Vet AI Scribe for Exotic

Spike

Friday, July 31, 2026 at 10:20 AM

Subjective

Chief Complaint

Owner reports reduced appetite and lethargy over the past 7–10 days in a 4-year-old male bearded dragon. Mild weight loss and fewer bowel movements also noted.

History

• Diet consists primarily of mealworms, occasional vegetables.
• No recent changes in enclosure, lighting, or feeding schedule.
• UVB bulb is approximately 9 months old.
• Substrate: reptile carpet
• Previous history of mild stomatitis last year, resolved with antibiotics.

Owner reports Spike has not been basking as frequently and seems less responsive than usual. No signs of aggression, trauma, or visible injury.

Objective

Vitals

• Weight: 450g (↓ from 480g two weeks ago)
• Temperature (basking site): 94°F (via owner report)
• Ambient temp: 78°F (measured in clinic cage)
• UVB strength: Unknown – bulb >9 months old

Physical Exam

• Mentation: Quiet but responsive; mildly lethargic
• Oral Cavity: Mild pale mucous membranes; no ulcers or lesions
• Eyes/Nares: Clear; no discharge noted
• Skin: Mild dryness, partial retained shed on tail
• Palpation: Coelomic cavity soft, no masses appreciated
• Musculoskeletal: Adequate muscle tone; no fractures or swelling
• Cloaca: Clean; no prolapse, normal tone
• Hydration Status: Slightly reduced skin elasticity; mild dehydration suspected

Assessment

Primary Problem List

1. Anorexia – duration >1 week
2. Lethargy
3. Possible UVB deficiency/metabolic imbalance
4. Mild dehydration
5. Weight loss (6%)

Differentials

• Early metabolic bone disease (nutritional secondary hyperparathyroidism)
• Subclinical infection (GI or hepatic)
• Inadequate husbandry – UVB intensity likely insufficient due to bulb age
• Early renal insufficiency
• Mild hypovitaminosis A

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Plan

Diagnostics

• CBC and chemistry panel
• Fecal flotation and direct smear
• Radiographs of spine, pelvis, and coelom
• UVB meter reading in-home recommended (or replace bulb)
• Evaluate basking temperatures in-home with infrared thermometer

Treatment / Management

• Fluids: Subcutaneous fluids administered (10 mL LRS)
• Nutrition: Start supportive feeding with critical care formula (1–2 mL orally BID)
• Husbandry: Recommend immediate replacement of UVB bulb (Zoo Med Reptisun 10.0 or equivalent), ensure fixture is within 10–12 inches
• Basking temps: Confirm hot spot reaches 95–100°F
• Bathing: Daily warm soaks to assist hydration and help with shedding

Follow-Up

• Recheck in 5–7 days or sooner if worsening
• Review bloodwork and radiographs within 48–72 hours
• Long-term: discuss dietary changes (more leafy greens, gut-loaded insects)

Client Communication:
Owner was educated on importance of UVB cycling, insect variety, calcium supplementation, and proper basking gradients. Handout provided on bearded dragon care and nutritional best practices.

— Dr. Lena Morris, DVM