ROME – 9783

DVM Intake Exam Estimated age: ~14-15 years Microchip noted on Intake? negative History : stray Subjective: BARH Observed Behavior – Reported to be very difficult in field and biting catch pole. Muzzled for exam. Frozen and very scared Evidence of Cruelty seen – no Evidence of Trauma seen – yes Objective P = wnl R = eupneic BCS 5/9 EENT: Eyes clear with nuclear sclerosis ou, ears clean with fly bite wounds on tips of pinnas au, no nasal discharge noted Oral Exam: no oral exam due to muzzle PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MI, 2 testicles descended MSI: LHL lameness with cachexia especially in LHL, skin free of parasites, no masses noted, unkempt hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: LHL lameness r/o fracture Geriatric Fly bites on ear pinna Plan: Continue to monitor while at BACC Hydromorphone 0.1mg/kg IM BID 2 view LHL and pelvic rads tomorrow with sedation (dexdomitor 10mcg/kg IV + butorphanol 0.2mg/kg IV with antisedan reversal) Keep in medical Recheck tomorrow Prognosis: Fair to poor SURGERY: permanent waiver from surgery due to age

[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.

Progress exam-LHL lameness History : stray intake 10/14-reported to be limping on LHL. Started on hydromorphone. Subjective: BARH. Resting comfortably in cage. Eating and drinking well on own. Very difficult to get out of cage and will try to lunge and bite. Objective -very limited exam due to behavior BCS 5/9 EENT: Eyes clear with nuclear sclerosis ou, ears clean with fly bite wounds on tips of pinnas au, no nasal discharge noted. Otoscopic exam revealed mild debris in deep canals but tympanic membrane intact AU MSI: LHL lameness with cachexia especially in LHL, skin free of parasites, no masses noted, unkempt hair coat CNS: mentation appropriate, left head turn and tilt. Unable to fully assess due to behavior Assessment: LHL lameness r/o fracture Geriatric Fly bites on ear pinna Left head turn and tilt r/o vestibular vs central lesion Plan: Continue to monitor while at BACC Hydromorphone 0.1mg/kg IM BID-reassess 10/19-switch meds? 2 view LHL and pelvic rads tomorrow with sedation (dexdomitor 10mcg/kg IV + butorphanol 0.2mg/kg IV with antisedan reversal) -complete transverse closed fracture of the left femoral distal diaphysis with significant caudomedial displacement and callus formation (chronic fracture) Keep in medical Recheck tomorrow CBC-wnl Chem-wnl Due to chronicity of fracture, will likely need a LHL amputation Add rimadyl 4.4mg/kg PO SID x7d Prognosis: Fair to poor

Progress exam-LHL lameness History : stray intake 10/14-reported to be limping on LHL. Started on hydromorphone. 10/16: CBC-wnl Chem-wnl 2 view LHL and pelvic rads -complete transverse closed fracture of the left femoral distal diaphysis with significant caudomedial displacement and callus formation (chronic fracture) Started on rimadyl Subjective: BARH. Resting comfortably in cage. Eating and drinking well on own. No c/s/d/v Objective -very limited exam due to behavior BCS 5/9 EENT: Eyes clear with nuclear sclerosis ou, no nasal d/c MSI: LHL lameness with cachexia especially in LHL, skin free of parasites, no masses noted, unkempt hair coat CNS: mentation appropriate, left head turn and tilt. Unable to fully assess due to behavior Assessment: LHL lameness-complete femoral fracture with significant callus formation Geriatric Fly bites on ear pinna Left head turn and tilt r/o vestibular vs central lesion Plan: Continue to monitor while at BACC Hydromorphone 0.1mg/kg IM BID-reassess 10/19-switch meds? Keep in medical Recheck tomorrow Due to chronicity of fracture, will likely need a LHL amputation Continue rimadyl 4.4mg/kg PO SID until 10/23 Prognosis: Fair to poor