Professional Clinical Assessment

Veterinary observations in Kora are specialised records distinct from standard observations that animal owners create. While owner observations might note "the cow seems off her feed today," veterinary observations provide professional clinical assessments: "Diagnosis: Ruminal acidosis. Clinical findings: Depressed demeanour, reduced rumination, diarrhoea. Treatment plan: IV fluids, thiamine, gradual feed reintroduction."

This professional documentation serves multiple purposes: guides current treatment, informs future caregivers, supports regulatory compliance, creates medico-legal records, and integrates with biosecurity systems to trigger automatic disease management responses when contagious conditions are diagnosed.

When to Create Veterinary Observations

Create veterinary observations for:

Clinical examinations - Physical exams during farm visits, clinic consultations, or field assessments. Document findings even when no specific disease is diagnosed.

Diagnostic outcomes - Record diagnoses resulting from clinical examination, laboratory tests, imaging studies, or necropsy findings.

Treatment planning - Document recommended treatments, prescriptions, management changes, or follow-up requirements.

Emergency care - Rapid clinical assessment during emergencies creates documentation for continuity when other veterinarians take over care.

Follow-up evaluations - Assessment of treatment response, monitoring recovery progress, or adjusting treatment plans based on clinical outcomes.

Health certifications - Professional examination results supporting health certificates, export certifications, or breeding soundness evaluations.

Zoonotic disease - Any diagnosis or suspicion of diseases transmissible to humans requires professional documentation for public health purposes.

Regulatory reporting - Reportable diseases, welfare concerns, or conditions requiring authority notification need professional veterinary documentation.

Veterinary observations complement standard observations. Owners record day-to-day health notes. You provide professional clinical assessments adding diagnostic expertise to the animal's health record.

Creating a Veterinary Observation

When viewing an animal's record, the "Create Veterinary Observation" button opens the professional documentation form:

Required Information

Observation Date - When you conducted the clinical examination (defaults to today but can be backdated for delayed documentation).

Diagnosis - Your professional clinical diagnosis (required field, 5-200 characters). Be specific: "Acute ruminal acidosis" not "sick cow." If no specific diagnosis, state "Clinical examination - no abnormalities detected" or "Suspected respiratory infection - pending diagnostics."

Clinical Findings - Detailed physical examination findings, vital signs, body condition scoring, and objective observations (required field, 10-1000 characters).

Symptoms - Presenting signs or symptoms observed by you or reported by owners (required field, 10-1000 characters). Distinguish between what you observed clinically and what was reported historically.

Severity - Clinical severity assessment using standard categories:

• Low - Minor conditions requiring routine monitoring
• Medium - Moderate conditions requiring specific treatment
• High - Serious conditions requiring intensive intervention
• Critical - Life-threatening conditions requiring emergency care

Optional Professional Documentation

Disease ID - Link to specific disease in the Knowledge API if diagnosis matches a catalogued disease (Foot-and-Mouth Disease, Avian Influenza, Bovine TB). This linkage powers automatic biosecurity features (see Section 20.5).

Diagnostic Tests - Document which diagnostic tests were performed:

• Clinical Examination (physical exam)
• Bacteriology (bacterial culture)
• Virology (viral testing)
• Parasitology (parasite identification)
• Serology (antibody testing)
• PCR (molecular diagnostics)
• Rapid Test (point-of-care diagnostics)
• Imaging (radiography, ultrasound)
• Necropsy (post-mortem examination)
• Other (specify)

Test Results - Summarise diagnostic findings. Laboratory results, imaging interpretations, culture outcomes, or necropsy findings. This field supports detailed documentation for complex cases.

Treatment Recommendations - Your professional treatment plan. Include medications (drug, dose, route, frequency, duration), management changes, dietary modifications, housing adjustments, or supportive care measures.

Prognosis - Clinical outlook for recovery:

• Excellent - Full recovery expected
• Good - Recovery expected with appropriate treatment
• Fair - Recovery possible but uncertain
• Guarded - Significant risk of complications or incomplete recovery
• Poor - Unlikely to recover; palliative care appropriate
• Grave - Death imminent or euthanasia recommended

Prescriptions - Specific medication prescriptions including drug name, strength, dose, route of administration, frequency, duration, and any special instructions. This field creates professional prescription records.

Differential Diagnoses - Alternative diagnoses considered during clinical reasoning. Documenting differential diagnoses demonstrates thorough clinical thinking and informs future assessments if initial diagnosis proves incorrect.

Follow-up Requirements - Whether this case requires follow-up examination, when follow-up should occur, and what should be assessed. Creates professional accountability for continuity of care.

Follow-up Date - Specific date when follow-up examination should be conducted. System can generate reminders approaching this date.

Follow-up Instructions - What the owner should monitor, when to contact you, what signs indicate improvement or deterioration, and what to do if condition worsens.

Zoonotic Disease Flag - Mark whether this condition can transmit to humans. Triggers enhanced documentation, owner education, and potential public health notification requirements.

Public Health Recommendations - If zoonotic, document recommendations to protect human health: personal protective equipment, hygiene measures, exposed person monitoring, or authority notification.

GPS Field Observation Integration

If this veterinary observation originated from a GPS field observation (mobile field assessment later attributed to this animal), you can link the two records:

Location data automatically captured:

• GPS latitude and longitude
• Location accuracy (metres)
• Elevation above sea level
• GPS timestamp (when field observation occurred)

This linkage connects professional clinical assessments to precise geographic locations. Valuable for wildlife management, outbreak investigations, or field practice documentation.

Veterinary vs. Standard Observations

Understanding the relationship between veterinary observations and standard observations:

Standard Observations (Chapter 10.1):

• Created by animal owners, farm staff, or non-veterinary caregivers
• Document day-to-day health status, behavioural changes, or concerns
• May note symptoms without professional diagnosis
• Support daily management and early problem detection

Veterinary Observations:

• Created by licensed veterinarians only
• Provide professional clinical diagnoses and assessments
• Include treatment recommendations and prognosis
• May trigger automatic biosecurity responses
• Create medico-legal documentation

Linking the two:

When owners create observations noting health concerns, those observations might prompt veterinary consultation. You can link your veterinary observation to the original owner observation, showing:

Owner Observation (March 14):
"Bella seems lethargic and not eating normally. Noticed yesterday evening."

↓ Led to professional consultation

Veterinary Observation (March 15):
Dr. Martinez examination findings:
Diagnosis: Acute gastroenteritis
Clinical Findings: Dehydrated (5%), elevated temperature (39.8°C), mild abdominal discomfort
Treatment Plan: Subcutaneous fluids, metoclopramide, bland diet for 48 hours
Prognosis: Good - expected full recovery within 3-5 days
Follow-up: March 18 if symptoms persist

This linkage creates comprehensive medical documentation showing symptom onset, owner concern, professional diagnosis, and treatment plan in chronological context.

Clinical Severity Assessment

Severity ratings guide clinical priorities and inform treatment urgency:

Low Severity Examples: Minor abrasions or superficial wounds, mild parasitic infections responding to routine treatment, benign lumps or masses requiring monitoring, routine geriatric changes not affecting quality of life, mild dental disease manageable with standard care.

Medium Severity Examples: Moderate lameness requiring specific treatment, upper respiratory infections requiring antibiotics, moderate parasitic burdens affecting body condition, uncomplicated reproductive disorders, moderate pain managed with analgesics.

High Severity Examples: Severe lameness preventing weight-bearing, pneumonia requiring intensive antibiotic therapy, metabolic disorders (ketosis, milk fever) requiring emergency intervention, dystocia (difficult birth) requiring obstetric assistance, significant trauma with risk of complications.

Critical Severity Examples: Shock or collapse requiring immediate stabilisation, bloat or colic requiring emergency surgery, severe respiratory distress, life-threatening haemorrhage, toxin ingestion or poisoning requiring antidotal therapy, neurological emergencies (seizures, paralysis).

Severity ratings help owners understand clinical urgency and assist other veterinarians in triaging cases when you're unavailable.

Treatment Recommendations and Prescriptions

Professional treatment documentation serves multiple purposes: guides owner actions, informs other veterinarians, creates prescription records, and supports antimicrobial stewardship (Chapter 19).

Treatment recommendation components:

Medications:

Example:
Amoxicillin 250mg PO q12h for 7 days
(Amoxicillin, 250 milligrams, by mouth, every 12 hours, for 7 days)

Meloxicam 0.5mg/kg PO q24h for 5 days
(Meloxicam, 0.5 milligrams per kilogram body weight, by mouth, once daily, for 5 days)

Withdraw meat: 14 days, Withdraw milk: 72 hours

Include drug name, dose, route of administration, frequency, duration, and withdrawal periods for food-producing animals.

Management changes: Housing modifications (isolation, shelter improvement), dietary adjustments (feed type, quantity, feeding frequency), exercise restrictions or requirements, environmental management (temperature, humidity, bedding).

Supportive care: Fluid therapy (volume, route, frequency), nutritional support (tube feeding, appetite stimulants), wound care (cleaning, bandaging, medication application), physical therapy or rehabilitation.

Monitoring instructions: What owners should observe (appetite, temperature, symptoms), how frequently to monitor, what findings indicate improvement or deterioration, when to contact you for reassessment.

Clear treatment documentation supports owner compliance, ensures continuity if other veterinarians become involved, and creates professional records for regulatory or medico-legal purposes.

Zoonotic Disease Documentation

When diagnosing conditions transmissible to humans, additional documentation protects public health:

Zoonotic Disease Flag - Mark the observation as involving zoonotic disease. This flag alerts owners to human health risks, triggers public health recommendations, may create regulatory notification requirements, informs other professionals working with the animal.

Common zoonotic diseases in animal management: Rabies (various species), Brucellosis (cattle, goats, pigs), Q Fever (livestock), Leptospirosis (cattle, dogs), Salmonellosis (many species), Ringworm (cattle, horses, pets), Avian Influenza (poultry, wild birds), Toxoplasmosis (cats, sheep), Anthrax (livestock, wildlife).

Public health recommendations might include:

Example for Q Fever diagnosis in dairy cattle:

Public Health Recommendations:
1. Farm workers should wear gloves and masks when handling animals or birthing materials
2. Pregnant women should avoid contact with animals and facilities
3. Anyone developing flu-like illness within 30 days should inform healthcare provider of animal exposure
4. Milk from affected animals should not be consumed raw
5. Report to local health department if human cases suspected
6. Practice strict hygiene (hand washing) after animal contact

Documenting these recommendations protects exposed individuals, demonstrates professional duty of care, and creates records supporting public health investigations if human cases occur.

Follow-up Scheduling and Requirements

Professional follow-up ensures treatment effectiveness and clinical continuity:

When to require follow-up: Complex cases requiring re-examination to assess treatment response, conditions with uncertain prognosis needing reassessment, surgical cases requiring suture removal or complication monitoring, chronic diseases requiring periodic monitoring, treatment plans that may need adjustment based on response, regulatory requirements (health certificates, export inspections).

Follow-up scheduling:

Set specific follow-up dates based on clinical timeline:

• 24-48 hours: Critical cases requiring rapid reassessment
• 3-5 days: Typical for infections, injuries, or post-surgical checks
• 7-14 days: Routine follow-up for improving conditions
• 30+ days: Chronic disease monitoring or long-term assessments

Follow-up instructions guide owners on what to monitor and when to seek earlier reassessment:

Example follow-up instructions:

Follow-up appointment: March 22 (7 days)
At follow-up, I will reassess lameness, check wound healing, and determine if continued anti-inflammatories are needed.

Before follow-up appointment:
- Monitor daily for increased swelling or discharge from wound
- Continue twice-daily bandage changes as instructed
- Restrict exercise to hand-walking only
- Contact me immediately if:
  * Lameness worsens despite treatment
  * Wound develops foul odour or yellow/green discharge
  * Horse develops fever (>38.9°C)
  * Horse stops eating or becomes depressed

Clear follow-up documentation improves owner compliance, supports continuity when other veterinarians cover emergencies, and creates professional accountability for ongoing case management.

Differential Diagnoses Documentation

Professional clinical reasoning considers multiple possible diagnoses before reaching conclusions. Documenting differential diagnoses demonstrates thorough assessment, shows you considered alternative explanations for clinical findings, guides future reassessment if initial treatment fails, educates other veterinarians and owners about clinical thinking process, supports specialist referral by providing clinical context.

Example differential diagnosis documentation:

Primary Diagnosis: Acute ruminal acidosis

Differential Diagnoses Considered:
1. Hardware disease (traumatic reticuloperitonitis) - ruled out by lack of specific pain response on withers pinch, no fever
2. Abomasal displacement - ruled out by lack of characteristic "ping" on auscultation/percussion
3. Grain overload/carbohydrate engorgement - consistent with clinical history (accidental access to grain bin) and findings
4. Peritonitis - less likely given absence of fever and localised pain; will monitor

Diagnostic reasoning:
History of grain consumption (2-3 kg of concentrate), clinical signs of depression, diarrhoea, reduced rumination, and mild dehydration most consistent with ruminal acidosis. Will initiate treatment and reassess in 24 hours.

GPS Field Observation Integration

Mobile veterinary practice often involves field assessments where animal identification may be uncertain or where you examine animals before they're registered in Kora. GPS field observations (Section 20.6) capture clinical findings with geographic coordinates, which you later convert into formal veterinary observations once animal identification is confirmed.

Field observation to veterinary observation workflow:

1. During field visit - Create GPS observation recording clinical findings, photos, and symptoms with automatic GPS capture
2. Later identification - Animal is identified (tag reading, owner confirmation, capture and examination)
3. Attribution - Link field observation to confirmed animal
4. Conversion - GPS observation data auto-populates veterinary observation form
5. Professional completion - Add diagnosis, treatment plan, and follow-up requirements
6. Record creation - Complete veterinary observation with linked GPS data

This workflow supports mobile wildlife veterinary work, herd health assessments, community animal health programmes, and emergency response where rapid clinical assessment precedes formal identification.

Integration with Other Kora Features

Veterinary observations integrate throughout Kora:

Animal Management (Chapter 8) - Your observations appear in animals' lifetime health histories, accessible to current and future owners for complete medical documentation.

Health Management (Chapter 10) - Veterinary observations complement standard observations, providing professional clinical context to owner-reported concerns.

Biosecurity (Chapter 11, Section 20.5) - Contagious disease diagnoses automatically trigger contact tracing, exposure identification, and quarantine recommendations.

Laboratory Workflows (Chapter 20.4) - Diagnostic test ordering, results recording, and findings interpretation link directly to veterinary observations.

Antimicrobial Stewardship (Chapter 19) - Prescription documentation supports responsible antimicrobial use tracking, clinical justification requirements, and stewardship compliance.

Traceability (Chapter 12) - Veterinary observations create immutable traceability events documenting professional clinical interventions in animals' lifetime histories.