Veterinary nurse disease checklist

Patient Information*: Name, species, breed, age, weight, sex, and owner's contact details.

Date and Time*: Record the date and time of the examination.

Presenting Complaint*: Briefly describe the reason for the visit.

Medical History*: Record any previous medical conditions, surgeries, or hospitalizations.

Medication History*: Note any current medications or supplements the patient is receiving.

Vaccination History*: Include up-to-date vaccination records.

Vital Signs*: Measure the patient's body temperature, heart rate, respiratory rate, and blood pressure.

General Appearance*: Assess the patient's overall condition, body condition score, and behavior.

Skin and Coat*: Check for any abnormalities, lesions, rashes, or signs of parasites.

Eyes*: Inspect the eyes for redness, discharge, cloudiness, or abnormalities.

Ears*: Examine the ears for signs of infection, discharge, or inflammation.

Nose*: Check for any nasal discharge, congestion, or abnormal smell.

Mouth and Teeth*: Assess the oral cavity for dental disease, tartar, gingivitis, or oral masses.

Heart and Lungs*: Perform auscultation to evaluate heart and lung sounds.

Abdomen*: Palpate the abdomen to detect any abnormalities or masses.

Musculoskeletal System*: Observe the patient's gait, check joints for pain or swelling, and assess muscle condition.

Lymph Nodes*: Palpate for any enlarged or abnormal lymph nodes.

Urogenital System*: Examine the genitalia for any abnormalities or signs of infection.

Neurological System*: Evaluate the patient's coordination, reflexes, and overall neurological status.

Blood Work*: Indicate if any blood tests (e.g., complete blood count, blood chemistry) were performed.

Urinalysis*: Specify if a urinalysis was conducted.

Imaging*: Note if any radiographs, ultrasounds, or other imaging modalities were used.

Diagnosis*: Record the veterinarian's diagnosis or differential diagnoses.

Treatment Plan*: Outline the recommended treatment options, medications, and therapies.

Follow-up Care*: Provide instructions for follow-up appointments, medication administration, and monitoring.

Client Education*: Summarize important information or instructions given to the owner.

Additional Recommendations*: Include any dietary modifications, exercise restrictions, or environmental changes.

Veterinarian's Signature*: Veterinarian's name and signature.

Date*: Date when the checklist was completed.

Remember to adapt this checklist to your specific needs and requirements as a veterinary nurse.