Veterinarian Template

Inpatient (Veterinary Emergency)

A professional Veterinarian template for healthcare professionals.

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Specialty

Veterinarian

Used

89 times

Type

Note

Last edited

9/8/2024

Created by

Shan Li

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About this template

This Inpatient Veterinary Emergency template is designed for veterinarians handling acute cases in a veterinary emergency hospital setting. It provides a comprehensive structure for documenting the presenting complaint, history, triage, examination, diagnostics, and treatment plan for animal patients. This template is particularly useful for veterinarians dealing with emergency cases, ensuring all critical information is captured systematically. It includes sections for problem lists, differential diagnoses, and detailed assessments, making it an essential tool for efficient and thorough veterinary documentation. Ideal for emergency veterinary clinics, this template helps streamline patient care and communication.

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REASON: Vomiting and lethargy HISTORY: - The patient, a 5-year-old Labrador Retriever named Max, presented with acute vomiting and lethargy for the past 24 hours. - Owner reports that Max has been less active and has not eaten since yesterday. - Pre-existing conditions: No known pre-existing conditions - Access to toxins: No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged. - Current vaccination status: Up to date - Current medications: Nil mentioned TRIAGE: - HR: 120 bpm - RR: 30 breaths/min - Temp: 39.0°C - Mm: Pink and moist - Crt: <2 seconds - Mentation: QAR - Pain Scale (0-4): 2 - Hydration status (%): 5% dehydrated - Blood pressure: 120/80/95 - Spo2: 98% EXAMINATION: Body Condition Score: 6/9 Pain Scale (0-4): Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous Respiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge Neurological: Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performed Musculoskeletal: Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed Gastrointestinal: - Oral: NSF - Abdominal: Mild discomfort on palpation - Rectal: not performed Urinary: NSF Reproductive (incl ext genitalia): NSF Integumentary system: NSF Lymph Nodes: WNL on palpation Eyes: NSF PROBLEM LIST: 1. Vomiting 2. Lethargy 3. Dehydration DIFFERENTIAL DIAGNOSIS: Gastroenteritis, pancreatitis, foreign body ingestion DIAGNOSTICS: Nil performed ASSESSMENT: Max is a 5-year-old Labrador Retriever presenting with acute vomiting and lethargy. The primary concerns are dehydration and potential gastrointestinal upset. Differential diagnoses include gastroenteritis, pancreatitis, or foreign body ingestion. Further diagnostics are recommended to rule out these conditions. TREATMENT: - Administered subcutaneous fluids (Lactated Ringer's Solution) 500ml - Prescribed antiemetic (Cerenia) 24mg once daily PLAN: - Discharge instructions: Monitor for any further vomiting or lethargy. Ensure Max has access to fresh water at all times. - Recommendations for monitoring and follow-up care: Recheck in 48 hours if symptoms persist or worsen. Consider abdominal ultrasound if no improvement.