4/10/2025

DVM Intake Exam Estimated age: approx 1-3 years based on dentition and conformation Microchip noted on Intake? scanned negative History: o surrender Subjective: QAR Observed Behavior - timid, tried to flee, allowed for handling and tasks Is there evidence of Cruelty? N Is there evidence of Neglect? N Is there evidence of Trauma? N Objective T = np P = wnl R = wnl BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: clean adult dentition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: MI, two scrotal testes MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment APH Prognosis: good Plan: intake exam and tasks awaiting sort SURGERY: Okay for surgery: Y

4/11/2025

Pre-surgical exam, anesthesia, and surgery performed by offsite vet. Medical record uploaded to Vet Documents. Green linear tattoo placed lateral to incision.

4/13/2025

[Post Surgical Exam] Attitude/demeanor: [BAR] Appetite: [eating well] C/S/V/D: [none] Incision site: [no swelling, bruising, or bleeding; sutures appear intact] Pain level: [appears comfortable] Licking, chewing, or biting surgical site noted: [no] Additional notes: [add any unusual notes here and notify VET or LVT if concerns present]

4/16/2025

Start gabapentin 100 mg PO BID for FAS in shelter

4/22/2025

Progress exam: Sneezing reported on rounds board Subjective: QBAR, no C/S/V/D. Poor appetite noted Objective: EYES: Clear, no discharge LUNGS: Eupneic, no sign of respiratory distress NASAL CAVITY: mild clear serous discharge MUSCULOSKELETAL: Ambulatory x4, no lameness or lesions NEURO: Appropriate mentation ASSESSMENT: Presumed URI PLAN: Per standing orders -Under the weather, ppe sign & monitor log placed on kennel -Start doxy 50mg/ml PO q24h x10days & medical feedings PO q12h x5days -CTM, recheck in 3 days

4/26/2025

PROGRESS EXAM - URI S/O: QAR; food trays left untouched from this AM, did not eat yesterday. Moderate nasal discharge and serous/mucoid ocular discharge. A: URI - moderate Anorexia P: Continue: doxycycline 10 mg/kg PO SID x 10 days Start following: -SQ LRS 100 ml SID x 3 days -Cerenia 1 mg/kg SQ SID x 3 days -Daily topical mirataz x 3 days *CTM closely on rounds and recheck again in 2 days

4/28/2025

recheck URI, reportedly not eating S/O QAR, food trays untouched, no c/v/d, S+ EENT: moderate thin mucoid ocular dc, moderate thick mucoserous nasal dc bilat HL: eupneic, RUAS MSI: amb x 4 A. URI with hyporexia r/o anorexia P. Move to med-iso for closer monitoring d/c doxy, start enro 5mg/kg SID IM x 5 days Com't with fluids, cerenia, and mirataz- extended thru 4/30 recheck 4/30

4/29/2025

Progress exam: CIRDC day 7 recheck Subjective: QBAR, no C/S/V/D. Congestion noted. Poor appetite untouched food in bowls. Objective: EYES: Clear, no discharge LUNGS: Eupneic, no sign of respiratory distress NASAL CAVITY: crusted discharge MUSCULOSKELETAL: Ambulatory x4, no lameness or lesions NEURO: Appropriate mentation ASSESSMENT: Presumed URI PLAN: Per standing orders -CTM

4/30/2025

Discontinuing gabapentin at this time due to anorexia secondary to URI.

4/30/2025

Recheck URI and anorexia, reweighed today - lost nearly 3 pounds in 20 days S/O: QAR, not eating, multiple untouched food dishes No c/s/v/d noted, congestion audible EENT: No active nasal discharge; OD moderate blepharospasm and mucoid discharge, OS mild blepharospasm and mucoid discharge LUNGS: Eupneic CNS: Appropriate mentation A: Prolonged anorexia URI + conjunctivitis Severe, rapid weight loss P: Reweigh today Extend SQ LRS, cerenia, mirataz, medical feeding (adjusted doses for updated weight) Start entyce 2 mg/kg PO SID x 3 days Start ofloxacin OU BID x 7 days Seek placement ASAP for hospitalization and e-tube placement Recheck daily, continue to house in med iso

5/1/2025

recheck URI with anorexia S/O QAR, in the den, old wet food tray is 3/4 empty, when open den door, p comes to the front and starts to eat the new wet food tray, no c/s/v/d appreciated EENT: moderate epiphora OU, moderate thin bilat mucoserous nasal dc HL: eupneic, audible congestion MSI: amb x 4, good skin turgor A. URI Anorexia appears improved aTT P. Add in nebulization SID x 3 days Decrease enro to match current weight and extend 3 days (0.14mL) recheck tomorrow, con't other treatments as written

5/2/2025

Brief recheck - QAR, ate well overnight! no c/s/v/d noted, no active nasal discharge, mild serous ocular discharge OU, eupneic. Plan: Continue current treatment plan and CTM on rounds, recheck URI/appetite in 2-3 days