C09981978 / invoice 10000

Reason: Bloods And Weight Check. BKAppointment Notes: Overdue reminders  ------- Sms reply: YHISTORY:  Presented for recheck and medication review.Owner reports Arthur has been sneezing daily, approximately 3-4 times in a row, with no discharge. This has been ongoing since the last visit.There was a single day of diarrhoea, which has since resolved. No vomiting. Appetite and energy levels are good.Weight has decreased slightly to 4.97kg. Owner reports a reduction in the amount of biscuits offered in the morning. Current meds: Pred 0.75 once daily, Atopica 2.5mg once daily.Vaccination: UTDParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 4/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): 1/4- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussed PROBLEM LIST:1. Chronic sneezing2. Previous single episode of diarrhoea (resolved)3. Minor weight loss (4.97kg) DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Viral diarrhoea (resolved) DIAGNOSTICS:Bloods were taken for testing: awaiting results- Please find attached to the patient record. ASSESSMENT:Arthur presents for recheck. Clinically well. History of daily sneezing and a resolved episode of diarrhoea. Examination is unremarkable. Weight is 4.97kg, a slight decrease, possibly due to dietary changes at home. Bloods taken for routine monitoring. TREATMENT:  No change to current medications (Pred, Atopica). PLAN:Plan is to review blood results. If bloods are stable, consider reducing prednisolone to 0.5ml.Continue current management.Home into owner's care. CLIENT COMMUNICATION:Discussed the plan to review bloodwork before making any medication changes. Advised that if results are good, the aim is to reduce the prednisolone dose. Discussed the current medications and confirmed the largest available size for Atopica. Addressed the minor weight loss, likely related to reduced food intake.    Vital Signs    Weight: 4.97;