Initial consultation/intake (Vet)

PATIENT: 12345 5, DOB: 01/15/2018 Male, Neutered Weight: 25 lbs Microchip #: 987654321 VISIT: Reason: Annual check-up and vaccination Veterinarian: Dr. Emily Johnson, DVM Check In: 10/10/2023 09:00 AM Check Out: 10/10/2023 09:45 AM Referring Practice: SUBJECTIVE: History: Max is a 5 year old Labrador Retriever who was presented today for recheck to monitor weight and general health. The owner reports that Max has been eating well and is active, but has occasional episodes of scratching. Current medications: None OBJECTIVE: - Vitals: - Temperature: 101.5°F - Heart Rate: 90 bpm - Respiratory Rate: 20 breaths/min - Weight: 25 lbs - Physical Exam: - General Appearance: Alert and responsive - EENT: Eyes clear, ears clean, no nasal discharge - Oral Cavity: Teeth and gums in good condition - CV: Heart sounds normal, no murmurs - Resp: Lungs clear, no wheezing or crackles - Neuro: Normal gait, no neurological deficits - Integument: Coat shiny, mild scratching noted - Abdomen/GI: Soft, non-tender, no masses - Musculoskeletal: Normal range of motion, no lameness - Urogenital: Normal, no abnormalities - Lymph: No lymphadenopathy - Rectal: Normal, no abnormalities - Diagnostic Results: None ASSESSMENT: - Max is a healthy 5 year old Labrador Retriever with mild scratching likely due to seasonal allergies. PLAN: - Diagnostic/Treatment Plan: Continue monitoring weight and general health. Administered annual vaccinations. Recommended antihistamine for scratching. - Recommendations: Follow up in 6 months for weight check and any concerns regarding scratching.