C10009215 / invoice 10000

Reason: Follow Up Appointment Notes: SKReason:  consult  History: Brought in by: Diet: Worming: Heartworm:Fleas: Ticks:  Medications:  Other:Vaccines/other meds due or near due: Examine: 1. BCS:     /52. 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: not examined 12. Behaviour: 13. Other: Treatment: Diagnosis: Plan:Reminders  Updated: YES/NOVerified: NoHistory:Presenting for: Luna presented for a routine checkup and evaluation of a mild odour that the owner noticed returning since being away in America.Historical Conditions: Previous lip fold dermatitis with associated malodour that required surgical correction (cheiloplasty) approximately one year ago after initial medical management with topical treatments was unsuccessful.Current Meds: Regular walking routine established for weight management.Examination:Mentation: BARWt: 14.4 kg (previously 16.9 kg)BCS: Overweight - could lose another 2 kgBehavioural: Initially tolerant during examination but becomes grumpy with prolonged handling, particularly around lip fold area. Much more cooperative when not experiencing discomfort.Oral: Mild plaque accumulation and gingivitis present but not problematic.Integumentary: Surgical sites from previous cheiloplasty healing well with excellent cosmetic result. Mild scabbing noted at one surgical site consistent with normal healing. Matted hair present around facial area requiring trimming. Some soiling noted around mouth area when resting on furniture.Assessment:Weight loss - excellent progress with 2.5 kg reduction over past yearMild facial odour - likely related to matted facial hair and minor soiling rather than recurrence of lip fold dermatitis. Previous surgical correction remains successful with no evidence of infection or inflammation.Plan:Additional Discussion:- Continue current feeding regimen to maintain weight loss progress- Regular facial hair trimming recommended to prevent matting and associated odour- Gentle cleaning of lip fold areas with warm water as needed- Monitor for any worsening of odour or signs of infectionClient Comms:- Check with mother regarding vaccination preferences before scheduling- Vaccinations will be required if boarding is needed in future- Facial hair trimming to be performed by senior nurse today    Vital Signs    Weight: 14.4;