4/1/2026

DVM Intake Exam Estimated age: 3 years Microchip noted on Intake? Negative History: ACO Owner Surrender. Patient was reportedly the victim and also a biter in a dog fight. Designated as a DOH bite case. QAR MM pink, moist, CRT <2 sec Observed Behavior - Sedation needed for Intake d/t significant injuries Is there evidence of suspected cruelty? - No Objective: P = 80 hr (sedated) R = 16 rr (sedated) BCS 5/9 Wt = 55.5 lbs EENT: Multiple puncture wounds, lacerations, and abrasions on head and neck. Significant red-brown, hemorrhagic debris in both ears (L>R), presumed to be hemorrhage from injuries, and significant bruising of left ear at base. Oral Exam: Mild dental calculus and enamel discoloration PLN: No enlargements noted H/L: NSR, no apparent murmur, CRT < 2, Lungs clear, eupneic ABD: Soft, small (~1 cm), non-reducible umbilical hernia noted U/G: MI (2 testicles descended) MSI: Ambulatory x 4. Multiple puncture wounds, lacerations, and abrasions on head and neck (R>>>L). Multiple areas of old scarring on the head, neck, and shoulders Assessment: -Multiple puncture wounds, lacerations, and abrasions secondary to dog bite trauma -Small, soft umbilical hernia Prognosis: Fair Plan: Standard Intake Procedures for Dogs Performed (exception: Rabies vaccine withheld per DOH bite protocol) Sedation protocol: Ketamine (2.2 mg/kg), dexmedetomidine (11 ug/kg), and butorphanol (0.22 mg/kg) administered as 0.55 mL each IM. Supplemented with 1% isoflurane and oxygen. Additional pain control with methadone (0.5 mL IM) and local lidocaine (~2 mL total). Partial (0.28 ml IM) reversal with atipamezole. Fluids: LRS 500 mL SQ Carprofen 2.2 ml (4.4 mg/kg) SQ once (24-hour dose) Clavamox 375 mg PO BID x 7 days (first dose given PM of 4/1) - give in addition to Convenia Gabapentin 600 mg PO BID indefinitely (first dose given PM of 4/1) Carprofen 50 mg PO BID x 4 more days (start PM of 4/2) Additional methadone (0.5 ml IM) scheduled to be given around 6:30 pm on 4/1 *UPDATE: not taking oral meds; gave Convenia 8 mg/kg, 2.5 ml SQ once at 6:45 pm on 4/1; gave in addition to scheduled Clavamox **Wound Description & Management** * Overall injury pattern: Extensive dog bite trauma involving the head, ears, cheeks, chin, and neck with numerous puncture wounds, lacerations, and abrasions bilaterally. All wounds were clipped, aseptically cleaned, and copiously flushed with dilute chlorhexidine solution and sterile saline. Approximately 2 mL lidocaine used locally for wound repair. Selected wounds were partially apposed with 3-0 Vicryl monofilament simple interrupted sutures to allow drainage; remaining wounds were left open to heal by second intention. Left side (head/ear/neck): * At least 11 fresh puncture wounds ventral and caudal to the ear, at the ear base, dorsal head, and neck; flushed and left open for drainage and second intention healing * Bruising at the base of the left ear pinna * Multiple superficial abrasions on the left side of the head; cleaned and left open * Fresh puncture wound near the corner of the mouth; flushed and left open Right side (head/ear/neck): * Complex jagged approximately 3-inch full-thickness skin and muscle laceration at the base of the right ear; partially closed with four simple interrupted sutures with two ventral dependent portions left open to allow drainage * Approximately 40–50 small to moderate puncture wounds on the right cheek, chin, and lateral neck; flushed and left open for second intention healing * Two approximately 1-1.5 cm full-thickness puncture/lacerations on the ventral right neck (one near midline approaching the shoulder and one several inches dorsal); one simple interrupted suture placed in each to allow partial closure with drainage Top of Head: * Approximately 1.5-inch laceration above the right eye; one simple interrupted suture placed centrally with ends left open to drain * Deep full-thickness 1-inch puncture/laceration on the top right of the head; one simple interrupted suture placed with ends left open to drain * Approximately 10 superficial abrasions and at least five puncture wounds on the dorsal head; flushed and left open SURGERY: Temporary waiver for DOH Hold and wound recovery; consider umbilical hernia repair at time of neuter surgery

4/1/2026

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.

4/1/2026

0.5 ml of Methadone given at 6:30 pm per 2585.

4/2/2026

recheck, bite wounds S/O QAR, trembling, reluctant to come out of kennel but came out with a lot of coaxing and baby talk- leash made into sling as not to bother the wounds around the neck region EENT: no ocular or nasal dc, mm pm < 2 HL: eupneic, panting MSI: amb x 4 but reluctant to walk, multiple punctures wounds and lacerations mostly around the head and neck region. Moderate swelling and erythema to the R side of the neck, suture are intact. Wound by AD partially closed, no active draining noted at this time but d/c noted on bedding. Didn't palpate d/t p showing high level of FAS and painful A. Bite wounds - under treatment Anorexia - suspect second to pain and FAS - not taking meds even in HVTs when crushed P. Givem 0.5mL methadone IM today- extend to giving through 4/4 IM BID as well, wounds are quite extensive and painful Con't to encourage to eat- staff instructed to take p out when time allows and offer variety of HVTs, try to make more comfortable and lower FAS. D/c clav and gaba aTT bc not eating. D/c oral carpro, changed to injectable x 2 days until appetite improved MF BID x 2 days Recheck in 2 days CTM closely on rounds

4/3/2026

Recheck bite wounds S/O: BAR, stands in kennel and wags tail, empty food dishes from overnight; after receiving methadone he is very quiet, not interested in food, looks dumpy; no c/s/v/d noted EENT: No ocular or nasal discharge LUNGS: Eupneic MSI: Extensive wounds along head and neck - some dried discharge ventrally, but minimal active discharge, mild swelling UG: Paraphimosis noted post methadone injection, resolved later in the day CNS: Very quiet on methadone A: Bite wounds Umbilical hernia Paraphimosis - resolved later in the day Anorexia - resolved, but decreased appetite noted on methadone P: Okay to d/c methadone Continue carprofen SQ Add gabapentin 12 mg/kg PO BID CTM closely on rounds

4/4/2026

Recheck extensive bite wounds at head/neck S/O: QAR in kennel, brightens out of kennel, low tail wag, some distance decreasing behaviors; ate well overnight but doesn't eat during the day, not taking HV treats offered; no c/s/v/d noted EENT: No ocular or nasal discharge LUNGS: Eupneic MSI: Ambulatory x 4 with no notable lameness, bite wounds stable and healing appropriately with dried discharge and mild swelling CNS: Appropriate mentation A: Bite wounds Umbilical hernia Hyporexia - seems to eat well overnight P: Switch to oral carprofen - will try to give PO tonight Extend medical feedings Continue gabapentin Recheck in 2 days

4/6/2026

Recheck extensive bite wounds at head/neck S: BARH - slightly hesitant but warms up quickly --> soliciting attention with loose body language pink moist mm no c/s/v/d noted d/u/d/e WNL - great appetite and taking meds in food for 24 hours O: EENT: No ocular or nasal discharge HL: No HMA, SSPPs, normal BV sounds, eupneic MSI: Ambulatory x 4 with no notable lameness, bite wounds stable and healing appropriately with dried discharge and mild swelling - no pain on palpation of wounds CNS: Appropriate mentation A: Bite wounds - healing / under treatment HX Umbilical hernia Hyporexia - resolved MI P: CWCT OK to move to gen pop DVM recheck 4/8 for end of analgesic course

4/8/2026

Recheck bite wounds S/O: BAR, fearful today - tucked tail, tense, trying to get back into kennel, but still allows all handling. More barking than usual as recovery full of surgery dogs. No c/s/v/d noted. EENT: No ocular or nasal discharge LUNGS: Eupneic MSI: Ambulatory x 4, wounds at various stages of healing, more superficial wounds healed, others are scabbed and healing; minimal swelling, no active discharge. A: Bite wounds to head/neck/face FAS Umbilical hernia P: Extended gabapentin for pain and FAS Start trazodone 8 mg/kg PO BID for FAS CTM on rounds, recheck +/- suture removal in 3-4 days

4/10/2026

Recheck bite wounds day 10 S/O: QAR-BAR, high FAS when out of kennel - pulls hard on neck lead persistently to get back into kennel; good appetite but not eating meds, no c/s/v/d noted **Sedated for thorough exam and flushing of wounds - dex/torb 0.5 ml IM of each, full atipamazole reversal, smooth recovery EENT: No ocular or nasal discharge, OU mild ectropion with hyperemic conjunctiva/sclera ORAL: mm pink and moist, CRT <2; mild-mod tartar, stage 2-3 ddz LUNGS: Eupneic MSI: Extensive wounds to face, head, neck in various stages of healing. Removed sutures from healed wound caudal to AD; wounds not fully healed with mild bleeding +/- pocketing upon cleaning/flushing noted at ventral neck/cranial chest, dorsal to OD, and several smaller wounds at left and right side of head. Scabbing and dark dried discharge in surround fur. A: Bite wounds - in various stages of healing Umbilical hernia Dental disease High FAS in shelter, not eating meds Hyperemic conjunctival and sclera - suspect secondary to pulling hard on neck lead P: Harness placed Removed several sutures from healed wounds Clipped fur from least healed wounds, scrubbed wounds and surrounding areas with dilute chlorhex, flushed wounds with copious amts of sterile saline No change to medication at this time, wounds do not appear infected and patient isn't eating oral meds regularly Continue trazodone and gabapentin for FAS - try different HV foods CTM on rounds and recheck wounds in 3 days

4/12/2026

DOH release from observation S: BARH - at front of kennel soliciting attention pink moist mm at distance no c/s/v/d reported O: EENT: No ocular or nasal discharge, corneas clear. Visually tracking with no nystagmus Oral: No ptyalism, pink moist mm at distance MSK: Ambulatory x4 NEURO: Normal mentation, no ataxia A/P: P is not showing any neurologic symptoms or signs of rabies at this time and is released from rabies observation. Report submitted via email.

4/15/2026

Recheck wounds S/O: BAR, wagging tail, seeking contact, allows all handling (*seems excited to be back with familiar staff from vet services, tries to go back into previous kennel that he stayed in) MSI: Wounds healing appropriately (many, in various stages of healing). Wound dorsal to OD healed with suture, wound at dorsal head healed with suture. A: Wounds - mostly healed Dental disease Umbilical hernia P: Removed remaining sutures Continue gabapentin and trazodone CTM while at QACC

4/15/2026

Rabies vaccine /// Done Records updated.

4/21/2026

Progress exam: CIRDC signs noted on rounds Subjective: BAR, no V/D. Sneezing & occasional coughing present. AS:1 noted Objective: EYES: Clear 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 CIRDC PLAN: Per standing orders -Move to iso, ppe sign & monitor log placed on kennel -Start doxycycline 10mg/kg PO q24h x10days & medical feedings PO BID x5days -CTM, recheck in 3 days