.09 ml IM of a dexmedetomidine (10 mcg/kg) and butorphanol (0.2 mg/kg) combination. An additional 0.04 ml of dexmedetomidine was given for more robust sedation. Reversed with 0.13 ml Antisedan IM. *DIAGNOSTICS*: -In-house CBC and Chemistry panel performed. *TREATMENTS AND PROCEDURES*: -Clipped and cleaned the affected skin on the ventrum and paws with dilute chlorhexidine solution. -Applied Silver Sulfadiazine (SSD) cream to abraded areas. -Placed an E-collar. -Administered 90 ml LRS subcutaneously. -Administered 0.25 ml Vitamin B12 (1000 mcg/ml) subcutaneously. *MEDICATIONS DISPENSED*: -Convenia (cefovecin) 80 mg/ml: 0.44 ml (8 mg/kg) administered SQ once. -Gabapentin 50 mg/ml suspension: 0.9 ml (10 mg/kg) to be given PO BID for 7 days. -Silver Sulfadiazine (SSD) cream: Apply to affected skin BID for up to 3 days. *OTHER RECOMMENDATIONS, FOLLOW-UP CARE*: -Maintain E-collar for up to 3 days, depending on patient tolerance. -Schedule veterinary recheck tomorrow to re-evaluate skin and assess tolerance for continued E-collar use and SSD application, as well as subcutaneous fluids. SURGERY: Permanent waiver d/t age -Older

11/11/2025

Recheck urine scald and skin issues S/O: QAR, attempts to flee, bedding soaked in urine, malodor from kennel. Sedated for exam with telazol 0.16 ml IM. EENT: No ocular or nasal discharge, erythema and alopecia at bridge of nose ORAL: mild-moderate tartar and gingivitis; mm pink and moist MSI: Diffusely unkempt haircoat with yellow staining ventrally and at palmar/plantar aspects of limbs UG: Ulceration/open wound at left scrotum, pigmentation, swelling, and comedone at prepuce; upon extruding penis - there is a large amount of fur with white moist debris matted and wrapped around penis, flushed and removed - no discoloration or necrosis appreciated A: Ulceration/wound at left scrotum - ro self mutilation secondary to below vs other Hair matted/caught around penis - removed Matted, unkempt, soiled haircoat Overweight Dental disease Fleas - treated at intake Alopecia/erythema at bridge of nose P: Removed caught fur from penis/prepuce Bathed and thoroughly dried while sedated Onsior 2 mg/kg SQ once Zorbium applied Discontinue SSD as he does not allow application. Removed e-collar as worsening FAS Continue gabapentin for FAS and pain Monitor urination/LB usage closely. Recheck in 2-4 days

11/14/2025

Recheck urine scald/wound; matted fur found wrapped around penis at last exam S/O: QAR, dilated pupils, poor appetite, no c/s/v/d noted EENT: No ocular or nasal discharge LUNGS: Eupneic ABD: Small soft UB palpated MSI: Haircoat unkempt but urine staining/malodor improved; erythema at bridge of nose resolved UG: Ulceration/wound at scrotum contracting and dried out with minimal swelling, prepuce unchanged (appears slightly swollen with one large comedone) A: Anorexia vs hyporexia Ulceration/wound at scrotum Matted/unkempt haircoat Dental disease Hx fur matted and caught in prepuce surrounding penis P: Start SQ LRS 100 ml SID Start cerenia 1 mg/kg SQ SID Start mirataz SID Start medical feedings BID Monitor closely in ICU, recheck in 2 days

11/16/2025

recheck -unkempt coat on intake -hyporexia in care -urine scalding S/O QAR, no c/s/v/d appreciated or noted, noted to not be eating food trays or the med feedings, recoils into the back of the kennel for exam, needed towel EENT: no ocular or nasal dc, dilated pupils HL: eupneic GA/GU: npm, moderate flaccid bladder, able to extrude penis - no debris or hair visible, scabbing to the scrotum MSI: amb x 4, good skin turgor, thin hair coat very the caudal half of the body. A. Hyporexia r/o anorexia r/o second to FAS Scabbing/dermatitis to the scrotum- appears to be healing P. Given 0.2mg/kg midazolam IM for appetite P would benefit from cage cover - lower stress environment. Strongly suspect that anorexia is second to FAS. Recheck tomorrow to see if midazolam helped, can repeat tomorrow if did

11/18/2025

Recheck urine scald, wound at scrotum, poor appetite; reweigh today - lost about 0.7 lbs S/O: QAR, tense and hunched at back of kennel, allows touch/petting and exam with towel restraint, mild attempts to flee when out of kennel; not eating today, offered HV foods and not interested, no c/s/v/d noted, small area of urine in LB EENT: No ocular or nasal discharge, fresh laceration at left side of nares LUNGS: Eupneic MSI: Not observed ambulating due to FAS, unkempt haircoat with minimal malodor and staining, underweight with DMW; plantar surface of pelvic limbs distal to tarsi have thick caked/matted scab covering ulcerations, bleed readily when fur clipped away; ulceration at scrotum healing with scab CNS: Quiet mentation A: Wounds/ulceration at tarsi bilaterally - ro secondary to previous matting and soiled haircoat (not previously noted, but suspect not a new problem) Anorexia vs hyporexia Healing wound at scrotum Underweight, weight loss P: Start SQ LRS 100 ml SID x 3 days Start cerenia 1 mg/kg SQ SID x 3 days Entyce 3 mg/kg PO once Start medical feedings BID x 5 days Start onsior 2 mg/kg SQ SID x 2 days Zorbium applied Monitor closely on rounds, no clay litter

11/19/2025

Recheck wounds/appetite S/O: QAR, tense and hunched in place all day, urine noted in LB this morning; poor appetite. Allows handling with towel, allows very slow petting. EENT: Mild congestion and mucoserous nasal discharge MSI: wounds at caudal aspect of paws/tarsi stable with no discharge, slight contraction. A: Wounds Mild URI Anorexia vs hyporexia Dental disease Weight loss, underweight Dehydration PLAN: Continue SQ LRS, cerenia, onsior, and med feedings and recheck tomorrow

11/20/2025

Recheck S/O: QAR, hunched in one place all day, no c/s/v/d noted, allows slow handling and slow petting, but growls and hisses when picked up or restrained for medical treatments Food disturbed and dumped in kennel this morning so unable to tell if ate anything overnight, not eating today; suspect anorexia EENT: No ocular or nasal discharge noted LUNGS: Very quiet congestion, otherwise eupneic MSI: Ambulatory x 4 (only observed ambulating in kennel - low and hunched posture likely due to FAS), unkempt and patchy haircoat, dorsal muscle wasting, wound at scrotum healing - scabbed and contracted, wounds at plantar tarsi stable with healthy granulation tissue visible, no active discharge but wound beds moist CNS: Quiet and appropriate mentation A: Anorexia and weight loss - ro FAS vs illness vs other Mild URI Wounds at tarsi - ro secondary to poor husbandry +/- inactivity vs autoimmune vs other Wound at scrotum Dental disease Dehydration P: Continue SQ LRS, cerenia, medical feedings Start mirataz SID Midazolam 0.2 mg/kg given IM today for appetite stimulation Monitor closely on rounds, seek placement outside shelter for lower stress environment, more space, etc

11/20/2025

Addendum: Ate all of wet food tray within a few hours of receiving midazolam IM.