4/01/2018

DVM Intake Exam Estimated age: ~2-4yrs Microchip noted on Intake? No History : Stray, brought in by NYPD Subjective: BARH. Voracious appetite Observed Behavior – Active, attention seeking, allowed all handling, wagging tail throughout exam Evidence of Cruelty seen – No Evidence of Trauma seen – Yes Objective P = WNL R = WNL BCS 4/9 EENT: Left eye clear, right eye swollen with hyphema, hyperemic conjunctiva, defect/trauma towards ventral/lateral cornea, non-visual in left eye, ears clean, no nasal discharge noted Oral Exam: mild dental tartar, pink mm PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male MSI: Ambulatory x 4, skin free of parasites, no masses noted, healing wound with healthy granulation tissue at right axilla extending caudally, ~3cm wound at right flank completely scabbed over, healing wound with healthy granulation tissue at right side of anus, perianal pressure sores, healing wound at left cranial thigh with areas of scabbing, and areas of healthy granulation tissue, deepest part of wound is full thickness skin wound but already has healthy granulation tissue present — no discharge, swelling or signs of infection from any wounds; mild swelling of both carpi with thickening of skin and pressure sores, comfortable on palpation, normal ROM; multiple healing wounds to face, linear scar at right side of rostral lip with defect of lip distally, wounds around right eye CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Multiple wounds in various stages of healing, including trauma to left eye. All wounds appear at least 10 days old. Underweight Plan: Rec clavamox 125mg PO q12 x 10 days, rimadyl 37.5mg PO q12 x 5 days, clean wounds with nolvasan q24 x 3 days. TAB OS q12 x 5 days. Continue to monitor while at BACC. Prognosis: Good SURGERY: Okay for surgery

8/01/2018

[Progress Exam Template] S: BAR, very friendly, rechecking eye (OS) after sustaining unknown trauma resulting in hyphema and edema O: friendly, hypema os and serosanguinous d/c os EENT: od wnl, os hyphema and corneal edema, non-visual, cannot see outline of pupil clearly Oral Exam: some wear and tarter H/L:wnl Abd: wnl/mi x 2 MSI: multifocal abrasions and skin lesions of varying sizes and states of healing – no d/c, odor pressure sores hind end/perianal area Mentation:bar A: repeated unkown trauma/wounds blunt force trauma in area of os r/o detachment of retina (+/- permanent blindness) vs uveitis vs glaucoma vs lens luxation skin wounds – healing P: stain – neg os tonometry (limited) os 13 od 15-20 neopolydex bid ultimately, may need exam by ophthalmologist and may have permanent blindness Is the Initial Medical Status being Changed? New Medical Status:n Is the Initial Behavior Status being Changed? New Behavior Color: n

10/01/2018

CIRDC noted on rounds S/O: BAR. Active, attention seeking, eating well EENT: Right eye clear, no discharge, mild swelling, hyphema OS, moderate serous nasal discharge HL: Sneezing, mild cough, normal RR/RE INTEG: Multiple wounds in various stages of healing, all healing well MS: Ambulatory x 4 UG: Male A: Early/Mild CIRDC; multiple wounds including wound/injury to left eye P: Adding doxycycline 250mg PO q24 x 14 days. Excellent prognosis

11/01/2018

Progress exam-recheck OS S/O: BAR barking at the front of the cage. No cvd but is sneezing. EENT: Right eye clear no d/c, OS has hyphema filling entire chamber, difficult to assess vision, no d/c, mild serous nasal discharge HL: Sneezing, normal RR/RE INTEG: Multiple wounds in various stages of healing, all healing well MS: Ambulatory x 4 NEURO: A&A A: CIRDC Multiple wounds including wound/injury to left eye Hyphema OS P: Continue doxycycline until 1/23 Rec ophthalmology consult for left eye-may need enucleation CTM while at BACC Continue clavamox until 1/13 Ok to d/c TAB ointment Excellent prognosis