C09983809 / invoice 10000

Primary Presenting Complaint - unwell
only eating tiny amoutns as treats
no lamenes, cough etc. 
no vom/diarr
slight cough 

Other Complaint - 
         Loyalty Reward Program - Y/N
History - 
not eaten properly for 6 days 
will take treats at park but niting else 
faeces normal 
drinking a bit more than normal 
behaviour hasnt changed 
no V+
hypersalivation 
doesnt seem sore 
         Last Normal -
         Frequency   -
         Last Ate       -
         Medicine Hx  - gaba 
         Diet              -
         Vacc Current -
         Worming Hx  -
         Heartworm    -
         Microchip       -  Y / N    -  scanned - ok?

Examination -
         Attitude -relatively BAR doesn't want to be here
         Body Score -  5  /10
         Temperature - 39.6
         Heart -  108 HR. Murmur - none heard
         RR -about 20
         Dental - Score(0-4)=  2  .Comment nad in oral cavity but somewhat limited exam
         CRT - immediate
         Eyes - NVL
         Ears - clean and discharge free
         Abd Palpation - Unremarkable. nsf
         Gastrointestinal -  No Sig Findings
         Urogenital -  No Sig Findings
         Skin - 
         Musculoskeletal -  No Sig Findings
         Neurological -  No Sig Findings
         Lymphatic - all reg LN sl enlarged but nto huge/firm
         Other key findings = 

Assessment - 
Problem List - inappetant, wt loss
DDx                 - infection (neoplasia, lymphoma)
Discussed      - defs pyrexic. recomm bloods and go from there
Treatment Plan - tba
Prescriptions(on-going) -n
Next Visit            -tba

bloods 
elevated wcc, neut (no bands noted)
crp elevated
otherwise unremarkable

infection? poss chest if has slight cough? lymphoma??? other neopalsai? uncertain underlying pathology. recomm abs and paracetamol (on beransa), 
if doing well, revisit  at end of  week rpt crp and send off cbc for lab
ini ini will need imaging (chest abdo rads, poss abdo scan)

Primary Presenting Complaint - 
Other Complaint - 
         Loyalty Reward Program - Y/N
History - 
         Last Normal -
         Frequency   -
         Last Ate       -
         Medicine Hx  -
         Diet              -
         Vacc Current -
         Worming Hx  -
         Heartworm    -
         Microchip       -  Y / N    -  scanned - ok?

Examination -
         Attitude -
         Body Score -    /10
         Temperature - 
         Heart -   HR. Murmur - 
         RR -
         Dental - Score(0-4)=    .Comment
         CRT - immediate
         Eyes - NVL
         Ears - clean and discharge free
         Abd Palpation - Unremarkable
         Gastrointestinal -  No Sig Findings
         Urogenital -  No Sig Findings
         Skin - 
         Musculoskeletal -  No Sig Findings
         Neurological -  No Sig Findings
         Lymphatic - No Sig Findings
         Other key findings = 

Assessment - 
Problem List - 
DDx                 - 
Discussed      - 
Treatment Plan - 
Prescriptions(on-going) -
Next Visit            -