C10032621 / invoice 10000

Reason: Vaccination and Annual Health Check
History: using neocort to manage ventral abdo pruritis. No other concerns. Coping fairly well with Ella passing away last week, a bit quiet and staying near Coral
 - EDUF: normal
 - V#/ D#/ Coughing: none

Current medications: No medications currently being provided at time of examination, with the exception of those recorded on patient file.

What Preventative health cover is being used and do you need to purchase any today? due KC (2)
Worming: 
Flea control:
Heartworm control:
TWP discussed: Y/N

Examine: 
Mentation: BAR
BCS:                 3.5          /5   
MM: Pink      and moist    
CRT: 1-2 seconds
HR:      100                       beats/min
RR:            20                 breaths/min
Dental Stage: Evidence of gingivitis and calculus - looking at cohat
Temperature:    38.7          degrees Celsius
Gastrointestinal: No masses or abnormalities noted on palpation
Integumentary: No significant abnormalities noted during routine physical examination, mild erythema ventral abdo
Musculoskeletal: No evidence of lameness

Assessment: fit for vacc 

Treatment: KC (2), neocort for skin management
Vaccination given: Nobivac Pi inj and BB oral 
Batch number: 2513401 2520502

Reason: nail clip
Consult Nurse: amariah

Px brought in for nail clip, no other concerns according to O
MO held in consult while nails were being trimmed
Nails were noticeably overgrown, with both dewclaws (forelimbs) curling on itself

Px was timid, anxious

AL
Trimmed all nails with MO holding in consult room helped with holding the leg as well 
Was able to trim all nail 
Very well behaved for app today