AI Scribe for Veterinarians

SICK VISIT — SOAP

Patient: Buddy
Owner: Sarah M.
Signalment: 9-year-old MN Labrador Retriever, 32.4 kg, BCS 6/9
DVM: Dr. K. Hayes, DVM
Date: Today, 10:42 AM

PRESENTING COMPLAINT:
Vomiting and lethargy x 2 days.

SUBJECTIVE / HISTORY:
Owner reports Buddy began vomiting yesterday morning — initially food, then yellow bile by afternoon (~5 episodes total over 24 hr). Decreased appetite, drinking less, lethargic. No diarrhea per owner. Owner notes Buddy got into the kitchen trash 3 days ago — possible exposure to chicken bones, cooked fat, and a small amount of chocolate (unknown quantity). No known toxin exposure otherwise. Last vomit 2 hr prior to presentation. Urinating normally. No coughing or sneezing.
Diet: Purina Pro Plan adult, 3 cups/day, no recent changes.
Medications / Preventives: Heartgard Plus monthly (last given 2 wk ago), NexGard monthly (current), Adequan q3 weeks for OA.
Vaccinations: DA2PP, Rabies, Bordetella, Lepto — all current per record.
PMH: Bilateral hip OA managed with carprofen 75 mg PO BID and Adequan; no prior GI issues.

OBJECTIVE:
Vitals: T 39.4°C (103.0°F), HR 120 bpm, RR 28 brpm, BP 142/86 (oscillometric, R forelimb), CRT 2 sec.
General: QAR, mildly depressed, hydration ~5–7% deficit, MM pink and tacky, skin tent prolonged.
EENT: No icterus, no nasal/ocular discharge.
CV: Strong, synchronous femoral pulses; no murmur on auscultation.
Resp: Lungs CV bilaterally; no crackles or wheezes.
Abd: Mildly tense on cranial palpation, no organomegaly, no obvious mass or foreign body palpable, no fluid wave.
MS: Bilateral hip stiffness consistent with chronic OA; no acute lameness today.
Neuro: A/A/R; CN II–XII WNL; no ataxia.
Lymph: No peripheral lymphadenopathy.

DIAGNOSTICS ORDERED:
CBC, chemistry panel, electrolytes, abdominal radiographs (3-view), fecal centrifugation, cPL SNAP.

RESULTS (in-house):
- CBC: Mild leukocytosis (WBC 19.4 × 10⁹/L; ref 6–17), neutrophilia with mild left shift, no toxic change.
- Chem: ALT 142 U/L (ref 10–110), ALP 95 (WNL), BUN 28 (mildly elevated, consistent w/ dehydration), creat 1.3 (WNL), glucose 96, total protein 7.4, albumin 3.6, electrolytes WNL.
- cPL SNAP: Negative.
- Abdominal radiographs: No radiopaque foreign body, no obstructive gas pattern, mild gastric distension with food/fluid; small intestine within normal diameter; no free abdominal gas.
- Fecal: Negative for ova and parasites.

ASSESSMENT:
1. Acute gastroenteritis — likely dietary indiscretion (trash exposure 3 days ago). Pancreatitis ruled out (cPL negative). No radiographic evidence of foreign body obstruction.
2. Mild dehydration (~5–7%).
3. Stress / inflammatory leukogram secondary to GI inflammation.
4. Mildly elevated ALT — likely secondary to GI inflammation or transient hepatocellular stress; recheck in 2 weeks.
5. Chronic bilateral hip OA — stable, continue current management.

PLAN:
- Hospitalize for IV fluid therapy: LRS at 1.5x maintenance (~98 mL/hr) for 12 hr, then reassess.
- Maropitant (Cerenia) 1 mg/kg IV once, then 1 mg/kg SQ q24h x 3 days.
- Metronidazole 12 mg/kg PO BID x 5 days.
- NPO x 12 hr, then offer small amount bland diet (boiled chicken + white rice) — small frequent meals over 3 days, transition back to normal diet.
- HOLD carprofen until GI signs resolve x 48 hr; monitor renal values on recheck.
- Recheck phone call in 24 hr; in-person recheck in 7 days with chemistry panel (focus on ALT).
- Owner discharge instructions provided (see attached).

CONTROLLED-SUBSTANCE ENTRY: None administered today.

OWNER DISCHARGE INSTRUCTIONS (auto-generated):
Buddy had an upset stomach from eating something he shouldn't have. We gave him fluids under the skin and started anti-nausea and antibiotic medication. Feed boiled chicken and white rice in small amounts every 4 hours starting tomorrow. Hold his arthritis medication for 2 days. Call us right away if vomiting returns, he won't drink, becomes very weak, or you see blood in vomit/stool. Recheck appointment scheduled for one week from today.

DVM signature: K. Hayes, DVM