C09973248 / invoice 10000

Appointment Notes: UTI Primary complaint/relevant information:  Disease onset Progression and duration: Current Medications: None  Medical conditions: None  Appetite: Energy Levels: Exercise/Exercise intolerance: Vomiting: Diarrhoea:  Weight loss/gain: Thirst: Urination: Coughing/Sneezing/Respiratory signs: Diet:  Flea/tick:  Worming: Indoor/outdoor: Toxin exposure: Travel history: EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge Ears: Minimal debris, no inflammation or odour Lymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detectedTeeth: Dental grade 0/4, normal occlusion. COHAT Level Estimated: (A, B, C, D, E) Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen Abdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable MSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses Neurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed Reproductive/Urogenital: External genitalia normal in appearance Rectal: Not performed PROBLEM LIST: N/A DIAGNOSTICS: N/A ASSESSMENT/DDX: PLAN:MEDICATION: CLIENT COMMUNICATION: N/A TREATMENT: Handouts given: Health report / Dental / Arthritis / Other (Name)Estimate provided (Y/N or NA)Inhouse Urinalysis:Sample collected at  am/pm   via:USG:LEU:NIT:pH:PRO:GLU:KET:BIL:UBG:ERY:Hb:Cytology :Plan:    Vital Signs