GEN: BARH Wt= kg T= P= R= BCS /9 mm=pink, moist CRT < 2 sec
EENT: Eyes – cornea and anterior chamber clear, no ocular discharge. adequate tear film
OU. Pink conjunctiva and white sclera
Ears - mild ceruminous debris both ears, no odor or erythema, smooth otic epithelium
Nose - Clean, moist, no discharge, Smooth moist nasal planum
Throat-no cough elicited on tracheal palpation
Oral-minimal/moderate calculus and tartar on all teeth, gingivitis present throughout. No
oral masses or lesions appreciated
INTEG: clean, full coat. No ectoparasites appreciated.
CV: no murmurs/arrythmias, strong, synchronous femoral pulses
RESP: Normal lung sounds all quadrants, no crackles/wheezes auscultated.
MS: BCS /9, ambulatory x 4, symmetrical, appropriate muscling. No pain or crepitus on
palpation of thoracic and pelvic limbs with normal range of motion.
GI/GU: Liver not palpable beyond costal border, no obvious masses. No apparent pain on
palpation. Kidneys Bladder Bowel loops
Rectal: Smooth, normal sized urethra. Normal, symmetrical coccygeal muscles. No
palpable masses or sublumbar LNs. Normal feces present on glove afterwards.
LN: Mandibular, superficial cervical, and popliteal LNs smooth and symmetrical, all < 0.5
cm. Axial/inguinal LNs not palpable.
Reminders:
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Pediatric exams: always check for umbilical hernia and descended testes (males)
Small dogs: always check for luxating patellas
Large dogs: always note if stifle buttressing and comment on muscle
symmetry/atrophy
Cats: comment on whether there is a thyroid slip
All animals: comment on calculus and gingivitis
DISCHARGE SUMMARY
<b> Problem 1) Vaccination
A: Core appropriate, due for XX
P: Give XX today. Next XX due 10/13.
<b> Problem 2) Parasite Management
A: Flea, Tick, Heartworm and GI parasite prevention appropriate.
P: Fecal was submitted to assess current status. Patient currently on XX. Recommend
XX.
<b> Problem 3) Oral Health
A: Dental disease. Calculus and tartar build up. Gingivitis.
P: Recommend brushing teeth. Refer to VOHC website.
<b> Problem 4) Behavior
A: Patient resents examination.
P: Advised owner to continue training at home, puppy classes were also recommended.
Also asked owner to desensitize patient at home to oral examination, manipulation of
feet, restraint etc. to reduce his stress level in these situations. Direct to NILIF website.
<b> Problem 5) Reproduction, microchip
A: Not neutered yet, no microchip
P: Owner is planning on neutering around 6 months of age and microchipping was
recommended at that time.
<b> Problem 6) Diet
A: Owner free feeding diet. Overweight. Unbalanced.
P: Advised feeding rationed meals according to guidelines on the food bag. Give owner
BCS handout.
DISCHARGE INSTRUCTIONS
Thank you for bringing XX in to see us for XX Exam.
VACCINATION
Thumper was due for his XX vaccines today. Though rare, vaccine reactions do occur so
please watch for vomiting, diarrhea, swelling of the face or hives and contact us if you
notice any of these reactions. Some lethargy and inappetance for 24 hours afterwards
can be normal, though if these signs persist or the dog is extremely depressed please
contact us.
PARASITE MANAGEMENT
ORAL HEALTH
XX is still young and his teeth look great, however we recommend getting him used to
tooth brushing and preventing future dental disease. For tips on brushing teeth and other
ideas to improve oral heath we would like to refer you to the website of the Veterinary
Oral Health Council which has some great ideas to improve oral health in addition to
brushing: http://www.vohc.org/
BEHAVIOR
DIET
Thank you again for trusting us with XX's wellness, XX was a pleasure to work with.
If you have any questions or concerns, feel free to contact us at (530) 752-1393
Senior Student: Lisa Kentfield
Faculty Clinician: Dr.
-----------------------------------------------------------------REMINDERS:
-X due in 3-4 weeks
-Next Heartworm Test: 10/15
-Rabies due 10/16