DVM Intake Exam Estimated age: Reported 9 years old – exam is consistent with this Microchip noted on Intake? Scanned pos on intake History : Owner surrender. A few years ago, pt jumped off a bed and injured his leg (owner wasn’t sure which leg), and needed surgery. No other health concerns. Subjective: Playful! Energetic. Play-bows when I say hello. Observed Behavior – Allows all handling Objective BAR-H, MMs pink and moist, BCS 8/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Severe tartar and gingival recession, teeth are angled outwards PLN: No enlargements noted H/L: Grade 2/6 systolic murmur, PMI left base. NSR. Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, testicles S/S MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: Normal externally Assessment: 1. Severe dental disease 2. Heart murmur Prognosis: Fair-good Plan: 1. Recommend repeated chest rads and monitoring for cardiac symptoms after placement 2. Recommend dental cleaning with rads and likely extractions if heart disease permits SURGERY: Permanent waiver due to heart murmur. 1088

Your newly adopted pet has been diagnosed with a heart murmur and the staff veterinarians are issuing a permanent waiver from the spay/neuter requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.

Observed hacking cough during morning walk BARH BCS 7/9 Temp 102.5 – no nasal discharge, no sneeze appreciated – seems to have harsh cough with leash, could be tracheal irritation/collapse vs early CIRDC vs component of heart dz (has heart murmur) vs other P: monitor +/- chest rads

Request for rechecking cough – R/O pulling on leash vs. CIRDC vs. heart disease. Today pt is not coughing at all. No sneezing, no nasal discharge. Nose is moist. I suspect pt was coughing due to pulling on the leash. 1088

Coughing reported by staff yesterday but appeared clear on recheck S/O -QAR, resting comfortable -sneezing, excessive serous nasal discharge -appears eupnic A CIRDC P move to isolation doxycycline 100 mg PO SID x 14 days cerenia 1 ml SQ SID x 2 days recheck 10/24

Diagnosed with CIRDC on 10/18, started on doxycycline and given cerenia SQ on 10/18 and 10/19; ACS reports that he has not been eating since 10/20 S/O QAR, appears docile but nervous in kennel mm pk, tacky; CRT 2 sec sneezing, excessive serous nasal discharge expiratory cough with intermittent end gag eupnic A CIRDC Inappetance-r/o secondary to CIRDC vs behavioral vs early pneumonia P 150 ml SQF SID x 2 days cerenia 1 ml SQ SID x 2 days recheck energy, appetite tomorrow; if no improvement, then rec’d CXR to r/o pneumonia