C09977861 / invoice 10000

Record complete Y/N

Reason/concerns:  

History:
suspect injured LHL ~4d ago, licking and limping on LHL
hesitate to jump up on furniture
doing a lot better now

Pre-exisitng Conditions / Medications:
- No pre-exisitng conditions noted at the time of examination
- No medications currently being provided at the time of examination

Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm).

Examine: 
Mentation: BAR
BCS:                           /5   
MM: Pink          
CRT: 1-2 seconds
HR:                             beats/min
RR:                             breaths/min
Temperature:              degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: Some gingivitis and calculus observed.
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.
Problem List:

Patient Assessment: 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- None performed 

Treatment with medication 
dose rates (if any):

Client Communication
& Plan: 
(see attached vetcheck client information sheets if provided)

On-going medications required: Y/N (use prescription tab for further supply):

Next check up date:

Reason:
Consult Nurse:
History:
     EDUF:
     Nutrition:
     V#/D#/Coughing?
     
What Preventative health cover is being used and do you need to purchase any today?
Vaccination:
Worming: 
Flea control: 
Heartworm Prevention: 

Examine:
     General Appearance:
     Body Score:
     Coat/Skin:
     Ears/Eyes:
     Dental Stage:

Microchip:

Assessment:

Treatment:

Email Sent:

Next Appointment:

Reason: Courtesy phone call post surgery/ procedure
Nurse: N.P 
History: Castration 
     Demeanour: BAR 
     Eating/ Drinking: NAD
     Toileting: NAD
     Any concerns? no 

Surgery site/ sutures: NAD
Eliz collar: yes

Treatment:
     Medications being given: meloxicam 
     Patient taking meds as prescribed? yes 

Assessment: P is recovering well at home. 

Next Appointment: