11/2/2025

Subjective: DVM Intake Exam Name: Puff Animal ID: 240728 Species: Dog Estimated age: 15+ years Microchip noted on Intake? Negative History: Agency intake. BAR MM pink, moist, CRT <2 sec Observed Behavior - Green; Easily examined, took treats readily, relaxed, seeking human attention and affection Evidence of Cruelty seen - No Evidence of Trauma seen – No Evidence of Neglect- Yes Objective: P = 110 bpm R = 32 rpm BCS 3/9 Wt = 14.4 lbs EENT: Significant matted fur with yellow-green discharge is present over the left eye, obstructing a full examination. The right eye has significant yellow-green discharge, scleral injection, chemosis, and conjunctivitis. The right cornea appears cloudy, and the pupil is difficult to visualize, with suspected anterior uveitis. After cleaning, the left eye appears similar to the right but with less pronounced corneal cloudiness. The patient appears to be blind. Lenticular sclerosis is noted. Oral Exam: Severe, grade 4/4 periodontal disease is present with significant halitosis, tartar, gingivitis, missing teeth, and gingival recession with suspected exposed bone. PLN: No enlargements noted H/L: NSR, Grade 1-2/6 systolic heart murmur appreciated. Heart sounds are faint. Lungs clear, eupneic. ABD: Abdomen has a pot-bellied appearance. Palpation elicited a retch and hack. Suspect cranial organomegaly (hepatosplenomegaly). U/G: MI (2 testicles descended) MSI: Ambulatory x 4, but appears weak and wobbly in the hind limbs. There is generalized, significant muscle atrophy, most pronounced over the lumbar spine, pelvis, and hindlimbs. Bilateral grade 2/4 medial patellar luxations are present. Nails are overgrown. CNS: Mentation appropriate. Patient presents as blind. Delayed conscious proprioception is noted in both hindlimbs. Assessment: Geriatric with suspect chronic conditions. *ASSESSMENT, INCLUDING PROBLEM LIST WITH DIFFERENTIALS*: - *Severe bilateral ocular disease*: Differentials include keratoconjunctivitis sicca (KCS), uveitis, glaucoma, corneal ulceration, and secondary bacterial infection. Blindness is likely secondary to chronic ocular pathology. - *Severe (Grade 4/4) periodontal disease*: With significant gingival recession and suspected osteomyelitis. - *Grade 1-2/6 heart murmur*: Differentials include chronic valvular disease such as myxomatous mitral valve disease. - *Underweight (BCS 3/9) with generalized muscle atrophy*: Differentials include chronic disease (renal, cardiac, hepatic, neoplasia), malabsorption/maldigestion, metabolic disease (e.g., hyperadrenocorticism), or inadequate caloric intake. - *Pot-bellied appearance with suspect organomegaly*: Differentials include hepatosplenomegaly, ascites, or hyperadrenocorticism. - *Hindlimb weakness/ataxia with delayed CP deficits*: Differentials include intervertebral disc disease (IVDD), degenerative myelopathy, severe arthritis, or lumbosacral disease. - *Bilateral medial patellar luxation (Grade 2/4)*: Congenital/developmental condition. *NEW DIAGNOSTIC INFORMATION*: - *CBC*: Mild normocytic, normochromic, non-regenerative anemia (HCT 32.1%). Thrombocytosis noted. - *Chemistry Panel*: SDMA is mildly elevated at 15. T4 is within normal limits. All other values are within normal limits. *REVISED ASSESSMENT WITH DIAGNOSTICS*: - *Early Chronic Kidney Disease*: Suspected based on mildly elevated SDMA. - *Anemia of Chronic Disease*: Mild anemia is likely secondary to multiple chronic inflammatory conditions. - *Reactive Thrombocytosis*: Elevated platelet count may be secondary to inflammation. - Other assessments remain unchanged. The cause of neurologic deficits, pot-belly, and muscle wasting requires further investigation. *CONFIRMED DIAGNOSES*: - *Grade 4/4 Periodontal Disease* - *Bilateral Medial Patellar Luxation (Grade 2/4)* *UNCERTAIN DIAGNOSES*: - *Early Chronic Kidney Disease* - *Myxomatous Mitral Valve Disease* - *Keratoconjunctivitis Sicca* - *Uveitis* Prognosis: Guarded Plan: Standard Intake Procedures: Rabies vaccine (performed earlier today) DA2PP vaccine (performed earlier today) Bordetella vaccine (performed earlier today) Heartworm SNAP Pyrantel deworm Frontline Plus Microchip *DIAGNOSTICS*: - *In-house bloodwork (CBC, Chemistry, SDMA, T4)*: Performed. - *Urinalysis*: Deferred. Sample was collected and subsequently discarded. *TREATMENTS AND PROCEDURES*: - *Ocular Cleaning*: Gently soaked and removed matted fur and discharge from around both eyes using ophthalmic wash. - *Grooming*: Trimmed hair away from eyes and paws, including interdigital hair, to improve comfort and traction. - *Nail Trim*: Performed. *MEDICATIONS DISPENSED*: - *Gabapentin (100 mg/mL oral suspension)*: Give 0.7 mL (70 mg, ~10.8 mg/kg) PO BID indefinitely for pain management. First dose administered. - *Ofloxacin ophthalmic solution*: Instill 1 drop in both eyes (OU) BID for 7 days. First dose administered.

11/3/2025

recheck geriatric dog with multiple comorbidities S/O EENT: OD: mild exophthalmic, episceral injection and mucoid dc, OS mild mucoserous dc, no nasal dc HL: eupneic MSI: amb x 4, weakness in the hind end, muscle wasting, good skin turgor A. Geriatric Conjunctivitis r/o KCS vs allergic Muscle wasting, weak hindend- noted MLP on intake bilat P. Con'twith gaba and genta seek placement recheck in 5 days, if no improvement in eyes, consider adding in optimmune

11/5/2025

Recheck exam - has been noted on boards to have difficulty walking (known condition from intake) Patient is BAR, wags tail when interacting. Unable to obtain reliable menace response OU. ~grade 1-2/6 HM noted, PMI on left. No elicitable pain on spinal palpation, but moderately muscle wasted on epaxials. Ambulatory but paraparetic with significant muscle atrophy over hindlimbs. Suspect proprioceptive ataxia - CPs delayed to absent on LH, delayed but present on RH. A. Geriatric dog with suspect chronic conditions - Paraparesis/ataxia r/o IVDD vs orthopedic - bilateral MPLs - blind with bilateral ocular disease r/o KCS vs glaucoma vs other - light heart murmur (grade I-II/IV) r/o cardiac disease vs physiologic - Generalized muscle atrophy - Possible early CKD (SDMA 15) P. *Not flagging as cruelty* Recommend placing in EPL - patient is stressed in kennel, has trouble ambulating, needs management of various chronic diseases Seek NH ASAP Continue gabapentin indefinitely Recheck QOL and comfort in 2 days

11/7/2025

recheck exam, geriatric, mobility issues S/O BAR, walked into medical, difficulty ambulating with the hind legs, moderate mucoid dc OU, negative menace response, takes treats readily and wagging tail, CP appears delayed in the hind end but difficult to assess as patient starts to kick when leg lifted. A. Paraparesis/ataxia blind, suspect KCS HM MPL bilat P. Start optimmune BID indef Seek placement asap Recheck as scheduled