Inpatient Vet Note

Reason for presentation: [Brief description of the patient's presenting complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in a single sentence.) Pertinent History: [Detailed description of the patient's presenting complaint and events leading up to presentation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use dash points and write in full sentences.) Additional History: [Details of any patient history not directly related to the presenting complaint, such as past health events, behavioural notes, previous treatments etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use dash points and write in full sentences.) Pre-existing conditions: [Document any known pre-existing medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If no conditions are mentioned, write verbatim "No known pre-existing conditions.") Diet: [Describe the patient’s current diet] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If not discussed, write verbatim "not discussed.") Access to toxins: [Describe any known or suspected access to toxins, including bait, rubbish, medications, chemicals or scavenged substances] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If not discussed, write verbatim "No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.") Current vaccination/preventatives status: [Summarise current vaccination and parasite preventative status, including specific products used if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If not discussed, write verbatim "not discussed.") Current medications: [List all current medications the patient is receiving, including name, dosage, frequency and reason for administration] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If not discussed, write verbatim "nil mentioned.") Neurological examination: (Include this section only if a full neurological exam has been discussed. Present each of the following sub-sections even if only some are documented.) - Mentation: [Describe mentation status] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) - Posture/gait: [Describe posture and gait abnormalities] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) - Postural reactions: [Detail postural reaction testing] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) - Spinal reflexes: [Describe spinal reflex testing and findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) - Cranial nerves: [Outline cranial nerve assessment findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) - Spinal pain: [Document presence or absence of spinal pain] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) - Neuroanatomical localisation: [State the suspected localisation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) Problem List: (For each identified clinical problem, repeat the following structure as many times as needed. List in order of significance.) - [Title of the clinical problem] - DDx: [List of potential differential diagnoses with brief justifications for each] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.) - P: [Diagnostic and therapeutic plan specific to the problem] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.) Diagnostics: [List only abnormal or significant results. Include reference intervals where appropriate. Organise in the following categories.] - PCV/TP: [Summarise PCV/TP values and serum colour] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - ABL: [Document arterial blood gas or radiometer results] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Procyte haematology: [Summarise in-house haematology findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Catalyst chem17: [Summarise chemistry profile results, including any additional slides such as CRP or CK] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Vetnostics haematology and biochemistry: [Summarise external pathology if available, or write verbatim "_pending_"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Point-of-care ultrasound: [Summarise POCUS findings including presence of effusion or cardiac parameters] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Specialist abdominal ultrasound: [Include verbal interim findings from specialist abdominal ultrasound] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - CT scan: [Include verbal interim findings from CT scan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Instrumentation: [List each item placed, with details including type, date of placement and anatomical location (e.g. central line, arterial line, nasogastric tube, oesophagostomy tube)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.) Assessment: [Begin with assessment of the patient's haemodynamic, respiratory and neurological stability. Then summarise new physical exam findings. Describe changes since last review (e.g. overnight/morning) and updates on diagnostics or treatment. Include your clinical reasoning by linking history, examination and diagnostics into a coherent interpretation.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in detailed, chronological paragraphs with full sentences.) Client Communications: [Document client discussions in detail. Start with "Spoke with [name]" then include summary of discussion, options provided, decisions made, and potential risks or complications explained.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and be thorough.) Ongoing Assessment / Evening Update: [Include any afternoon reassessment and updates from continued hospitalisation. Document any further client communications or decisions made during follow-up contact.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Treatment: [List treatment interventions including drugs, fluids, supportive care etc. Include drug name, dose, frequency and route of administration] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in succinct bullet points without omitting key details.) Plan: - Discharge instructions: [Outline specific instructions for the owner upon discharge] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) - Monitoring and follow-up: [Summarise ongoing care plan including medications, monitoring requirements, and follow-up diagnostics or appointments] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use 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. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)