Vet Intake Note

**PATIENT:** Patient ID: 54321 Age, date of birth: 5 years, D.O.B. 15/03/2019 Sex, neutering status: Female, spayed Weight: 18 kg Microchip number: 987654321098765 **VISIT:** Reason: Annual wellness check and vaccination booster Veterinarian: Dr. Emily Davis, DVM Check in: 01 November 2024, 09:30 AM Check out: 01 November 2024, 10:15 AM Referring practice: N/A **SUBJECTIVE:** **History:** Luna, a 5-year-old female spayed Labrador Retriever, presents for her annual wellness examination and routine vaccination boosters. The owner, Ms. Sarah Johnson, reports that Luna has been generally healthy. She is fed a commercial dry dog food twice daily and receives regular walks. No recent changes in appetite, thirst, urination, or defecation have been noted. Luna lives indoors and has regular contact with other dogs at the local park. Ms. Johnson reports that Luna occasionally experiences mild seasonal allergies, manifesting as paw licking, which is currently well-controlled. There have been no episodes of vomiting, diarrhoea, coughing, or sneezing. Her last vaccination was approximately one year ago. **Current medications:** - Apoquel 5.4mg PRN for seasonal allergies (last dose 3 weeks ago) - NexGard Spectra monthly for flea, tick, and worm prevention (due next week) **OBJECTIVE:** **Vitals:** - Temperature: 38.5°C - Heart rate: 96 bpm - Respiratory rate: 24 bpm - Weight: 18 kg **Physical exam:** - General appearance: Bright, alert, and responsive. Good body condition score (BCS 4/9). Coat is shiny and well-maintained. - EENT: Eyes are clear, no discharge. Pupils responsive to light. Ears are clean, no odour or discharge. Pinnae are normal. Nose is moist, no nasal discharge. Throat appears normal upon visual inspection. - Oral cavity: Pink mucous membranes, CRT <2 seconds. Mild dental tartar on premolars. No evidence of gingivitis or oral masses. - CV: Normal heart sounds, no murmurs auscultated. Femoral pulses strong and synchronous. - Resp: Lungs clear on auscultation, no adventitious sounds. Normal respiratory effort. - Neuro: Cranial nerves intact, normal gait and mentation. No signs of ataxia or paresis. - Integument: Skin supple, no lesions, masses, or parasites observed. Mild staining on paws consistent with occasional licking. - Abdomen/GI: Abdomen soft, non-painful on palpation. No organomegaly or masses detected. Normal bowel sounds. - Musculoskeletal: No lameness or pain on palpation of limbs or spine. Full range of motion in all joints. - Urogenital: External genitalia appear normal. No discharge or discomfort on palpation of bladder. - Lymph: Peripheral lymph nodes (submandibular, prescapular, popliteal) are small and symmetrical, non-painful. - Rectal: Not performed at this visit. **Diagnostic results:** - Faecal flotation: Negative for parasites - Routine bloodwork (CBC, Chemistry panel): All parameters within normal limits (previous results from 6 months ago reviewed). **ASSESSMENT:** - Healthy adult Labrador Retriever presenting for routine wellness and vaccination. - Mild dental tartar requiring future dental scaling. - History of well-controlled seasonal allergies. **PLAN:** **Diagnostic/Treatment plan:** - Administered DAPPv and Leptospirosis vaccines. - Discussed importance of ongoing flea, tick, and worm prevention. - Recommended annual senior bloodwork starting next year. - Discussed a future dental cleaning procedure. **Recommendations:** - Continue current diet and exercise regimen. - Continue monthly NexGard Spectra as scheduled. - Monitor for any changes in allergy symptoms and contact clinic if they worsen. - Schedule dental cleaning within the next 6-12 months.