Vet SOAP Note

Veterinarian Vital Signs: - Temp: 38.5°C - Pulse: 110 bpm - Respiratory Rate: 28 breaths/min History: - Reason for current visit: new onset lameness in the left hind leg for 3 days, intermittent. Owner reports no known trauma. - Dietary habits: Fed commercial dry food (Royal Canin), 2 meals daily. No raw food or home-cooked meals. No recent dietary changes. - Energy levels: Owner reports slight lethargy, less keen on walks. - Current or past medical issues: No significant past medical history. Up to date on vaccinations. Physical Exam Findings: - BCS: 5/9 (Ideal) - Mentation: Alert and responsive - Behaviour: Friendly but slightly nervous during palpation of the left hind leg. Eyes: - Clear, no discharge, pupils responsive to light, no conjunctivitis. Ears: - Clean, no discharge, no odour, no signs of inflammation in either ear. MM: - Pink and moist CRT: - <2 seconds Oral Cavity: - Moderate dental tartar on canines and molars, no missing teeth, mild gingivitis noted. Recommendation for future dental prophylaxis discussed. Lymph Nodes: - Submandibular, prescapular, popliteal lymph nodes all symmetrical and non-enlarged. Cardiovascular: - Heart sounds clear, no murmurs auscultated. Pulses strong and synchronous. Respiratory: - Lung sounds clear bilaterally, normal breathing pattern, no upper airway noises. Abdomen: - Soft and non-painful on palpation, no palpable masses or distension. Musculoskeletal: - Left hind limb lameness observed at trot. Pain on palpation of left stifle joint. No obvious swelling or crepitus. Muscle tone appears normal. Integument: - Coat shiny, no alopecia, no pruritus, no lesions or flea dirt observed. Urogenital: - External genitalia appear normal, no discharge. Spayed female. Neurological: - Proprioception intact in all four limbs, normal reflexes, cranial nerve function appears normal. Rectal Exam: - Not performed Diagnostic Results: - Radiographs of left stifle joint performed: Mild osteophyte formation noted, suggestive of early osteoarthritis. Assessment: - Problem list: 1. Left hind limb lameness 2. Early osteoarthritis of left stifle 3. Mild dental disease Plan: - Medications prescribed: Carprofen (NSAID) 2.2 mg/kg PO BID for 7 days. Gabapentin 10 mg/kg PO BID for 7 days for pain management. - Follow-up care or additional recommendations: Return for recheck in 7 days to assess response to medication. Recommend joint supplements (glucosamine/chondroitin) long-term. Discussed weight management and controlled exercise. Recommended dental prophylaxis in 3-6 months. Communications: - Discussed diagnosis of early osteoarthritis with owner, explaining the nature of the condition and long-term management. Reviewed medication administration, potential side effects, and importance of completing the full course. Provided home care instructions including restricted activity and monitoring for improvement. Scheduled a follow-up appointment.