Initial consultation/intake

PATIENT: Patient ID: PAW001 10 years, DOB: 01/05/2014 Female, Spayed Weight: 25.3 kg Microchip #: 981000000123456 VISIT: Reason: Annual wellness check and vaccination booster Veterinarian: Dr. Emily White, BVSc Check In: 01/11/2024 09:30 Check Out: 01/11/2024 10:15 Referring Practice: Green Meadows Veterinary Clinic SUBJECTIVE: History: Daisy is a 10-year-old Labrador Retriever presented for recheck to monitor overall health and receive her annual vaccinations. The owner reports Daisy has been active, eating well, and no changes in behaviour. She has had no episodes of coughing, vomiting, or diarrhoea since her last visit. The owner noted a slight increase in thirst over the past month but no changes in urination frequency. Current medications: Rimadyl 50mg, 1 tablet BID as needed for mild osteoarthritis, last given 3 days ago. OBJECTIVE: Vitals: - Temperature: 38.5°C - Heart Rate: 100 bpm - Respiratory Rate: 24 rpm - Weight: 25.3 kg Physical Exam: - General Appearance: Bright, alert, and responsive. Good body condition score 4/9. - EENT: Eyes clear, no discharge or redness. Ears clean, no odour or discharge, canals patent. Nose moist, no discharge. No evidence of inflammation or pain on palpation. - Oral Cavity: Mild dental tartar present, particularly on molars. Gums pink and moist, capillary refill time <2 seconds. No oral lesions noted. - CV: Normal heart sounds, no murmurs or arrhythmias detected. Femoral pulses strong and synchronous. - Resp: Lungs clear on auscultation, no adventitious sounds. Normal respiratory effort. - Neuro: Cranial nerves intact. Proprioception normal in all four limbs. No ataxia or neurological deficits observed. - Integument: Coat is clean and shiny, no alopecia or ectoparasites noted. Skin supple, no lesions or masses palpated. Small lipoma caudal to left elbow, stable in size. - Abdomen/GI: Abdomen soft and non-painful on palpation. No organomegaly or masses detected. Normal bowel sounds. - Musculoskeletal: No lameness noted on gait analysis. Mild crepitus in both stifles, consistent with known osteoarthritis. Full range of motion in all joints with no pain on manipulation. - Urogenital: External genitalia appear normal for a spayed female. No discharge. - Lymph: Peripheral lymph nodes non-palpable and within normal limits. - Rectal: Normal anal tone, no perianal abnormalities. Diagnostic Results: Routine senior blood panel (CBC, Chemistry, Urinalysis) sent to external lab; results pending. Previous urinalysis 6 months ago was normal. Current in-house urine specific gravity: 1.028. ASSESSMENT: Daisy is a 10-year-old spayed female Labrador Retriever presenting for an annual wellness exam. Overall good health, but age-related changes are noted, including mild dental disease and osteoarthritis. The owner's observation of increased thirst warrants investigation with a pending blood panel and urinalysis to rule out underlying metabolic or renal issues. PLAN: Diagnostic/Treatment Plan: Awaiting full blood panel and urinalysis results. Recommended dental scaling and polishing in the near future. Continue Rimadyl as needed for osteoarthritis; consider daily joint supplement. Discussed potential for senior diet. Recommendations: Owner advised to monitor Daisy's water intake and urination closely. Follow-up call to discuss lab results once available. Scheduled a dental consult for next month. Advised on the importance of regular exercise and weight management for osteoarthritis.