NALA aka PIPER – 15385

5/12/2017

DVM Intake Exam Estimated age: ~1yr Microchip noted on Intake? no History : Stray Subjective: BARH Observed Behavior – Very active, attention seeking, allows all handling Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective P = WNL R = WNL BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Teeth clean, pink mm PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Apparently healthy Plan: Continue to monitor while at BACC Prognosis: Excellent SURGERY: Okay for surgery

7/12/2017

Subjective:CAGE EXAM FOR PRE ALTER Observed Behavior – DOCILE Objective BARH BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted NO SIGNS OF URI MSI: Ambulatory x 4, no masses noted, healthy hair coat Assessment HEALTHY FEMALE Prognosis:EXCELLENT SURGERY: Okay for surgery

10/01/2018

DVM Intake Exam Estimated age: 1yr Microchip noted on Intake? yes (981020025023493) History: unknown Subjective: Dog is BARH, very hyper Observed Behavior – immediately social, panting and jumping around, difficult to examine, but only because she has trouble sitting still Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective T = NA P = wnl R = pant BCS 4/9 EENT: Eyes and ears appear grossly normal Oral Exam: Healthy adult dentition; Grade 0-1/4 dental dz H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: wnl; green linear tattoo ventral abdomen MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment: Apparently healthy Prognosis: Good-Excellent Plan: On Hold SURGERY: Already spayed

12/02/2018

DVM Intake Exam Estimated age: ~1 year Microchip noted on Intake? Positive 981020025023493 History : stray came in injured on RHL Subjective: BARH. Painful on RHL manipulation. Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective P = wnl R = eupneic BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: clean adult dentition, no oral lesions noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FS (spay tattoo noted), no MGTs, no vulvar d/c MSI: Ambulatory x 3 with NWB RHL lameness, skin free of parasites, no masses noted, healthy hair coat, ~3cm superficial wound on right flank, bruising on ventrum and right flank, right thigh swollen CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Compound closed fracture of the right pelvis through the body of the ilium and the body of the ischium Small superficial wound on right flank Plan: Continue to monitor while at BACC Pelvic and RHL rads: Compound closed fracture of the right pelvis through the body of the ilium and the body of the ischium, no fractures of the leg Start hydromorphone 0.1mg/kg IM BID x5d until 2/17 (3 doses given today every 4 hours-10:30am, 2:30pm, 6:30pm) Sedated with dexdomitor IM for rads (reversed with antisedan) Start rimadyl 4.4mg/kg PO SID x5d until 2/17 (first dose given SQ) Start clavamox 13.75mg/kg PO BID x7d until 2/19 Clipped and scrubbed wound on right flank Rec placement for surgery ASAP **ADDENDUM** at 4:00pm she had vomited 3 times (likely from hydromorphone). Cerenia 1mg/kg SQ given once. Prognosis: Good with surgical correction SURGERY: spayed

13/02/2018

Recheck fractured pelvis S/O: BARH. Active, attention seeking, allows all handling. BCS 4/9 Normal urination on walk, formed stool with small amount of frank blood. Excellent appetite. Drinking water EENT: Eyes clear, no ocular or nasal discharge, pink mm, minimal dental staining, ears WNL HL: Normal thoracic auscultation INTEG: Full coat, wound at right flank – road rash with ~1-2cm lacteration, deepest central area has small amount of purulent discharge MS: Ambulatory x 3, non ambulatory on RHL, mild swelling at thigh UG: Spayed A: Right sided pelvic fracture – complete closed fractures through body of right ischium and ilium P: Adding nolvasan cleaning of wound q12 x 3 days. Continue with other treatment and monitoring plan. Requires surgical repair – good prognosis with appropriate treatment and care

14/02/2018

Recheck fractured pelvis S/O: BARH. Active, attention seeking, allows all handling. Clean cage, appears house trained, normal urination and small/normal formed stool on walk. Eats well overnight, appears slightly lethargic and inappetant after hydromorphone. BCS 4/9 EENT: Eyes clear, no ocular or nasal discharge, pink mm, minimal dental staining, ears WNL HL: No coughing or sneezing, normal RR/RE INTEG: Full coat, wound at right flank – road rash with ~1-2cm lacteration, deepest central area appears healthy, no discharge, mild swelling, healing abrasion at caudal axillary region MS: Ambulatory x 3, non ambulatory on RHL, mild swelling at thigh UG: Spayed A: Right sided pelvic fracture – complete closed fractures through body of right ischium and ilium P: Continue with other treatment and monitoring plan. Requires surgical repair – good prognosis with appropriate treatment and care

15/02/2018

Progress exam History : Third time intake (12/5 and 1/10-APH). Spayed 12/7. 2/12-intake with fractured pelvis-jumped out of owners car. Started on hydromorphone, rimadyl, clavamox, and given cerenia for vomiting. Pelvic and RHL rads: Compound closed fracture of the right pelvis through the body of the ilium and the body of the ischium, no fractures of the leg 12/13-started on nolvasan cleaning of wound on right flank. Subjective: BARH. Has been growling and barking in cage especially towards men. Is able to bear weight on all 4 limbs but is still limping on RHL. Will need surgery. Objective P = wnl R = eupneic BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: clean adult dentition, no oral lesions noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FS, no MGTs, no vulvar d/c MSI: Ambulatory x 3 with toe touching RHL lameness, skin free of parasites, no masses noted, healthy hair coat, ~5cm superficial wound on right flank with healthy granulation tissue and no d/c, bruising on ventrum and right flank CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Compound closed fracture of the right pelvis through the body of the ilium and the body of the ischium Small superficial wound on right flank Plan: Continue to monitor while at BACC Continue hydromorphone 0.1mg/kg IM BID until 2/17 Continue rimadyl 4.4mg/kg PO SID until 2/17 Continue clavamox 13.75mg/kg PO BID until 2/19 Last day of nolvasan treatment of wound on right flank Rec placement for surgery ASAP Prognosis: Good with surgical correction

Nala was very active during intake with a loose, wiggly body. She pulled hard on the leash but was easily restrained. She was licking counselor and jumping on her lap for attention.