9/25/2025

DVM Intake Exam Estimated age: 2-4 years based on dentition Microchip noted on Intake? Scanned negative History: Acquired by ACO, caller notified driver about injured cat Subjective: QAR Observed Behavior - tense/trembling, sedated to assess clinical status using 0.2 ml Dexmedetomidine (500mcg/ml) + 0.2 ml Butorphanol (10mg/ml) + 0.2 ml Ketamine (100mg/ml) IM Is there evidence of Cruelty? No Is there evidence of Neglect? No Is there evidence of Trauma? Yes, epistaxis Objective T = P = 120 bpm (Sedated) R = WNL BCS: 4/9 EENT: Eyes clear, ears dirty AU, epistaxis, no ocular discharge noted Oral Exam: Adult dentition, mild tartar, fractured tip of right mandibular canine, complete hard palate fracture PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: Externally WNL, intact male, 2 scrotal testes MSI: Ambulatory x 4 (prior to sedation), skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities (prior to sedation) Rectal: Externally WNL Wood's Lamp Exam: not performed Assessment Hard palate fracture Fracture right mandibular canine Epistaxis Intact male Prognosis: Poor to fair Plan: Intake tasks + exam CBC/CHM in house AFAST- no free fluid, bladder appears intact Feed slurry Simbadol 1.8 mg/ml 0.6 ml SQ q24hr x3d Monitor appetite 0.2 ml antisedan IM SURGERY: Temporary waiver due to clinical status

9/25/2025

CBC HCT 38.1% Hgb 13.1 g/dL WBC 34 K/uL (2.87-17.02) - neutrophilia 32 k/uL CHM Mild hyperglycemia 229 mg/dL SDMA 12 ug/dL Creatinine 1.0 mg/dL BUN 19 mg/dL Lytes WNL ALT 495 U/L ALP WNL A: Marked leukocytosis- r/o inflammatory vs. infectious Mild hyperglycemia Elevated ALT- r/o secondary to trauma vs. other P: Convenia 80mg/ml 0.45 ml SQ once Monitor appetite Consider adding on additional abx if indicated

9/26/2025

SO: Hx head trauma with hard palate fracture post high rise trauma BAR, sitting at front of kennel. Does not appear to have eaten overnight eent: eyes clear, no ocular or nasal dc apparent oral: having difficult time closing mouth h/l: eupneic, no coughing or sneezing appreciated msi: ambulatory x4 neuro: mentation alert and appropriate A: high rise hard palate fracture head trauma P: continue simbadol 100ml LRS sc SID x5d 0.4ml robenacoxib 20mg/ml sc SID x3d

9/27/2025

SO: In medical on treatment for head trauma and hard palate fracture BAR, head bunting and seeking attention. Allows all handling for brief exam eent: eyes clear, dried nasal dc apparent oral: mouth appears to be closing better, no drooling h/l: eupneic, no coughing or sneezing appreciated msi: ambulatory x4 neuro: mentation alert and appropriate A: head trauma hard palate fracture P: monitor appetite, does not appear to be eating significant amount continue supportive care and pain management

9/28/2025

Issue List: - head trauma - hard palate fracture - high rise trauma QAR eating EENT: no nasal or ocular discharge noted H/L: eupneic PLN: WNL ABD: relaxed U/G: MC/MI/FS/FI MSI: adequate body condition CNS: Mentation quiet - no signs of neurologic abnormalities A) highrise trauma P) CWSC

9/28/2025

Fractured rostral mandible ventral to canine teeth. Left and possibly right mandible affecteed.

9/29/2025

Pet is curled up in rear of cage and tolerates petting. He did not eat overnight. Urine is present in litter box. EEN: No ocular or nasal discharge. Oral: Repeated licking of nose and swallowing. RESP: Eupneic A: Anorexia r/o pain due to fracture vs other Prognosis: Fair Plan zorbium 1ml topical Q 3 days Advise placement in veterinary clinic for pain management and relief of stress from shelter.

9/30/2025

Yuri leans into pets. Urinated in box. He sniffs at a variety of food but does not eat. EEN: Wet nasal congestion. Dried blood on nose Oral: Frequent licking of lips. Some laxity in rostral mandible. Pet resists exam of hard palate. RESP: Eupneic MSI: Ambul x 4 NEURO: QAR A: Anorexia Nasal congestion r/o inflammation from trauma Friendly Prognosis: Poor to fair Plan LRS 100 mls SQ sid x 2 days Cerenia 10mg/ml 0.4 ml SQ sid x 3 days advise at risk placement

10/2/2025

Ate tuna when offered