C09972620 / invoice 10000

REASON: {__}
Nurse: {__}
Presented by: {__}
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HOME CARE AND PREVENTIONS
Vaccinations: {__}
Nutrition: {__}
Worming: {__}
Hwp: {__}
Flea Treatment: {__}
CE: {__}
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SUBJECTIVE / HISTORY: 
{__}
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
{__}
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OBJECTIVE / EXAM:
ASA Status (1-5): {__}
BCS (1-9): {__}
DS (0-4): {__}

T: {__}
P: {__}
R: {__}

APPEARANCE/DEMEANOUR: {__}
SKIN & COAT: {__}
EARS: {__}
EYES: {__}
ORAL: {__}
MM: {__}
CVS: {__}
RESP: {__}
ABDO/GIT: {__}
UROGEN: {__}
NEURO: {__}
MSK: {__}
LN: {__}
n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
{__}

Ddxi:
{__}

Further Procedure & Diagnostic Needs [Client Response]:
{__}

Medication:
{__}

Ongoing medication prescriptions? Renewed prescriptions: {__}
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
{__}
Finalised by {__}
Rec = Recall     Rev = Revisit     Rem = Reminder

REASON: Semi HC + c3 
Nurse: JL 
Presented by: Sally
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HOME CARE AND PREVENTIONS
Vaccinations: KC due in 2 months 
Nutrition: Farmers market + RC dental 
Worming: advocate  
Hwp: ^^ 
Flea Treatment: ^^ 

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SUBJECTIVE / HISTORY: 
EDUD n 
Has only coughed a couple of times since dental

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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
Fluoxetine 5mg SID 
Trazodone 0.4ml as needed for holidays 
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OBJECTIVE / EXAM:
ASA Status (1-5): 1
BCS (1-9): 5
DS (0-4): 1

T: 38
P: 124
R: panting 

APPEARANCE/DEMEANOUR: BAR, anxious 
SKIN & COAT: n
EARS: clean 
EYES: clear and bright 
ORAL: mild staining on upper carnassials only 
MM: pink 
CVS: regular, no murmur 
RESP: thorax clear 
ABDO/GIT: comfortable on palpation 
UROGEN: n
NEURO: n
MSK: n
LN: n
n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
nil 

Fit for vaccination. 
Duramune C3 given s/c dorsal neck at the level of the shoulder blades.

Trazodone for holidays - try 5mg/kg (0.4ml) as needed, if no side effects and not working can try 5mg/kg (0.5mls). Stop medication if any signs of d+, v+, appetite loss, or signs seizure 

Ongoing medication prescriptions? Renewed prescriptions: yes, fluoxetine
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
JL to take home KC in Nov
Rem 6m HC vet
Finalised by ALX
Rec = Recall     Rev = Revisit     Rem = Reminder

Dispensed Trazodone for travelling