C10001641 / invoice 10000

Presenting Complaint -  Vaccination/Check up
Other Complaint -  upped food and treats- weight ok ? goes on and off bickies, fussy boy. 
         Loyalty Reward Program - Y/N
History - 
         Medicine Hx  - 
         Worming Hx  - sipmarica trio 
         Heartworm    -
         Microchip      -  Y / N     scanned -  ok?

Primary Presenting Complaint:
Routine wellness check/weight monitoring

Other Complaint:


History:


    - Last Normal - 
    - Frequency - 
    - Last Ate - Eating normally, though prefers mixed food to dry alone
    - Vomiting - 
    - Stool - 
    - Urination - 
    - Drinking - Drinking normally
    - Medicine Hx - 
    - Diet - Diet recently increased, receiving more treats. Prefers wet food mixed with dry kibble rather than dry food alone
    - Vacc Current - 
    - Worming Hx - 
    - Heartworm - 
    - Microchip - Y/N - scanned - ok?

Examination:
Healthy patient with appropriate weight gain

    - Attitude - Happy and bright
    - Body Score - Appropriate body condition
    - Hydration status - 
    - Temperature - 
    - Heart - HR. Murmur -
    - RR - 
    - Dental - Score(0-4)= 
    - 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:
Healthy patient with successful weight gain to appropriate level

Problem List:


DDx:


Discussed:
Owner reports patient doing well overall. Discussed that current weight is appropriate and feeding regimen should continue. Owner aware of food preferences (mixing wet with dry)

Treatment Plan:
Continue current diet and feeding plan

Ongoing Prescriptions:


Next Visit:
Return as needed

The above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.

O collected P at 3pm wednesday and will bring him back at 5pm for another night. She has dropped off his dinner and breakfast for tomorrow. She will collect him tomorrow at 3pm.