Veterinarian Template

Outpatient (Veterinary Emergency)

A professional Veterinarian template for healthcare professionals.

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Specialty

Veterinarian

Used

99 times

Type

Note

Last edited

9/8/2024

Created by

Shan Li

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About this template

This Outpatient Veterinary Emergency template is designed for veterinarians handling urgent cases in a veterinary emergency hospital setting. It provides a comprehensive structure for documenting the presenting complaint, history, triage, examination, problem list, differential diagnosis, diagnostics, assessment, treatment, and plan for follow-up care. This template is ideal for veterinarians who need to efficiently record detailed clinical notes during emergency visits, ensuring all critical information is captured. It is particularly useful for cases involving acute symptoms such as vomiting, lethargy, or potential toxin exposure. The template is optimized for use with Heidi, an AI medical scribe, to streamline documentation processes.

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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 not eaten in the last 12 hours and has been less active than usual. - 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 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 clinical signs and examination findings suggest a possible case of gastroenteritis or pancreatitis. Dehydration is noted, and supportive care is required. TREATMENT: - Administered subcutaneous fluids (Lactated Ringer's Solution) 500ml - Prescribed antiemetic (Cerenia) 24mg once daily for 3 days - Advised bland diet for 3 days PLAN: - Discharge instructions: Monitor for any further vomiting or lethargy. Ensure Max is drinking water and eating the prescribed diet. - Recommendations for monitoring and follow-up care: Recheck in 48 hours if symptoms persist or worsen.