Automatická Zdravotná Dokumentácia

Call Summary

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Príklady Zdravotnej Dokumentácie

Zhrnutie Hovoru

Bella

Thursday, July 30, 2026 at 5:15 PM

Call Summary

Discussed Bella’s recent test results, current treatment progress, and next steps for her ongoing care. The call lasted approximately 12 minutes and included updates on bloodwork, medication adjustments, and follow-up scheduling.

Tests

  • Blood Panel: Mild elevation in liver enzymes (ALT slightly above normal range)
  • Urinalysis: Normal, no signs of infection or crystalluria
  • Fecal Exam: Negative for parasites
  • X-Rays (from July 28): No foreign objects; mild arthritis noted in hips

Treatment

  • Continued prescription diet (Hill’s i/d) for gastrointestinal support
  • Added joint supplement (Dasuquin) to help manage early arthritis signs
  • Discontinued previous probiotic due to GI stabilization

Monitoring

  • Watch for vomiting, diarrhea, or decreased appetite
  • Note any changes in mobility or signs of discomfort, especially after exercise
  • Monitor water intake and urination frequency

Medications

  • Carprofen (25 mg): ½ tablet twice daily with food, for inflammation/pain
  • Maropitant (Cerenia): 16 mg once daily for 5 days, if nausea recurs
  • Dasuquin Chews: 1 chew daily with food

Follow-Up

  • Recheck liver values in 3–4 weeks (tentatively scheduled for August 27)
  • Call clinic sooner if GI symptoms return or Bella becomes lethargic
  • Consider follow-up x-rays in 6 months to reassess hips
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