1/24/2025

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.

1/24/2025

DVM Intake Exam Estimated age: 12-16 years Microchip noted on Intake? N History: Agency intake Subjective: Observed Behavior - Friendly, allowed handling Is there evidence of Cruelty? N Is there evidence of Neglect? N Is there evidence of Trauma? N Objective BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Grade IV/IV periodontal disease H/L: NSR, grade IV/VI L heart murmur, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MI, two scrotal testes MSI: Ambulatory x 4, skin free of parasites, no masses noted, overgrown coat with some matting, mild diffuse muscle wasting CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Soft swelling lateral to anus. On digital rectal exam, R perineal hernia Assessment Geriatric SMB dog Grade IV/VI L heart murmur- r/o MMVD vs. other R perineal hernia Severe (grade IV/IV) periodontal disease Prognosis: Fair Plan: Monitor defecation and urination Sent out CBC/chem Shaved mats- recommend further grooming with placement Recommend cardio consult for echo with placement + perineal hernia repair and dental if appropriate anesthetic candidate SURGERY: Permanent waiver due to age

1/25/2025

Bloodwork results: monocytes high 1.2 eosinophils low 0.044 platelets high 467 creatinine low 0.4 ALT mildly elevated 172 AST mildly elevated 56 TT3 low normal 1.3 r/o inflammatory process i.e dental disease, other underlying dx *no significant concerns on bloodwork; mildly elevated liver enzymes, monocytosis and thrombocytosis suspected due to inflammatory process i.e dental disease *Recommend cardio consult + perineal hernia repair and dental once placed (if anesthetic candidate) *Hung monitoring log to monitor urination, defecation and appetite *Recheck on 1/27

1/28/2025

Brief recheck, no reported concerns on rounds board S/O: BAR, wagging tail and panting at front of kennel; no monitoring log in place Fresh food in kennel is uneaten, does not take treat offered (jerky treat) No c/s/v/d noted, stool smashed into bedding ORAL: mm pink and moist, visible dental disease MSI: Ambulatory x 4 CNS: Appropriate mentation A: Senior to geriatric dog Perineal hernia Dental disease Heart murmur P: Replaced monitoring log Overall recheck in 2 days CTM closely on rounds

1/30/2025

Recheck perineal hernia, heart murmur S/O: BAR, wagging tail and loose body, but cries out and gently bites when performing rectal exam (painful vs uncomfortable) Appetite scores: initially 3's, then a 1 yesterday, food dish in kennel is nearly empty this morning No c/s/v/d noted; one small piece of stool in kennel otherwise smears of feces on bedding in multiple places UG: Perineal hernia right of anus, feels malleable when palpating, but patient very resistant to palpation RECTAL: Very reactive, unable to fully palpate into hernia - suspect feces impacted A: Perineal hernia - suspected fecal impaction Heart murmur Dental disease Geriatric P: Monitor fecal output closely, noted on log to monitor stool Seek placement - recommend cardiology consult with echo. Patient would benefit from surgical repair of perineal hernia and a dental procedure. CTM while at QACC