Vet SOAP Note

Vital Signs: - Temp: 101.5°F - Pulse: 80 bpm - Respiratory Rate: 20 breaths/min History: - Bella, a 5-year-old Labrador Retriever, presented for her annual wellness exam. The owner reports no changes in dietary habits and maintains a high energy level. No current or past medical issues were noted. Physical Exam Findings: - BCS: 5/9 - Mentation: BAR - Behaviour: Friendly and tolerant Eyes: - Corneas clear. No ocular discharge present. No redness or blepharospasm noted. Conjunctiva normal. Ears: - Ears are clean and free of debris. No sign of otitis externa. No redness or erythema noted of pinna or ear canal. MM: - Pink and moist CRT: - <2 sec Oral Cavity: - Acceptable occlusion. No dental tartar or gingivitis noted on examination. Lymph Nodes: - No abnormalities on palpation of mandibular, prescapular or popliteal lymph nodes. Cardiovascular: - Normal, no audible murmur noted on auscultation. Good rhythm and rate. Femoral pulses present and synchronous. Respiratory: - Normal auscultation all fields. No wheezes or crackles appreciated. Normal inspiratory and expiratory effort. Tracheal palpation elicited no response. No coughing or sneezing noted by owner or in exam room. No nasal discharge present. Abdomen: - No discomfort on abdominal palpation. Abdomen soft. No pain/guarding/splinting noted on palpation. No masses, organomegaly or distention appreciated. Auscultation normal. Musculoskeletal: - Ambulating normally throughout exam. Normal ROM all limbs, no swelling or discomfort on palpation of limbs and joints. Integument: - No masses or lesions found. Normal skin tent. Good coat. Urogenital: - Normal; no inflammation or discharge. Neurological: - Normal conscious proprioception and mentation. No neuro exam performed. Rectal Exam: - Not performed Diagnostic Results: - None performed Assessment: - Problem list: 1. None identified Plan: - No medications prescribed. Continue current diet and exercise routine. Schedule next wellness exam in one year. Communications: - Discussed with the owner the importance of maintaining Bella's current diet and exercise routine to ensure continued health.