Veterinarian Template

Vet Medical Consult

A professional Veterinarian template for healthcare professionals.

About this template

Effortlessly document comprehensive animal health assessments with our 'Vet Medical Consult' template. Perfect for veterinarians and veterinary nurses, this clinical notes template ensures thorough recording of vital signs, patient history, physical examination findings, and detailed diagnostic and treatment plans. Capture everything from musculoskeletal assessments to neurological observations, along with precise dietary information and follow-up care instructions. Heidi, our AI medical scribe, intelligently populates this template from your consultation, streamlining your workflow and helping you maintain impeccable veterinary documentation. Optimised for clarity and completeness, it’s an essential tool for every modern veterinary practice looking for efficient medical documentation examples.

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Clinician Specialty: Veterinarian Vital Signs: - Temp: 38.5°C - Pulse: 120 bpm - Respiratory Rate: 30 bpm History: - Reason for current visit: Owner reports 3-day history of lethargy, decreased appetite, and intermittent vomiting in "Max," a 5-year-old male neutered Labrador Retriever. - Dietary history: Max typically eats Royal Canin Adult Large Breed dry food, 2 cups twice daily. No recent changes to diet, but has been picking at food for the past 3 days. No known dietary indiscretions. - Energy levels: Significantly reduced; usually very active but has been mostly sleeping. - Current or past medical issues: No significant past medical history. Up-to-date on vaccinations and deworming. Physical Exam Findings: - BCS: 5/9 (Ideal) - Mentation: Dull but responsive - Behaviour: Cooperative but subdued during examination. Eyes: - Clear, no discharge. Pupils equal and reactive to light. Conjunctivae pink. Ears: - Clean, no discharge or odour. No signs of inflammation. MM: - Pale pink, slightly tacky CRT: - 2 seconds Oral Cavity: - Mild tartar accumulation on canines and premolars. No obvious foreign bodies or lesions. Recommended dental cleaning in the next 6-12 months. - Teeth and gums appear healthy otherwise. Lymph Nodes: - Submandibular lymph nodes palpably normal. Other peripheral lymph nodes not enlarged. Cardiovascular: - Regular rhythm, no murmurs auscultated. Strong femoral pulses. Respiratory: - Clear lung sounds bilaterally, no crackles or wheezes. No increased respiratory effort. Abdomen: - Soft and non-painful on palpation. No obvious organomegaly or masses. Mildly distended with gas. Musculoskeletal: - No lameness or pain on palpation of limbs or spine. Normal gait observed. Integument: - Coat dull, but no ectoparasites, lesions, or alopecia noted. Skin turgor slightly reduced. Urogenital: - No external abnormalities noted. Testicles descended and normal. Neurological: - Cranial nerves appear intact. Proprioception normal. No ataxia or paresis. Rectal Exam: - Not performed. Diagnostic Results: - Complete Blood Count (CBC): Mild leukocytosis with neutrophilia. - Serum Chemistry: Mildly elevated BUN and Creatinine (pre-renal azotemia suspected), mild hypokalemia. - Abdominal Radiographs: Mild diffuse gas pattern in intestines; no foreign bodies or obvious obstructions. Assessment: - Problem list: 1. Anorexia/Hyporexia 2. Vomiting 3. Lethargy 4. Dehydration (mild) 5. Pre-renal azotemia Plan: - Medications prescribed or sent home: Maropitant (Cerenia) 16mg SC once daily for 3 days; Metronidazole 250mg PO BID for 5 days; Hills i/d canned food for 3 days. - Follow-up care or additional recommendations: Recheck in 48 hours for reassessment. Encourage small, frequent meals of bland diet. Ensure access to fresh water. Advised owner to monitor hydration status and vomiting frequency. Communications: - Discussed findings of dehydration, potential gastroenteritis, and mild kidney stress with owner. Explained treatment plan including medication administration, dietary changes, and follow-up. Owner approved diagnostics and treatment.

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.)

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