Veterinary Handover Template

Handover Notes: Patient Name: Buddy Species: Canine Breed: Labrador Retriever Age: 5 years Sex: Male Presenting Complaint: Buddy presented with a two-day history of vomiting and lethargy. History: Buddy has a history of mild seasonal allergies. He is up-to-date on vaccinations and parasite preventatives. Medications: Currently taking Apoquel 3.6mg once daily for allergies. Allergies: Seasonal allergies (mild). Physical Examination: Buddy is bright, alert, and responsive. Mildly dehydrated. Abdomen is soft, but there is some tenderness on palpation. Temperature: 102.5°F, Heart Rate: 120 bpm, Respiratory Rate: 28 breaths/min. Diagnostics: Bloodwork revealed elevated liver enzymes and mild dehydration. Abdominal radiographs were unremarkable. Treatment: Administered intravenous fluids and an antiemetic. Started on a bland diet. Plan: Continue intravenous fluids overnight. Monitor vital signs and hydration status. Recheck bloodwork in the morning. Consider abdominal ultrasound if symptoms persist. Additional Notes: Owner is concerned about Buddy's condition. Discussed potential causes and treatment plan with the owner. Advised owner to contact the clinic immediately if Buddy's condition worsens. Illness Severity: - Moderate Patient Summary: - Buddy, a 5-year-old male Labrador Retriever, presents with a two-day history of vomiting and lethargy. He is currently on Apoquel for seasonal allergies. No known drug allergies. - Current clinical status includes mild dehydration, elevated liver enzymes, and a temperature of 102.5°F. Abdominal radiographs were unremarkable. - Received intravenous fluids and an antiemetic. Action List: - Continue intravenous fluids overnight. - Monitor vital signs and hydration status. - Recheck bloodwork in the morning. - Consider abdominal ultrasound if symptoms persist. - Provide owner with updates and discharge instructions. - Schedule a follow-up appointment in 2 days. - Handover date: 1 November 2024