3/01/2018

DVM Intake Exam Estimated age: ~10 years Microchip noted on Intake? negative History : stray Subjective: BARH. Reported to be straining to defecate while in shelter. Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures. Muzzled for exam. Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective P = wnl R = eupneic BCS 5/9 EENT: Eyes clear with nuclear sclerosis ou, ears clean with mild erythema of pinna, no nasal discharge noted Oral Exam: limited oral exam due to muzzle PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MN MSI: Ambulatory x 4 with crepitus of hips, skin free of parasites, no masses noted, unkempt hair coat with old healed scars, hematochezia CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Suspect osteoarthritis Hematochezia Plan: Continue to monitor while at BACC Start metronidazole 15mg/kg PO BID x5d until 1/8 (first dose given today) Rec geriatric workup Rec joint supplements Prognosis: Good SURGERY: neutered

7/01/2018

Progress exam History : stray intake 1/3. Had hematochezia on intake and has been noted to be straining to defecate in shelter since intake. Subjective: QARH. Reported to be straining to defecate while in shelter but today had a bowel movement that was normal at the beginning but soft at the end. During PE had FS 6/7 diarrhea. Has a left head tilt. Objective P = wnl R = eupneic BCS 5/9 EENT: Eyes clear with nuclear sclerosis ou, ears clean externally, no nasal discharge noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MN MSI: Ambulatory x 4, skin free of parasites, no masses noted, unkempt hair coat with old healed scars CNS: mentation appropriate – left head tilt, CN wnl Assessment: Suspect osteoarthritis Hematochezia/straining to defecate Left head tilt Plan: Continue to monitor while at BACC Continue metronidazole 15mg/kg PO BID until 1/8 CBC-machine currently not working, will try again tomorrow Chem-wnl T4-wnl Rec joint supplements Cleaned ears-debris deep in canal AD Fecal pending Rec neuro consult for head tilt Prognosis: Good

8/01/2018

Progress exam History : stray intake 1/3. Had hematochezia on intake and has been noted to be straining to defecate in shelter since intake. 1/7 Chem-wnl T4-wnl Fecal negative Subjective: QARH. Had massive amounts of diarrhea and vomiting today. Vomited chunks of food. Standing and crying in the cage. No coughing or sneezing. Good appetite. Objective EENT: Eyes clear with nuclear sclerosis ou, no nasal discharge noted H/L: eupneic MSI: Ambulatory x 4, skin free of parasites, no masses noted, unkempt hair coat with old healed scars CNS: mentation appropriate – left head tilt Assessment: Vomiting Suspect osteoarthritis Diarrhea Left head tilt Plan: Continue to monitor while at BACC AXR scheduled for tomorrow Rec NH placement ASAP Start LRS 20ml/kg SQ SID x3d until 1/10 Start cerenia 1mg/kg SQ SID x3d untul 1/10 Extend metronidazole 15mg/kg PO BID until 1/13 CBC-machine currently not working, will try again when machine working Rec joint supplements Rec neuro consult for head tilt Prognosis: Good

9/01/2018

Progress exam History : stray intake 1/3. Had hematochezia on intake and has been noted to be straining to defecate in shelter since intake. 1/7 Chem-wnl T4-wnl Fecal negative 1/8-started vomiting. Started on LRS and cerenia. Subjective: QARH. No csvd reported since yesterday. No signs of CIRDC. Seems unhappy in the shelter. Objective EENT: Eyes clear with nuclear sclerosis ou, no nasal discharge noted H/L: eupneic, normal RR/RE MSI: Ambulatory x 4, skin free of parasites, no masses noted, unkempt hair coat with old healed scars CNS: mentation appropriate – left head tilt Assessment: Geriatric Vomiting-once on 1/8 Suspect osteoarthritis Diarrhea-resolved Left head tilt Decreased serosal detail of cranial abdomen r/o mass vs other Spondylosis deformans of lumbar spine Plan: Continue to monitor while at BACC AXR-lots of ingesta with mineral opacity in the stomach, decreased serosal detail in the cranial abdomen cannot rule out mass etc, feces in colon with mineral opacities, spondylosis deformans along lumbar spine in each intervertebral space, possible splenomegaly Rec AUS Used telazol 0.8ml IM sedation for AXR Rec NH placement ASAP Continue LRS 20ml/kg SQ SID until 1/10 Continue cerenia 1mg/kg SQ SID until 1/10 Continue metronidazole 15mg/kg PO BID until 1/13 CBC-machine currently not working, will try again when machine working Rec joint supplements Rec neuro consult for head tilt Prognosis: Good

7/01/2018

Vet does not desire rads at this time. Chemistry results entered in vet documents; CBC not in working order – rescheduled. Fecal test run on sample during bw/negative.

Upon intake Pillow was placed in the kennel.