CLINICAL NOTE TEMPLATE

BY NEWGRADVETS.COM @FOREIGNVETS

history:
information provided by the owner

}
vital signs:
mentation:
mucous membranes (mm):
Vital signs are most
capillary refill time (crt):
important medical signs
heart rate (hr):
that indicate the status
respiratory rate (rr):
of the body’s vital functions
body temperature (temp):
body condition score (bcs):

clinical examination:

}
eyes:
lymph nodes:
ears/skin:
cardiovascular: clinical examination
respiratory: and your observations
gastrointestinal:
oral:
abdominal:
rectal:

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 CLINICAL NOTE TEMPLATE
BY NEWGRADVETS.COM @FOREIGNVETS

muscoskeletal:
urinary:
reproductive:

problem list:
all abnormalities noted during history taking and clinical examination

differential diagnosis:
is a list of possible conditions or diseases that could be causing the
symptoms

plan / diagnostics:
write down what plan you discussed with owner
results of any additional tests

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 CLINICAL NOTE - EXAMPLE
NEWGRADVETS.COM @FOREIGNVETS

history:
Acute vomiting that started 2hours prior to presentation. Vomited with food, then last two vomits contained bile/saliva and
small amount of fresh blood.
No diet change according to owner. Dog ate cooked chicken bones yesterday.
Last full meal this morning, ate everything - 1 cup of dry food RC. Been drinking water all day, O had to refill the bowl.
Faeces last seen yesterday evening - normal colour and consistency.
Very lethargic today, not himself. Has never been unwell in the past. Up to date with vaccination (C5) and worming.
On Revolution spot-on monthly.

vital signs:
temperament: quiet alert responsive (QAR)
mm: pink, dry
crt: <2 sek
hr: 176bpm
rr: 32bpm
temp: 39.7'C
bcs: 7/9

clinical examination:
eyes: no abnormalities noted
lymph nodes: normal size, not painful
skin/ears: skin tenting 3 seconds, no other abnormalities noted
cardiovascular: cardiac auscultation normal, no murmur, pulse normal and synchronous, femoral pulse = heart rate
respiratory: thoracic auscultation normal bilaterally, clear sounds, no abnormalities noted
gastrointestinal:
oral: mild periodontal disease stage (0-4): 2, no mouth pain, 
abdominal: moderate pain when cranial abdomen palpated, no palpable abnormalities
rectal: moderate amount of soft faeces, brown colour, watery consistency
musculoskeletal: no lameness noted, no palpable neck or spinal pain, limbs and joint normal on examination
urinary: no significant abnormalities noted, small bladder - not painful on palpation
reproductive: no abnormalities noted, castrated

problem list:
Acute vomiting - haematemesis
Moderate tachycardia 176bpm
Lethargy
Fever 39.7'C
Painful cranial abdomen
5% dehydration
Periodontal disease 2/4

differential diagnosis:

plan / diagnostics:

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 CLINICAL NOTE TEMPLATE
NEWGRADVETS.COM @FOREIGNVETS

history:

vital signs:
mentation:
mucous membranes (mm):
capillary refill time (crt):
heart rate (hr):
respiratory rate (rr):
body temperature (temp):
body condition score (bcs):

examination:
eyes:
lymph nodes:
ears/skin:
cardiovascular:
respiratory:
gastrointestinal:
oral:
abdominal:
rectal:
muscoskeletal:
urinary:
reproductive:

problem list:

differential diagnosis:

plan / disgnostics:

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