9/14/2025

[DVM Intake] DVM Intake Exam Estimated age: ~ 3 year Microchip noted on Intake? Scanned negative History: Agency Subjective: BAR Observed Behavior - Very sweet and friendly, food motivated, gives kisses, exam and tasks well tolerated. Is there evidence of Cruelty? No Is there evidence of Neglect? No Is there evidence of Trauma? YES Objective P = 124 R = Panting BCS = 5/9 EENT: Eyes clear, ears- clean AD, mild brown waxy debris and erythema AS, no nasal or ocular discharge noted Oral Exam: Mild diffuse tartar, pink mm PLN: No enlargements noted H/L: Grade 4/6 Systolic Murmur. NSR, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: Intact male. Left testis descended, Right testis inguinal. MSI: Ambulatory x 4. Weight-bearing lameness x4. Palpable SQ emphysema L axilla and R cranial shoulder. skin free of parasites, no masses noted. Multiple small superficial wounds/scabs (R facial, R carpus) CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Externally normal Assessment Lameness - TR Lameness Left Front - TR Lameness Left Hind - TR Lameness Right Front - TR Lameness Right Hind - TR Wounds (Superficial) - TR Cryptorchid - TR Dental Disease - TR Otitis Externa AS - TR Heart Murmur - No Clinical Disease - TM Prognosis: Fair Plan: Intake exam and tasks Carprofen - 4.0mg/kg SQ @ 12:30pm Simplera/Claro AS Gabapentin 300mg- 1 cap PO q 8-12hr CBC/Chem/4DX- (in-house)- Mild neutrophilia, consistent w/ inflammation, otherwise insignificant. 4DX- negative x4 Recommend follow up with sedated radiographs SURGERY: Permanent waiver due to heart murmur

9/14/2025

Spay/Neuter Waiver - Permanent Your newly adopted pet has been diagnosed with a heart murmur of 4/6 and the staff veterinarians are issuing a PERMANENT waiver from the spay/neuter requirements of the City of NY. ACC does not have the facility to safely sterilize your pet with his/her current condition. However, your veterinarian will provide consultation on whether this procedure can or should be performed under their supervision. Follow up care at your regular veterinarian is recommended to ensure continued treatment and proper oversight of your pet's health. All costs for follow up care and subsequent surgery is at the expense of the adopter.

9/15/2025

recheck, lameness noted to the RHL and RFL on intake, possible shifting leg lameness, grade 4 HM, needs rads. S/O BAR, A+A, solicits pets, no c/s/v/d appreciated, excellent appetite EENT: non ocular or nasal dc, mm pm <2 HL: 5-6/6 holosystolic HM, clear, eupneic MSI: amb x 4, p walks with the RHL stiff but able to bend at the stifle when manipulated, appears to be lame on the RFL as well. No pain or swelling appreciated upon palpation of 4x limbs and hips. Rads- note: elected to not sedate p d/t to severity of heart murmur along with breed. Rads taken to r/o any fractures or issues that would warrant immediate care such as fractures Cardiomegaly, appearance of enlarged RA and LV, possible enlargement of great vessels, no signs of pulmonary involvement Ortho rads: no obvious fx's or abn A. -No underlying cause found for p lameness, r/o old injury vs soft tissue versus open. As noted, underlying fx could be present but cannot safely sedate in shelter d/t cardiac disease -HM, auscultates to ~ 5-6/6 and cardiomegaly P. -Okay to leave ICU for adopts with signage that says medical is aware and short walks only -Con't with gaba as written -Seek placement asap - p have significant heart murmur and lameness. Should be seen by full service vet hospital for further work up -recheck in 4 days to ensure doing well

9/18/2025

recheck pup with lameness and HM S/O BAR, A+A, takes treats, no c/s/v/d appreciated EENT: no ocular or nasal dc, mm pm <2 HL: 5/6 holosystolic HM, stertorous breathing making it difficult to properly auscultate, eupneic MSI: amb x 4, good skin turgor, lameness to the LHL most notably, no pain or swelling upon palpation A. Unilateral crypt HM approx 5/6 shifting leg lameness, most notable to the LHL r/o old injury or conformation BOAS - stertorous breathing- assumed elongated soft palate, mildly stenotic nares P. CTM- p BAR and stable aTT, seek placement asap as p has multiple comorbidities and would be at risk for complications if developed respiratory illness in shelter Recheck in 1 week

Upon intake dog was very friendly and outgoing. Staff was easily able to scan for MC, pet, leash and walk down the halls to pre-exam where he entered the kennel with no complications.