C10007446 / invoice 10000

Verified: NoHistory:Presenting for: Daisy presented for routine vaccination and health checkHistorical Conditions: Previous dental procedure performed, history of elevated abdominal levels years ago (resolved with dietary management)Diet: Hills seafood diet (selected due to previous abdominal issues), freeze-dried treats, appetite variable - sometimes skips meals or eats only half portionsCurrent Meds: NexGard Spectra monthly (up to date), quarterly worming (not due until April)Lifestyle Risk Factors: Attends group walks twice weekly, limited off-leash exposure unless familiar with other dogsOther: Client concerned about possible glaucoma in eyes, noted small skin tag on legExamination:Mentation: BARWt: 21 kg (previously 22.9 kg last year, 20.1 kg in 2022, 17.3 kg when acquired from pound in 2020)BCS: OverweightBehavioural: Anxious at veterinary clinic, pre-medicated with Trazodone 100mg (night before and morning of appointment) and Gabapentin 300mg (morning of appointment). Muzzle applied for procedures - well toleratedEyes: Lenticular sclerosis present bilaterally, vision adequate for daily activities but may have some difficulty with fine focusOral: Dental examination performedIntegumentary: Small 2mm skin tag noted on right stifle, benign appearance, no growth expectedCardiovascular: HR and rhythm normalAbdominal: Palpation performedAssessment:Overweight - current weight 21kg, target weight 20kgLenticular sclerosis - age-related lens changes, not glaucoma, vision functionally adequateBenign skin tag right stifle - no treatment requiredOtherwise apparently healthyPlan:Vaccinations:- Kennel Cough vaccine administered- Lepto booster recommended in 2-6 weeks due to recent case at Darlinghurst practice and client's proximity to areaNew Meds/Tx:- Gabapentin 300mg capsules dispensed (10 capsules) - give one capsule 2 hours before veterinary appointments- Trazodone 100mg tablets dispensed (10 tablets) - give one tablet night before and one tablet 2 hours before veterinary appointmentsDiet Recs:- Reduce daily food portions to match smallest amount consumed in a typical week- Reduce treats and supplemental feeding on days when extra treats/bones are given- Target weight loss to 20kgAdditional Discussion:- Lenticular sclerosis explained as normal age-related change, not glaucoma or cataracts- Skin tag assessed as benign, monitoring only required- Pre-medication protocol effective for anxiety management- Client address updated to 2/222 Road, New South, Double Bay EastClient Comms:- Weight management plan discussed - portion control based on minimum weekly intake- Lepto vaccination timing and rationale explained- Eye condition clarified as benign age-related change- Pre-medication protocol confirmed effective for future visits    Vital Signs    

Reason: Vaccination / Health CheckAppointment Notes: Paws App Details:Booking Type: Vaccination / Health Exam Check Booking Vet: - Any -Booking Notes: Health check and vaccinationReason:  vacc   History: Brought in by: Diet: Worming: Heartworm:Fleas: Ticks:  Medications:  Other:Vaccines/ other medications due or near due:Examine: 1. BCS:     /5    IDEAL WEIGHT      KG 2. Integument: nad3. Musculoskeletal: nad 4. Teeth: nad 5. Eyes: nad 6. Ears: nad 7. Lymph Nodes: nad 8. Cardiovascular/Circulatory:   nad  9. Respiratory/Pulmonary:  nad 10. Uro-genital: nad 11. Gastrointestinal: nad ->11a Anal Sacs: 12. Behaviour: 13. Other: Treatment: Vacc Durramune C3 due in 3 years Vacc Bronchshield III intranasal due in 1 year MSD (Nobivac) Lepto 2 Proheart SR12 inj     mls s/c  Worming:Flea/Tick: Bravecto Quantum inj         mls s/cPlan: Reminders  Updated: YES/NO    Vital Signs    Weight: 23.3;