Vet AI Scribe for Behavioral

Digby

Monday, August 4, 2025 at 1:21 PM

Subjective

Chief Complaint

Digby, a young small dog, presented for a behavioral consultation regarding reactivity and anxiety.

Additional History

• Owner reports Digby is reactive on walks, particularly to people on foot, joggers, and sometimes dogs.
• Digby is better behaved when walked by Alex but still reactive with both owners.
• Digby's reactivity is lessened when he is in a car or picked up but he exhibits fear at higher speeds in the car.
• He reacts strongly to sudden appearances of people, especially men, and is more reactive to single individuals than individuals with dogs.
• Digby is generally friendly with dogs when allowed to approach but may bark if humans interact with him during these encounters.
• He has a history of barking at neighbors' dogs through the fence and has a reactive relationship with certain dogs in the neighborhood.
• Digby is described as conflicted, showing both fear and affection towards new people, and takes time to warm up to visitors.
• He has been on fluoxetine (Prozac) since April 12th, 10 mg daily, with some improvement in reactivity and recovery time after outbursts.
• Owners report Digby is highly intelligent, enjoys mental stimulation, and learns new tricks quickly but can become impatient during training.
• Digby has a history of being fostered for 2-3 months before adoption and was described as reactive by the foster family.
• Owners have been using clicker training and baby food as rewards during training and walks.

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 appear clean with minimal tartar, suggesting a young age.
• Cardiovascular: Heart auscultation attempted but not fully completed due to patient movement.
• Respiratory: Clear lung fields bilaterally, no crackles or wheezes.
• Abdominal: No organomegaly or mass effects. No pain on palpation.
• Lymphatic: Lymph nodes palpated and appeared normal.
• Coat and Skin: Healthy hair coat and skin, no ectoparasites seen.
• Musculoskeletal: Observed walking and jumping without apparent pain.
• 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

Digby exhibits fear-based reactivity and anxiety, particularly in response to people, sudden movements, and certain dogs. His behavior is consistent with a combination of genetic predisposition, environmental factors, and possible lack of early socialization. He shows improvement with fluoxetine and training but remains highly reactive in certain situations. No significant physical pain or orthopedic issues were identified during the visit, though luxating patella remains a possibility based on owner observations.

Plan

• Continue fluoxetine (Prozac) 10 mg daily and reassess in three weeks for full effect.
• Implement a structured training plan focusing on:
  • Alternate behaviors (e.g., "look," "find it," "touch," "back up").
  • Pattern games (e.g., "1-2-3 game") to improve focus and engagement.
  • Gradual desensitization and counter-conditioning to triggers.
• Use clicker training to reinforce desired behaviors and gradually phase out treats as reliability improves.
• Develop a safe space (e.g., bed or crate) for Digby to retreat to when overwhelmed, associating it with high-value rewards.
• Monitor and log daily reactivity levels and triggers on a scale of 1-10 to track progress.
• Consider a trial of gabapentin (100 mg) on high-stress days (e.g., weekends) to further reduce baseline anxiety if needed.
• Provide enrichment activities, including nose work and puzzle toys, to meet Digby's mental stimulation needs.
• Reassess in three weeks to evaluate progress and determine if medication adjustments or additional interventions are necessary.

Client Discharge Note

Thank you for bringing Digby in today. It was a pleasure meeting him and discussing his care plan with you both.

Summary

Digby is a sweet and intelligent dog who is currently experiencing some anxiety and reactivity, particularly on walks and in certain situations involving people and other dogs. He has made progress with fluoxetine (Prozac) since starting it on April 12th, but it will take another three weeks for the medication to reach its full effect. His reactivity has improved slightly, with less lunging and quicker recovery from outbursts. However, he still exhibits conflicted behavior, especially in new or stimulating environments. Digby is physically healthy overall, though there is a possibility of a luxating patella, which is common in small dogs. This does not appear to be causing him significant pain or mobility issues at this time. His weight is slightly on the higher side, but this can be addressed once his anxiety is better managed.

Key Topics We Discussed

• Behavioral Training and Management:

  • Focus on teaching Digby alternate behaviors to replace barking and reactivity. Start with simple commands like "look at me," "find it," and "touch."
  • Use short training sessions (2-3 minutes) a few times a day to practice these behaviors.
  • Gradually increase the difficulty of tasks and practice in different environments as he becomes more proficient.
  • Use high-value treats (e.g., baby food, cheese) to reinforce positive behaviors and counter-condition his response to triggers.

• Daily Monitoring:

  • Keep a log of Digby's reactivity on walks and at home. Note the triggers, his response, and the distance at which he reacts.
  • Use a scale of 1 to 10 to rate his anxiety and reactivity levels. This will help track his progress and determine if adjustments to his medication or training plan are needed.

• Medication:

  • Continue fluoxetine (Prozac) at the current dose. It will take another three weeks to reach full effect.
  • If Digby's reactivity remains high or you notice frequent outbursts, consider a trial of gabapentin (100 mg) on days with higher activity or potential triggers. This can be given 60-90 minutes before walks or outings and lasts about 8 hours. Please email for further guidance if you decide to try this.

• Enrichment and Safe Spaces:

  • Provide Digby with mental stimulation through puzzle toys, nose work games, and other enrichment activities. Rotate toys to keep him engaged.
  • Create a safe space for Digby, such as a bed or crate, where he can retreat and decompress. Make this space highly rewarding by offering special treats or toys when he uses it.
  • Establish house rules that when Digby is in his safe space, he is not to be disturbed.

• Door Reactivity:

  • Continue managing door-related triggers by keeping the doorbell disconnected and using a sign to discourage knocking.
  • Work on teaching Digby to go to his bed or crate when someone comes to the door. Start with treat scatters to redirect his attention, then transition to sending him to his safe space.

• Physical Health:

  • Monitor Digby's gait and movement for any signs of discomfort or limping, particularly on stairs. Record videos of him walking and descending stairs for reference.
  • Consider starting a dental care routine, as his teeth show mild tartar buildup.

• Next Steps:

  • Focus on management and training for the next three weeks while the fluoxetine takes full effect.
  • Email with updates on Digby's progress, including his reactivity levels and any changes in behavior.
  • If needed, schedule a follow-up to discuss medication adjustments or additional training support.

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

— Dr. Moki Griffie