9/6/2025

DVM Intake Exam Estimated age: 3-6 y/o based on dentition but appears slightly older based on overall appearance. Microchip noted on Intake? scan negative History: DOH-B, stray, possibly HBC, bit handler as they attempted to lift P up into car. Subjective: BARH Observed Behavior - very tense and whale-eyed when handling, slightly stiff and frozen suspected also due to underlying pain. Turned head around slowly with stiff body as microchip scanned. Elected to sedate for full exam using Dexmedetomidine 6mcg/kg + ketamine 3mg/kg + methadone 0.2mg/kg (from Premix bottle). Sufficient sedation level achieved. Is there evidence of Cruelty? no Is there evidence of Neglect? no Is there evidence of Trauma? YES, reported hbc Objective T = not taken P = 86 bpm R = 35 bpm BCS 5/9 EENT: Scleral hemorrhage left eye, OS also slightly proptosed in appearance; ears clean, no nasal or ocular discharge noted Oral Exam: minimal to no tartar or plaque present PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: tense on palpation, no masses palpated U/G: male intact, 2 testes palpable MSI: Ambulatory x 4, very stiff in pelvic limbs on ambulation with consistent LHL lameness. Skin free of parasites, no masses noted, healthy hair coat. Large superficial abrasion (~8inch patch) with slightly wet appearance on left side of inguinum, with bruising around prepuce extending slightly towards scrotum. Small superficial wounds on lateral aspect of L antebrachium. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal RADIOGRAPHS: no obvious fractures though possible irregularities around acetabula (L>>R). Splenomegaly, prostatomegaly, no obvious FF. No appreciable F. BLOODWORK (in-house): neutrophils high 13.97, eos low 0.01, glucose high 146, otherwise WNL Assessment: ~3-6 y/o MI Scleral hemorrhage OS - no observed neurological deficits Slightly proptosed left eye Superficial wound on left side of inguinum and scrotum LHL lameness *Trauma impacting left side of body, suspecting HBC Prognosis: Fair to guarded Plan: Keep housed in ICU, use caution Adminstered: -Carprofen 4.4mg/kg SQ -Convenia 8mg/kg SQ once for abrasion Start: Carprofen 75mg PO q24h x 7 days Gabapentin 400mg (20mg/kg) PO q12 x 14 days *Recheck appetite and comfort daily on rounds, general mobility check in 2 days SURGERY: Temporary waiver due to medical condition

9/7/2025

P is BAR, at the front of the kennel, abrasions visible to the ventral abdomen when jumps up, food tray mostly empty. CTM and recheck as scheduled

9/8/2025

recheck, reported to be HBC 9/6, no overt fx's noted on intake, LFL lameness. S/O- visual exam only d/t temperament and bite hx BAR, at the front of the kennel, no c/s/v/d appreciated, food trays mostly empty EENT: no ocular or nasal dc HL: eupneic MSI: amb x 4, no appreciable lameness aTT (but difficult to tell as p at the front of kennel), abrasions visible to ventral abdomen A. Hx of possible hbc Hx of LHL - unable to properly assess as patient at front of the kennel but appears to be bearing equal weight P. Con't with current pain meds P is scheduled to be moved to other housing - if non-sedated for move, consider brief exam of possible lameness then Recheck in 3 days CTM while at QACC

9/11/2025

Your newly adopted pet has been diagnosed with HEAD TRAUMA 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 through to the resolution of the issue. At the time of a full recovery you may choose to have your veterinarian perform the spay/neuter surgery, or make provisions to return the pet to ACC for sterilization.

9/11/2025

Recheck lameness, possibly HBC; visual exam only S/O: QAR to BAR, eating well, timid initially but comes forward with coaxing, intermittently panting at front; no c/s/v/d noted EENT: No ocular or nasal discharge. scleral hemorrhage ventrolateral OS, no notable proptosis or buphthalmos OS. LUNGS: Eupneic, then panting MSI: Ambulatory x 4, walks slowly around kennel, walks onto kuranda bed - no appreciable lameness CNS: Appropriate mentation A: Suspect HBC >5 days ago Superficial wounds at scrotum and inguinum - not examined LHL lameness - improved vs resolved Scleral hemorrhage OS Slight proptosis OS - apparently resolved P: No additional treatment indicated Continue gabapentin for pain/FAS CTM while at QACC

9/12/2025

On 09/12/2025 Knox was examined. The patient has appropriate mentation at this time (no neurological signs present) and has not exhibited any neurological signs while at QACC.

9/16/2025

Behavior team reports hyperactivity in kennel - bouncing off kennel door. Start trazodone 8 mg/kg PO BID.

9/16/2025

On 09/16/2025 Knox was examined. The patient has appropriate mentation at this time (no neurological signs present) and has not exhibited any neurological signs while at QACC.