C09997468 / invoice 10000

HISTORY: Polly is presenting for general health check and vaccination.
Onset: Owner reports head shaking has been common for Polly, tried an ear cleaner, seems better now. 
EDDU normal, no CSVD.
Diet: kibble, chunkers, table scraps
Current medications/supplements: none
Flea/tick/intestinal worming prevention: UTD

PE:

General Appearance & Behavior: Alert, friendly, active and wiggly during exam.
Hydration Status: Euhydrated, normal skin tent, MM pink and moist, CRT <2 sec
BCS: 7/9 - recommend weight loss
Eyes: NSF, clear and free of discharge, pupils normal size, globes symmetrical OU
Ears: AD with mild erythema of the medial pinna and excoriations consistent with recent scratching; AS appears normal. Cytology: NAD bilaterally
Oral Cavity: Mild yellow dental calculus on caudal teeth; no gingivitis.
Nasal Cavity: NSF, no nasal discharge noted
Integument: NSF, skin appears normal; hair coat in good condition, no ectoparasites or masses noted
Lymph nodes: NSF, no peripheral lymphadenopathy noted
Thyroid: NSF, no enlargement or painful palpation noted
Cardiovascular: NSF, no murmurs or arrhythmias noted, pulses strong and synchronous, HR: 96
Respiratory: NSF, eupneic, lungs sounds clear in all 4 quadrants; no cough elicited on tracheal palpation, RR: panting, RE normal
Abdomen: NSF, no pain notes in abdominal palpation; no masses or organomegaly noted
Urogenital: NSF, no discharge noted. No abnormalities notes on bladder or kidney palpation
Musculoskeletal: NSF, normal ambulation x4, normal muscle mass
Neurologic: NSF, normal mentation, no obvious deficits notes, full neuro exam not performed
Urogen: NAD
Rectal: Rectal exam not performed

Assessments:
Healthy for vaccination today 

Problem List:
Overweight body condition - Discussed weight management: advised gradual weight reduction by decreasing total daily food by approximately 10% and monitoring treats and table scraps. Recommended slow weight loss over several months with periodic weigh-ins. Mentioned availability of lower-calorie satiety diets if needed.

Treatment:
Nobivac Pi/BB (killed) inj SC (Batch no: 2526207, exp 04-2027)

Plan:
Next vacc due: 1 year
WRMRQ: N
FLRQ: N
WEIGHT: 32.80

HISTORY: Hx:
EDUF normal
Diet: metabolinc and salmon
Flea/tick/IW/HW prevention: change products as can be hard to give to Opie - o always uses a combination that covers hw and fleas/ticks - currently simparica trio but likely to change back to HG and bravecto spot on
Any known health conditions:
skin allergies - mild at the moment - some mild inflam on groin
Current medications:
topical cream for skin
o declines any work up or additional meds for skin at the moment

PE:
seen outside - no weight recorded today
BAR
Ears, eyes, nose: clean, no discharge
Mouth: NAD, dental Grade: 1/4
Peripheral LNs: NAD
Cardiovascular: No murmur detected HR: 130, no jugular distension, SSFP, mm p+m, crt <2s
Respiratory: Lung sounds clear, RR: pant
Abdomen: NAD, comfortable on abdo palpation
Integument: very mild inflam on lateral caudal ventral skin, no evidence of fleas
MSK: NAD, not fully examined
Neuro: NAD, not fully examined
Temperature: not taken

Assessment:
Fit for vaccination

Treatment:
Nobivac Pi/BB (killed) inj SC scruff

Plan:
Next vacc due: 12 months
Ongoing parasite prevention: bravecto/HG
Recheck if skin issue worsens

HISTORY: Hx:
EDUF normal
Flea/tick/IW/HW prevention: heartwormer monthly. bravecto spot on every 3-4 months

PE: lovely dog
BAR
Ears, eyes, nose: clean, no discharge
Mouth: NAD, dental Grade: 1/4
Peripheral LNs: NAD
Cardiovascular: No murmur detected , no jugular distension, SSFP, mm p+m, crt <2s
Respiratory: Lung sounds clear
Abdomen: NAD, comfortable on abdo palpation
Integument: NAD, no evidence of fleas
MSK: NAD, not fully examined
Neuro: NAD, not fully examined
Temperature: 38.5

Assessment:
Fit for vaccination

Treatment:
Nobivac DHP (modified live canine distemper, canine adenovirus and parvovirus) inj SC
Nobivac KC (pi/bb modified live) intranasal
WEIGHT: 27.5