1/17/2018

[DVM Intake] DVM Intake Exam Estimated age:7y Microchip noted on Intake?n Microchip Number (If Applicable): History :stray Subjective: Observed Behavior -allows exam Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T = P =200 R =wnl BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: ddz: missing several teeth, heavy tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G:no ss seen MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: dental dz Prognosis:good Plan:dental in future, ohe SURGERY: Okay for surgery \

1/22/2018

Pre-op exam: S/O) BAR. Mild dehydration. MM pale pk. EENT: Eyes clr. NND. Marked ddz - missing teeth, marked calculus. MSI: BCS= 3/9, thin, amb x4. H/L good. Abd: SNP, NMP. UG: kidneys slightly small, small bladder, F, no spay scar seen. PLN: WNL. A) Age 7-10 yo F DSH. Severe ddz. Mild dehydration Thin P) Unable to run BW in AM due to machine issues. Urinalysis: Dipstick - no gluc, prot 1 +, leuk trace. Urine SpGr= 1.060+ Gave 100 cc sqf. Sedated in PM. MM more pale post sedation. Able to run BW now - machine fixed. While sedated, performed dental procedure: Removed most of hard tartar. Extracted 3 teeth - 1) L upper molar - marked tartar and loose, 2) L mandibular canine - loose with marked gum recession, 3) R upper maxillary canine - marked gingival swelling and neck lesion. Blood work interpretation: CBC: Mild anemia = 28.9%, else wnl. Chem and T4 WNL. Waiver from surgery due to dehydration and mild anemia and geriatric age. Recom SQF 100cc a day x 3 days. Recom re-check Hct in 3 days. Possibly consider spay then or permanently waive. [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.

1/24/2018

Rejected from surgery on 1/22 due to underweight and dehydration; blood work showed mild anemia S/O -BAR, interactive but a little skittish, approaches and then regresses -good appetite -no nasal discharge or sneezing -mm pk, sl tacky; CRT <2 sec -OU: open and clear -eupnic -soft abdomen -BCS 4.5/9 A 1. Underweight-r/o parasites vs poor nutrition vs other 2. Anemia, mild-r/o poor nutrition vs other P -rec'd repeat CBC, weight check in 7-10 days

1/31/2018

Hx: Underweight and slightly dehydrated on previous exams. S: Alert, friendly, allows all handling O: BAR, estimated 5% dehydrated based on decreased skin turgor, BCS 4/9, MMs pink EENT: No discharge OU, AU, nose. Severe tartar/gingivitis. 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. No skin lesions noted. UG: Female Neuro: Alert and appropriate, no sign neurological deficiencies CBC/chemistry - eosinophilia. Anemia resolved. A: Weight loss, dehydration, good appetite, eosinophilia - R/O GI parasites vs. IBD vs. neoplasia vs. other cause Short-term prognosis: Good-fair P: 1. Vit B12 0.25 ml SQ, given during exam 2. Drontal for Cats and Kittens, 1 tab PO given during exam 3. TEMPORARY spay waiver - recheck in 1 week 1088

1/31/2018

TEMPORARY SPAY WAIVER Your newly adopted pet has been diagnosed with weight loss and dehydration and the staff veterinarians are issuing a temporary waiver from the spay/neuter requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.

2/6/2018

Hx: originally lost weight after intake; blood work at that time showed mild anemia which has since resolved; latest blood work from 2/2 showed mild eosinophilia but no other concerns; was reweighed last night and recorded as 4# but suspect that was an error as reweigh today was 5.34# S/O -BAR, friendly and docile -mm pigmented, moist; oligodontia -good appetite, normal stool production in box -no nasal discharge or sneezing noted or reported -OU: open and clear -eupnic, clear lung sounds; no murmurs or arrhythmias -soft abdomen, no palpable abnormalities -still slightly underweight but BCS improved (4.7/9) A 1. Underweight, improving 2. Weight loss, resolved P -fecal float and 2 view radiographs ran today prior to reweigh, no concerns on either -no concerns at this time, weight was entered incorrectly and she is up from intake weight; has consistently had a good appetite, normal stool production and no vomiting or other concerns noted

2/9/2018

S/O: BAR, eating and drinking. Reported snnezing. EENT: UR Sneezed while examining A: URI Plan: Suspect viral URI so move to iso - will not give antibiotics until a bacterial infection is suspected. Cerenia - 0.2 cc SQ for 3 days Recheck in 3 and 7 days

Upon intake Destiny had a relaxed body posture inside the carrier. Her eyes were semi dilated and her tail was to the side. She was receptive to handling and very quiet. She allowed to be collared and to be removed from her carrier. Outside the carrier she kept her body low and she walked away slowly from the counselor. She allowed the counselor to carry her and centered her for a picture. She walked inside her carrier willingly and accepted food. She ate 1/2 can of wet food.