C10011765 / invoice 10000

Reason/concerns:  Vaccination

History:
Dawn came in today
EDUF: normal with very good appetite
Diet: Ziwi Peak BID
O has difficulties walking lately and exercise was reduced, O is going to hospital for treatment soon and will get back on track with daily routine

Pre-exisitng Conditions / Medications:
Multiple teeth extractions before - only a few teeth left 

Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm) control is attached to patient file. UTD

Examine: 
Mentation: QAR
BCS:   6/9
MM: Pink moist          
CRT: 1-2 seconds
HR: 100 beats/min
RR: 30 breaths/min
Temperature:   NE

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: G0/4. Mild tartar noted
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities. Smooth coat
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Problem List:
Overweight

Patient Assessment: 
sweet but anxious patient, freeze in the consult 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- None performed 

Treatment with medication 
dose rates (if any):
PI2 SC between shoulder blade - 5264015
oBB - 5245044A

Client Communication
& Plan: 
(see attached vetcheck client information sheets if provided)
Advised on vaccine reaction, clsoe monitoring needed for the next 48 hours
Advised on reducing feed due to reduce on exercise with multiple factors in life, O understood

Next vaccine due: Aug 2026 PI2 + oBB #2

Reason: post dental extractions check 
History: 9x dental extractions 5 days ago. EDUF fine, taking meloxicam well, no concerns

Examine: BAR bcs 4/5 dental gd 0 mm pk crt <2 HR  108 RR wnl  temp nt
dental extraction sites healing well, sutures all holding, no sign infection

assessment: extractions sites healed, well, recommend cont soft diet for antoher 2-3 days then transition back to regular food. discussed dental prevention inc dental diets and plaque off as O struggles to brush teeth. 

plan: book infor rpt bloods (ALP) in a month to assess if levels reduced 

Reason: Courtesy phone call post-dental
Nurse: Jen T
History:
     Demeanour: QAR, but ok
     Eating/ Drinking: Yes, soft food.
     Toileting: Yes
     Any concerns? No, just not quite herself yet but getting there

Treatment:
     Medications being given: NSAIDs
     Patient taking meds as prescribed? Yes

Assessment: 

Next Appointment: This Thursday