6/9/2026

[DVM Intake] DVM Intake Exam Estimated age: 3yrs based on dentition Microchip noted on intake? scans negative History: Stray reported to be dragging hind leg Subjective: QAR, prefers to be recumbent on left side but can stand up and walk a few steps on his own. Observed Behavior - calm, tolerated all tasks and handling, purring and leaning in for pets Is there evidence of suspected cruelty? no Objective: T = 103.6 P = 210 R = 24 BCS 6/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Adult dentition with mild staining, palate intact PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: tenses on abdominal palpation, no masses palpated U/G: MI; 2 testicles descended MSI: motor x 4 and can stand and walk around on his own but is mostly recumbent and laying on his left side, there is a small wound on the medial aspect of the LHL at the mid-tibia approx. 2mm diameter, flea dirt present, no masses noted, dirty hair coat CNS: Mentation quiet but appropriate - ataxic in hind legs but has motor in all 4 limbs. Prefers to be recumbent on his left side. Normal cranial nerves. Decreased tail tone. Rectal: externally normal with normal anal tone Wood's Lamp Exam: not performed Assessment: Approx. 3yr MI DSH Ataxia in hind limbs with motor x 4 (r/o trauma (fractures vs spinal injury) vs neuro vs congenital) Decreased tail tone (R/o trauma to sacrum/caudal vertebrae and nerves) Small wound medial LHL Dirty haircoat Hyperthermic (r/o febrile (infectious vs inflammatory) vs pain vs stress vs hot ambient temperatures) Prognosis: fair pending further diagnostics Plan: cbc/chem in-house (x) neutrophilia, lymphopenia, eosinopenia, mildly elevated ALT (146) Radiographs (x) right coxofemoral luxation, left ischium transverse fx, sacral-caudal luxation SQ fluids 20ml/kg (x) convenia 8mg/kg sq (x) Clean wound LHL (x) Onsior 1mg/kg SQ (x) Buprenorphine 0.01mg/kg IM (x) Expedite lost and found search Place in ICU; consider emergent placement for treatment of fractures/hip luxation with 24hr deadline vs EHR if pain cannot be adequately managed in the interim or signs of incontinence emerge DVM recheck tomorrow + continue buprenorphine q8hrs vs switch to zorbium SURGERY: Temporary waiver due to traumatic injuries

6/9/2026

Your newly adopted pet has been diagnosed with a fracture 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.

6/9/2026

Radiopgraphs: right coxofemoral luxation left ischium transverse fx sacral-caudal luxation

6/10/2026

Recheck lameness S/O: QAR, laying on right side and then in loaf, not eating, no c/s/v/d noted EENT: No ocular or nasal discharge ORAL: mm pink and mildly tacky, mild-mod staining and gingivitis LUNGS: Eupneic MSI: Diffusely dirty haircoat, ambulatory x 4 (reluctant to walk, but when brought out of kennel he is able to walk x 4 and step back into kennel); creptius and abnormality in ROM of right coxofemoral joint, painful during exam even under sedation; tense and reactive to palpation of LHL but no notable abnormalities palpated; small full thickness wound at medial aspect of left tarsus with no discharge CNS: Appropriate mentation Sedated to repeat rads for better views (dex/torb 0.12 ml IM of each, full antisedan reversal, smooth recovery): no pelvic fracture noted, right coxofemoral luxation (craniodorsal displacement) A: Right coxofemoral luxation - suspect trauma Anorexia Small wound LHL Obese Mild-mod ddz Mild ALT elevation - ro trauma vs other P: Start SQ LRS 150 ml SID Start cerenia 1 mg/kg SQ SID Start mirataz SID Start medical feedings BID Cancel buprenorphine tonight and instead apply zorbium tonight Monitor ambulation closely - obese cat, may need limb amputation but will need to be able to walk on one HL

6/11/2026

Recheck lameness S/O: QAR, laying on right side and then in loaf, fair appetite for wet food, rolling / soliciting attention, no c/s/v/d noted EENT: No ocular or nasal discharge ORAL: Mild-mod staining and gingivitis LUNGS: Eupneic MSI: Diffusely dirty haircoat, ambulatory x 4 (reluctant to walk, but when brought out of kennel he is able to walk x 4 and step back into kennel), did not palpate hips due to prior pain CNS: Appropriate mentation A: Right coxofemoral luxation - suspect trauma Anorexia - improving Small wound LHL Obese Mild-mod ddz Mild ALT elevation - ro trauma vs other No defecation since admit r/o 2ary to anorexia vs 2ary to not being able to posture vs early constipation vs other P: CWCP DVM recheck hyporexia / defecation / pain 6/12 Monitor ambulation closely - obese cat, may need FHO as salvage procedure if unable to perform lux reduction (susp will be unable due to chronicity) but will need to be able to walk on one HL Consider ARL at end of stray hold due to P needing an orthopedic consult and surgical intervention that is not an option in shelter

6/12/2026

Recheck exam S/O: QAR, timid, but leans into petting, growls while changing position once; wet food dish smashed but appears partially eaten, no c/s/v/d noted, no defecation noted or reported on log EENT: No ocular or nasal discharge LUNGS: Eupneic MSI: Difficult to assess ambulation due to FAS/size - but able to bear weight x 4 and climb back into kennel (moves very quickly and returns to laying immediately), observed laying on right and left side in kennel today (left more often); haircoat diffusely dirty, wound at medial LHL healing A: Right coxofemoral luxation Anorexia improved, ro hyporexia Obese Small wound LHL Dental disease Mild ALT elevation No defecation since intake P: Start gabapentin 100 mg PO BID for pain and FAS Continue medical feedings, SQF, cerenia Monitor closely on rounds for defecation

6/13/2026

Recheck right hip lux, obesity S/O: QAR-BAR, headbutts and leans into petting, but dilated pupils and head whipping during exam; great appetite overnight, no c/s/v/d noted, no defecation noted EENT: No ocular or nasal discharge LUNGS: Eupneic ABD: Difficult to assess due to obesity, no obvious constipation/obstipation appreciated MSI: Ambulatory x 4 - difficult to assess lameness due to FAS. Flees quickly back to kennel or attempts to flee under cages. Lays in litterbox in left and right recumbency all day. Obese. A: No defecation since intake - ro initially decreased appetite vs uncomfortable posturing vs other Right coxofemoral luxation Obese Small wound LHL Dental disease Mild ALT elevation P: Monitor closely for defecation now that appetite is stable Consider miralax vs lactulose if not defecating Seek placement for further orthopedic options

6/14/2026

S: BAR in kennel, sleeping in litterbox, purring and rolling over for attention. Eating well. One small piece of firm, dry stool (~1cm x 3cm) present in box. O: EENT: Clear/bright, no ocular/nasal discharge/sneezing/coughing observed ABD: Difficult to palpate due to BCS, but appears comfortable and does not have large amount of stool obviously present MSI: Able to stand and ambulate x4; full orthopedic exam not performed Rectal: Anal tone present, but anus is dilated with piece of stool stuck--allowed rectal exam (moderate hard stool present) and tolerated manual removal of 4 small pieces of stool (~1cm x2cm each) A: Right coxofemoral luxation History of pelvic fractures Constipation- r/o secondary to opioids vs dehydration vs inability to posture due to pain vs combination of the above vs other P: Gave 100ml LRS SQ once Start lactulose 1ml PO BID x 3 days (consider indefinite if working or increasing dose +/- adding miralax if not) Continue monitoring and indefinite gabapentin

Upon intake, Ginger Spice was meowing and docile. He didn't move much and allowed all handling.