11/19/2019

DVM Intake Exam Estimated age: ~ 5 years Microchip noted on Intake? No History :Stray Subjective: BARH. No csvd Observed Behavior - Very sweet, loose body, tail wagging, seeking attention. Allowed all handling Evidence of Cruelty seen - no Evidence of Trauma seen - no Objective P = wnl R = wnl BCS 7-8/9 EENT: No ocular/nasal discharge. AS mild to moderate ceruminous debris, errythematous, AD WNL. Oral Exam: adult dentition, scant tartar noted on molars and canines, no oral lesions. MM pink, moist, CRT <2s. PLN: No enlargements noted H/L: No murmurs or arrythmias ausculted. Normal BV sounds, no crackles or wheezes. ABD: Soft, non painful, no masses palpated but difficult to palpate due to weight U/G: FI,no spay scar/tattoo noted, pendulous mammary glands, no MGT, no discharge MSI: Ambulatory x 4, no ectoparasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: not performed, normal externally Assessment: Obese Otitis externa AS Prognosis: Good Plan: CTM while at BAC Cleaned ears Start Mometamax 2-3 drops AS BID x 7 days Recheck ears 11/27 SURGERY: Ok for sx

11/24/2019

History 11/19/19 stray intake: Obese, otitis AS, cleaned and started mometomax. 11/24 today: Lameness and reluctance to walk noted S/O: QARH, tense and timid, but no signs of aggression and allows all handling. Walks well at times, but refuses and pulls against lead or sits down at other times. EENT: Eyes clear, ears greasy (likely from medication), no nasal discharge noted Oral Exam: mm pink, CRT <2, scant tartar H/L: muffled due to obesity, but no obvious murmur, SSP; Lungs eupneic ABD: Tense, non painful, no masses palpated but unable to palpate deeply due to obesity U/G: Female intact, pendulous MGs MSI: Ambulatory x 4 with waddling gait, unable to discern single limb lameness (generalized lameness), LHL bows out laterally when bearing weight, repeatable crack in left stifle when flexed, left stifle feels thickened, BCS 9/9 CNS: Mentation appropriate -CBC: NSF -CHEM: mild hyperglobulinemia 4.7 (2.5-4.5), mild hyperchloesterolemia 330 (110-320) -T4: low 0.8 (1-4) A: Obese Otitis Lameness - non specific, suspect chronic changes/OA in multiple joints secondary to obesity Low T4 - ro true hypothyroidism vs euthyroid vs other P: CBC/CHEM/T4 Start rimadyl 4.4 mg/kg PO SID x 7 days, then recheck Suspect lameness will not resolve until adequate weight loss is achieved Recommend thryoid panel to determine if hypothyroidism.

11/26/2019

Hx: 11/19 stray intake: Obese, otitis AS, cleaned and started mometamax 11/24: Lameness and reluctance to walk. Repeat bloodwork, low T4. Started on rimadyl. -CBC: NSF -CHEM: mild hyperglobulinemia 4.7 (2.5-4.5), mild hyperchloesterolemia 330 (110-320) -T4: low 0.8 (1-4) 11/26: Pre-op exam, scheduled for sx at outer clinic tomorrow. SO: BARH, no c/s/v/d. Excellent appetite, unremarkable elimination. Eyes: Grossly appropriate OU. Nasal Cavity: No nasal discharge. Lungs: Eupneic U/G: Normal external genitalia. No discharge. Musculoskeletal: Ambulatory x 4 with waddling gait, unable to discern single limb lameness (generalized lameness), LHL bows out laterally when bearing weight. BCS = 9/9 Integument: Otherwise unremarkable haircoat. Neuro: Appropriate mentation. Rectal: Not performed. Externally normal. A: Obese Otitis (not examined today) Lameness- suspect chronic changes/OA most likely secondary to obesity Low T4- r/o true hypothyroidism vs euthyroid vs other P: CTM while at BACC Spay Continue rimadyl 4.4mg/kg PO SID x 7 days until 12/1 Suspect lameness will not resolve until adequate weight loss is achieved Recommend thryoid panel to determine if hypothyroidism Sx: Ok for sx

12/9/2019

Pre-op exam: Hx: Otitis externa AS 11/19 on intake. Treated with mometamax x 1 wk. Obese. Unspecified lameness 11/24. Treated with rimadyl. BW 11/26 showed low T4 - r/o hypothyroid vs sick euthyroid. Was in foster. Here for spay tomorrow. S/O) BARH. MM pk. EENT: Eyes clr OU. Ears - slight brown d/c AD, cln AS. NND. Oral: Grade 1/4 ddz. MSI: BCS= 8/9, obese. But lost 2 lbs since 11/19. H/L: no c/s. NSR, NM. clr and eup. Abd: SNP. UG: Pendulous MG, no MGT's. Skin in spay area clr. A) Obese Otitis externa resolved AS but Slight AD. No signs of lameness. P) Cleaned ears. Ok for spay. Weight loss necessary - hx of lameness. Recom repeat full BW with T4, add on T4 panel if suspect hypothyroidism.

1/17/2020

DVM Progress Exam History: Check spay incision (spay done 12/10/19) Subjective: BARH Observed Behavior - Rolls over for belly rubs immediately! Very friendly. Objective BCS 8/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: neg oral PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: spay incision CDI, no discharge, fully healed; gray spay tattoo present MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: mild amount liquid-ey stool ventral tail base and perineum Assessment 5 yo FS mix 1. post spay - incision healed Prognosis: Good Plan: Follow up with regular DVM as needed

1/17/2020

DVM Intake Exam Estimated age: 5 yo Microchip noted on Intake? Yes History: Stray Subjective: BARH Observed Behavior - Very sweet and gentle. Rolls over for belly rubs. Allows all handling. Evidence of Cruelty seen - No Evidence of Trauma seen - No Objective P = 108 R = 28 BCS 8/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: neg oral PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FS, green spay tattoo, no active vaginal discharge noted during exam but mucopurulent blood-tinged vaginal discharge dripped on the floor in holding area prior to exam MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat, stiff gait x 4 CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: small amount fecal matter caked to ventral tail base Assessment 5 yo FS mix 1. vaginal discharge r/o vaginitis vs. UTI vs. stump pyometra vs. other 2. obese 3. stiff gait r/o DJD vs. 2o to obesity vs. other Prognosis: Good Plan: Intake tasks UA with culture (U/S guided cysto) Cleaned perivulvar area with chlorhexidine solution Clavamox 375 mg PO BID x 10 days R/c vulvar discharge in 1 week Start weight management plan SURGERY: Already spayed

1/21/2020

Urinalysis and Urine Culture and Sensitivity NSF

1/24/2020

BAR sitting in the front of kennel. Eating well. She is very calm and friendly. Takes treats very gently. No vaginal discharge noted today. Continue with current tx plan.

1/29/2020

Hx: previously diagnosed with osteoarthritis. Has been developing some behavior issues that had not been noted during previous time in shelter. When in shelter last time was on carprofen course. Will restart S: BAR in kennel, taking treats O: eyes clear, no ocular or nasal dc apparent walking with stilted gait A: Osteoarthritis P: Rimadyl 100mg 1 tablet PO SID x14d recheck in 14d, if tolerating well then plan to extend indefinitely

1/31/2020

Starting trazodone for in shelter anxiety Trazodone 100mg 1 and 1/2 tablets PO BID indefinitely unless otherwise instructed

Pearl allowed to be collared, scanned for a microchip, and have a leash placed on her. Pearl jumped out of the car on her own and would come towards counselor when called over. Pearl had a loose body throughout intake and allowed all petting.