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AS

Dr. Andrea Salazar

Owner Admin

Max

Vaccination visit

Finalized

Jul 31, 2024 · Dr. Miguel Tan

Weight

7.10 kg

Temperature

38.7 °C

Heart rate

114 bpm

Resp. rate

22 rpm

Body condition

5 / 9

Mucous membranes

Pink, moist

Cap. refill

<2 s

Hydration

Normal

Clinical note (SOAP)

Subjective
First puppy visit. New rescue, settling in well at home.
Objective
BAR. Bright puppy, good body condition. Full physical examination — no abnormalities.
Assessment
Healthy puppy — fit for first vaccination.
Plan
5-in-1 1st dose given. Return in 3 weeks for the 2nd dose. Start deworming.

Physical examination

General / demeanour

Bright and playful. Ideal body condition for breed and age.

Eyes, ears & nose

Clear and unremarkable throughout.

Oral & dental

Clean teeth, healthy pink gums. Adult dentition complete.

Heart & lungs

Heart sounds normal; respiratory effort unremarkable.

Abdomen

Comfortable on deep palpation; no abnormalities.

Skin & coat

Healthy coat and skin. No evidence of fleas or ticks.

Musculoskeletal / gait

Sound on all four limbs; good muscle mass.

Lymph nodes

Normal.

Neurological

Bright mentation; reflexes normal.

Charges

No charges yet.

Medications

No medications prescribed.