11/26/2025

DVM Intake Exam Estimated age: 11 years Microchip noted on Intake? Negative History: Agency, Stray MM appeared pink, moist Observed Behavior - Orange; Limited ability to fully examine, body tense, growling, lunging, snapping when attempting exam of the head, and trembling. Evidence of Cruelty seen - No Evidence of Trauma seen – No Evidence of Neglect- No Objective: P = 120 hr R = 32 rr BCS 4/9 Wt = 14 lbs EENT: Severe bilateral ocular disease is present. Both globes are enlarged (buphthalmos), with the right appearing larger than the left. Marked conjunctival and scleral hyperemia, cloudy corneas, and a thick, yellow-white mucopurulent discharge are noted in both eyes. Discharge is also accumulating in the nasal folds. Vision is suspected to be minimal to absent. A complete ear examination could not be performed due to patient temperament. Oral Exam: A thorough oral examination could not be performed. PLN: No enlargements noted H/L: Auscultation was difficult due to patient trembling and growling. A possible low-grade heart murmur was suspected. Lungs clear, eupneic. ABD: Non painful, no masses palpated U/G: MI (2 testicles descended) MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment: Geriatric with suspect chronic conditions -Severe bilateral buphthalmos, likely secondary to chronic glaucoma. Suspect blindness. -Possible low-grade heart murmur requiring re-evaluation. Prognosis: Fair Plan: *DIAGNOSTICS*: -Send out bloodwork: CBC, Chemistry Panel, T4. *MEDICATIONS DISPENSED*: -Gabapentin (100 mg/mL suspension) 100 mg (1 mL) PO BID x 7 days. *OTHER RECOMMENDATIONS, FOLLOW-UP CARE*: -Recheck with veterinarian in 2 days to review bloodwork results. -Recheck with veterinarian in 7 days to reassess patient's anxiety, re-auscultate heart, and attempt a more thorough examination of the eyes, ears, and mouth. -A sedated examination may be considered in the future if deemed medically necessary. SURGERY: Permanent waiver d/t age

11/28/2025

CBC: sl anemia (40.0) sl leukocytosis (18.2) sl neutrophilia (11.9) monocytosis (2.0) thrombocytosis (484) CHEM: sl hyperglycemia (117) sl hyponatremia (140) sl hypoalbuminemia (2.3) H globulins (4.6) H LEs (ALT 512, AST 123) TT4 wnl A stress vs inflam leukogram thrombocytosis r/o stress vs inflam vs reactive electrolyte inbalances r/o losses L albumin r/o losses H LEs r/o primary hepatic vs open P. Con't with current treatment plan recheck blood work in 2 weeks - monitor liver enzymes Seek placement, p had suspected glaucoma and is in need of further workup

11/28/2025

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.

12/2/2025

Brief recheck S/O: BAR at front, barking when approached, diarrhea FS 6 in kennel, FS on log is 4; no c/s/v noted EENT: Severe mucoid discharge and crusts OU with chronic corneal changes and scleral hyperemia; no nasal discharge LUNGS: Eupneic MSI: Ambulatory x 4 CNS: Appropriate mentation A: Severe and chronic ocular disease - conjunctivitis, suspect KCS vs other Diarrhea Geriatric Heart murmur Elevated LEs P: Start proviable 1 cap PO SID x 7 days Unable to medicate/treat ocular disease in shelter due to behavior Continue gabapentin for pain/discomfort and behavior Seek placement ASAP for continued care and treatment plan

upon intake: Apple Jack allowed staff to pick him up, place the leash on him, collar and take his picture and place him into the kennel