9/1/2024

DVM Intake Exam Estimated age: 10 years Microchip noted on Intake? Scanned negative History: Owner passed away. Pet brought in by agency. Ate can of wet food. Subjective: BAR Observed Behavior - Swatting, hissing, lunging. Is there evidence of Cruelty? No Is there evidence of Neglect? No Is there evidence of Trauma? No Objective P = 160 R = WNL BCS 8/9 EENT: Eyes clear. AD: crinkled pinna, with stenotic ear canal. AS: black debris. Pet scratches ears when touched. No nasal or ocular discharge noted Oral Exam: Stained teeth. Moderate tartar and gingivitis cheek teeth. PLN: No enlargements noted H/L: NR, NMA, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: Male intact MSI: 2 cm umbilical hernia - partially reducible. Matts along dorsum. Mild erythema left lateral chest. Ambulatory x 4, skin free of parasites, no masses noted CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: WNL externally Blood glucose: 230 high r/o stress Assessment Otitis externa Obese Periodontal disease stage 3/4 Umbilical hernia - appears to be open DOH-B Prognosis: Good Plan: Sedated with Dexdomitor 0.5mg/ml 0.46 ml IM About half splashed on coat. Additional 0.2ml given IM Butorphanol 10mg/ml 0.5 ml IM Pet growling but exam and tasks were possible Shaved matts Selamectin 1 tube 45mg/ml + 1 tube 15 mg/ml Antisedan 0.3 ml IM SURGERY: Okay for neuter and umbilical hernia repair

9/10/2024

On 9/10/2024 at approximately 10 am, I examined Dominos 209176. He has appropriate mentation at this time with no neurologic signs present, and has not exhibited any neurological signs while at ACC.

9/13/2024

SO: Reported not eating QAR, tense when approached in kennel, untouched food plates eent: eyes clear, serous ocular dc apparent, crusting nasal dc, ears AD healed aural hematoma, AU ceruminous cystomatosis oral: small central tongue ulcer h/l: eupneic, no coughing or sneezing appreciated, audible congestion msi: ambulatory x4 neuro: mentation alert and appropriate A: URI-mild/moderate anorexia P: sedate using 0.15ml dexmedetomidine 500mcg/ml, 0.15ml ketamine 100mg/ml and 0.15ml butorphanol 10mg/ml IM provided light sedation While sedated plan placement of IV catheter reweigh-19.3lbs cbc/chem/T4 to lab-attempted to get urine for UA but bladder was too small 0.25ml vitamin b12 1000mcg/ml sc 0.8ml cerenia IV SID x5d nebulize 15 mins with saline SID x5d zorbium for weight monitor appetite

9/15/2024

Patient developed swelling of right front paw where IVC was located. IVC was not able to be flushed. Sedated using 0.15ml dexmedetomidine 500mcg/ml, 0.15ml ketamine 100mg/ml and 0.15ml butorphanol 10mg/ml IM. Removed IVC. Administered 0.8 ml Cerenia SQ instead of IV. Reversed with 0.15 ml Antisedan IM as per Dr. 2419.

9/16/2024

Patient in medical iso due to moderate URI and anorexia. AS noted as 2, some uneaten plates noted High FAS - unable to do much without sedation - visual exam EENT: Moderate mucoid nasal discharge with ulceration of the nasal planum. OU blepharospasm. Oral: Thick saliva Abd: no obvious distension MSI: Shaved dorsum A Moderate URI Suspect ulceration P. Cannot do SQ fluids do to behavior Will try oral meds in food - doxycycline 1.75ml PO SID x 10 days - gabapentin 100mg PO BID x 10 days - scheduled zorbium due 9/17 Prioritize placement - high FAS, obese BCS and poor appetite may put at risk of hepatic lipidosis

9/16/2024

chem/cbc/t4 not remarkable

9/17/2024

Severe URI and anorexia S/O: Contiued anorexia overnight. First dose of Zorbium given this AM. Growling when approached kennel. Moderate muco-purulent discharge at nares with ulceration of nasal planum, audible congestion. Increased inspiratory effort. P: *Continue to monitor appetite now with Zorbium on-board. *Continue with oral meds as previously prescribed *Re-listed on ARL due to severity of condition exacerbated by behavior concerns (unable to provide injectable supportive care) *Reassess fully on 9/19 - if continuing to be anorexic or deteriorates, recommend EHR due to poor prognosis and QOL in shelter.