C10031970 / invoice 10000

Primary Presenting Complaint - nqr 
Other Complaint - not eating 2 days vomited on friday but was not unwell been very lethargic has increased glunk O noticed dead bird in front yard might have licked 
         Loyalty Reward Program - Y/N
History - 
         Last Normal - teus 
         Frequency   -
         Last Ate       - last ate on tuesday 
         Medicine Hx  - 
         Diet              - lyka been on for years 
         Vacc Current - due 
         Worming Hx  - UTD - nextgaurd 
         Heartworm    -
         Microchip       -  Y / N    -  scanned - ok?

Examination -
         Attitude - QAR 
         Body Score -    6/10
         Temperature - 38.6
         Heart - 96   HR. Murmur - none heard 
         RR -panting 
         Dental - Score(0-4)=  0  .Comment healthy young teeth 
         CRT - 1-2s pink and moist 
         Eyes - mild green thick discharge bilaterally no blepharospasm or indication of eye issue concunctiva normal colour no chemosis or reddness 
         Ears - clean and discharge free
         Abd Palpation - Unremarkable comfotable no obvious organomegaly 
         Gastrointestinal -  No Sig Findings no d+ at home no vomiting 
         Urogenital -  No Sig Findings O has not noticed change in urination 
       
         Skin - 
         Musculoskeletal -  No Sig Findings
         Neurological -  No Sig Findings
         Lymphatic - mild increased size of pre scap lymph nodes 
         Other key findings = 

Assessment - very non specific presentation 
Problem List - Lethargy, inappetence, marginal pyrexia 
DDx                 - viral infection, GI disease, UTI other infection source 
Discussed      - many possibe causes of presentation gave options for 1. proceeding with further work up to try get more clues with what may be causes her to be unwell. this would include blood work, urinalysis 2. treat symptomatically and see how she goes. O opt for 2. 
advised that if she does not get better over the next day or gets worse eg starts vomitng, d+ then she should seek further diagnostics and treatment 
Treatment Plan - paracetamol for pain management ondansetron for anti nausea to see if inappetece is due to nausea 
Prescriptions(on-going) -
Next Visit            - as needed 

Presenting Complaint -  Vaccination 
Other Complaint -  
         
History - 
         Medicine Hx  -     none 
         Worming Hx  -       not sure     
         Heartworm    - 
         Microchip      -  Y / N     scanned -  ok?

going good 
d+ cleared up fully.      no vomit 
o has no concerns 

on puppy kibble and wet 

Examination -
         Attitude -  BAR 
         Body Score -  5 /10
         Temperature if indicated -   not indicated 
         Heart -   Any Murmur Present? -  none heard 
         Respiration Character Normal ? -  normal 
         Dental Bite Character -   NAD   very wriggly 
         CRT -    1.5 
         Eyes and Eyelids -   NAD 
         Ears -   NAD 
         Abd Palpation -   NAD 
         Gastrointestinal/Any History of Dia? - nil 
         Urinary -   NAD
         Genitals(No of testicles) -  female , good vulva conformation 
         Skin - NAD 
         Musculoskeletal -   NAD 
         Other key findings = 

General Health Assessment - healthy for vacc 
Discussed - advised worming ongoing - nextguard spectra as heartworm, flea tick etc coverage.  feed abit more food as too lean.    desex 6 month and ensure all baby teeth lost otherwise need to sx remove . can go public in  2 wk 
Plan            -  c3 vacc sq intrascap 
Any future vaccinations? -  12 month 
Recommended age of Desexing -  6month 
Heartworm: nextguard spectra (free sample given) 

Presenting Complaint -  Vaccination 
Other Complaint -  
History - nobivac 20/05/25
-since been in o presence for 3w has had runny poo, not able to pick up with a scoop.
-black hawk puppy bisc (what breeder was giving) o did add hills science diet, but stopped this incase this was the reason why she has runny poo.
-still full on energy, no vomiting noticed. No bloods on the stool. Good appetite. 
-UTD with drontal.
         Medicine Hx  -
         Worming Hx  - drontal wormer 11/06. 
         Heartworm    -
         Microchip      -  Y / N     scanned -  ok?

Examination -
         Attitude -BAR
         Body Score -    5/10
         Temperature if indicated - 38.6
         Heart -  120  Any Murmur Present? - no heart murmur
         Respiration Character Normal ? - wnl
         Dental Bite Character - deciduous dentition 
         CRT - <2s
         Eyes and Eyelids - nad
         Ears - clean and no discharge 
         Abd Palpation - soft and comfortable on palpation 
         Gastrointestinal/Any History of Dia? - yes
         Urinary - nad
         Genitals(No of testicles) - good vulva conformation 
         Skin - healthy coat
         Musculoskeletal - nad, ambulatory, full MSK examination not performed.
         Other key findings = 

General Health Assessment - Suggested to postpone the vaccination due to D+.
Discussed - O wants to get the vaccination even though I mentioned to O that the vaccination might make the D+ worse. O said she does not want to postpone as has already made her family plan trip. O aware the risk of getting the vaccination done with the current problem. 
Plan            - Vaccination given: C5 (C3 + intranasal)
Any future vaccinations? - C3 in 4 weeks time.

Medication to go home with:
-Fenbendazole 1ml SID for 5 days.
-Mentioned to O that if D+ no improving, need to consider faecal PCR test. O aware.