History:
* Presenting complaint of lethargy and decreased appetite for 2 days.
* Vaccinated annually.
* No known allergies.
Current medications:
* None.
Current flea, tick, worming, heartworm medication and frequency of administration:
* Bravecto, every 3 months.
Examination:
Weight 10 kg
Body condition 3/5
Dental findings: Not recorded
Demeanour: Depressed
Oral findings: Oral mms pink, moist
Chest auscultation findings: Chest auscultation normal. Heart rate 120 bpm.
Respiratory findings: Respiration normal
Abdominal palpation findings: Abdominal palpation normal
Lymph node findings: Lymph nodes normal
Mentation: Mentation normal
Skin and coat findings: Skin/coat normal
Eye findings: Eyes normal
Ear findings: Ears normal externally
Temperature: 39.5°C
Rectal examination findings: not performed
Additional physical examination findings not already mentioned: Mild dehydration.
Laboratory:
Findings from cytology performed during consult: Not performed.
Assessment:
* Suspect gastroenteritis.
* Rule out other causes of lethargy and anorexia.
Treatment:
* Administered intravenous fluids.
* Administered anti-emetic injection.
Plan:
* Continue intravenous fluids overnight.
* Monitor for vomiting and diarrhoea.
* Repeat blood work in the morning.
* Discuss further diagnostics if no improvement.
History:
[history including presenting complaints, duration, and relevant background information] (Only include if explicitly mentioned in transcript, context or clinical note. Group similar symptoms or information together in one bullet point. Use separate bullet points for unrelated problems or symptoms. Please do not omit any information.)
[current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
[current flea, tick, worming, heartworm medication and frequency of administration] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
Examination:
[Weight] (Only include if explicitly mentioned in transcript, context or clinical note. Write value on the same line.)
[Body condition] (Only include if explicitly mentioned in transcript, context or clinical note. Write value on the same line.)
[Dental findings] (Only include if explicitly mentioned in transcript, context or clinical note, else write "not recorded". Write on the same line.)
[Demeanour] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on the same line.)
[Oral findings] (Always include fixed text phrase "Oral mms pink, moist" unless oral mms are described differently in transcript, context or clinical note.)
[Chest auscultation findings] (Always include fixed text phrase "Chest auscultation normal" unless described differently in transcript, context or clinical note. Include any comments about a heart murmur and record heart rate on the same line.)
[Respiratory findings] (Always include fixed text phrase "Respiration normal" unless described differently in transcript, context or clinical note.)
[Abdominal palpation findings] (Always include fixed text phrase "Abdominal palpation normal" unless described differently in transcript, context or clinical note.)
[Lymph node findings] (Always include fixed text phrase "Lymph nodes normal" unless described differently in transcript, context or clinical note.)
[Mentation] (Always include fixed text phrase "Mentation normal" unless described differently in transcript, context or clinical note.)
[Skin and coat findings] (Always include fixed text phrase "Skin/coat normal" unless described differently in transcript, context or clinical note.)
[Eye findings] (Always include fixed text phrase "Eyes normal" unless described differently in transcript, context or clinical note.)
[Ear findings] (Always include fixed text phrase "Ears normal externally" unless described differently in transcript, context or clinical note.)
[Temperature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
[Rectal examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else write "not performed". Write on the same line.)
[Additional physical examination findings not already mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, otherwise omit section entirely.)
Laboratory:
[Findings from cytology performed during consult] (Only include if skin or ear cytology is explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Assessment:
[Assessment based on history and examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bullet point list of full sentences.)
Treatment:
[List of vaccinations, worming tablets or procedures performed in consult such as nail trims] (Do not include medications dispensed for home use or examinations.)
Plan:
[Plan for treatment, further investigations, and follow-up] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list. Do not include vaccinations or treatments given in consult in this section.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output.)
