C10023935 / invoice 10000

Presented with/REASON for visit:
annual vacc 
Salient HISTORY: all well
No vomiting, no diarrhea, or tenesmus
Normal appetite. 
No polydipsia or polyuria
No coughing.

Current MEDICATIONS: -
Allergies: none we are aware of

Preventatives and Vaccinations: C5 is due
Body Condition Score: 5/9.

Patient compliance with this exam- (compliant/limited/ restricted) = compliant

VITALS: Heart Rate - approximately 120, Mucous Membranes pink, moist, Capillary Refill Time ~2 seconds, Respiratory Rate ~26, Temperature 38.7°C.

MENTATION: Bright, Alert, Responsive.

HEAD:
Eyes: No conjunctival or scleral vessel injection/congestion, no blepharospasm, or discharges. Cornea clear /moist, limited vision of anterior posterior chambers.
Ears: No discharge or discomfort.
Nose: No significant findings, no discharges noted during examination.
Oral: No significant findings
dentition ~1/4.

INTEGUMENT: No significant findings, coat condition is fair, skin turgor normal.
Pruritis score 0/10

CARDIOVASULAR System: No murmur detected. Pulses synchronous and normodynamic.
RESPIRATORY: Normal breathing effort and normal bronchovesicular sounds throughout both hemithoraces.

ABDOMEN: Abdominal splinting at the time of examination, no significant reaction on palpation of abdomen. No organomegaly detected.
Rectal: Not performed, externally normal.
Urogenital: No discharge observed.

Lymph Nodes: Palpable peripheral lymph nodes within normal limits.

NEUORLOGICAL: Cranial Nerves - Facial sensation intact, pupils equal and reactive to light, head carriage normal, no spontaneous nystagmus or deviation of eyeballs.
Spinal Nerves - no ataxia, voluntary motor functions intact in all limbs. Full neuro exam not done
MSK: Normal ambulation observed during consultation. Adequate muscling in all appendicular limbs. No palpable joint or neck pain. A full musculoskeletal examination not performed.

Summary of Problems:
Unremarkable PE
Fit for vacc
Recommended/Additional DIAGNOSTICS:
-
TREATMENT and PLAN- discussed with Owner:
VAcc C4 and i/o BB (5260009/5245041B)
discussed preventatives wormer HW, potential vaccination s/e
Revisit as indicated.