Veterinarian SOAP Note (custom)

Veterinarian TPR: - Temp: 38.5°C - Pulse: 120 bpm - Respiratory Rate: 30 bpm History: - "Max", a 5-year-old neutered male Labrador Retriever, presents with a 2-day history of lethargy, decreased appetite, and intermittent vomiting. Owner reports no known toxin exposure. Vaccinations are up-to-date. - Dietary habits: Eats Royal Canin Large Breed Adult, typically finishes meals. Recently, has been picking at food. - Energy levels: Significantly decreased from usual energetic self. Reluctant to play or go for walks. - Any current or past medical issues: History of seasonal allergies, managed with Apoquel as needed. No other significant past medical history. General Physical Exam : - BCS: 5/9 (Ideal) - Mentation: Dull but responsive - Behaviour: Cooperative but subdued during examination. Eyes: - Clear, no discharge. Pupils equally reactive to light. Conjunctiva pink. Ears: - Clean, no discharge, no odour. Pinnae soft and pliable. No pain on palpation. MM: - Pale pink, slightly tacky. CRT: - <2 seconds Oral Cavity: - Mild dental tartar noted on canines and premolars. No gingivitis. Recommendation for future dental assessment and cleaning. - Oral cavity examination findings: No foreign bodies or masses observed. Lymph Nodes: - Submandibular lymph nodes mildly enlarged but symmetrical and non-painful. Other peripheral lymph nodes not palpable. Cardiovascular: - Sinus rhythm, no murmurs or arrhythmias detected. Heart sounds clear and strong. Respiratory: - Lungs clear on auscultation. No abnormal lung sounds. Respiratory effort normal. Abdomen: - Soft, non-painful on palpation. No organomegaly or masses detected. Mild abdominal distension. Musculoskeletal: - Ambulation normal, no lameness. Muscle tone good. No signs of pain on palpation of joints or long bones. Integument: - Coat dull, but no ectoparasites, lesions, or excessive shedding. Skin elasticity normal. Urogenital: - External genitalia appear normal. No discharge from prepuce. Palpation of bladder unremarkable. Neurological: - Cranial nerves intact. Proprioception and reflexes normal. No ataxia or tremors. Rectal Exam: - Rectal examination findings: Not performed at this visit. Diagnostic Results: - Summary of any diagnostic tests performed: In-house blood work (CBC, Chemistry Panel) revealed mild elevation in BUN and Creatinine, mild dehydration. Urinalysis showed concentrated urine with no active sediment. Assessment Summary: • Acute Gastroenteritis • Mild Dehydration • Possible Renal Azotemia (pre-renal vs. renal to be differentiated) • Dental Tartar (incidental finding) Tx and Management Plan : - Medications prescribed or sent home: Maropitant (Cerenia) 16mg PO SID for 3 days; Metronidazole 250mg PO BID for 5 days. Subcutaneous fluids (Lactated Ringer's Solution) 300ml administered in clinic. - Follow-up care or additional recommendations: Recheck in 24-48 hours or sooner if condition worsens. Offer small, bland meals frequently. Encourage water intake. Discuss dental cleaning at next routine visit. Discussion: - Summary of discussions with the owner regarding treatments: Owner was informed of diagnostic findings and the presumptive diagnosis of acute gastroenteritis with mild dehydration. Discussed medication administration, fluid therapy, and dietary recommendations. Prognosis is generally good with appropriate care. Owner consented to treatment plan and was provided with aftercare instructions.