5/28/2026

DVM Intake Exam Estimated age: 3-6 years Microchip noted on Intake? scanned pos History: owner surrender Subjective: Observed Behavior -bar, nervous but amenable to handling and tasks Is there evidence of suspected cruelty? no Objective: BCS 5/9 EENT: enucleated os, discharge and pruritic au, severe mucoid with blood nasal discharge Oral Exam: moderate periodontitis of caudal dentition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: neutered male MSI: Ambulatory x 4, live fleas, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: grossly normal Assessment: URI Enucleated os Otitis externa Fleas Prognosis: good Plan: DVM intake and tasks awaiting sort Tresaderm au bid x 7 days Doxycycline 10 mg/kg po sid x 7 days Capstar administered po SURGERY: Permanent waiver due to already altered

5/31/2026

Progress exam S: BAR - lying on top of carboard hide in kennel, tense posture, shaking, mydriatic pupils OU, flinches / flattens ears / feigns sleep when approaching for exam - brief exam to limit FAS NATA MMs dt behavior HX anorexia but fair appetite this AM spontaneous productive sneeze reported no c/v/d normal urine voids, no stool since admit O: BCS 5/9 EENT: enucleated os, severe mucoid with mild frank blood nasal discharge, audibly congested Oral Exam: NE dt behavior H/L: Eupneic at distance MSI: Sternal recumbency, ambulation not witnessed CNS: Mentation appropriate - no signs of neurologic abnormalities A: Moderate URI, Rhinitis r/o 2ary to URI vs other OS enucleated prior Moderate FAS Hyporexia r/o 2ary to URI HX Otitis externa - under treatment HX Fleas - treated P: ADD Nebulize 10-15min BID x5d ADD Gabapentin 100mg PO BID TFN DVM recheck URI/hyporexia 6/2 Otherwise CWCT

6/2/2026

Progress exam S: BAR - lying on top of carboard hide in kennel, tense posture, shaking, mydriatic pupils OU, flinches / flattens ears / feigns sleep when approaching for exam - brief exam to limit FAS NATA MMs dt behavior fair to good appetite yesterday no c/s/v/d reported today normal urine voids, soft formed stool yesterday O: BCS 5/9 EENT: enucleated os, moderate mucopurulent nasal discharge, audibly congested Oral Exam: NE dt behavior H/L: Eupneic at distance MSI: Sternal recumbency, ambulation not witnessed CNS: Mentation appropriate - no signs of neurologic abnormalities A: Moderate URI - slight improvement, no frank blood appreciated today Rhinitis r/o 2ary to URI vs other OS enucleated prior Moderate FAS - persists Hyporexia - improving HX Otitis externa - under treatment HX Fleas - treated P: ADD Fortiflora 1pkt PO SID x7d Otherwise CWCT, DVM recheck 6/4 at end of doxycycline course

6/3/2026

Recheck URI, staff report hissing and lunging when attempting to administer medications S/O: QAR, hisses when approached, appetite fair to good, no c/s/v/d noted EENT: Mild mucoserous nasal discharge, no ocular discharge, OS enucleated LUNGS: Eupneic A: URI Enucleated OS Otitis vs ear mites noted at intake Dental disease High FAS P: Discontinue tresaderm Extend doxycycline - okay to put into HV food Start medical feedings BID CTM on rounds, recheck in 4 days

6/7/2026

Recheck URI S/O: QAR, hisses when approached, food dishes and medication dish undisturbed today EENT: Mild mucoserous nasal discharge, no ocular discharge, OS enucleated LUNGS: Eupneic A: URI - improving Anorexia - recurring Enucleated OS Otitis vs ear mites noted at intake Dental disease High FAS P: Monitoring sheet placed DVM cageside recheck 6/9

6/9/2026

Recheck URI, high FAS - unable to medicate directly into mouth BAR, resting in kennel Appetite score 3 reported No recent c/s/v/d reported EENT: No ocular or nasal discharge H/L: Eupneic, normal RR, no audible congestion CNS: Normal mentation A: URI - improving Anorexia - resolved Enucleated OS Dental disease High FAS Plan: Ok to continue medicating in food CTM URI signs

6/12/2026

Progress exam: URI recheck Subjective: BAR, no C/S/V/D. Audibly congested, hard swallow noted. AS:2/3. Already completed 14 days of doxy Objective: EYES: Clear LUNGS: Eupneic, no sign of respiratory distress NASAL CAVITY: Mild mucoid discharge MUSCULOSKELETAL: Ambulatory x4, no lameness or lesions NEURO: Appropriate mentation ASSESSMENT: Presumed URI persists PLAN: Per standing orders -DVM recheck

6/13/2026

Recheck persistent URI signs despite 14 day course of doxycycline (unable to medicate orally, meds have been placed into food). S/O: QAR on shelf, hisses when approached, consistently fair appetite, no c/s/v/d noted EENT: No ocular discharge (OS missing), mild mucoserous nasal discharge LUNGS: Eupneic CNS: Appropriate mentation A: URI - persistent, mild High FAS Dental disease P: Restart fortiflora PO SID x 10 days CTM closely on rounds, recheck in one week

6/20/2026

Progress exam Hx persistent URI signs S/O. BAR on shelf, hisses when approached, consistently good appetite, possible vomit in kennel (only 1 episode observed/reported), c/s/d noted EENT: No ocular discharge (OS missing), mild serous nasal discharge, slightly amount of dry crusted brown d/c OD LUNGS: Eupneic CNS: Appropriate mentation A. URI - resolved High FAS - continued Possible vomit in kennel today Dental disease P: Continue with Fortiflora PO SID x another 7 days to provide immune support Continue with gabapentin BID for high FAS in shelter No additional treatments needed at this time *Recheck in 7 days *CTM on rounds daily

6/27/2026

Recheck persistent URI S/O: QAR on shelf, hisses when approached, appetite scores indicate fair to good appetite consistently, no c/s/v/d noted EENT: OS missing, no ocular discharge; moderate mucoserous nasal discharge LUNGS: Eupneic CNS: Appropriate mentation A: URI - persistent High FAS P: Continue gabapentin and fortiflora Seek placement outside shelter for better chance at recovery

Upon intake Cowboy was taken immediately back to medical due to extreme discolored nasal discharge. Minimal handling done.