Initial Outpatient Note Template

Clinical History template:
Presenting Complaint:  
Bella, a 5-year-old Golden Retriever, is experiencing lethargy and reduced appetite.
When did clinical signs first start?  
The symptoms began about 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 but drinking normally. No changes in urination or bowel movements. No vomiting observed.  
- Current medications: None  
- Vaccination status: Up to date. Heartworm/flea prevention: Monthly  
- Food allergies: None  
Social History:  
- Bella resides with two other dogs and has been with the owner since she was a puppy. Her usual diet consists of 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 showing signs of lethargy and decreased appetite, possibly due to a mild gastrointestinal disturbance or early infection signs.
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.