Halopen output
“"Subjective — Bella, 6-year-old spayed female yellow Labrador, 32 kilograms, presented for two-day history of intermittent vomiting and decreased appetite. Owner reports four episodes of vomiting yesterday containing food and bile, two episodes today containing only foamy yellow material. No diarrhea. Drinking water but in smaller amounts. Energy decreased but still ambulatory. No known toxin exposure; owner reports no dietary indiscretion she's aware of, but the dog had access to the yard unattended for several hours yesterday afternoon. — Objective — Temperature 39.1, heart rate 88, respiratory rate 24, mucous membranes pink and tacky, capillary refill time 2 seconds, mild dehydration estimated at 5 percent, abdomen soft and non-painful on palpation though slightly tense in the cranial abdomen, no palpable foreign body, no organomegaly. Body condition score 5 out of 9. — Assessment — Acute gastritis, etiology undetermined; differentials include dietary indiscretion, foreign-body ingestion (low-medium given non-painful abdomen), pancreatitis (rule out via lipase), early Addisonian crisis (lower probability given stable hemodynamics). — Plan — Diagnostics: CBC, chemistry panel with electrolytes, lipase, urinalysis. Treatment: maropitant 1 milligram per kilogram subcutaneous, ondansetron 0.5 milligrams per kilogram IV, lactated Ringer's 350 milliliters subcutaneous over the next four hours. Hold food for 12 hours; offer small amounts of bland diet starting tomorrow morning if no further vomiting overnight. Recheck tomorrow at 10am or sooner if vomiting recurs more than twice or if patient becomes lethargic. Discussed plan with owner; she's agreeable; wrote estimate."”
- · 290-word SOAP note dictated in a single ~110-second hold
- · Species, breed, weight, vital signs, drug doses-per-kilogram all preserved verbatim
- · Differential diagnosis with reasoning preserved exactly as spoken
- · Voice version: ~110 seconds; typed version between appointments would have been 8-12 minutes