Outpatient Initial Note

Clinical History template: Presenting Complaint: Bella, a 5-year-old Golden Retriever, presents with lethargy and decreased appetite. When did clinical signs first start? The clinical signs started approximately 3 days ago. Vitals: - HR: 90 bpm - RR: 20 breaths/min - Temp: 38.5°C - Mm: Pink and moist - Crt: <2 seconds - Mentation: QAR - Pain Scale (0-4): 2 - Hydration status (%): 5% - Blood pressure: 120/80 - Spo2: 98% General History: - Bella has been eating less and drinking normally. No changes in urination or defecation habits. No vomiting noted. - Current medications: None - Vaccination status: Up to date. Heartworm/flea prevention: Monthly - Food allergies: None Social History: - Bella lives with two other dogs and has been with the owner since she was a puppy. Typical diet includes dry kibble and occasional wet food. - Stressors: Loud noises and unfamiliar dogs - Favorite treat: Peanut butter biscuits Physical Exam: Observations: Bella appears lethargic and less responsive than usual. Mentation: QAR Integument: Coat is dull, no lesions noted Eyes: Clear, no discharge Ears: Clean, no signs of infection Nose: Moist, no discharge Oral Cavity: Gums pink, no dental issues Cardiovascular: Normal heart sounds, no murmurs Respiratory: Clear lung sounds, no wheezing Abdomen: Soft, non-tender Genitourinary: Normal, no abnormalities Rectal: Normal, no masses Musculoskeletal: Mild stiffness in hind legs Neurologic: Normal reflexes Lymph Nodes: No enlargement noted Other: None Assessment: Bella is presenting with lethargy and decreased appetite, likely due to a mild gastrointestinal upset or early signs of an infection. Plan: - Recommend blood work to rule out any underlying conditions. - Prescribe a bland diet for the next few days. - Monitor for any changes in behavior or appetite. - Follow-up appointment in one week to reassess. - Owner to contact the clinic if symptoms worsen or new symptoms appear.