Dermatology/Allergy Visit Note

Date/Time: [Date and time of visit]

Patient: [Name], [Species], [Breed], [Age], [Sex], [Weight]

Client: [Owner name]

Visit Type: [new / recheck / urgent]

Referring DVM: [Name and clinic] (Only include if applicable)

History

Chief Complaint: [Client-stated concern and clinical terminology for presenting signs including onset, duration, progression, distribution, seasonality, and response to prior therapies] (If key elements are unavailable, document as "unknown.")

Owner Pruritus Score (0-10): [Current score] (For rechecks, include baseline/previous: [value] and trend: [improved / stable / worsened].)

Prior Therapies: [Topicals, systemic therapies, ear treatments, and response/adverse effects]

Ectoparasite Control

• Current product and last dose: [product name, date]
• All in-contact pets treated: [yes / no / unknown]
• Exposure risk: [indoor only / indoor-outdoor / boarding / dog park / grooming]

Diet History

• Current diet: [brand, protein sources, formulation]
• Treats/table foods: [items] (If none, state none.)
• Flavored meds/preventives: [list or none]
• Prior diet trial: [diet, duration, compliance, response] (If none, state none.)
• Feasibility concerns: [household factors if diet trial planned]

Objective

Vitals/BCS: [Weight, temperature if measured, body condition]

General Exam: [Brief assessment; note non-dermatologic abnormalities or state unremarkable]

Dermatologic Exam

• Lesion morphology: [observed lesion types]
• Distribution: [affected regions, note symmetry and predominant areas]
• Synthesis: [Brief statement linking morphology to distribution and suspected primary vs secondary lesions]

Otic Exam (Only include if ears involved)

• Left ear: [pinna, canal, discharge character, pain/pruritus, otoscopic findings if performed]
• Right ear: [pinna, canal, discharge character, pain/pruritus, otoscopic findings if performed]

Cytology (If not performed, document reason deferred and plan to obtain.)

• Site: [location] — Method: [tape / swab / impression / FNA]
  • Findings: [bacteria type and quantity, yeast quantity, inflammatory cells]
  • Interpretation: [infection / colonization / contamination] — Culture indicated: [yes / no with rationale]

Assessment

(List problems in order of clinical importance. Do not document a definitive diagnosis without supporting criteria and completed rule-outs or trials.)

[Problem 1]: [Primary problem]

• Evidence: [Key history, distribution, morphology, cytology findings]
• Differentials: [Prioritized list]
• Working diagnosis: [Diagnosis] — Confidence: [low / moderate / high]

[Problem 2]: [Secondary problem]

• Evidence: [Findings]
• Differentials: [Prioritized list]
• Working diagnosis: [Diagnosis] — Confidence: [low / moderate / high]

(Add additional problems as needed.)

Plan

(Organize by problem with start/stop/continue actions. For treatment trials, document rationale, intervention, success/failure criteria, and recheck timing.)

[Problem 1 Plan]

• Start: [New therapies]
• Continue: [Ongoing therapies]
• Stop/Taper: [Therapies to discontinue]
• Success/failure criteria: [Target outcomes and escalation triggers]
• Recheck: [Interval and what will be reassessed]

[Problem 2 Plan]

• Start: [Details]
• Continue: [Details]
• Stop/Taper: [Details]
• Success/failure criteria: [Details]
• Recheck: [Details]

Ectoparasite Control Trial (Include if indicated)

• Product: [name, dose, frequency]; all in-contact pets treated: [yes / no]
• Duration: [weeks]; Success criteria: [reduced pruritus, resolution of bite lesions]

Antimicrobial Therapy (Include if treating infection)

• Indication: [pyoderma / Malassezia / otitis]
• Agent and dosing: [topical/systemic, dose, frequency, duration]
• Recheck/culture plan: [interval and criteria for culture]

Diet Trial (Include if planned)

• Selected diet: [hydrolyzed / novel protein, brand]
• Strict rules: Permitted items only; no treats/table scraps/flavored meds unless diet-approved
• Duration: [8-12 weeks]; Challenge phase: [plan if improved]

Recheck Criteria

• Scheduled: [interval]
• Reassess: [pruritus score, cytology, lesion status, treatment tolerance]
• Earlier return if: [worsening signs, new lesions, adverse effects]

Medications

• [Medication] — [dose, route, frequency, duration]; Indication: [reason]; Instructions: [key notes]

(If none prescribed, state "None.")