C10030537 / invoice 10000

Annual Health Check
Hx Concerns : 
- lump on tail
- diarrhoea yesterday and off food today
- heart has been good - no coughing or dyspnoea
- lip folds currently ok

Worming product used and last given : {__}
Flea Treatment used and last given: {__}
Heartworm Treatment used and last given : {__}
Current Diet given daily : {__}
Current dental products used : {__}
Any dental recommendations given : {__}
Dental Score :  1/4
Body Condition Score:  3/5

Vaccine given today - KC Injectable P12 + BB (Parainfluenza and Bordetella) Killed Vacc
Batch number/exp - 2520701, 06-2027

Ex : 
1. Eyes : blind, cloudy lenses, no scleral injn
2. Ears : NAD, not inflamed or dirty
3. Mouth : lip folds moist but not currently inflamed or malodourous - continue current management regime
4. Heart :  hr 128, grade 4 heart murmur. 
5. Respiratory/Nasal : settled resp, neg tracheal pinch, lung fields sound clear
6: Abdomen : a bit potty in abdo, mild tensing
7. Musculoskeletal : NAD, weak
8. Neuro : NAD 
9. Urogenital : NAD 
10. Rectal/Anal glands: not examined  
11. Skin : lots of lumps all over. Cornified mass/protrusion 3/4 way down tail as identified at last visit - extending approx 12mm, trimmed back with nail trimmers
12. BT : 38.4 
13: Behaviour issues: WNL
14: Lymph nodes: WNL

Assessment : 
- heart dz, stable
- ongoing issues w/ lip folds, currently ok
- inappetant today but NAD on exam to explain this. Well enough to vacc but adv monitor over next 24 hours and revisit if any further symptoms emerge.

Recommended Products: {__}
Goals:  {__}

Ingrid bought Louis in as he was at the groomers today and she is worried that his tail was cut and had some bone exposure. 
Had a look and definitely not bone exposure, it is just one of his sebaceous cysts that has grown and curled. Advised Ingrid to not worry there is definitely no bone and Louie is fine.
Louis is booked in for vacc on friday and i will make a note for the vet to have a look at his tail too. I think we could probably pull it off? 

Hydro/Dry: YES/NO
Nails: YES/NO
Clipped with:  {__}
Face-  {__}
Body-  {__}
Legs-  {__}
Poodle Feet: YES/NO

OR

Brush out: Description  {__}

Temperament:  {__}
Was a muzzle required: YES/NO
Sedation required: NO/YES Dose: {__}

Any abnormalities detected:  
{__}