C09991200 / invoice 10000

GapOnly Claim Insurance Summary

First Clinic Signs:        

Summary:                        

Diagnosis:                           

Treatment: 

Reason: Vaccination
History: no concerns at all
went to derm, since moved down here, O said hasnt flare up
- seen by Murdoch derm in the past
normal diet: kangaroo, + some chicken carcasses, which hasnt flare allergies up yet so far
occasional licking at the paws, no head shaking or scratching so far
 - EDUF: normal 
 - V#/ D#/ Coughing: none

Current medications: None

What Preventative health cover is being used and do you need to purchase any today? due for vacc, had KC last year but been having C4 protech + BB inj yearly

Examine: was ok for PE and vacc today, MO holding for checking ears
Mentation: BAR
BCS:    3.5/5   
MM: Pink and moist         
CRT: 1-2 seconds
HR:  120    beats/min
RR:  20  breaths/min
Dental Stage: 1
Temperature:38.8 degrees Celsius
Ears: mild yellow/brown exudate noted on both ears upon otoscopic exam. TM intact. Cytology: L ear cocci 2+, yeast 2+, R ear cocci 1+, yeast 1+
Gastrointestinal: No masses or abnormalities noted on palpation
Integumentary: No significant abnormalities noted during routine physical examination
Musculoskeletal: No evidence of lameness

Assessment: fit for vacc
bilateral OE

Treatment: able to vacc fine with MO holding
Vaccination given: duramune + bb inj
Batch number: 5260010//15504
annual vac due: KC1 2026

dermotic both ears bid for 10d
epiotic flush both ears sid for 10d

Reason for visit:
vacc
Salient History: No vomiting or diarrhea. No tenesmus
Normal appetite. Commercial food/Mix
No polydipsia or polyuria
No coughing.

Current Medications: -
Allergies: none we are aware of
Preventatives and Vaccinations: KC booster due
Body Condition Score: 5/9.

Patient compliance with this exam- good/limited/ restricted- limited--- O must hold CARE

Vitals: Heart Rate - approximately 120, Mucous Membranes pink, moist, Capillary Refill Time ~2 seconds, Respiratory Rate ~24bpm , Temperature 38.8°C.

Mentation: Bright, Alert, Responsive.

System Examination:
Eyes: No conjunctival or scleral vessel injection, blepharospasm, or discharges. 
Ears: No discharge or discomfort.
Nose: No significant findings, no discharges noted during examination.
Oral: No significant findings, approximately 1/4 dentition.

Integument: No significant findings, coat condition is fair, skin turgor normal.
Pruritis score 0/10

Cardiovascular System: No murmurs detected. Pulses synchronous, normodynamic.
Respiratory: Normal breathing effort and normal bronchovesicular sounds throughout both hemithoraces.

Abdomen: Mild abdominal splinting at the time of examination, no significant reaction on palpation of abdomen. No organomegaly detected.
Rectal: Not performed, externally normal.
Urogenital: No discharge observed.
Lymph Nodes: Palpable peripheral lymph nodes within normal limits.

Neurological: Cranial Nerves - Facial sensation intact, pupils equal and reactive to light, head carriage normal, no spontaneous nystagmus or deviation of eyeballs.
Spinal Nerves - a full neuro exam was not performed. No ataxia, voluntary motor functions intact in all limbs. 
Musculoskeletal: Normal ambulation observed during consultation. Adequate muscling in all appendicular limbs. No palpable joint or neck pain. A full musculoskeletal examination not performed.

Summary of Problems:
An unremarkable physical exam.

Recommended/Additional Diagnostics:
-
Plan/ Treatment discussed with Owner:
vacc Pi2 and inj BB((5260008/15404))
Revisit as indicated.