C10009604 / invoice 10000

Appointment Notes: Overdue remindersDate and Time:Veterinarian:History: Preventative Care:Diet:Current Medications:Examination: CardiovascularHR – Cardiac sounds - Normal S1/S2. No murmur or arrhythmiaMM, CRT - Pulses , peripheries - Femoral pulses normodynamic and synchronous. Peripheral temperature warm.NIBP -RespiratoryRR - Respiratory pattern - Normal respiratory patternBreath sounds - Normal breath sounds all lung fields. Gastrointestinal/Nutrition/Hepatobiliary/Endocrine/UrogenitalOral Exam - NADAbdominal palpation - No palpable mass or organomegaly, no reaction to palpation.Urogenital - NADRectal examination - NAD Renal/Fluid/ElectrolyteHydration - Body Weight - Immunology:Rectal temperature -Peripheral lymph nodes - Peripheral nodes palpably normalMusculoskeletal:Gait - Normal gaitMusculoskeletal - NADBody condition score - Neurology/PainMentation – Normal MentationModified Glasgow Pain Scale - / 24MGCS: Motor /6 , Brain Stem Reflexes /6, Level of Consciousness /6, Total /18Integument / Special Senses:Integument – NADOcular / Vision – NADInstrumentation:Peripheral Intravenous Catheters – Location? Last re-wrapped and assessed? PatencyDiagnostic plan: DOG - PCV (37-55 %):TP (55-75 g/l):Serum:Haematology (Abnormalities):Biochemistry (Abnormalities):Blood Smear:-	RBC Morphology - -	WBC Morphology - -	Platelets - CAT -PCV (30-45 %):TP (62-81 g/l):Serum: Haematology (Abnormalities):Biochemistry (Abnormalities):Blood Smear:-	RBC Morphology - -	WBC Morphology - -	Platelets - Assessment: Problem List (active) and Differential List:1.2.3.4.PLAN: In-hospital care plan / Contingencies: ----Medications at Discharge:Pending Test ResultsCLIENT COMMUNICATION / INFORMATION: -INTERNAL COMMUNICATION / NOTES: -Thank you for this referral. Please do not hesitate to contact us by phone (03) 8721 1414 or email our team at gvhwerribee@greencrossvet.com.au if you would like to discuss this case further.History-Update:    Vital Signs