AI-Generated Veterinary SOAP Note

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.