Subjective:
- Reason(s) for visit, including specific concerns or symptoms observed by the owner such as changes in behavior, appetite, activity level, vomiting, diarrhea, coughing: "Buddy, a 5-year-old Golden Retriever, presented with a three-day history of vomiting and lethargy. The owner also reported decreased appetite."
- Detailed history of the presenting complaint(s), including onset, duration, severity, progression of symptoms, any known triggers or exposures, and any home treatments attempted: "The vomiting started suddenly three days ago, occurring several times a day. The vomitus initially contained undigested food, but later progressed to bile. Buddy has been less active than usual and has shown little interest in his food. The owner did not administer any home treatments."
- Past medical history, including vaccinations, previous illnesses or surgeries, chronic conditions, medications, any known allergies: "Buddy is up-to-date on his vaccinations. He had a bout of kennel cough last year, but otherwise has been healthy. No known allergies. He is not on any medications."
- Dietary history, including type of food, feeding regimen, any recent diet changes: "Buddy eats a commercial dry dog food, twice a day. No recent diet changes."
- Environmental history, such as indoor/outdoor access, exposure to other animals, recent travel, active or sedentary lifestyle: "Buddy is primarily an indoor dog with access to a fenced backyard. He has not been exposed to any other animals recently and has not travelled. He has a moderately active lifestyle with daily walks."
Objective:
- Vitals, including temperature, pulse, respiration rate, body condition score, weight: "Temperature: 103.5°F (39.7°C), Pulse: 120 bpm, Respiration: 28 breaths/min, Body Condition Score: 6/9, Weight: 75 lbs."
- Physical examination findings, systematically covering general appearance, integumentary system, musculoskeletal system, cardiovascular system, respiratory system, gastrointestinal system, urogenital system, nervous system, eyes, ears, nose, throat: "General appearance: Lethargic. Integumentary: Normal. Musculoskeletal: Normal. Cardiovascular: Normal. Respiratory: Mildly increased respiratory effort. Gastrointestinal: Abdominal palpation revealed mild discomfort. Urogenital: Normal. Nervous: Normal. Eyes, Ears, Nose, Throat: Normal."
- Any specific diagnostic tests performed during the visit, such as blood work, urinalysis, fecal examination, imaging studies: "Blood work was performed, including a complete blood count (CBC) and chemistry panel."
Assessment & Plan:
1. Issue or Condition
- Assessment, including the likely diagnosis based on the subjective and objective findings: "Likely diagnosis: Gastroenteritis."
- Differential diagnoses: "Other differential diagnoses include dietary indiscretion, foreign body ingestion, or infectious disease."
- Recommended diagnostic tests to confirm the diagnosis or rule out other conditions: "Further diagnostic tests: Abdominal radiographs to rule out foreign body."
- Treatment plan, detailing medications prescribed, dosage, route, frequency, and duration, as well as any dietary recommendations, activity restrictions, or additional care required at home: "Treatment plan: Administer antiemetic medication (Maropitant) 1mg/kg subcutaneously once daily for 3 days. Provide a bland diet (boiled chicken and rice) for 24 hours, then gradually reintroduce the regular diet. Restrict activity for 2 days."
- Follow-up care, including when to return for reevaluation, signs to monitor for improvement or deterioration, any additional recommendations for management of the condition: "Follow-up care: Return for reevaluation in 2 days if symptoms do not improve or if they worsen. Monitor for continued vomiting, lethargy, or loss of appetite. Contact the clinic immediately if any of these signs are observed."
Additional Notes:
- Owner education on the diagnosed condition(s), care instructions, medication administration tips, and prevention of future occurrences: "Educated the owner on the importance of following the prescribed treatment plan and monitoring for any adverse signs. Discussed the potential causes of gastroenteritis and ways to prevent future occurrences, such as avoiding table scraps and ensuring Buddy does not have access to potentially harmful substances."
- Emergency care instructions, including when and how to seek urgent care: "Provided instructions on when to seek emergency care: if Buddy becomes severely dehydrated, develops bloody vomit or diarrhea, or becomes unresponsive."
- Any specific owner concerns addressed during the consultation: "Addressed the owner's concern about the potential causes of Buddy's illness and reassured them about the prognosis with appropriate treatment."
Subjective:
- [Reason(s) for visit, including specific concerns or symptoms observed by the owner such as changes in behavior, appetite, activity level, vomiting, diarrhea, coughing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Detailed history of the presenting complaint(s), including onset, duration, severity, progression of symptoms, any known triggers or exposures, and any home treatments attempted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Past medical history, including vaccinations, previous illnesses or surgeries, chronic conditions, medications, any known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Dietary history, including type of food, feeding regimen, any recent diet changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Environmental history, such as indoor/outdoor access, exposure to other animals, recent travel, active or sedentary lifestyle] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- [Vitals, including temperature, pulse, respiration rate, body condition score, weight](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical examination findings, systematically covering general appearance, integumentary system, musculoskeletal system, cardiovascular system, respiratory system, gastrointestinal system, urogenital system, nervous system, eyes, ears, nose, throat] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Any specific diagnostic tests performed during the visit, such as blood work, urinalysis, fecal examination, imaging studies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment & Plan:
[1. Issue or Condition]
- [Assessment, including the likely diagnosis based on the subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Recommended diagnostic tests to confirm the diagnosis or rule out other conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Treatment plan, detailing medications prescribed, dosage, route, frequency, and duration, as well as any dietary recommendations, activity restrictions, or additional care required at home] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Any procedures performed or scheduled, such as surgery, dental cleaning, vaccinations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow-up care, including when to return for reevaluation, signs to monitor for improvement or deterioration, any additional recommendations for management of the condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[2. Additional Issues or Conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow the same structure as above for each additional issue or condition identified](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Additional Notes:] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Owner education on the diagnosed condition(s), care instructions, medication administration tips, and prevention of future occurrences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Emergency care instructions, including when and how to seek urgent care ] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Any specific owner concerns addressed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)