C10023777 / invoice 10000

12/03/2026 Record complete N

Reason/concerns: 

History:

Medications:


Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm).

Examine: 
Mentation: BAR
BCS:  /9 
MM: Pink, moist          
CRT:  <2 seconds
HR:      beats/min
RR:        
Temperature:              

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: G /4
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia. Strong synchronous pulses. 
Respiratory: Respiratory rate and effort considered normal for the patient. Normal BVS
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
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:

Patient Assessment: 

Diagnostics performed:
-

Treatment:

Client Communication
& Plan: 


On-going medications required: Y/N