5/9/2026

DVM Intake Exam Estimated age: 2-5 y/o based on appearance and dentition Microchip noted on Intake? scan negative History: Stray; presented to off-site hospital for care after suspected fight with another dog. Has been on gabapentin and Clavamox since admitted on 5/7. Subjective: QAR, hydrated; IV catheter in place and dressing around head Observed Behavior - tense, timid during handling and occasional lip licking, suspected painful; allowed all handling. Is there evidence of suspected cruelty? YES Objective: P = 90 bpm R = WNL BCS 4/9 ENT: Eyes clear, no nasal or ocular discharge noted Oral Exam: mild staining of teeth and small tip fractures of incisors; minimal tartar on buccal aspect of teeth PLN: moderately enlarged mandibular LNs, otherwise no obvious enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: no spay scar or tattoo present; female intact MS: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat Integ: dirty malodorous yellow/stained coat. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal EARS/HEAD: Moderate generalized swelling on head; large number of open puncture wounds around heck/neck/ears are open (>20-30 count) extending into SQ tissue, with foul smell and moderate amount of yellow/brown discharge from wounds. AS: multiple open lacerations and puncture wounds (<5mm deep) with dried hemorrhagic discharge on outer pinna, bled when cleaned/disturbed. Pinna however remains intact. Canal is clean with minimal discharge. AD: Significant severe, deep full thickness wounds (up to 1.5 cm deep) at the base of the pinna, splitting pinna in two. 3x4cm long loose fragment of cartilage present at base (see photos on vet docs). Moderate amount of thick yellow/brown discharge in canal. Assessment: Severe, infected wounds on head/neck and ears Severe injury of AD pinna Numerous open punctures, too numerous to count on head and ears - *Wounds are consistent with dog bites, injury and wounds are ~4-5 days old. Prognosis: Guarded to Fair Plan: Ok for intake tasks Sedate for cleaning, flushing +/- debridement. IV catheter replaced today (prior to sedation P was seen biting and pulling out her catheter) SURGERY: Temporary waiver until infection/wounds improve

5/10/2026

Administered IM for sedation: -Dexmedetomidine 0.01mg/kg -Methadone 0.2mg/kg -Ketamine 1mg/kg Elected to anesthetize due to extensiveness of wounds. Induced with propofol TTE and maintained on isoflurane inhalant. Cleaned and flushed all wounds with copious about of sterile saline using 3-way tap. Clipped coat around wounds, dried coat well. Placed medical grade honey into wounds. Then placed non-adhesive dressing over wounds and placed bandage over head, including R pinna. L pinna remains visible. P recovered smoothly, but marked drooling present once ambulatory. Administered Cerenia 1mg/kg 2.27ml IV slow. PLAN: Keep IV catheter in place House in ICU Started at 4pm, continue: -Unasyn 15mg/kg (11ml, 30mg/ml) IV q8-12h - SLOW over 30 minutes -Enrofloxacin 10mg/kg (2.27ml, 100mg/ml) SQ or IV q24h -Carprofen 4.4mg/kg (2ml, 50mg/ml) SQ q24h -Gabapentin 600mg (27mg/kg) PO q12h for added analgesia and mild sedation *Continue with injectable antibiotics until pinnectomy, then switch to orals when eating. *Brief appetite and comfort check tomorrow *Sedate, flush/clean and replace dressing on 5/11 *Schedule pinnectomy for 5/12

5/10/2026

[Spay/Neuter Waiver - Temporary] Your newly adopted pet has been diagnosed with WOUNDS 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.

5/10/2026

Progress exam - wounds S: QARH - cautious initially - hesitant and whale eye once but warmed up during exam quickly - loose tail wags and soliciting attention, loves treats and chicken. Sits politely for treats. pink moist mm, CRT <2s great appetite no c/s/v/d reported O: BCS 4/9 EENT: Eyes clear, no nasal or ocular discharge noted. Head bandage in place encompassing AD - no strikethrough, no pain on light palpation. AS - visible wounds as prior with no overt discharge @tt Oral Exam: mild staining of teeth and small tip fractures of incisors; minimal tartar on buccal aspect of teeth PLN: moderately enlarged mandibular LNs, otherwise no obvious enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, vulva clean, no palpable MGTs MS: Ambulatory x 4, no masses noted INT: dirty malodorous yellow/stained coat. Large number of open puncture wounds around heck/neck/ears as prior. Superficial laceration to LF carpal pad with no discharge @tt. Multifocal superficial wounds on distal limbs. No ectoparasites appreciated. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal A: HX Severe, infected wounds on head/neck/limbs TNTC HX Severe injury of AD pinna - bandage in place FI mature adult medium mixed breed canine P: P cleaned with waterless shampoo CWCP - continue injectables until eating post surgery, continue daily rechecks for analgesia IVC replaced on 5/9 - day 4 is on 5/13 (consider replacement vs extend vs remove) IH AD pinnectomy surgery scheduled 5/12

5/10/2026

IV catheter check - flushing ok and patent? // completed - patent and flushing ok

5/11/2026

Progress exam - wounds S/O: BARH - IVC not patent and P very resistant to IM/SQ medications (scream, flail). Whale eye after attempting but took peanut butter and calmed down quickly, then was soliciting attention. Elected to sedate to replace IVC, remove bandage, flush wounds, and re bandage pale pink moist mm Great appetite this AM No c/s/v/d reported CBC/biochem IH due to repeated sedation in short time and due to pale appearance of MMs A/P: Administered IM for sedation: -Dexmedetomidine 0.5mL -Butorphanol 0.5mL -Ketamine 0.5mL Moderate sedation achieved - P still reactive to touching of wounds once bandage removed - topical 2% lidocaine (~1mL total) was applied to wounds, slight improvement in reaction /analgesia Cleaned AD canal with dry gauze. Most of AD wounds had mild mucopurulent discharge (mixed in with medihoney) with scant frank blood. Some granulation tissue present but edges of aspect of major wound at caudal aspect of AD pinna appeared slightly necrotic at edges. Auricular cartilage visible multifocally. Cleaned and flushed all wounds copiously with sterile saline using 18g catheter tip. Dried area well. Placed medical grade honey into wounds. Then placed non-adhesive dressing / 3 layer bandage over wounds, including R pinna. L pinna remains visible. P reversed with 0.5mL antisedan IM and was observed closely until sternal IVC replaced today - 4th day will be 5/15 ADD Trazodone 175mg (~7.5mg/kg) PO BID TFN Otherwise CWCP - injectable antibiotics until pinnectomy, then switch to orals when eating. Brief appetite and comfort check tomorrow AD Pinnectomy scheduled for 5/12

5/11/2026

Bloodwork Interpretation CBC- Mild non-regenerative anemia (Hct 28% L, Hemoglob 9L, RBC 4.35L, MCH 20.7L, RDW 13.3L) r/o pre regenerative vs increased consumption vs decreased production vs increased destruction Mild monocytosis (1.65H) r/o infectious vs inflammatory Mildf thrombocytosis (615H) r/o stress re splenic contraction vs other Biochemistry - WNL Discussed case (wounds and anemia) w 1657 will assess wounds intra op for surgical planning tomorrow 5/12

5/11/2026

New IVC placed in LFL

5/12/2026

On 5/12/2026 at approximately 9:15 AM, Rain was examined. The patient has appropriate mentation at this time (no neurological signs present) and has not exhibited any neurological signs while at MACC. Hx: on DOH-V rabies observation QAR H eent- no nasal and no ocular discharge; head bandage in place hl- clear and eupneic msi- ambulatory x 4; bcs- 5/9 neuro- no apparent deficits A) no apparent neuropathy present wound to right ear P) consider pinna surgery continue observation

5/12/2026

Right Sided Ear Repair Surgery: at base of lateral ear, fleshy protuberance was freshened and folded ventrally like skin pedicle and secured with 2-0 nylon in SI on the caudal pinna, a tear was reduced using 2-0 PDS SI through and through sutures post-op head bandage placed change head dressing in 3-5 d's SR in 10-14 d's

5/12/2026

ADD Buprenorphine 1.5mL (0.02mg/kg) IV or IM BID --> 5/15 For multimodal analgesia post operatively

5/13/2026

Recheck - surgery to repair wounds to pinna yesterday S/O: QAR, good appetite, ate carprofen in HV treat, no c/s/v/d noted EENT: No ocular or nasal discharge, bandage in place around head and covering AU LUNGS: Eupneic CNS: Appropriate mentation A: Wounds AD P: Continue enro, unasyn, carprofen, gabapentin, buprenorphine, and trazodone *Made note to offer carprofen PO tomorrow instead of SQ CTM closely on rounds, recheck as scheduled

5/15/2026

Recheck - sedated for bandage removal/wound assessment. Dex/torb 0.5 ml each IM. S/O: (prior to sedation) BAR, no c/s/v/d noted; eating meds well in HV foods WOUNDS AD: sutures intact, skin apposed and wounds healing, significantly thickened pinna, heavy dark black/brown discharge in canal AD without notable inflammation WOUNDS AS: scabbed and healing, moderate brown discharge in canal -Cleaned ears while sedated -Scrubbed around wounds with dilute chlorhex and flushed with sterile saline -Leave bandage off at this time, removed IV catheter PLAN: Full atipamezole reversal, smooth recovery Switch to oral carprofen 4.4 mg/kg SID Switch to oral enrofloxacin 10 mg/kg PO SID Continue gabapentin and trazodone Keep e-collar on, recheck in 3-4 days CTM while at QACC

5/18/2026

Recheck AD post op Eating well, no v/d reported, e-collar on BAR, seeking attention and treats, allows handling AD surgical site c/d/i, sutures in place, mildly erythematous with marked thickening of pinna, mild dark brown debris from external ear canal Plan: Continue medications as previously prescribed CTM surgical site Recheck AD in 3-4 days, consider moving out of ICU if continuing to heal well

5/20/2026

On 05/20/2026 Rain was examined. The patient has appropriate mentation at this time (no neurological signs present) and has not exhibited any neurological signs while at QACC.

5/22/2026

DVM Progress Exam History: Recheck AD, 10 days post-surgical repair on 5/12 S/O: -P is BAR-H; no C/S/V/D -No E-collar on -Allows handling for examination of surgical site: C/D/I, healing well, sutures in place, some loosening; scant erythema, moderate thickening of pinna, mild dark brown debris in external ear canal Plan: -Recheck AD in 3-4 days for suture removal (if DVM approved) and gentle cleaning of external ear canal -Consider moving out of ICU

5/26/2026

Recheck ear wounds and suture removal S/O: BAR, good appetite, no c/s/v/d noted; soft muzzle placed as precaution - ate HV food while removing sutures, no escalation EENT: No ocular or nasal discharge; AD pinna wounds healed with significantly thickened pinnae at level of wounds; moderate dark brown/black discharge in canal without notable inflammation LUNGS: Eupneic MSI: Ambulatory x 4 A: Wounds to pinna AD - healed with thickened pinna Discharge AD - ro discharge from wound > otitis P: Okay to move out of ICU, continue gabapentin Start clonidine 0.03 mg/kg PO BID for dog reactivity reported by staff Continue trazodone, increase to 9 mg/kg PO BID. CTM while at QACC

6/11/2026

Behavior staff requesting behavior modification medication due to persistent signs of FAS (jumping on handler persistently). P on trazodone and clonidine PO BID (note - P has gained ~5lbs since intake, increasing doses accordingly). INCREASE Trazodone 250mg (~10mg/kg) PO BID TFN INCREASE Clonidine 1.2mg (~0.047mg/kg) PO BID TFN

6/24/2026

Pre-Op Exam S/O: BAR, no c/s/v/d noted EENT: No ocular or nasal discharge noted Lungs: Eupneic, normal respiratory rate/effort ABD: No obvious distention MSI: Ambulatory x 4, no notable lameness CNS: Mentation appropriate A: Appears to be suitable candidate for anesthesia, ASA status I P: Accepted for surgery - spay/neuter today Was this dog in heat, pregnant or have a pyometra? no Ventral Midline Incision Ovaries Ligated with: 0-0 PDS two circumferential ligatures Uterine Body Ligated with: 0-0 PDS two circumferential ligatures Abdominal Closure: 0-0 PDS simple continuous pattern Skin closure: 0-0 PDS intradermal pattern Green Linear Tattoo Placed near Midline Surgeon: 990665 Additional Comments:

6/25/2026

Post Surgical Exam Attitude/demeanor: QAR 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: NOT EATING POST OP MEDS. 992299