C10023729 / invoice 10000

NOTES: First Clinical Signs: 12/03/26
Summary: Yelping in pain
Diagnosis: Sof tissue injury
Treatment: meloxicam

NOTES: Case Summary:
Magnolia was brought in for vaccinations and a general health checkup after being adopted. The owners wanted to ensure she is healthy, and the veterinarian confirmed she appears fit with no significant health concerns.

NOTES: Reason for Consultation:
Vaccination and general health checkup.

History:
Magnolia was adopted at nine months old and turned one in March. Owners report she has settled in well, is friendly and active, and has no significant health concerns.  She is eating well on a diet of kibble and raw meat. Stools are described as normal with no D+. Owners are unsure if they are feeding her enough as they can feel her ribs and spine. She has a small scar from being spayed. EDDU normal.

- Prophylaxis: NexGard Spectra monthly; Drontal every three months.
- Diet: Half a cup of kibble in the morning with two heaped tablespoons of raw meat, and a third of a cup of kibble in the afternoon.

Clinical Exam
Temperature 38.2C
Heart rate 100bpm, no arrhythmias or murmurs detected
Respiratory rate: 20, no crackles or wheezes detected
Chest auscultation:  Normal bronchovesicular sounds present bilaterally. No audible murmurs, dysrhythmia's or gallop rhythm detected; 
MMs: pk   CRT: <2 sec
BCS: 4/9
Oral/nasal WNLs
Dental score 1/5
Eyes: WNLs, no discharge
Ears: WNLs, no discharge
Abdomen: WNLs, no pain or masses on palpation
Urogenital- WNLs
Lymph nodes: WNLs
Integument: WNLs, no ectoparasites detected
Neurological:  WNLs, no deficits
MSK- WNLs, no lameness, no spinal or neck pain

Assessment:
Magnolia is in good overall health with no significant concerns. Slightly arched back observed but not problematic. Skin and coat are in good condition. Owners are feeding an appropriate diet but may slightly increase food quantity to maintain a lean body condition.

Problem List and DDx:
- Slightly arched back (DDx: normal breed conformation vs mild MSK abnormality).

Discussions/Client Communications:
- Confirmed Magnolia is in good health and body condition.
- Advised maintaining a lean body condition to prevent health issues.
- Discussed current diet and suggested a slight increase in food quantity.
- Confirmed parasite prevention is appropriate and up to date.
- Vaccines administered; reminders for future vaccinations to be set up.

Treatment/Plan:
- Administered vaccinations (specific vaccines not detailed).
- Continue NexGard Spectra monthly and Drontal every three months.
- Maintain current diet with a slight increase in food quantity.