Scribe IA Veterinario per Medicina Generale

Il nostro scribe IA è progettato specificamente per i veterinari di Medicina Generale — genera note SOAP in tempo reale e riduce il carico documentale.

Esempi di Cartelle Cliniche

Medicina GeneraleEmergenzaMedicina InternaChirurgiaOdontoiatriaCardiologiaOncologiaNeurologiaOrtopediaOftalmologiaDermatologiaComportamentaleEquinoEsotici

Maddie

Friday, September 6, 2024 at 8:41 AM

Subjective

Chief Complaint

Judy brought in her 10-week-old puppy, Maddie, for her second round of vaccinations.

History

  • Maddie is active, eating well, and playing well.
  • House training is progressing fairly well.
  • Owner has been keeping Maddie in their yard to limit exposure until fully vaccinated.
  • Maddie has been dewormed once but not on a monthly schedule yet.
  • Owner is feeding Maddie a third of a cup of food twice daily, recently split into smaller meals with water added.
  • Maddie has no history of vomiting, diarrhea, coughing, or sneezing, though she occasionally gets hiccups.
  • Bowel movements and urination are normal.
  • Owner is interested in starting heartworm prevention next month.
  • Owner plans to spay Maddie at 6 months of age.

Objective

Vital Signs

  • Temperature: WNL
  • Weight: WNL
  • Heart Rate: WNL
  • Respiratory Rate: WNL
  • Capillary Refill Time: WNL
  • Body Condition Score: BCS 4-5/9

Physical Exam

  • Eyes: Clear with no discharge
  • Ears: Clean with no discharge or erythema AU.
  • Oral: Teeth clean, no gingivitis or tartar.
  • Cardiovascular: Normal heart rate, sinus rhythm, no murmurs. Strong and synchronous pulses bilaterally.
  • Respiratory: Clear lung fields bilaterally, no crackles or wheezes.
  • Abdominal: No organomegaly or mass effects. No pain on palpation.
  • Lymphatic: No peripheral lymphadenopathy.
  • Coat and Skin: Healthy hair coat and skin, no ectoparasites seen.
  • Musculoskeletal: Ambulation normal, no lameness observed.
  • Neurological: Normal neurologic exam with normal mentation. No proprioceptive deficits or overt ataxia; normal cranial nerve exam.
  • Neck and Thyroid: No peripheral lymphadenopathy.
  • Reproductive and Urinary: Normal external genitalia, no discharge or inflammation.
  • Mammary: No significant findings
  • Rectal: Not examined

Assessment

  • Maddie is a healthy 10-week-old puppy presenting for her second round of vaccinations.
  • No current signs of illness or abnormalities on physical examination.
  • Owner is appropriately managing house training and feeding, though grazing behavior is noted.
  • Owner is cautious about exposure to other animals and wildlife until vaccinations are complete.

Plan

  • Administered the 10-week distemper-parvo combination vaccine in the right shoulder.
  • Discussed potential vaccine reactions, including lethargy, localized pain, swelling, hives, vomiting, diarrhea, and rare anaphylactic reactions.
  • Scheduled follow-up vaccinations at 13 and 16 weeks, with rabies vaccine planned for 16 weeks.
  • Discussed additional vaccines, including Bordetella (kennel cough) and leptospirosis, based on potential exposure risks.
  • Recommended monthly deworming until 6 months of age.
  • Advised starting heartworm prevention at the next visit.
  • Encouraged continued nail trimming and desensitization to handling of paws, mouth, and other body parts.
  • Owner to monitor for any vaccine reactions and report if severe symptoms occur.

Client Discharge Note

Thank you for bringing Maddie in today. It was a pleasure meeting her, and she is such an adorable and well-behaved puppy!

Summary

Maddie is doing well overall. She is active, eating, and playing well. Her house training is progressing nicely, and her health check was normal. She received her second distemper/parvo vaccine today, and we discussed her vaccination schedule, deworming, and other preventative care.

Key Topics We Discussed

  • Vaccination Schedule:

    • Maddie received her 10-week distemper/parvo vaccine today.
    • Please return in 3 weeks (at 13 weeks) for her next vaccine, and again at 16 weeks for her final distemper/parvo vaccine and rabies vaccine.
    • Monitor Maddie for any vaccine reactions, such as lethargy, mild pain at the injection site, or swelling. Contact us immediately if you notice severe reactions like facial swelling, hives, vomiting, diarrhea, or difficulty breathing.

  • Deworming:

    • Continue monthly deworming until Maddie is 6 months old.
    • Bring a stool sample during your next visit to check for parasites.

  • Heartworm Prevention:

    • Maddie can start heartworm prevention next month. We will discuss this further during your next visit.

  • Socialization and Exposure:

    • Continue limiting Maddie's exposure to other dogs and public areas until she is fully vaccinated, including her rabies vaccine.
    • Consider Bordetella (kennel cough) and leptospirosis vaccines if Maddie will be exposed to other dogs (e.g., dog parks, puppy classes) or wildlife.

  • House Training and Feeding:

    • Your current house training routine is excellent. Keep up the good work!
    • Feeding smaller, more frequent meals (e.g., twice in the morning and twice in the afternoon) is a great approach to help regulate her digestion and bathroom schedule.

  • Handling and Grooming:

    • Continue handling Maddie's paws, mouth, and tail to get her accustomed to being touched in these areas. This will help with grooming and in case of emergencies.
    • Trim her nails regularly, focusing on just the sharp tips to avoid discomfort. Monitor her dewclaws, as she seems to chew on them occasionally.

  • Spaying:

    • Plan to have Maddie spayed at around 6 months of age. We can discuss this further during her next visits.

Thank you for entrusting us with Maddie's care! Please do not hesitate to contact us if you have any questions or concerns.

— Dr Jan Lhuthe

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