C09978329 / invoice 10000

REASON: hc
Nurse: -
Presented by: Tania
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HOME CARE AND PREVENTIONS
Vaccinations: not doing
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SUBJECTIVE / HISTORY: 
- The owner presented for a health check..
- The owner reports that the animal appears to be gaining weight, describing them as "a bit chubby". The animal's weight was 28.4 kilograms in August and is estimated to be approximately 28 kilograms currently. Previous weights were recorded at 26.5 kilograms and 25.4 kilograms, indicating a gradual increase.
- The animal is described as active but also lazy. They do not enjoy long walks and will sometimes need to be carried home from the park. The owner notes that after a long walk, the animal's hips seem to be affected. The animal is also sensitive to heat and will become immobile once they overheat.
- The owner reports that the animal is no longer limping, which was previously observed for a period of time. However, it has been noted that the animal does not place as much weight on one of their legs.
- The animal's diet consists of a very light dinner, and they no longer receive breakfast. Treats are given infrequently and are free from sugars.
- The owner reports that the animal will indicate when they want to play by looking at them with a "crooked ear" and will follow them around the house to initiate play.
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
antinol
apoquel
gaba
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OBJECTIVE / EXAM:
ASA Status (1-5): 1
BCS (1-9): 6
DS (0-4): 0

T: -
P: 120
R: panting

APPEARANCE/DEMEANOUR: bar
SKIN & COAT: nad - looking cointrolled at the moment
EARS: bit red but O cleans as necessary
EYES: nad
ORAL: teeth clean
MM: pink moist
CVS: reg pulse - unable to listen to heart as reacting to stethoscope
RESP: normal rre
ABDO/GIT: nad
UROGEN: -
NEURO: -
MSK: hind legs bow legged - no obvious discomfort felt
LN: nad
n : Normal     - : Not Examined
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ASSESSMENT: 
1. Weight Management
- The animal has shown a gradual weight gain over time, with current weight estimated at 28 kilograms.
- It was recommended to reduce food portions slightly to manage weight.
- It was also advised to implement shorter, more frequent walks rather than one long walk per day, which may be more comfortable for the animal's joints.

2. Joint Health
- The owner reports that the animal's hips seem affected after long walks and that they are sensitive to heat.
- A repeat prescription for Antinol was provided to assist with joint health and advised to keep on gaba.

3. Vaccination Status
- The owner has elected not to vaccinate at this time.

4. Skin
- Controlled with the apoquel - script put on file

Ongoing medication prescriptions? Renewed prescriptions: apoquel
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
hc 6 months

Finalised by kp.

Rec = Recall     Rev = Revisit     Rem = Reminder

O requested we call today to confirm/ cancel/ reschedule next Mondays booking (5pm on Monday 2nd March)
Unable to STO but LAM asking for a call back to confirm, booking left as is for now 

O called back and confirmed 5pm on 2/3 VP

Type of Appointment: semi health check with vet
Time of Appointment: 5 pm on 16/2
SMS CANCELLATION: sent owner SMS to cancel pre-booked appt today as they had not confirmed