Main GHC template

Patient presented for: Lethargy and decreased appetite. Salient History: Patient is a 10-year-old female spayed domestic shorthair cat. Owner reports lethargy for 3 days and decreased appetite for 2 days. No vomiting or diarrhoea. Vaccinations and preventatives: Up to date on vaccinations. Receiving monthly flea and tick preventative. Current medications: None. Current diet: Dry cat food, twice daily. VITALS: - Heart rate: 180 bpm - Respiratory rate: 32 bpm - Mucous membranes: Pink, capillary refill time <2 seconds - BCS: 5/9 - Mentation: BAR INTEGUMENT: - Coat condition: Good, no alopecia noted. - Pruritis score: 0/10 LYMPH NODES: - Sub-mandibular: Within normal limits. - Pre-scapular: Within normal limits. - Popliteal: Within normal limits. HEAD: - Eyes: No ocular discharge, pupils equal and responsive to light. - Ears: Clean, no discharge. - Nose: No nasal discharge. - Oral: Mild dental tartar. - Dental score: 2/5 CARDIOVASCULAR and RESPIRATORY: - Heart: No murmur auscultated. - Lungs: Clear lung sounds bilaterally. - Pulses: Strong, synchronous pulses. ABDOMEN: - Abdominal findings: No abdominal pain on palpation. RECTAL: - Rectal findings: Normal. UROGENITAL: - Urogenital findings: No abnormalities noted. NEUROLOGICAL: - Cranial nerves: Within normal limits. - Spinal nerves: Within normal limits. - Other neuro findings: No neurological deficits noted. MSK: - Ambulation: Normal gait. - Musculature: Normal muscle mass. - Joints (elbows, shoulders, carpi, hips, stifles, tarsi): No joint effusion or pain on palpation. DIAGNOSTIC TESTS, DONE, RECOMMENDED OR INDICATED: - Complete blood count (CBC) recommended. - Chemistry panel recommended. SUMMARY OF PROBLEMS: - Lethargy. - Decreased appetite. TREATMENT AND PLAN, discussed with owner: - Blood work to be performed. - Supportive care: encourage water intake, offer palatable food. - Recheck in 2 days. Owner decisions: - Accepted: Blood work. Next visit: - Recheck in 2 days for blood work results.