2/26/2026

DVM Intake Exam Estimated age: 6-8 years based on dentition Microchip noted on Intake? Scanned positive History: Stray, finder reported ocular issue and vomit/diarrhea. Finder also noted lameness or issue with hindlegs. Subjective: QAR Observed Behavior - tense but allows all handling, vocalized during blood draw and growled at conclusion of restraint but did not escalate. No interest in food offered. Is there evidence of suspected cruelty? No Objective: T = P = WNL R = WNL BCS: 3/9 5% dehydrated EENT: Micro-ophthalmia OD with mucoid ocular discharge OD, clear OS. Ears clean AU, no nasal discharge noted. Oral Exam: Adult dentition, moderate calculus -- limited exam performed. PLN: No enlargements noted H/L: NSR, grade V/VI parasternal mumur, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: Externally WNL, neutered male MSI: weakly ambulatory x 4, skin free of parasites, no masses noted, dull hair coat. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Externally WNL Wood's Lamp Exam: not performed Assessment: Grade V/VI heart murmur- r/o HCM vs. other Reported hindleg lameness by finder, but weakly ambulatory on exam Underweight Dehydration Vomit/diarrhea noted Micro-ophthalmia/ocular abnormality OD Prognosis: Guarded Plan: Intake tasks + exam Panleuk SNAP- negative Awake D/V radiograph performed, no apparent pelvic or hindleg fractures noted. Possible tail fracture but may just be positional. CBC/CHM in house LRS 100mls SQ once Cerenia 10mg/ml 0.3 ml SQ once Vitamin B12 0.25 ml SQ once Zorbium for appropriate weight Monitor in medical for vomit/diarrhea Consider EHR after stray hold + MC trace if declining in care SURGERY: Already neutered

2/26/2026

CBC HCT 26.4% (30.3-52.3) Hgb 7.9 g/dL (9.8-16.2) WBC 22.3 K/uL (2.87-17.02) - moderate neutrophilia 20.15 K/uL - otherwise normal differential CHM Glucose 149 mg/dL SDMA 16 ug/dL (0-14) Creatinine 1.3 mg/dL BUN 46 mg/dL (16-36) Hypernatremia 169 mmol/L (150-165) Hyperchloremia 130 mmol/L (112-129) Other lytes WNL ALT WNL ALP < 10 U/L TT4 wnl A: Mild anemia without reticulocytsis- r/o pre-regenerative vs. non-regenerative Leukocytosis with neutrophilia- r/o inflammatory vs. infectious vs. other Elevated SDMA with elevated BUN- r/o pre-renal vs. renal Hypernatremia with hyperchloremia- r/o hydration status vs. other Decreased ALP, not clinically significant P: CTM throughout stray hold

2/28/2026

SO: BAR, tense on kennel floor, but then begins rolling over and making biscuits while petting eent: eyes OD globe of eye shrunken with third eye lid elevation and upper and lower lid entropion, thick yellow mucoid dc, no nasal dc apparent h/l: eupneic, no coughing or sneezing appreciated msi: ambulatory x4 neuro: mentation alert and appropriate A: phthisis bulbi OD heart murmur underweight P: lameness not appreciated, but not seen walking continue current plan to monitor

3/2/2026

Pet is eating and gained weight. CV/RESP: Eupneic Grade 4-5/6 murmur A: Pet appears comfortable and stable with heart murmur and anemia Prognosis: Poor to fair P: okay for adoption/placement Advise echocardiogram to further assess heart murmur Move out of medical

3/10/2026

EEN: grey nasal discharge and congestion. Yellow ocular discharge OD CV/RESP: RR 32 RE WNL Lungs quiet MSI: BCS 3/9 Decreased skin turgor NEURO: QAR A: Anorexia URI moderate Dehdyration Lost weight Pet walks around table but is not interested in food. Prognosis: Poor Plan Move to medical isolation Advise at risk placement Advise humane euthanasia if declining. LRS 60 mls SQ sid x 2 days Doxycycline 100mg/ml 0.3 ml po sid x 7d