8/28/2025

DVM Intake Exam Estimated age: 12-14 years old based on dentition/ocular changes, c/w owner reports Microchip noted on Intake? Scanned negative History: Owner surrender, owner is losing vision and can no longer care for Subjective: BAR Observed Behavior - wagging tail, lose body, allows all handling for exam + is food motivated, allows muzzling for tasks but vocalizes for blood draw Is there evidence of Cruelty? No Is there evidence of Neglect? No Is there evidence of Trauma? No Objective T = P = 120 bpm R = WNL BCS: 5/9 EENT: Nuclear sclerosis OU, ears clean, no nasal or ocular discharge noted Oral Exam: Adult dentition, moderate tartar + halitosis (limited due to muzzle). ~2-3 cm round soft swelling at the aspect of left mandible. PLN: No enlargements noted H/L: NSR, grade 4/6 heart murmur, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: Externally WNL, intact male, 2 scrotal testes MSI: Ambulatory x 4, skin free of parasites, 2-3 cm round soft fatty like mass on ventral abdomen. 3-4 cm ulcerated round firm mass on R shoulder. Healthy hair coat. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Externally WNL Wood's Lamp Exam: not performed Assessment Moderate dental disease Senior suspect chronic condition Mass on L mandible- r/o lymphadomegaly vs. enlarged salivary gland vs. other Soft fatty mass on ventral thorax- r/o lipoma vs. other Large ulcerated mass on R shoulder- r/o ruptured cyst vs. mass vs. other Grade 4/6 heart murmur- r/o DCM vs. other Prognosis: Fair Plan: Intake tasks + exam Await sort Recommend rescue placement where mass removal can be performed under anesthesia with cardio safe medications that we do not carry in shelter Rx: Clavamox 375mg PO BID x10d Rx: Gabapentin 300mg PO BID x14d SURGERY: Permanent waiver due to age

8/31/2025

[Spay/Neuter Waiver - Age] It is the policy of ACC not to perform surgery on any animal over the age of 8-10 years due to the higher risks incurred in a shelter setting. The veterinarian is hereby issuing a permanent spay/neuter waiver, from the spay/neuter requirements of the City of NY due to the estimated age of this animal. ACC does recommend you consult with your veterinarian to determine if surgical sterilization is appropriate.

8/31/2025

QAR MSI: 6 cm firm, ulcerated mass with yellow discharge right lateral shoulder. I can lift the mass completely from underlying tissues. chem/cbc BUN 28 sl high Creat 0.9 wnl SDMA 7 wnl Na 161 sl high Globulin 4.6 sl high ALT 242 sl high ALP 193 WNL CBC 32% sl low Retics 61k wnl WBCs 13k wnl Monocytes 1.3k sl elevated Basophils 0.2k elevated A: Anemia - mild Heart murmur Mass could be narrowly excised and skin closed without tension but exercise may need to be restricted 2 weeks post op to avoid dehiscence. r/o neoplasia + chronic inflammation Prognosis: Guarded given advanced age and severity of multiple morbidities. Plan Consider EHR

9/5/2025

Overnight it was reported that Nino had traumatized his mass causing bleeding and was licking it and worsening the bleeding. Staff placed e-collar and monitored. This morning Nino appears comfortable, resting in his kennel, with dried serosanguineous discharge around the mass. No other discharge noted on bedding. E-collar on. P: Continue with medication protocol Advise NH group about trauma Recommend mass removal ASAP for overall comfort/QOL

9/5/2025

Cleaned ulcerated mass using LRS fluids vigorously. Also cleaned dried serosanguineous discharge using hydrogen peroxide. Mass appears severely ulcerated from time of intake exam. Nino was also observed to be coughing repeatedly. A: CIRDC Geriatric suspect chronic condition Heart murmur Mass, ulcerated PDDZ P: Rx: Doxycycline 275mg PO SID x10d Follow up with rescue group due to concerns about developing pneumonia given age and worsening of mass ulceration in such a short time Consider EHR if rescue is no longer comfortable taking due to worsening prognosis P: Doxycycline

Upon intake, Nino had a loose body and greeted staff with their tail high, wagging. Nino allowed all handling.