Veterinary Release Paperwork Template

History:
- Bella, a 5-year-old Labrador Retriever, presented with fatigue and reduced appetite over the last three days.
Physical Exam Findings:
- General appearance and vital parameters: Bella appeared tired with a temperature of 102.5°F, heart rate of 120 bpm, and respiratory rate of 30 breaths per minute.
- Mucous membrane description and capillary refill time: Pale mucous membranes with a capillary refill time of 3 seconds.
- Cardiovascular exam findings: Tachycardia observed with no murmurs.
- Respiratory exam findings: Mild crackles heard in the lower lung fields.
- Lymph node exam findings: No lymphadenopathy noted.
- Other physical exam findings: Mild abdominal tenderness upon palpation.
Diagnosis:
- Suspected bacterial pneumonia.
Laboratory/Medical Imaging Findings:
- EPOC: Venous blood gas results indicated mild metabolic acidosis.
- Complete Blood Work: Leukocytosis with a left shift.
- Chemistry Panel: Elevated liver enzymes.
- Imaging: Thoracic radiographs showed a diffuse interstitial pattern consistent with pneumonia.
Summary of Case Management:
- Diagnostic tests included complete blood count, chemistry panel, venous blood gas analysis, and thoracic radiographs. Bella was admitted for IV fluid therapy and antibiotics.
Recommended Treatment/Management:
- Monitor Bella's breathing rate and effort at home. Ensure she stays hydrated and encourage small, frequent meals.
- General signs of complications to watch for include increased breathing effort, persistent cough, or fatigue.
Medications:
- Administer Amoxicillin 500 mg orally every 12 hours for 10 days.
Rechecks:
- Recheck appointment in 7 days to evaluate clinical improvement and repeat thoracic radiographs.
Additional Information:
- Owner advised to keep Bella indoors and limit physical activity until recheck.
Sincerely,
Dr. Emily Carter
s10.ai Veterinary Clinic
Discharge Disclaimer:
- The above instructions have been explained to me, and I understand the importance of following them for Bella's recovery.
- Signature lines for owner/agent and staff witness
_________________________ (Owner/Agent)
_________________________ (Staff Witness)