Vet SOAP Note

Specialty: Veterinarian History: - Summary of reason for current visit: Owner reports dog, Bella (Golden Retriever, 5 years old, spayed female), has been scratching excessively and has developed a rash on her abdomen and inner thighs for the past 3 days. Also noted some hair loss in affected areas. Appetite and water intake normal. No vomiting or diarrhoea. - Dietary habits: Fed Royal Canin Adult dry food twice daily. Receives occasional dental chews. No recent dietary changes or new treats. - Energy levels: Normal energy levels, still playful on walks, but seems restless at night due to itching. - Current or past medical issues: History of seasonal allergies last year, managed with Apoquel. Up-to-date on vaccinations and deworming. Vital signs: - Temp: 38.5°C (WNR) - Heart rate: 100 bpm (WNR) - Respiratory rate: 24 breaths/min (WNR) Physical exam findings: - BCS: 5/9 (Ideal) - Mentation: Bright, alert, responsive - Behaviour: Cooperative, but frequently attempting to scratch at abdomen during examination Eyes: - Clear, no discharge, conjunctiva pink, pupils responsive to light. No corneal opacities or signs of irritation. Ears: - Pinnae clean, no discharge or odour from ear canals. No redness or inflammation noted. Oral cavity: - Mucous membranes assessment: Pink and moist - Capillary refill time: <2 seconds - Dental health assessment and recommendations: Mild tartar accumulation on caudal premolars. Recommend dental prophy in the next 6-12 months. - Oral cavity examination findings: No lesions, masses, or foreign bodies detected. Lymph nodes: - Peripheral lymph nodes (submandibular, prescapular, popliteal) are small, soft, and symmetrical. No lymphadenopathy noted. Cardiovascular: - Cardiovascular system assessment: Strong, regular femoral pulses. No murmurs or arrhythmias detected on auscultation. Thoracic auscultation clear. - Pulse assessment: Strong, synchronous bilateral femoral pulses. Respiratory: - Respiratory system assessment: Clear lung sounds bilaterally. No coughing or nasal discharge. Abdomen: - Abdominal palpation findings and assessment: Soft, non-painful on palpation. No organomegaly or masses detected. Distended abdomen with erythematous maculopapular rash on ventral abdomen and medial thighs, with evidence of self-trauma (excoriations, alopecia). Musculoskeletal: - Musculoskeletal system assessment: Ambulates normally, no lameness or pain on limb manipulation. Full range of motion in all joints. Integument: - Skin and coat assessment: Dry, flaky skin on abdomen and inner thighs with multifocal areas of erythema, papules, and alopecia. Evidence of lichenification in chronic areas. Hair coat otherwise healthy. Urogenital: - Urogenital system assessment: Female external genitalia appear normal. No discharge or inflammation. Neurological: - Neurological examination findings: Cranial nerves intact, normal gait, conscious proprioception WNL in all four limbs. No nystagmus or ataxia. Rectal exam: - Rectal examination findings or state not performed: Not performed (not indicated). Diagnostic results: - Summary of any diagnostic tests performed or state none performed: Skin scrape performed from affected area: Negative for demodex and sarcoptes mites. Cytology of skin impression smear: Numerous cocci and neutrophils, suggestive of superficial pyoderma. Assessment: - Problem list: 1. Pruritus 2. Erythematous maculopapular rash with alopecia and excoriations (ventral abdomen and medial thighs) 3. Superficial pyoderma (secondary to allergies) 4. History of seasonal allergies Plan: - Medications prescribed or sent home: - Cephalexin 250mg, 1 tablet by mouth twice daily for 14 days. - Apoquel 5.4mg, 1 tablet by mouth twice daily for 7 days, then once daily thereafter. - Malaseb medicated shampoo, bathe twice weekly for 3 weeks. - Follow-up care or additional recommendations: Recheck in 14 days to assess response to treatment. Discuss allergy management plan, including potential environmental allergen testing if clinical signs persist. Communications: - Summary of discussions with owner regarding treatments: Discussed findings, diagnosis of allergic dermatitis complicated by secondary bacterial infection. Explained treatment plan including antibiotics and anti-itch medication, and medicated shampoo. Owner understands medication administration and importance of follow-up. Owner approved all diagnostics and treatments.