C10023545 / invoice 10000

HISTORY: Unilateral Cherry Eye L side.
WEIGHT: 3.8

HISTORY: REASON – In for third puppy vaccination 

HISTORY - 
In good health.
Cherry eye first appeared 3 days ago, went back in the next day but now out again.

Appetite: normal
Water intake: normal
Urination: normal
Faeces: normal
Energy levels: good
Coughing or sneezing: none
Vomiting: none
Diet: 3 meals a day.  Advance puppy kibble + tin food, also a dog roll.
Parasite Control: Monthly HW/worm/flea, UTD
Puppy High School: considering.  Socialising with daughter's pup.
Current Medications: none

EXAMINATION
Demeanour: Alert and responsive
BCS: 5/9
Integument: Tear staining below eyes
Eyes: Cherry eye OS
Ears: NAD
Nose: NAD

Mouth: NAD
CRT: < 2 sec
MM: p+m
Cleft Lip or Palate: no
Jaw occlusion: normal
Teeth: normal juvenile dentition

HR: 120  BPM,    Rhythm: sinus; No arrhythmia
RR: 24  BPM,    Effort: wnl; Normal bronchovesicular sounds
Temp: not taken
Peripheral LN's: wnl
Abdomen: soft and compliant, NAD on palpation
Musculoskeletal: NAD
Neurological: NAD
Urogenital: NAD, both testes descended
Rectal: Not examined

ASSESSMENT:
Prolapsed nictitans gland OS
Apparently healthy for vaccination

CLIENT COMMUNICATION:
Advised to book in for Sx to repair cherry eye ASAP.  I will email an estimate (done).

TREATMENT:
Protech C3 sc Batch: 4964022A Exp: 06.01.2027
Parasite control: UTD

ADDITIONAL DISCUSSED:
1, Puppy patient folder with information given, photo attached: already have one
2, Puppy high school: discussed puppy school
3, Penn hip scoring NO - not relevant for breed
4, Desexing: YES (10-12 months of age)
5, Insurance YES - organised with Woolworths
6. Vaccination Reaction: YES
7. Socialisation: YES

ESTIMATE:
$1654.00 for Cherry Eye Sx (unilateral) including meds.

PLAN:

REVISITS TO BOOK IN TODAY:
1, book puppy high school
2, book next vaccination - 15 months of age 
3, book Penn hip scoring with ASC 16-18 weeks of age
4, book teenage health/behaviour visit at 20 weeks of age
WEIGHT: 3.80

HISTORY: REASON – In for second puppy vaccination (at or over 10 weeks of age)

HISTORY - BIOP 7 days

Appetite: NAD
Water intake: NAD
Urination: NAD
Faeces: NAD
Energy levels: Good
Coughing or sneezing: No
Vomiting: No
Diet: biscuits
Parasite Control: No
Puppy Pre-School: discussed
Current Medications: none

EXAMINATION 
Demeanour: BAR
BCS: 5/9
Integument:  NAD
Eyes: NAD
Ears: NAD
Nose: NAD

Mouth:NAD
CRT:<1sec
MM: pink
Cleft Lip or Palate: No
Jaw occlusion: No
Teeth: NAD

HR: 140 BPM,    Rhythm:  Normal
RR: 18  BPM,    Effort: None
Temp:   NT
Peripheral LN's: NAD
Abdomen: NAD
Musculoskeletal: NAD
Neurological: NAD
Urogenital: two testicles
Rectal: NAD

ASSESSMENT: Fit for vacc

CLIENT COMMUNICATION:  Doing well

TREATMENT:
Protech C3 sc Batch: 4964023B  Exp:21.04.2027
Protech Intranasal  Batch:  5267026B  Exp: 23.04.2027
Parasite control:  Come back for Nexgard Spectra in a week as we dont' have stock right now.  

PLAN:

ADDITIONAL DISCUSSED:
1, Puppy patient folder with information given, photo attached: YES
2, Puppy pre-school: YES
3, Penn hip scoring YES
4, Desexing: YES
5, Insurance YES
6. Vaccination Reaction: YES
7. Socialisation starts in 2 weeks time

REVISITS TO BOOK IN TODAY:
1, book puppy pre-school - can start after first vaccination 
2, book third  puppy vaccination - between 14-16 weeks of age 
3, book Penn hip scoring with ASC 16-18 weeks of age
4, book teenage health/behaviour visit at 20 weeks of age
WEIGHT: 1.90