12/22/2025

DVM Intake Exam Estimated age: 14 years Microchip noted on Intake? scanned negative History: Agency - found in a box in a park Subjective: QAR Observed Behavior - sitting in cage, not standing or walking. no signs of aggression. easy to handle. Is there evidence of Cruelty? No Is there evidence of Neglect? YEs Is there evidence of Trauma? No Objective BCS: 5/9 ideal for size EENT: Blind. right eye - cloudy, corneal ulcer and rupture, bulging, left eye - bulging, cloudy, Nose: sniffly - slight serous discharge ears clean, severely matted fur around ears Oral Exam: Grade V periodontal disease. left mandibular canine fell out, approx. six teeth present. severe receding gums, dark grey and black tartar, some roots exposed, It appears that tartar is holding teeth in place and suspect a dental will be quick as there are not very many teeth left. PLN: mandibular lymph nodes slightly enlarged H/L: NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: thick smelly urine collected. Matted fur around vulva. tattoo observed. small nipples MSI: non-ambulatory skin free of parasites, severely matted fur on face, tail, and all four feet. extremely long nails - some embedded into paws, one curled. CNS: Mentation appropriate for blind geriatric dog- no signs of neurologic abnormalities Rectal: matted fur with feces Assessment: blind geriatric dog - osteoarthritis - blind - periodontal disease - corneal ulceration and rupture - matting Prognosis: poor Plan: sedated with 0.35ml DKM for shaving and full exam. Bella did not fully sedate with this dose, she began to move when feet were being shaved. I suspect she does not like them touched hence the extreme matting on legs and feet Bella is able to walk and move once the matts were shaved and her nails were cut. Recommend new owner do dental prophy and extractions Surgery: Permanent waiver due to previously altered Placed in Medical

12/22/2025

Staff note pet falling to side. RESP: Eupneic Neuro: Blind. Left head tilt. Rotary nystagmus with fast phase to right. Intermittent falling over to each side when walking. Alert and leans into pets. HCT 32% low WBCs 20k high BG 139 wnl BUN 24 nl Creat 1 wnl liver values wnl T4 1.2 ug/dl wnl A: Vestibular disease r/o reaction to sedation vs idiopathic vs neoplasia Prognosis: Guarded Plan Cerenia 10mg/ml 0.5 ml SQ Consider EHR

12/23/2025

Hx: Came in severely matted, non-ambulatory, with severe dental disease, bulging eyes, report of corneal ulceration, thick fur coat and embedded nails. Was sedated for shaving and nail trimming yesterday morning. After this, pt was able to walk. In the evening, a left sided head tilt, falling to both sides, and rotary nystagmus with fast phase to the right were noted. Pt was given Cerenia. S: Lying in kennel, leaning to left. Unable or unwilling to stand. Passive for exam. O: QAR-H, MMs pink and moist Eyes: OU exophthalmos, soft globes when retropulsed, corneas cloudy and dull, engorged episcleral vessels with small conjunctival vessels. Suspect pt is blind. OD moderate corneal opacity, neovascularization, mucoid debris adhered to central cornea. OS mild corneal hazy opacity and neovascularization; the anterior chamber is visible with iris atrophy and a large sparkly irregular cataract. ENT: SEVERE tartar, many missing teeth. Clean AU, nose. Suspect pt is deaf. PLNs: Not enlarged H/L: NSR, NMA. Eupneic, no coughing or sneezing. Abd: Soft, not distended M/S/I: Non-ambulatory. When I hold her up, she buckles in the front legs especially LFL. BCS 5/9, moderate muscle wasting in hind legs, pain on hip extension bilaterally. Close cropped coat, no skin lesions noted. Neuro: Dull, passive, non-ambulatory. Head tilt to left, body curls to left when held in standing position. Horizontal or rotary nystagmus with fast phase to right. A: 1. Head tilt to left, nystagmus with fast phase to right - vestibular disease R/O idiopathic vs. neoplasia vs. other 2. Exophthalmos, dry corneas, corneal opacity, visible cataract R/O glaucoma vs. KCS vs. lens-induced uveitis vs. other 3. Severe dental disease 4. HL osteoarthritis 5. Hx matting - shaved P: 1. STT, fluorescein stain, IOP 2. Continue Cerenia 0.5 ml SQ SID x3 days 3. Monitor vestibular symptoms, consider humane euthanasia if they do not improve 1088

12/23/2025

Schirmer tear test: OD 8 mm in 60 sec OS 0 mm in 60 sec Fluorescein stain: OU no uptake IOP: OD 10, 10, 11, 12,11 (avg 10.8) OS 15, 13, 14, 17, 15 (avg 14.8) Exam with bright light: OD has a central divot OS has a central circle with different texture but no depth disparity ASSESSMENT: 1. Keratoconjunctivitis sicca OU 2. Evidence of prior corneal ulcers but no stain update - appear to be healed at this time 3. Mildly decreased IOP - R/O lens-induced uveitis vs. other PLAN: 1. Optimmune OU BID indefinitely 2. Typically uveitis is treated with topical steroids; however given pt's thin and diseased corneas, I do not feel comfortable starting steroids. If this is LIU, cataract surgery would be indicated. Recommend ophthalmologist consult. 1088

12/26/2025

SO: Senior dog in medical on treatment for suspected idiopathic vestibular disease. QAR, allows all handling for exam, eating canned food with very good appetite. eent: eyes OU complete opacity of corneas, no ocular dc apparent, heavy yellow nasal dc h/l: eupneic, repeated sneezing appreciated msi: ambulatory x4, improved ataxia neuro: mentation alert and appropriate A: CIRDC vestibular improving P: 50mg doxycycline PO SID x10d continue supportive care

12/27/2025

SO: Geriatric dog in medical with suspected vestibular episode BAR, initially sleeping when approached, but wakes up and stands up when spoken to. Attempted to clean nasal dc. Shows teeth and snaps, but otherwise allows all handling eent: eyes OU complete corneal opacity, yellow mucoid nasal dc apparent h/l: eupneic, repeated sneezing appreciated msi: ambulatory x4 placed onto ground, no lameness, walks a few steps and starts wagging tail when hind end patted neuro: mentation alert and appropriate A: vestibular episode apparently resolving CIRDC on treatment blind P: continue current treatment plan recommend placement ASAP