Vet SOAP Sheet

Clinician Specialty: Veterinarian Patient History: * Chief Complaint: "Fido, a 5-year-old male neutered Golden Retriever, presented for acute onset of vomiting and lethargy over the past 24 hours." * History of Present Illness: Vomited 3 times yesterday, yellow bile. Has not eaten since yesterday morning. Lethargic, not interested in play. No diarrhoea reported. Owner reports no known access to toxins or foreign objects. * Past Medical History: Up-to-date on vaccinations and deworming. No significant past medical history. * Medications: Bravecto (fluralaner) administered 2 months ago. * Allergies: No known drug or food allergies. * Family History: Sire had osteoarthritis. * Social History: Lives indoors with two other dogs and a cat. Gets daily walks in a fenced garden. Physical Exam and Other Findings: * Vital Signs: Temperature 39.2°C, Heart Rate 110 bpm, Respiratory Rate 24 bpm. * General Appearance: Lethargic but responsive, good body condition score (BCS 5/9), well-hydrated mucous membranes (CRT < 2 seconds). * Systemic Examination: * Abdominal Palpation: Mild cranial abdominal discomfort on palpation, no overt masses or foreign bodies felt. * Oral Exam: Mild periodontal disease. * Lymph Nodes: All peripheral lymph nodes normal size and consistency. * Cardiopulmonary: Clear lung sounds, no murmurs or arrhythmias detected. * Laboratory Results: * Complete Blood Count (CBC): Mild neutrophilia (15.5 x 10^9/L; ref range 6-12 x 10^9/L). * Serum Biochemistry: Elevated amylase (1500 U/L; ref range 100-1000 U/L) and lipase (2500 U/L; ref range 50-1500 U/L). Glucose, BUN, Creatinine, ALT, ALP all within normal limits. * Imaging Findings: Abdominal ultrasound revealed hyperechoic peripancreatic fat and a mildly enlarged, hypoechoic pancreas consistent with pancreatitis. Assessment: Acute Pancreatitis - Vomiting - Lethargy - Abdominal discomfort - Elevated amylase and lipase - Ultrasound findings consistent with pancreatitis Plan: * Hospitalisation for supportive care. * Intravenous fluid therapy (Lactated Ringer's Solution) at 5ml/kg/hr. * Analgesia: Maropitant (Cerenia) 1 mg/kg SC once daily for antiemetic effect; Buprenorphine 0.01 mg/kg IV q6h for pain management. * Anti-emetic: Maropitant 1 mg/kg SC q24h. * NPO for 12-24 hours, then gradual introduction of a low-fat, highly digestible diet. * Monitor vital signs, hydration status, and appetite closely. * Repeat bloodwork (CBC, biochemistry) in 24-48 hours to assess response to treatment. * Owner education on pancreatitis and dietary management upon discharge. * Follow-up appointment in 5-7 days post-discharge to re-evaluate Fido's condition.