Vet Medical Consult

Vital Signs: - Temp: [Temperature reading or state not taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Pulse: [Pulse rate or state not taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Respiratory Rate: [Respiratory rate or state not taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History: - [Summary of the reason for the current visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Dietary history including food type, feeding schedule, and recent changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Energy levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Any current or past medical issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Exam Findings: - BCS: [Body Condition Score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Mentation: [Mental status or state] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Behaviour: [Behaviour during examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Eyes: - [Eye examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Ears: - [Ear examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MM: - [Mucous membrane assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CRT: - [Capillary refill time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Oral Cavity: - [Dental health assessment and recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Teeth or Oral cavity examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Lymph Nodes: - [Lymph node examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Cardiovascular: - [Cardiovascular system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Respiratory: - [Respiratory system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Abdomen: - [Abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Musculoskeletal: - [Musculoskeletal system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Integument: - [Skin and coat assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Urogenital: - [Urogenital system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neurological: - [Neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Rectal Exam: - [Rectal examination findings or state not performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnostic Results: - [Summary of any diagnostic tests performed or state none performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: - Problem list: 1. [First problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. [Second problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. [Third problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 4. [Fourth problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 5. [Fifth problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Additional problems if any] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Continue numbering.) Plan: - [Medications prescribed or sent home] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Follow-up care or additional recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Communications: - [Summary of discussions with the owner regarding treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)