DVM Intake Exam Estimated age: ~5yrs Microchip noted on Intake? no History : stray Subjective: Observed Behavior – QARH. Allows all handling, very docile Evidence of Cruelty seen – no Evidence of Trauma seen – yes Objective P = WNL R = WNL BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Mild dental tartar/staining, mild gingivitis, pale pink mm PLN: No enlargements noted H/L: Grade 3/6 heart murmur, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, ~3cm mass protruding from vulva with areas of necrosis, able to replace mass/prolapse into vaginal canal but immediately protrudes back out MSI: Ambulatory x 4, RH lameness, possible femoral fracture, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: heart murmur, possible fractures, vaginal prolpase vs vaginal mass Plan: Cerenia 1.8ml SQ and hydromorphone 0.9ml IM. Radiographs pending Prognosis: Fair SURGERY: Permanent waiver due to prolapse, possible fracture Addendum: Palpated vaginal canal and confirmed protrusion is a tumor stemming from dorsal vaginal canal, not a vaginal prolapse. Cleaned around mass with dilute chlorohex solution and applied TAB

[Spay/Neuter Waiver – Medical Condition] Your newly adopted pet has been diagnosed with a vaginal prolapse, possible fracture & 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.

Monitor condition – Suspect HBC, heart murmur, TVT S/O: QARH. Allows all handling. Excellent appetite. Normal urine and stool in cage. EENT: Moderate dental tartar, pink/pale pink mm, eyes clear, no ocular or nasal discharge, ears wnl HL: Grade 3/6 heart murmur, lungs clear ABD: Soft, non tender INTEG: Slightly dirty, small amount of dried blood at front paws MS: Ambulatory x 4, toe tapping lameness RH, no palpable fractures, no obvious wounds, mild to moderate swelling UG: Female, swollen vulva, small amount of serosanguinous/bloody discharge, ~3cm tumor from dorsal vaginal wall inside vaginal cavity A: Heart murmur, RH lameness, vaginal mass – R/O transmissible venereal tumor vs other P: Adding rimadyl 37.5mg PO q12 x 5 days and clavamox 250mg PO q12 x 10 days. Continue to monitor while at BACC. Tumor may regress without intervention vs surgical excision. Good prognosis for benign tumors. Rec cardiology work up for heart murmur.

Right hind limb/pelvis for right hind lameness- lateral and VD: Long bones, spine, pelvis in tact. No fracture of RH observed

S/O: Q/BARH. Attention seeking, allows all handling, wagging tail, calm and sweet for exam. Excellent appetite. Normal urine and stool in cage. Blood spots in cage. BCS 5/9 EENT: Pink mm, moderate dental tartar/staining, eyes clear, no ocular or nasal discharge, ears wnl HL: Grade 3-4/6 heart murmur, lungs clear, no coughing or sneezing ABD: Soft, non tender INTEG: WNL MS: Ambulatory x 3, non weight bearing lameness on RHL with moderate swelling, no external injuries noted, no palpable fractures, no cranial drawer UG: Female, markedly swollen vulva, palpable vulvar mass ~0.5cm into vaginal canal, palpate ~2-3cm around, small amount of bloody vaginal discharge A: RH lameness – R/O soft tissue injury (radiographs negative for fractures/dislocations) Vulvar mass – R/O TVT vs other Heart murmur – no clinical disease at this time P: Continue with current treatment and monitoring plan. On rimadyl and clavamox. Rec cardiology work up. Rec cage rest for lameness, recheck after course of rimadyl. TVT may resolve without intervention vs require surgical excision vs benign neglect

[Progress Exam Template] S: BAR, eating well O: hx rh lameness, vaginal tumor, murmur EENT: wnl Oral Exam: several fx and worn teeth H/L: grade 3/6 sys murmu Abd: soft and non-painful, vaginal tumor MSI: stiff, stilted, and short-strided gain rh, no overt fx and no pain on f/e, decreased muscle mass right hind comp to left Mentation: pe pododermatitis x 4 and multiple abrasions and old scars around body A: murmur r/o hip issue vs soft tissue/previous injury vaginal tumor – r/o estrogen induced tumor vs tvt P: continue clavamox ovh and removal and histo of tumor rec: jt supplementation, fish oil, rimadyl Is the Initial Medical Status being Changed? New Medical Status: Is the Initial Behavnior Status being Changed? New Behavior Color: n

Shortcake allowed the counselor to collar her and take her picture with no problems.