12/28/2025

Estimated age: ~3-5yo Microchip noted on Intake? scanned negative History: owner surrender Subjective: BAR Observed Behavior - timid, allowed all medical handling Is there evidence of Cruelty? no Is there evidence of Neglect? no Is there evidence of Trauma? no Objective T = np P = 110bpm R = 24brpm BCS 5/9 EENT: clear OS, globe rupture OD, scarring OD, blind OD, ears clean, no nasal or ocular discharge noted Oral Exam: mild tartar accumulation, no oral lesions PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MI, 2 testes palpated MSI: Ambulatory x 4, skin free of parasites, severely matted on face, ears, chest, abdomen and limbs CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal Assessment ~4yo MI Shih tzu -globe rupture OD -severely matted Prognosis: good Plan: intake task sedated grooming tomorrow (torb 0.3mg/kg and dexdorm 10mcg/kg IM) needs enucleation OD SURGERY: Okay for surgery (do in house or send to offsite vet for enucleation + neuter)

12/29/2025

Per Dr. 1791, At 4:50pm gave 0.25ml butorphanol IM and 0.16ml dexmedetomidine IM in order to sedate for grooming. Sedation adequate for procedure - shaving, nail trim, anal gland expression AT 5:20pm gave 0.16ml atipamazole IM in order to reverse sedation Recovery uneventful, returned to kennel

12/31/2025

Intake tasks completed

1/11/2026

QAR and trembling on walk. Staff note watery diarrhea with blood EEN: OD: black pigmented cornea, shrunken globe, dried brown discharge on lids OD. OS: dilated pupil, blue cornea, brush like vessel at limbus, hyperemic conjunctiva. (image attached). No nasal discharge Oral: Moderate tartar and gingivitis NEURO: Menace present OS, absent OD. Palpebral present OU. RESP: Eupneic IOP: OS: 23, 24, 29 (high but expected higher given clinical appearance of eye) OD: 28, 25 33 STT: 9 OD; 20 OS stain cornea: negative OU A: Revising age to 4 to 7 years old given dentition Suspect uveitis and glaucoma OS Diarrhea r/o viral vs parasite vs other Corneal scar from previous rupture of right globe Blind OD and decreased vision OS KCS OD Dental disease stage 2-3/4 Prognosis: Poor Plan Fenbendazole 222mg/g 1.78 grams( 1/2 teaspoon) po sid x 5 days Psyllium 2 teaspoons po sid x 7d LRS 100 mls SQ NeoPolyDex OS bid x 7d 1/4 inch strip Genteal lubricating ointment OD sid indefinitely Advise placement for medical management of left eye +/- bilateral enucleation chem cbc t4 pending. Monitor for CIRDC

1/12/2026

HCT 42% wnl WBCs 29k high Neuts 22.5k high Monos 2.2k high BG 90 wnl BUN 17 wnl creat 0.7 wnl Ca 9.4 wnl Phos 4.6 wnl Electrolyte and liver values wnl T4 5.6 ug/dl high r/o variation of normal for handsome vs thyroid auto antibodies vs thyroid neoplasia Plan submit freeT4 palpate neck

1/12/2026

Pet did not eat overnight. EENT: OS: Hyphema in anterior chamber with red nodule on central ventral cornea (image attached) No masses palpable in neck CV/RESP: HR 120 SSP No murmur ausculted ABD/UG: MI SNP NMP MSI: BCS 5/9 ambul x 4 before sedation NEURO: WNL IOP: OS: 16, 18, 17 before sedation Stain cornea: Positive around central blood clot Machine would not measure blood pressure Doppler BP 110 RFL #4 cuff after sedation. Radiograph Enlarged cranial cardiac waist. No metastases seen. Stomach filled with ingesta Elliptical shaped body with calcified outline caudal to stomach on lateral projections and sharp edged mineral density on midline caudal to stomach on v/d projection. A: Ruptured cornea OS and history of ruptured cornea OD. Suspect left cornea ruptured overnight and sealed with blood clot. IOP is lower than yesterday. Ocular pain and Uveitis OS Anorexia r/o lens induced vs idiopathic vs neoplasia vs infectious vs other Enlarged cranial mediastinum with VHS 9 Mineralized body in abdomen. total calcium, phosphorus & liver values WNL High thyroid level r/o calcified pancreas/upper GI tract due to endocrine disease vs neoplasia vs other +/- foreign material in GI tract Prognosis: Poor to regain vision in left eye. Concern elevated thyroid level may be due to underlying neoplasia. Plan Pet needs placement for pain management of left eye and internal medicine workup including thoracic/abdominal ultrasound to manage thyroid level and determine significance of abdominal mineralization. free t4 pending sedated with Dexdomitor 0.5mg/ml 0.25 ml + Butorphanol 10mg/ml 0.25 ml IM LRS 200 mls SQ sid x 2 days Carprofen 50mg/ml 0.5 ml SQ Gabapentin 100 mg/ml 1.5 mls po bid Carprofen 25 mg 1 tablet po sid x 5 days start tomorrow am Ofloxacin 1 drop OS bid x 7d Discontinue neopolydex ophthalmic Antisedan 0.1 ml IM

1/13/2026

Pet did not eat overnight but ate some sausages today. Diarrhea and then drops of blood from rectum. No vomiting. Pet perks up and wags tail when outside. Temp 101.8 RR 12 while sleeping HR 120 EEN: Clear nasal discharge CV/RESP: WNL ABD/UG: Slightly tense cranially. No massess palpated. MSI: BCS 5/9 Ambul x 4 NEURO: QAR Free T4 1.2 ng/dl wnl 0.6 - 3.7 ng/dL Free T4 15.4 pmol/L wnl 7.7 - 47.6 pmol/L POCUS: No free fluid in abdomen. Stomach: amorphous hyperechoic ingesta. Gastric contractions appear normal. Bladder: Small with filamentous hyperchoic debris Unable mineralized body seen yesterday on radiograph Radiographs (V/D and right lateral were cropped and not diagnostic) A: Hyporexia melena Nasal discharge Uveitis/glaucoma Normal free t4 with elevated t4 Mineralized body on radiograph r/o viral (impending cirdc) r/o mineralized pancreas vs GI tract vs foreign body? + normal variation of thyroid level vs anti-thyroid antibodies Prognosis: Poor Plan Advise at risk placement in veterinary clinic with abdominal ultrasound +/- repeat sedated radiographs +/- doxycycline +/- bilateral enucleation