8/25/2026

DVM Intake Exam Estimated age: ~3-7 years based on dentition / condition Microchip noted on Intake? Scanned negative History: DOH-V, OS Subjective: BARH, pink moist mm, CRT <2s Observed Behavior - Friendly, soliciting attention Is there evidence of suspected cruelty? No Objective: P = WNL R = WNL BCS 2.5/9 MCS 3/3 EENT: Scant mucoid discharge at medial canthus OU, ears clean, no nasal or ocular discharge noted Oral Exam: Mild staining of dentition, limited view due to facial swelling PLN: moderate swelling of submandibular LNs H/L: NSR, NMA, CRT < 2s, Lungs clear, eupneic, negative ITC ABD: Soft, nonpainful, no masses palpated U/G: Female - appears intact no tattoo or spay scar MSI: Ambulatory x 4, full orthopedic exam not performed INT: No masses noted, no ectoparasites seen, severe facial swelling with many superficial scabbing wounds (no wounds more than 2-3mm deep) with few having purulent discharge (too numerous to count) CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Normal externally Wood's Lamp Exam: Not performed Assessment: Bite wounds on face with severe soft tissue swelling and purulent discharge -- DOH-V Ocular discharge susp 2ary to facial swelling Underweight FI mature adult mixed breed Prognosis: Fair Plan: OK for appropriate intake tasks DOH-V Keep in med ICU until swelling improves DVM recheck 8/27 ADD Diphenhydramine 0.6mL (2mg/kg) IM ONCE ADD Carprofen 1.3mL (4.4mg/kg) SQ ONCE START TOMORROW: ADD Carprofen 75mg (~4.4mg/kg) PO SID x14d - PM TREATMENT ADD Clavamox 250mg (~15mg/kg) PO BID x10d SURGERY: Temporary waiver for wounds

8/25/2026

Your newly adopted pet has wounds and 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.

8/27/2026

Recheck facial swelling- surrendering owners reported another dog bit her in the face, timeline unclear S/O: BAR, active, allows handling, eating well, no c/s/v/d noted; yawns and large defect visible at hard palate EENT: No ocular or nasal discharge ORAL: Examined under sedation - see below LUNGS: Eupneic MSI: Amb x 4, underweight; severe swelling along dorsal muzzle with pitting edema (appearance of bull terrier), multifocal lesions/superficial wounds along dorsal muzzle, ulceration/superficial lesions along lips, most notable rostrally CNS: Appropriate mentation Sedated with dex/torb 0.3 ml IM of each -Large defect/wound at left side of hard palate at level of 206-207 extending to midline. Defect extends laterally into buccal mucosa and missing and exposed dentition/roots appreciated (missing 206/207). -Smaller defect at right side of hard palate at level of 107 with exposed dentition/roots and alveolar bone -Nasal passages exposed and appear erythematous and malodor coming from opening Skull rads: Lucency noted on left lateral skull in region of defect, no other discernable abnormalities 2VCXR: NSF A: Severe hard palate injuries/defects, left > right - ro secondary to reported bite vs other trauma (electrical cord vs penetrating FB vs other) Severe swelling/pitting edema of dorsal muzzle - likely secondary to hard palate injury Wounds/lesions on lips Underweight P: Submitted CBC/CHEM/T4/UA to idexx Continue carprofen and clavamox CTM closely while at QACC - seek placement ASAP for surgical repair options

8/28/2026

Recheck, bw results S/O: BAR, great appetite, no c/s/v/d noted EENT: No ocular or nasal discharge, nasal congestion audible LUNGS: Eupneic MSI: Amb x 4; significant swelling of dorsal muzzle unchanged CNS: Appropriate mentation CBC: Hct 36.7 (L), WBC 24.8 (H), neutrophils 17.782 (H), monocytes 3.199 (H) CHEM: Phosphorus 6.6 (H) T4: 0.9 (L) UA: pH 5.5 (L), USG 1.030 A: Mild anemia Leukocytosis, neutrophilia, monocytosis - ro inflammation/infection (wound/swelling) Low T4 - ro euthyroid sick Severe hard palate injuries/defects, left > right - ro secondary to reported bite vs other trauma (electrical cord vs penetrating FB vs other) Severe swelling/pitting edema of dorsal muzzle - likely secondary to hard palate injury Underweight P: Continue current treatment plan Seek placement ASAP for surgical consult

8/31/2026

recheck p with hard palate injury S/O BAR, A+A, staff reported eating well, take HVTs, no c/s/v/d appreciated or noted EENT: no ocular or nasal dc HL: eupneic MSI: amb x 4, swelling/edema over the dorsal muzzle region A. Soft tissue swelling/edema- appears unchanged from last exam P. Cont with current tx plan and recheck as scheduled

upon intake: she let staff scan for ID and to take her picture, she was rushed back to medical and wasn't handled further