Veterinary SOAP NotesDocumentation Guide for DVMs

VETERINARY SOAP NOTE - WELLNESS EXAMINATION

Date: 12/18/2024
Clinician: Dr. Sarah Mitchell, DVM

PATIENT INFORMATION:
Patient: Max
Species: Canine
Breed: Golden Retriever
Age: 3 years
Sex: Male, Neutered
Weight: 72.4 lbs (32.8 kg)
Owner: Jennifer Thompson
Phone: (555) 123-4567

SUBJECTIVE:
Chief Complaint: Annual wellness exam and vaccinations

History (per owner):
- Eating well, normal appetite
- Normal water consumption
- Regular bowel movements, no diarrhea or constipation
- No vomiting
- Active, playful, normal energy level
- No coughing, sneezing, or nasal discharge
- No limping or mobility issues
- Indoor/outdoor dog, fenced yard
- On monthly heartworm prevention (Heartgard Plus)
- On monthly flea/tick prevention (NexGard)
- Last seen 12/2023 for annual exam

Current Medications:
- Heartgard Plus (68-136 lb) monthly - compliant
- NexGard (60.1-121 lbs) monthly - compliant

Diet: Blue Buffalo Adult Large Breed, 3 cups BID
Allergies: None known

OBJECTIVE:

General Appearance: BAR, well-hydrated, BCS 6/9 (slightly overweight)

Vital Signs:
- Temperature: 101.2°F (normal)
- Heart Rate: 88 bpm, regular rhythm
- Respiratory Rate: 20 breaths/min
- CRT: <2 seconds
- MM: Pink, moist

Physical Examination:
- EYES: Clear, no discharge, PLR normal OU, no lens opacity
- EARS: Clean, no odor, no erythema, no discharge AU
- NOSE: Moist, no discharge
- ORAL: Mild tartar buildup on upper premolars, no gingivitis, all teeth present
- LYMPH NODES: No lymphadenopathy palpated
- CARDIAC: NSR, no murmur, no arrhythmia, strong pulses
- RESPIRATORY: Clear lung sounds bilaterally, no crackles/wheezes
- ABDOMEN: Soft, non-painful, no organomegaly, no masses palpated
- MUSCULOSKELETAL: Ambulatory x4, no lameness, good muscle tone, full ROM
- INTEGUMENT: Coat in good condition, no masses, no parasites seen, no lesions
- UROGENITAL: Neutered male, no discharge, testicles absent
- NEUROLOGICAL: Appropriate mentation, normal gait

Diagnostics:
- Heartworm/Tick 4Dx Test: NEGATIVE (HW, Lyme, Anaplasma, Ehrlichia)
- Fecal Float: Negative for parasites

ASSESSMENT:
1. Healthy adult canine - annual wellness exam
2. BCS 6/9 - mildly overweight (ideal 5/9)
3. Grade 1 dental tartar - recommend dental prophylaxis within 6-12 months

PLAN:

Vaccinations Administered Today:
- Rabies 3-year (Imrab 3) - 1 mL SQ, right hind leg, Lot #12345, Exp 06/2026
- DHPP (Nobivac) - 1 mL SQ, left hind leg, Lot #67890, Exp 03/2026
- Bordetella intranasal - 0.5 mL each nostril, Lot #11111, Exp 09/2025
- Leptospirosis (Nobivac Lepto4) - 1 mL SQ, right shoulder, Lot #22222, Exp 08/2025

Recommendations:
1. Weight management: Reduce food to 2.5 cups BID, increase exercise. Goal: 68 lbs
2. Continue monthly HW and flea/tick prevention
3. Schedule dental prophylaxis within 6-12 months
4. Return in 1 year for annual exam or sooner if concerns

Client Education:
- Discussed weight management, provided handout
- Reviewed vaccine reactions to watch for (swelling, lethargy, vomiting)
- Dental disease prevention discussed

Follow-Up: Annual exam 12/2025 or PRN

______________________________
Dr. Sarah Mitchell, DVM
License #: VET-12345

VETERINARY SOAP NOTE - SICK VISIT

Date: 12/18/2024
Clinician: Dr. Sarah Mitchell, DVM

PATIENT INFORMATION:
Patient: Bella
Species: Canine
Breed: Labrador Retriever
Age: 5 years
Sex: Female, Spayed
Weight: 65.2 lbs (29.6 kg) - down from 68.4 lbs last visit
Owner: Michael Chen
Phone: (555) 987-6543

SUBJECTIVE:
Chief Complaint: Vomiting and diarrhea x 2 days

History (per owner):
- Vomiting started 2 days ago, approximately 4-5 episodes/day
- Vomit appears yellow/bile-colored, no blood noted
- Diarrhea started yesterday, loose to watery, 3-4x daily
- No blood in stool
- Decreased appetite - eating about 25% of normal
- Drinking water but vomits afterward
- Appears lethargic, less playful than usual
- No known toxin exposure or dietary indiscretion (owner unsure)
- No access to garbage or foreign objects
- Other household dog is healthy
- Up to date on vaccines
- Last meal: Attempted to eat this morning, vomited within 30 minutes

Current Medications: Heartgard Plus, Nexgard (monthly)
Diet: Purina Pro Plan, 2 cups BID
Allergies: None known

OBJECTIVE:

General Appearance: QAR, mild dehydration (5-6%), BCS 5/9

Vital Signs:
- Temperature: 102.8°F (mildly elevated)
- Heart Rate: 110 bpm
- Respiratory Rate: 28 breaths/min
- CRT: 2-3 seconds (mildly prolonged)
- MM: Tacky, light pink

Physical Examination:
- EYES: Clear, no discharge
- EARS: Clean
- ORAL: Tacky MM, skin tenting 2-3 seconds
- LYMPH NODES: No lymphadenopathy
- CARDIAC: Tachycardia, no murmur, strong pulses
- RESPIRATORY: Clear lung sounds, mild increase in rate
- ABDOMEN: Tense on palpation, pain response mid-abdomen, increased borborygmi, no masses or foreign body palpated, no organomegaly
- INTEGUMENT: Reduced skin turgor
- NEUROLOGICAL: Appropriate mentation, ambulatory x4

Diagnostics Performed:
- CBC: Mild stress leukogram (WBC 18.2), Hct 48% (mild hemoconcentration)
- Chemistry: BUN 32 (mild azotemia - prerenal), Glucose 95, ALT 45, ALP 78 (WNL)
- Abdominal Radiographs: Gas-filled intestinal loops, no foreign body, no obstruction pattern
- Fecal Float: Negative
- Parvo SNAP Test: NEGATIVE

ASSESSMENT:
1. Acute gastroenteritis - likely viral or dietary origin
2. Mild dehydration (5-6%)
3. Rule out: Dietary indiscretion, early pancreatitis, foreign body (low suspicion given radiographs)

PLAN:

Treatment Administered:
1. Lactated Ringer's Solution - 500 mL SQ (divided: 250 mL each side)
2. Cerenia (maropitant) 1 mg/kg - 30 mg SQ
3. Famotidine 0.5 mg/kg - 15 mg SQ

Medications Dispensed:
1. Cerenia 60 mg tablets - #4, give 1/2 tablet PO q24h x 4 days
2. Metronidazole 250 mg tablets - #14, give 1 tablet PO q12h x 7 days
3. Famotidine 10 mg tablets - #14, give 1.5 tablets PO q12h x 7 days
4. FortiFlora probiotic - 7 packets, sprinkle 1 packet on food daily x 7 days

Diet Instructions:
- NPO for 12 hours (small water sips OK)
- Then start bland diet: boiled chicken and white rice
- Small frequent meals (1/4 cup 4x daily) for 3-5 days
- Gradually transition back to regular food over 5-7 days

Owner Instructions:
- Monitor for: continued vomiting, bloody stool, worsening lethargy, collapse
- Offer small amounts of water frequently
- Return immediately if: vomiting continues despite medication, blood in vomit/stool, not eating after 48 hours, severe lethargy

Recheck: 48-72 hours if not improving, or 7 days for progress check

Prognosis: Good with supportive care

______________________________
Dr. Sarah Mitchell, DVM

VETERINARY SOAP NOTE - FELINE WELLNESS EXAM

Date: 12/18/2024
Clinician: Dr. Sarah Mitchell, DVM

PATIENT INFORMATION:
Patient: Luna
Species: Feline
Breed: Domestic Shorthair
Age: 8 years
Sex: Female, Spayed
Weight: 11.2 lbs (5.1 kg)
Owner: Amanda Rodriguez
Phone: (555) 456-7890

SUBJECTIVE:
Chief Complaint: Annual exam, due for vaccines

History (per owner):
- Indoor only cat
- Eating well, normal appetite
- Water consumption seems normal
- Using litter box regularly, normal urine and stool
- Active for age, likes to play in evenings
- Occasional hairballs (1-2x/month)
- No vomiting outside of hairballs
- No sneezing, coughing, or eye/nose discharge
- No behavior changes noted
- Lives with one other cat (healthy)

Current Medications: None
Diet: Hill's Science Diet Adult Indoor, 1/3 cup AM and PM
Treats: Greenies dental treats 2-3x weekly
Allergies: None known

Previous Medical History:
- Spayed at 6 months
- Dental cleaning 2022
- No significant illness

OBJECTIVE:

General Appearance: BAR, well-groomed, BCS 5/9 (ideal)

Vital Signs:
- Temperature: 101.0°F (normal)
- Heart Rate: 180 bpm (normal for stressed cat)
- Respiratory Rate: 32 breaths/min (mildly elevated - stress)
- CRT: <2 seconds
- MM: Pink, moist

Physical Examination:
- EYES: Clear, no discharge, PLR normal OU, mild nuclear sclerosis (age-appropriate)
- EARS: Clean, no debris, no erythema AU
- NOSE: Clear, no discharge
- ORAL: Mild gingivitis along gum line, Grade 1 tartar, no resorptive lesions visible
- LYMPH NODES: No lymphadenopathy
- CARDIAC: No murmur, no gallop rhythm, regular rate
- RESPIRATORY: Clear lung sounds bilaterally
- ABDOMEN: Soft, non-painful, kidneys normal size and shape, bladder small
- MUSCULOSKELETAL: Ambulatory x4, good muscle mass for age
- INTEGUMENT: Coat healthy, no masses, no fleas/flea dirt
- THYROID: No palpable nodules
- NEUROLOGICAL: Appropriate mentation

Diagnostics:
- Senior Wellness Panel (Cat > 7 years):
  - CBC: WNL
  - Chemistry: BUN 28, Creat 1.6 (WNL), Glucose 118, T4 2.1 (WNL)
  - Urinalysis: USG 1.045, no crystals, no bacteria, pH 6.5

ASSESSMENT:
1. Healthy senior feline - annual wellness
2. Mild gingivitis/dental tartar - Grade 1
3. Senior wellness bloodwork within normal limits

PLAN:

Vaccinations Administered:
- FVRCP (Nobivac Feline 1-HCPCh) - 1 mL SQ, right shoulder, Lot #33333, Exp 04/2026
- Rabies 1-year (Purevax Feline Rabies) - 1 mL SQ, right hind leg, Lot #44444, Exp 02/2026

Recommendations:
1. Transition to senior diet (Hill's Science Diet Senior 11+) over 1-2 weeks
2. Monitor water intake - consider water fountain to encourage drinking
3. Schedule dental cleaning within next 6 months (pre-anesthetic bloodwork complete today)
4. Continue hairball prevention - add Laxatone 1 inch 2x weekly
5. Annual senior wellness bloodwork recommended

Preventive Care Discussion:
- Indoor cats still need vaccines (rabies required by law)
- Signs of kidney disease to monitor (increased thirst, weight loss)
- Dental disease common in senior cats - watching for changes
- Keep stress low, maintain routine

Follow-Up: Annual exam 12/2025, dental cleaning as scheduled

______________________________
Dr. Sarah Mitchell, DVM

VETERINARY SOAP NOTE - EMERGENCY

Date: 12/18/2024 | Time: 7:45 PM
Clinician: Dr. Sarah Mitchell, DVM

PATIENT INFORMATION:
Patient: Duke
Species: Canine
Breed: German Shepherd
Age: 4 years
Sex: Male, Intact
Weight: 82 lbs (37.2 kg) - estimated
Owner: Robert Williams
Phone: (555) 234-5678
Emergency Contact: Same

SUBJECTIVE:
Chief Complaint: HBC (Hit by car) - approximately 1 hour ago

History (per owner):
- Dog escaped from yard and was hit by car
- Witnessed by neighbor, car traveling approximately 25-30 mph
- Dog was found on side of road, able to move but reluctant to stand
- No LOC observed
- Bleeding from mouth noted
- Right hind leg appears injured
- Last ate this morning, no pre-existing health conditions
- Up to date on vaccines per owner
- Not on any medications

On Presentation: Dog is in lateral recumbency, painful, moderate respiratory effort

OBJECTIVE:

TRIAGE ASSESSMENT: RED - Critical

General Appearance: Lateral recumbency, tachypneic, pale MM, painful, anxious

Vital Signs (Initial):
- Temperature: 99.2°F (mild hypothermia)
- Heart Rate: 160 bpm (tachycardia)
- Respiratory Rate: 48 breaths/min (tachypnea)
- CRT: 3 seconds (delayed)
- MM: Pale pink, tacky
- Blood Pressure (Doppler): 85 mmHg systolic (hypotensive)
- SpO2: 92% (low)

Emergency Physical Examination:
- HEAD: Oral bleeding from lip laceration, no mandibular fracture palpated
- EYES: PLR sluggish, pupils equal
- CHEST: Muffled heart sounds on right, absent lung sounds dorsal right hemithorax
- ABDOMEN: Tense, fluid wave suspected, painful on palpation
- PELVIS: Unstable, crepitus palpated left side
- RIGHT HIND LIMB: Severe swelling mid-femur, abnormal angulation, open wound with bone visible
- LEFT HIND LIMB: Intact
- FRONT LIMBS: WNL
- NEUROLOGICAL: Conscious, responds to stimuli, superficial pain intact all limbs

Diagnostics:

FAST Scan (Focused Assessment with Sonography for Trauma):
- Positive free fluid in abdomen (moderate volume)
- Suspect hemoabdomen

Thoracic Radiographs:
- Right-sided pneumothorax
- No rib fractures identified
- Pulmonary contusions suspected

PCV/TS: 32%/5.2 (low PCV, low TS - blood loss)
Lactate: 6.2 mmol/L (elevated - tissue hypoperfusion)
Blood Type: DEA 1.1 Negative

ASSESSMENT:
1. Hypovolemic shock secondary to trauma
2. Right pneumothorax
3. Hemoabdomen - suspected splenic or hepatic laceration
4. Open right femur fracture
5. Left pelvic fracture - suspected
6. Oral lacerations
7. Pulmonary contusions

PLAN:

Emergency Stabilization:
1. IV Catheter placed (18G, right cephalic)
2. Shock fluid resuscitation - LRS 30 mL/kg bolus over 15 minutes
3. Oxygen supplementation via flow-by
4. Right thoracocentesis performed - 180 mL air removed
5. Pain management - Methadone 0.3 mg/kg IV
6. Blood type performed for potential transfusion

Current Status (Post initial stabilization, 1 hour):
- HR: 120 bpm (improved)
- RR: 28 breaths/min (improved)
- BP: 100 mmHg systolic (improved)
- CRT: 2 seconds (improved)
- PCV/TS recheck: 28%/4.8 (declining - ongoing hemorrhage)

Recommended Treatment Plan - Discussed with Owner:
1. Emergency exploratory surgery for hemoabdomen (likely splenectomy)
2. Thoracostomy tube placement if pneumothorax recurs
3. Fracture stabilization (femur, pelvis) - may require referral to orthopedic specialist
4. Possible blood transfusion (pRBC)
5. 48-72 hour ICU hospitalization minimum
6. Estimated cost: $8,000-12,000

Owner Decision: Elected to proceed with surgery. Signed consent and estimate.

Preanesthetic Bloodwork:
- CBC, Chemistry pending - surgery authorized without due to emergency

Surgery scheduled: STAT exploratory laparotomy

______________________________
Dr. Sarah Mitchell, DVM

UPDATE 10:30 PM:
- Exploratory laparotomy completed
- Splenectomy performed - splenic laceration with active hemorrhage
- Liver laceration cauterized, bleeding controlled
- 500 mL blood removed from abdomen
- Transfused 1 unit pRBC intraop
- Currently recovering in ICU
- Plan: orthopedic consult tomorrow AM for femur/pelvis
- Prognosis: Guarded to Fair