2/10/2018

DVM Intake Exam Estimated age: adult, ~ 3-5 yrs Microchip noted on Intake? scan negative Microchip Number (If Applicable): 981020023037279 History: stray Subjective: Quiet, alert, mod dehydrated Observed Behavior - friendly, allowed all handling Evidence of Cruelty seen - no Evidence of Trauma seen - yes Objective P = 300 R = 15 BCS 2/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: nsf PLN: No enlargements noted H/L: tachycardic, poss arrhythmia, CRT < 2; Lungs clear, eupnic ABD: soft, non-painful, no masses palpated U/G: intact male MSI: Ambulatory x 4, skin free of parasites, scabbing healing neck wound/scar on ventral half of neck covered by matted hair, no parasites CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal Assessment: emaciated BCS, healing neck wound, dehydrated r/o underlying metabolic disorder, malnutrition, vs other Prognosis: open Plan: IV LRS 8 ml/hr x 24 hrs + recheck + CBC/Chem/UA/T4 + recheck neck wound +/- neuter at time of sedation SURGERY: Temporary waiver due to health

2/10/2018

[Spay/Neuter Waiver - Medical Condition] Your newly adopted pet has been diagnosed with a wound, emaciation, and dehydration and the staff veterinarians are issuing a temporary waiver from the spay requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.

2/11/2018

s/o: BAR, ate and drank, affectionate, comfortable BSC: 3.5/9 MSK: can palpate a suspected foreign body around neck H: 216 R: WNL CRT <2, MMB pink tachy Skin tent normal A: Suspected embedded foreign body around neck (e.g. elastic band) Plan: Shave area and take radiographs of neck

2/11/2018

Neck Rads - moderate thin hyperopaque band around neck likely secondary to scarring Abdominal rads - reduced peritoneal details in the cranial dorsal abdomen likely secondary to loss of fat (i.e. emaciation) Assessment: Thickened band around skin of neck secondary to scarring Plan: 0.3 cc Convenia SQ Monitor and recheck in 3 days

2/11/2018

Elevated HCT - likely secondary to dehydration Otherwise unremarkable

2/11/2018

S/O: Examined lesion around neck while sedated. No foreign body could be observed or palpated. Thickened area around neck likely secondary to scarring due to something being wrapped around the neck for a long period at this time (e.g. rubber band, rope, collar, etc). 1 cm wide Band of skin around neck is non painful, mildly inflammed, with no evidence of infection, 4 mm thickened fibrous/scar tissue Neck Rads - moderate thin hyperopaque band around neck likely secondary to scarring Abdominal rads - reduced peritoneal details in the cranial dorsal abdomen likely secondary to loss of fat (i.e. emaciation) Assessment: Thickened band around skin of neck secondary to scarring Plan: 0.3 cc Convenia SQ Monitor and recheck in 3 days Temporary waiver for 3 days due due replenish hydration status and body condition. Will be eligible for surgery after February 14th,2018.

2/12/2018

S/O: BAR, no c/s/v/d, normal U/BM, reported to be eating and drinking normally, friendly and allows for medical handling. CRT < 2 sec, MM pink and moist, mild skin turgor delay EENT: No URI sigsn, no ocular or nasal discharge. Integ: 1 cm wide band of skin around neck is non painful with no evidence of infection, 4 mm thickened fibrous/scar tissue. Thickened area around neck likely secondary to scarring due to something being wrapped around the neck for a long period at this time (e.g. rubber band, rope, collar, etc). Assessment: Thickened band around skin of neck secondary to scarring Thin BCS mild dehydration Plan: CTM in medical on IVF LRS @ 8ml/hr Recheck hydration status tomorrow 2/13, if euhydrated can pull IVC and move to adoptions Temporary waiver due to replenish hydration status and body condition. Will be eligible for surgery after February 14th,2018.

2/14/2018

Presented with old strangulating wound along ventral neck but no obvious foreign body present any longer; given convenia and started on IVF at 8 ml/hr, noted mild nasal abrasion yesterday so was moved to medical isolation but no notes entered S/O -QAR, docile and friendly, allows gentle handling -mild appetite -mm pk, moist; mild hypersalivation -superficial active nasal abrasion forming -mild nasal sniffling/congestion -OU: mild blepharospasm with crusting at medical canthus -eupnic, clear lung sounds, no murmurs or arrhythmias -soft, slightly doughy abdomen -has hunched appearance in hind limbs but good ROM at all joints an no obvious orthopedic or spinal discomfort -chronic wound along ventral neck healing well with thickening of tissue but no discomfort, swelling or discharge A 1. Strangulating wound, chronic, healing well 2. URI-r/o calicivirus vs other 3. Underweight P -d/c IVF -cerenia 0.2 ml SQ SID x 2 days -erythromycin OU BID x 7 days -suspect calicivirus infection so will not add antibiotics unless mucoid nasal discharge develops or course is noted to be prolonged/severe