8/29/2025

DVM Intake Exam Estimated age: 8-10 years old based on dentition, c/w owner reports Microchip noted on Intake? Scanned negative History: Owner surrender Subjective: QAR Observed Behavior - tense + flails on leash, bares teeth but does not escalate-- suspect uncomfortable with touch due to discomfort of skin/ears. Opted to sedate using 0.25 ml Dexmedetomidine (500mcg/ml) + 0.25 ml Butorphanol (10mg/ml), sedated but still reactive to stimuli so opted to give additional 0.1 ml Dexmedetomidine (500mcg/ml) + 0.1 ml Butorphanol (10mg/ml) + 0.1 ml Ketamine (100mg/ml) IM. Is there evidence of Cruelty? No Is there evidence of Neglect? No Is there evidence of Trauma? No Objective T = P = WNL R = WNL BCS: 5/9 EENT: Eyes clear, ears have thick pigmented multilobulated lesions AU with thick yellow waxy debris AU, no nasal or ocular discharge noted Oral Exam: Adult dentition, moderate tartar (PDDZ 2-3/4) PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: Externally WNL, neutered male, no palpable testes MSI: Ambulatory x 4 (prior to sedation), severely overgrown nails with nails curving into paw pads in hindpaws, skin free of parasites, no masses noted, thick pigmented raised lesion central dorsum with purulent discharge noted. Multi-focal lesions that extend cranial towards neck and head. CNS: Mentation appropriate - no signs of neurologic abnormalities (prior to sedation) Rectal: Externally WNL Wood's Lamp Exam: not performed Assessment Allergies- chronic Pyoderma- chronic Otitis externa- chronic Prognosis: Poor to fair Plan: Intake tasks + exam Await sort Trim nails + soaked paw pads in dilute chlorohexidine soln Clipped/cleaned hair around lesions Applied Duoxo Mousse to affected areas Skin cytology: TNTC neutrophils, TNTC rods + cocci Rx: Cefpodoxime 100mg PO SID x10d Rx: Apoquel 5.4mg 1/2 tablet PO BID x14d, then 1/2 tablet PO SID x7d 0.2 ml antisedan IM Pet will likely need TECA for both ears due to severity of otitis SURGERY: Already neutered

8/29/2025

[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.

8/29/2025

CBC HCT 29.6% (37.3-61.7) Hgb 10.0 g/dL (13.1-20.5) WBC 9.6 K/uL - normal differential CHM Glucose 52 mg/dL (70-143) SDMA 8 ug/dL Creatinine 0.6 mg/dL BUN 13 mg/dL Mild hyperproteinemia 8.7 g/dL Mild hyperglobulinemia 6.3 g/dL ALT/ALP WNL TT4 0.7 ug/dL (1.0-4.0) A: Mild anemia - r/o pre-regenerative vs. non-regenerative Hypoglycemia- r/o artifact vs. other (not clinical for hypoglycemia) Lytes WNL Mild hyperproteinemia w/ elevated globulins- r/o inflammation vs. other Hypothyroid- r/o sick euthyroid vs. other P: CWCT Prioritize placement

9/2/2025

Pet is QAR and ate overnight.

9/3/2025

Hx: chronic otitis externa, chronic allergies + untreated pyoderma S: QAR, laying down in kennel. Ate well o/n. O: Visual exam only due to discomfort with handling noted at time of intake EEN- eyes clear, no nasal or ocular discharge H/L- Eupneic MSK/i- Ambulatory x4, frequent head shaking on walk, shaved haircoat along dorsum and cranium, lesions on central dorsum have pinpoint scabbing and no appreciable discharge, lesion on head has some serosanguinous discharge Neuro- alert/appropriate A: Pyoderma- on treatment Allergies, chronic Otitis externa, chronic P: Continue with current treatment plan Follow up with placement ASAP

9/5/2025

Hx: chronic otitis externa, chronic allergies + untreated pyoderma S: BAR on walk with wagging tail, when approached by handlers becomes timid but allows some petting. Ate well o/n. O: EEN- eyes clear, no nasal or ocular discharge H/L- Eupneic but coughing MSK/i- Ambulatory x4, lesions on central dorsum have pinpoint scabbing but still no appreciable discharge, lesion on head has formed a scab Neuro- alert/appropriate A: Pyoderma- on treatment Allergies, chronic Otitis externa, chronic CIRDC P: Applied some duouxo mousse to dorsum and caudal dorsum -- tolerated well Rx: Doxycycline 75mg PO SID x10d CWCT Monitor