C10017513 / invoice 10000

Appointment Notes: Booked Online: 10/03/2026 15:48:34 PMBooking Type: Skin, Ears, Eyes or LumpsOwner Name: Alex ColeOwner Email: thecoles76@yahoo.comOwner Mobile Number: 0449993173Pet Name: RoccoPet Species: DogWeb BookingClient name: ColeContact number: 0449993173Email address: thecoles76@yahoo.comPatient name: RoccoReason: History:Presents for assessment of a lesion on the right side of tail. Onset and cause are unknown. Has been chewing at the lesionPreviously treated for a burst anal gland with antibiotics and meloxicam, with no adverse reaction to the anti-inflammatory. No other current medications.EDUF normal.No V+/D+.Examination:Mentation: Bright, alert, and responsive. Food-motivatedHydration status: Mucous membranes pink and moist, capillary refill time <2 seconds.CVS: HR: 90. No murmurs or arrhythmias auscultated. Pulses strong and synchronous.Resp: RR 40. Lungs clear on auscultation bilaterally, no abnormal respiratory sounds.EENO: Eyes and ears appear normal, no ocular or nasal discharge noted. Grade 3 dental, no oral pain.PLNs: Peripheral lymph nodes are normal in size and texture.Abdominal: Abdomen is soft and non-painful on palpation.Integument: 2cm crusted lesion/trauma on right side mid tail with surrounding erythemaRectal: Not performed.Neuro: Neurological examination is grossly normal, no deficits noted.Urogenital: Normal.Problem list:- Suspected bacterial infection, right tail.Diagnostic tests:- Impression smear on lesion on right tail. Neutrophils +++. Cocci +++Treatment:- Area disinfected with chlorhexidine in clinic.- TGH with meloxicam at 8kg SID PO for 5 days with foodand Amoxyclav 250mg (23mg/kg) PO BID for 7 daysPlan:- Topical disinfection: Dilute Betadine solution to a very light brown colour. Apply to the affected area BID for 5 days- Elizabethan collar to be worn if Rocco is licking or chewing at the area.- Keep separate from other dogs to prevent interference with the wound.- Re-check in 1 week or sooner if there are any concerns or if the lesion is not improving.Client Communication:Discussed diagnosis of a localised skin infection. Advised on administration of oral antibiotics and anti-inflammatories. Instructed on correct dilution and application of Betadine for topical cleaning. Advised to cease anti-inflammatory medication if vomiting or diarrhoea occurs. Recommended use of an e-collar to prevent self-trauma. Follow-up plan discussed. Client understands and agrees with the plan.    Vital Signs    

Appointment Notes: Booked Online: 03/11/2025 09:06:29 AMBooking Type: VaccinationOwner Name: Alex ColeOwner Email: thecoles76@yahoo.comOwner Mobile Number: 0449993173Pet Name: RoccoPet Species: DogWeb BookingClient name: ColeContact number: 0449993173Email address: thecoles76@yahoo.comPatient name: RoccoReason: HISTORY:  - Presenting for vaccination.- No other concerns. Happy, bright.- Eating kibble (Royal Canin Cavalier) and a pet food roll. - EDUF normal. Bowels and urination WNL. No V/D.- No scratching, chewing, or skin issues.- No stiffness or lameness noted. Current meds: noneVaccination: Due for annual booster. No previous vaccination reactions.Parasite Prevention: Simparica trio Monthly + 3 monthly wormerPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: HR 160 cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): 2- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: BAR, food motivated, excited, friendly PROBLEM LIST:- Overweight (BCS 6/9).- Dental disease- Due for annual vaccination. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:None DIAGNOSTICS:None ASSESSMENT:Rocco presented for a routine annual health check and vaccination. On examination, he is overweight with a body condition score of 6/9. There is some  tartar accumulation. Otherwise, the clinical examination was unremarkable. TREATMENT:  -Vanguard resp2 intranasal administered PLAN:- Home into owner's care.- Re-evaluation in 1 year for annual health check and vaccination.- Recommended weight loss plan.- Recommended dental home care. CLIENT COMMUNICATION:- Discussed examination findings, specifically the need for weight management and dental care.- Advised a 20% reduction in food quantity to aim for a target weight of approximately 9kg.- Advised on how to monitor body condition at home by feeling for ribs.- Discussed dental home care options, including daily tooth brushing and use of dental chews. Explained that a future general anaesthetic for a scale and polish with dental x-rays may be indicated.- Explained the intranasal vaccine protocol. Discussed monitoring for vaccine reactions. Advised to seek emergency veterinary care if any concerns.- Client counselled on monitoring for potential vaccine reactions (lethargy, V/D, breathing difficulty, facial swelling) and that mild sneezing/coughing for 2-3 days is normal.    Vital Signs    

Appointment Notes: Booked Online: 18/10/2024 14:43:30 PMBooking Type: VaccinationBooking Notes: VaccinationsOwner Name: Alex ColeOwner Email: thecoles76@yahoo.comOwner Mobile Number: 0449993173Pet Name: RoccoPet Species: DogWeb BookingClient name: ColeContact number: 0449993173Email address: thecoles76@yahoo.comPatient name: Rocco  ------- Sms reply: YHistory: BAREDUD normally no V/D Primary reason: Due vacc, parasite ctrl. No concernsExamination: Weight:BAREENO: mild tartar 1/4, tongue permanently out of mouth. No eye/nose/ear d/cThoracic ausc WNL, no murmur/arrythmia/adventitious lung soundsAbdominal palp NSFIntegument WNL LN WNL Hydration WNL MSKL - full orthopaedic exam not performed, ambulating well Neuro: - not performed, normal mentation Temp not attemptedLaboratory:NIL performedAssessment: 1. Fit for vacc. 2. Mild dental diseaseTreatment: C4 + oral BB Plan:Kc in12mo. Team based consulting (RVN: JG)TBC JGIParasiticides prepared by nurse.--- 29/10/2024 11:43:18 AM BRS:Vaccinations - Resolved -    Vital Signs    MMColour: pink;       Weight: 12;       HeartRate: 140;       BodyScore: 5;       DentalGrade: 2;       RespirationRate: 48;       CRT: 2s;