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Veterinarian Template

Bron's template

A professional Veterinarian template for healthcare professionals.
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About this template

Streamline your veterinary practice's documentation with our comprehensive Bron's template. This meticulously designed clinical notes template helps veterinarians quickly and accurately record essential patient information, from presenting complaints and medical history to detailed examination findings. Ideal for small animal practitioners, it ensures all crucial aspects, including current medications, flea/tick prevention, and in-consult treatments, are consistently captured. Heidi, your AI medical scribe, intelligently populates sections like lab findings and assessment based on your consultations, making your clinical notes robust and compliant. Enhance efficiency and focus more on patient care with this invaluable tool for organised and thorough veterinary record-keeping.

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Veterinarian History: * Presenting complaint: "Coco" (Canine, Staffordshire Bull Terrier, entire male, 4 years old) presented for a 3-day history of scratching his left ear and shaking his head. Owner reports a reddish discharge noted this morning. * Duration: 3 days. * Background information: Coco is an indoor/outdoor dog, up-to-date on vaccinations, and has no known allergies. No recent changes in diet or environment. He has a history of occasional ear infections, typically responding well to topical treatments. [List of current medications] * Pre-emptor (Afoxolaner/Milbemycin oxime) – monthly, last given 25 October 2024. * Nexgard Spectra (Afoxolaner/Milbemycin oxime/Praziquantel) - monthly, last given 20 October 2024. Examination: Body condition = 4/9 (ideal) Weight = 25.4 kg Dental exam = Mild tartar noted on canines and premolars. Demeanour = Bright, alert, and responsive; slightly head-shy when left ear approached. Oral mms-Pink, moist, CRT <2 seconds Chest auscultation-Heart rate 110 bpm, strong, regular rhythm. No murmurs or arrhythmias detected. Lung sounds clear and vesicular. Respiration-Eupnoeic, no increased effort. Respiratory rate 20 breaths/minute. Abdominal palpation-Soft, non-painful, no organomegaly or masses detected. Lymph nodes-Peripheral lymph nodes non-enlarged. Mentation-Alert and appropriate. Skin/coat-Coat is shiny and well-maintained. Mild erythema and excoriation noted around the left external ear canal. Eyes-Clear, no discharge, pupils responsive to light. Ears-Left ear canal erythematous with a moderate amount of reddish-brown, waxy discharge. Mild swelling of the pinna. Right ear appears normal. [Temperature] Rectal examination-Not performed Laboratory: * Left ear cytology: Abundant cocci bacteria and moderate numbers of Malassezia yeast. Occasional neutrophils noted. Assessment: * Otitis externa, left ear, consistent with bacterial and yeast overgrowth secondary to inflammation. * No signs of systemic illness or underlying foreign body in the ear canal at this time. Treatment: * Cleaned left ear canal with a gentle otic cleanser. * Administered antibiotic and antifungal ear drops into the left ear. * Provided anti-inflammatory injection (given in consult). Plan: * Prescribed topical ear medication for twice daily application for 10 days. * Recommend recheck in 10-14 days to assess response to treatment and repeat ear cytology. * Discussed potential underlying causes of recurrent otitis and recommended considering allergy work-up if condition recurs. * Advised owner to monitor for any changes in appetite, activity, or worsening of ear symptoms.
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Specialty

Veterinarian

Used

9 times

Type

Note

Last edited

31.3.2026

Created by

Anonymous

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