7/26/2019

DVM Intake Exam Estimated age: 10y Microchip noted on Intake? no History : owner deceased Subjective: BAR Observed Behavior - Very tense, will with draw quickly when approached, turns head and tenses when touched on neck. Allowed all handling. Evidence of Cruelty seen -no Evidence of Trauma seen -no Objective T = P =wnl R =wnl BCS 3-4/9 EENT: Eyes mild nuclear sclerosis, ears clean, no nasal or ocular discharge noted Oral Exam: severe dental disease, stage 4/4, oral exam limited to incisors and canines PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male intact, 2 testes palpable MSI: Ambulatory x 4, skin free of parasites, no masses noted, strip of alopecia along length of dorsum, hair on flanks soft undercoat, top coat seems to be gone CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: normal external Assessment: alopecia dental disease stage 4/4 mild nuclear sclerosis Prognosis: good pending blood work Plan: cbc/chem/t4 r/o hormonal cause of hair loss as symmetrical and non pruritic intake tasks SURGERY: Permanent waiver due to age

7/26/2019

[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.

7/26/2019

CBC/chem/T4 all values wnl

9/4/2019

[DVM Intake] DVM Intake Exam Estimated age: 10 years Microchip noted on Intake? Yes, previously placed at MACC History : Stray. Subjective: BAR Observed Behavior -Approaches the front of kennel wagging his tail. Timid. Did fine with minimal handling. Evidence of Cruelty seen -No Evidence of Trauma seen -No Objective T = P =120 bpm R =eup BCS 5/9 EENT: Nuclear sclerosis but otherwise clear OU, ears clean, no nasal or ocular discharge noted Oral Exam: 4/4 PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: M/I, both down MSI: Ambulatory x 4, skin free of parasites, no masses noted, alopecia mid to caudal dorsum CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Clean externally Assessment: -Hx of alopecia-r/o alopecia x vs. allergies vs. other (T4 was wnl) -Hx of dental dz Prognosis: Good Plan: -Recommend dental once placed -Consider skin biopsy SURGERY: Permanent waiver due to age

10/1/2019

DVM Intake Exam Estimated age: ~10yrs based on previous hx MC found? scanned positive. History: Surrendered by adopter due to bite incident in the home. This is the second DOH hold Subjective / Observed Behavior - BAR, tense, shaking during exam. Tail tucked tightly, whale-eyed Evidence of Cruelty seen - none Evidence of Trauma seen - none Objective BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: did not evaluate due to bite hx PLN: No enlargements noted H/L: No murmur auscultated; CRT < 2. Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male. testicles are smooth and symmetrical within scrotum MSI: Ambulatory x 4, skin free of parasites, no masses noted; generalized alopecia along the dorsum extending cranial / caudal CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal. Assessment alopecia, suspect secondary to behavior (crawling under furniture) Prognosis: good Plan: await behavioral assessment and placement SURGERY: Permanent waiver due to age

10/3/2019

SO BAR in kennel. Hard barking at kennel front EN -- eyes are clear. mucoid nasal discharge A CIRDC P doxycycline 50mg/ml -- give 1.2ml PO q24h x 14 days enrofloxacin 100mg/ml -- give 0.6ml PO q24h x 14 days cerenia 16mg tablet -- give 0.5 tablet PO q24h x 4 days

10/9/2019

SO BAR in kennel. EN -- eyes are clear. serous nasal discharge and sneezing A CIRDC P continue on current tx plan