Veterinarian's note (custom)

**Subjective:** - Reason(s) for visit, including concerns or symptoms observed by the owner such as changes in behavior, appetite, activity level, vomiting, diarrhea, coughing: "Bella, a 5-year-old Golden Retriever, presented with a two-day history of vomiting and lethargy. The owner reported a decreased appetite and reluctance to go for walks." - Detailed history of presenting complaint(s), including onset, duration, severity, progression, known triggers or exposures, and home treatments attempted: "Vomiting started two days ago, initially after meals. It has become more frequent, occurring several times a day. The owner has not given any home treatments." - Past medical history including vaccinations, previous illnesses or surgeries, chronic conditions, medications, known allergies: "Bella is up-to-date on vaccinations. No prior illnesses or surgeries. No known allergies. Currently not on any medications." - Dietary history including food type, regimen, and recent diet changes: "Bella eats a commercial dry dog food, twice daily. No recent diet changes." - Environmental history such as indoor/outdoor access, exposure to animals, travel, lifestyle: "Bella is an indoor/outdoor dog, with access to a fenced yard. No recent travel. She interacts with other dogs at the park." **Objective:** - Vitals: temperature, pulse, respiration, body condition score, weight: "Temperature: 103.5°F (39.7°C), Pulse: 120 bpm, Respiration: 28 breaths/min, Body Condition Score: 6/9, Weight: 65 lbs." - Physical examination findings: general appearance, integument, musculoskeletal, cardiovascular, respiratory, gastrointestinal, urogenital, nervous system, eyes, ears, nose, throat: "General appearance: lethargic. Integument: normal. Musculoskeletal: normal. Cardiovascular: normal. Respiratory: mild increase in respiratory rate. Gastrointestinal: abdominal tenderness on palpation. Urogenital: normal. Nervous system: normal. Eyes: normal. Ears: normal. Nose: normal. Throat: normal." - Diagnostic tests performed: blood work, urinalysis, fecal exam, imaging studies: "Complete blood count (CBC), chemistry panel, and urinalysis performed. Abdominal radiographs scheduled." **Assessment & Plan:** 1. Issue or Condition - Assessment including likely diagnosis based on subjective and objective findings: "Suspect gastroenteritis or possible foreign body obstruction." - Differential diagnoses: "Parvovirus, pancreatitis, dietary indiscretion." - Recommended diagnostic tests to confirm or rule out other conditions: "Abdominal radiographs, further blood work if indicated." - Treatment plan including medications (drug, dose, route, frequency, duration), diet, activity restrictions, and home care: "Administer intravenous fluids. Anti-emetic medication (e.g., maropitant) 1 mg/kg subcutaneously once daily. Withhold food for 12 hours, then offer small amounts of bland diet. Restrict activity." - Procedures performed or scheduled e.g., surgery, dental cleaning, vaccination: "Abdominal radiographs scheduled for later today." - Follow-up care: reevaluation timing, signs to monitor, additional recommendations: "Re-evaluate in 24 hours. Monitor for continued vomiting, lethargy, or abdominal pain. Contact us immediately if symptoms worsen." **Additional Notes:** - Owner education: condition details, care instructions, medication administration, prevention: "Explain the potential causes of vomiting and the importance of following the treatment plan. Demonstrate how to administer medications. Advise on the bland diet and activity restrictions." - Emergency care instructions: when/how to seek urgent care: "If Bella becomes severely lethargic, unable to keep down water, or develops bloody vomit or diarrhea, seek immediate emergency care." - Specific owner concerns addressed: "Addressed the owner's concerns about the cause of the vomiting and the potential need for surgery."