Reason for presentation:
Patient presented with a three-day history of lethargy, inappetence, and vomiting.
Pertinent History:
- The patient, a 5-year-old female spayed domestic shorthair cat, has been progressively less active over the past three days.
- The owner reports the cat has vomited several times, with the vomitus containing undigested food and bile.
- The cat has shown a decreased interest in food and water.
Additional History:
- The cat is an indoor-only cat.
- The cat is up-to-date on vaccinations.
- The cat has no known prior medical history.
Pre-existing conditions:
No known pre-existing conditions
Diet:
Currently eating a commercial dry cat food.
Access to toxins:
No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.
Current vaccination/preventatives status:
Up-to-date on FVRCP and rabies vaccinations. Receiving monthly flea and tick preventative (Revolution).
Current medications:
Nil mentioned
Vitals:
- BW: 4.5 kg
- HR: 180 bpm
- RR: 32 breaths/min
- Temp: 39.5 Celsius
- MM: Pink, moist
- CRT: 1.5s
- Mentation: BAR
- Pain Score: 2/24
- Hydration status (%): 5%
Physical Examination:
Body Condition Score:
5/9
Pain Scale (0–24):
2/24
Cardiovascular:
OMM pink, moist. CRT 1.5s. HS normal, no obvious HM or arrhythmias. Femoral pulses s/r, dorsal paedal pulses palpated.
Respiratory:
Eupnoeic. Normal BV LS all lung fields. No nasal discharge.
Neurological:
Mentation appropriate. No obvious neuro deficits. Full neuro exam not performed.
Abdominal:
Soft, comfortable and pliable. No obvious mass effects.
Musculoskeletal:
Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed.
Oral:
Unremarkable.
Genitourinary:
NSA. Normal external anatomy.
Integumentary system:
Skin turgor normal. NSA.
Lymph Nodes:
WNL on palpation.
Eyes:
NSA.
Rectal:
Not performed.
Problem List:
- Primary problem
- DDx: Gastroenteritis, foreign body obstruction, pancreatitis, hepatic lipidosis.
- P: Administer intravenous fluids, anti-emetics, and supportive care. Consider abdominal radiographs and bloodwork.
- Secondary problem
- DDx: Dehydration secondary to vomiting and decreased intake.
- P: Continue intravenous fluid therapy and monitor hydration status.
Diagnostics:
- PCV/TP: PCV 42%, TP 7.0 g/dL
- Catalyst chem17: ALT elevated, consistent with liver involvement.
Assessment:
The patient is a 5-year-old female spayed domestic shorthair cat presenting with a three-day history of vomiting, lethargy, and inappetence. Physical examination revealed mild dehydration. Initial diagnostics showed elevated liver enzymes. The patient is suspected to have gastroenteritis, with potential for other underlying causes. The patient was admitted for intravenous fluid therapy and supportive care.
Client communications:
The owner was informed of the cat's condition, the potential causes of the illness, and the treatment plan. The owner elected to proceed with diagnostics and hospitalization. The risks and complications of the treatment were discussed.
Treatment:
- Administered intravenous fluids (LRS) at a rate of 60 ml/hr.
- Administered anti-emetic medication (Maropitant).
Plan:
- Discharge instructions: Continue to monitor the cat's appetite, water intake, and vomiting. Contact the clinic immediately if the cat's condition worsens.
- Recommendations for monitoring and follow-up care, including medication list and future diagnostics or appointments: Recheck bloodwork in 24 hours. Continue anti-emetic medication as prescribed. Schedule a follow-up appointment in 3 days.
Reason for presentation:
[Brief statement of the presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Pertinent History:
[Details of patient's presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use dash points and always write in full sentences.)
Additional History:
[Detail any patient history not pertinent to the presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use dash points and always write in full sentences. Do not omit any information.)
Pre-existing conditions:
[Detail any pre-existing conditions, if not mentioned write "No known pre-existing conditions"]
Diet:
[Describe current diet] (If not mentioned please write "not discussed")
Access to toxins:
[List any known access to toxins the patient may have been exposed to/consumed] (If not mentioned write "No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.")
Current vaccination/preventatives status:
[Describe current vaccination, flea, tick, worming status. Include names of the vaccine/treatments used.] (If not mentioned please write "not discussed")
Current medications:
[List current medication, including dosage, frequency and reason for use] (If not mentioned please write "nil mentioned")
Vitals:
(Only include what is mentioned.)
- BW: [Body weight in kg] (Only include if explicitly mentioned.)
- HR: [Heart rate in bpm] (Only include if explicitly mentioned.)
- RR: [Respiratory rate in breaths/min] (Only include if explicitly mentioned.)
- Temp: [Temperature in Celsius] (Only include if explicitly mentioned.)
- MM: [Mucous membrane assessment] (Only include if explicitly mentioned.)
- CRT: [Capillary refill time] (Only include if explicitly mentioned.)
- Mentation: [Choose from either BAR, QAR, Dull, or Obtunded] (Only include if explicitly mentioned.)
- Pain Score: [Pain assessment score] (Only include if explicitly mentioned.)
- Hydration status (%): [Clinical assessment of hydration] (Only include if explicitly mentioned.)
- Blood pressure: [Blood pressure in format systolic/diastolic/MAP] (Only include if explicitly mentioned.)
- SpO2: [Pulse oximetry in %] (Only include if explicitly mentioned.)
Physical Examination:
Body Condition Score:
[Score out of 9 with interpretation if mentioned] (Leave placeholder blank if not mentioned.)
Pain Scale (0–24):
[Pain assessment score out of 24] (Only include if not already stated above.)
Cardiovascular:
[Findings from cardiac auscultation] (If not mentioned please write "OMM pink, moist. CRT 1.5s. HS normal, no obvious HM or arrhythmias. Femoral pulses s/r, dorsal paedal pulses palpated.")
Respiratory:
[Findings from thoracic auscultation] (If not mentioned please write "Eupnoeic. Normal BV LS all lung fields. No nasal discharge.")
Neurological:
[Neurological findings] (If not mentioned please write "Mentation appropriate. No obvious neuro deficits. Full neuro exam not performed.")
Abdominal:
[Abdominal palpation findings] (If not mentioned please write "Soft, comfortable and pliable. No obvious mass effects.")
Musculoskeletal:
[Musculoskeletal findings] (If not mentioned please write "Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed.")
Oral:
[Describe oral examination findings, including dental score out of 4 if mentioned.] (If not mentioned please write "Unremarkable.")
Genitourinary:
[Urinary system findings] (If not mentioned please write "NSA. Normal external anatomy.")
Integumentary system:
[Integumentary and ear examination findings] (If not mentioned please write "Skin turgor normal. NSA.")
Lymph Nodes:
[Lymph node examination findings] (If not mentioned please write "WNL on palpation.")
Eyes:
[Ophthalmic examination findings] (If not mentioned please write "NSA.")
Rectal:
[Rectal examination findings] (If not mentioned please write "Not performed.")
Problem List:
- [Primary problem]
- DDx: [List of potential differential diagnoses with brief explanation]
- P: [Potential diagnostic and therapeutic plan for the problem]
- [Secondary problem]
- DDx: [List of potential differential diagnoses with brief explanation]
- P: [Potential diagnostic and therapeutic plan for the problem]
- [Additional problem(s)]
- DDx: [List of potential differential diagnoses with brief explanation]
- P: [Potential diagnostic and therapeutic plan for the problem]
Diagnostics:
- PCV/TP: [Include results chronologically if stated]
- ABL: [Include if available]
- POCUS: [Include if available]
- Procyte haematology: [Include if available]
- Catalyst chem17: [Include if available]
- Vetnostics haematology and biochemistry: [Include if available]
Assessment:
[Detailed assessment of patient's condition and plan. Explain the suspected disease process, link history, exam and diagnostic tests, and summarise events during hospital stay in chronological order.] (Do not omit any information. Write in full sentences.)
Client communications:
[Detailed client communications. Include what was discussed, options presented, what the client elected, risks and complications mentioned.] (Be thorough to ensure all communications are documented accurately.)
Treatment:
- [Details of prescribed treatment/intervention, including medications, dosages, etc.] (Be succinct but complete.)
Plan:
- [Discharge instructions] (Include detailed owner instructions.)
- [Recommendations for monitoring and follow-up care, including medication list and future diagnostics or appointments.] (Write as bullet points for clarity.)
(Never repeat yourself throughout the note. Utilise chronological order when listing blood/diagnostic results. If radiology has occurred, ensure every body system in the above template is written. Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
