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.
Patient presented for:
[Presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Salient History:
[History details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Vaccinations and preventatives:
[Vaccinations and preventatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current medications:
[Current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current diet:
[Current diet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
VITALS:
- Heart rate: [Heart rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Respiratory rate: [Respiratory rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Mucous membranes: [Mucous membrane findings / Capillary refill time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- BCS: [Body condition score /9] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Mentation: [Mentation status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INTEGUMENT:
- Coat condition: [Coat description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Pruritis score: [Pruritis score /10] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LYMPH NODES:
- Sub-mandibular: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Pre-scapular: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Popliteal: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HEAD:
- Eyes: [Eye findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Ears: [Ear findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Nose: [Nasal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Oral: [Oral findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Dental score: [Dental findings / score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
CARDIOVASCULAR and RESPIRATORY:
- Heart: [Heart findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Lungs: [Respiratory sounds] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Pulses: [Pulse characteristics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ABDOMEN:
- Abdominal findings: [Abdominal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RECTAL:
- Rectal findings: [Rectal exam findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
UROGENITAL:
- Urogenital findings: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
NEUROLOGICAL:
- Cranial nerves: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Spinal nerves: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Other neuro findings: [Additional neurological findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MSK:
- Ambulation: [Ambulation findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Musculature: [Muscle condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Joints (elbows, shoulders, carpi, hips, stifles, tarsi): [Joint findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
DIAGNOSTIC TESTS, DONE, RECOMMENDED OR INDICATED:
- [Diagnostic test 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Diagnostic test 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SUMMARY OF PROBLEMS:
- [Problem 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Problem 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Problem 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TREATMENT AND PLAN, discussed with owner:
- [Plan item 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Plan item 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Plan item 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Owner decisions:
- Declined: [Declined interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Accepted: [Accepted interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Next visit:
- [Next visit timing and reason] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or contextual notes, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
