- Vaccinations that are due today and what they are receiving: Rabies vaccine
- EDDU: Owner concerned about recent weight loss and increased thirst.
- Current medication: Prednisolone 5mg PO SID
**Clinical Exam**
- MM: Pink, CRT <2 seconds
- Oral cavity: Grade 2 dental disease, mild gingivitis.
- Eyes: Clear, no discharge, PLR normal.
- Ears: Clean, no redness or discharge.
- Cardiac: Heart rate 120 bpm, no murmurs, regular rhythm, clear chest sounds.
- Respiratory: Respiratory rate 24 bpm, clear breath sounds, no coughing.
- Abd palp: No pain, no masses palpated.
- BCS: 6/9
- Temperature: 38.9 °C
- Musculoskeletal: No lameness, normal gait.
- Skin: Normal, no lesions.
- Other abnormalities found in clinical exam: Mildly enlarged lymph nodes.
- Lymph nodes: Mildly enlarged submandibular lymph nodes.
- Vaccinations, Proheart, Bravecto Quantum given today: Rabies vaccine given today.
- Other medications, injections, or procedures done today: Prednisolone prescription refilled.
- Recommendations made in the consult: Recommend dental cleaning and further investigation of weight loss.
- Other procedures apart from vaccination, additional medications given: None.
**Plan**
- Investigations planned (only include if not done today): Blood work to investigate weight loss.
- Treatment planned (only include if not done today): Continue Prednisolone, schedule dental cleaning.
- Other actions such as counselling, referrals, follow-up: Schedule follow-up appointment in two weeks.
- [Vaccination that is due today and what they are receiving] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- EDDU [Concerns raised by the owner] (Only include if explicitly mentioned…)
- Current medication [Medications the pet is currently receiving] (Only include if explicitly mentioned…)
**Clinical Exam**
- MM: [Gum colour and capillary refill findings] (Only include if explicitly mentioned…)
- Oral cavity: [Dental grade/4, gingivitis grade/4, any abnormalities or extractions required] (Only include if explicitly mentioned…)
- Eyes: [Eye appearance, discharges, PLR] (Only include if explicitly mentioned…)
- Ears: [Ear appearance, redness, discharge] (Only include if explicitly mentioned…)
- Cardiac: [Heart rate with bpm, murmurs, arrhythmia, chest sounds] (Only include if explicitly mentioned…)
- Respiratory: [Respiratory rate or panting with bpm, breath sounds, effort, coughing] (Only include if explicitly mentioned…)
- Abd palp: [Abdominal palpation findings] (Only include if explicitly mentioned…)
- BCS: [Body condition score /9] (Only include if explicitly mentioned…)
- Temperature: [Temperature in °C] (Only include if explicitly mentioned…)
- Musculoskeletal: [Findings on limbs, lameness, stiffness] (Only include if explicitly mentioned…)
- Skin: [Skin and coat findings] (Only include if explicitly mentioned…)
- [Other abnormalities found in clinical exam] (Only include if explicitly mentioned…)
- Lymph nodes: [Lymph node findings, enlargements, abnormalities] (Only include if explicitly mentioned…)
- [Vaccinations, Proheart, Bravecto Quantum given today] (Only include if explicitly mentioned…)
- [Other medications, injections, or procedures done today] (Only include if explicitly mentioned…)
- [Recommendations made in the consult] (Only include if explicitly mentioned…)
- [Other procedures apart from vaccination, additional medications given] (Only include if explicitly mentioned…)
**Plan**
- [Investigations planned (only include if not done today)] (Only include if explicitly mentioned…)
- [Treatment planned (only include if not done today)] (Only include if explicitly mentioned…)
- [Other actions such as counselling, referrals, follow-up] (Only include if explicitly mentioned…)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, clinical exam findings, vaccinations, procedures, treatments, plans, or recommendations—use only the transcript, contextual notes or clinical note as reference. If any information has not been explicitly mentioned, do not state that it was not mentioned; simply omit it. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)