Snake Consult

Reason for Presentation: [note the reason for the appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.) Signalment: [note species, age, colour, sex (if known), and desexed status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.) History: Duration of ownership: [duration of time pet has been in owner's possession] (Only include if explicitly mentioned in transcript or context, else omit.) Source: [where pet was obtained from] (Only include if explicitly mentioned in transcript or context, else omit.) Enclosure size: [dimensions in cm: L x W x H] (Only include if explicitly mentioned in transcript or context, else omit.) Basking temperature: [temperature in °C] (Only include if explicitly mentioned in transcript or context, else omit.) Cool end temperature: [temperature in °C] (Only include if explicitly mentioned in transcript or context, else omit.) Night time temperature: [temperature in °C] (Only include if explicitly mentioned in transcript or context, else omit.) Heating setup: [types of heating used, thermostat present, and thermostat temperature in °C if known] (Only include if explicitly mentioned in transcript or context, else omit.) UVB lighting: [presence of UVB, percentage, type (T5/T8/Compact/LED), last changed date, and daily duration] (Only include if explicitly mentioned in transcript or context, else omit.) Substrate: [type of substrate used] (Only include if explicitly mentioned in transcript or context, else omit.) Hygiene: [cage cleaned with what and how often] (Only include if explicitly mentioned in transcript or context, else omit.) Humidity and water availability: [humidity level, and statement regarding water availability] (Only include if explicitly mentioned in transcript or context, else omit.) Cage décor: [items in the enclosure] (Only include if explicitly mentioned in transcript or context, else omit.) Diet: [diet provided] (Only include if explicitly mentioned in transcript or context, else omit.) Supplementation: [supplements used and frequency] (Only include if explicitly mentioned in transcript or context, else omit.) Handling: [how often and for how long the pet is handled] (Only include if explicitly mentioned in transcript or context, else omit.) Most recent shed: [date or observation of most recent shed] (Only include if explicitly mentioned in transcript or context, else omit.) Most recent defecation: [date or observation of most recent defecation] (Only include if explicitly mentioned in transcript or context, else omit.) Other animals in collection: [presence of other animals] (Only include if explicitly mentioned in transcript or context, else omit.) Access to natural sunlight: [amount or frequency of access] (Only include if explicitly mentioned in transcript or context, else omit.) Previous medical history and medications: [details of previous medical issues or current medications] (Only include if explicitly mentioned in transcript or context, else omit. If nothing to report, write "Nil".) Pertinent History: [history relating to the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.) Physical Examination: Vital signs: Demeanour – [BAR/QAR/Lethargic/Obtunded/Stuporous/Comatose] (Only include if explicitly mentioned in transcript or context, else omit.) Weight: [weight in grams or kilograms] (Only include if explicitly mentioned in transcript or context, else omit.) Body condition: [score out of 5] (Only include if explicitly mentioned in transcript or context, else omit.) Integument: [describe condition of scales, signs of dysecdysis, masses, discolouration, lesions, or ectoparasites] (Only include if explicitly mentioned in transcript or context, else omit.) Eyes and nostrils: [note on erythema, discharge, spectacles, blepharospasm, shed retention] (Only include if explicitly mentioned in transcript or context, else omit.) Musculoskeletal: [ambulation, kinks, strength, function, musculature] (Only include if explicitly mentioned in transcript or context, else omit.) Neurological: [PLR, mentation, head posture, righting reflex] (Only include if explicitly mentioned in transcript or context, else omit.) Coelomic palpation: [comfort, masses, organomegaly] (Only include if explicitly mentioned in transcript or context, else omit.) Cloaca: [discharge, swelling] (Only include if explicitly mentioned in transcript or context, else omit.) Respiratory: [auscultation findings, breathing pattern] (Only include if explicitly mentioned in transcript or context, else omit.) Oral cavity: [mucous membranes, discharge, signs of stomatitis or respiratory involvement] (Only include if explicitly mentioned in transcript or context, else omit.) Heart and lung auscultation: [“Not attempted”] (Only include if explicitly mentioned in transcript or context, else omit.) Other: [document additional abnormal findings, e.g. “Lymph nodes: enlarged”] (Only include if explicitly mentioned in transcript or context, else omit.) Diagnostics: [list each diagnostic test as a bullet point with result. Use “result pending” if not yet available, or “test offered but owner declined” where relevant. If none, write “Nil”.] (Only include if explicitly mentioned in transcript or context, else omit. Format as bullet points.) Problem List: [list problems and physical abnormalities in decreasing order of significance. If none, write “No problems detected”] (Only include if explicitly mentioned in transcript or context, else omit.) Assessment: [diagnoses or clinical impressions. If none, write “Healthy”] (Only include if explicitly mentioned in transcript or context, else omit.) Treatment: [list treatments in bullet points, including drug name, dosage, frequency, and duration] (Only include if explicitly mentioned in transcript or context, else omit.) Plan: [follow-up, pending tests, owner instructions or communications] (Only include if explicitly mentioned in transcript or context, else omit.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. Only include a placeholder if it has been explicitly mentioned in the transcript or context — otherwise omit the section completely. Always write any numbers, such as weights, temperatures, durations, or scores, in digits not in words. Use paragraph format or bullet points where appropriate to reflect how information was communicated.)