Veterinary AI Scribe — Clinical Notes While You Focus on the Patient

VETERINARY SOAP NOTE Date: [Auto-filled] Provider: Dr. [Name], DVM Patient: Bella | Species: Canine | Breed: Labrador Retriever | Age: 6 years | Sex: Female (spayed) Owner: [Owner name] Visit type: Sick visit SUBJECTIVE Owner reports Bella has been lethargic for 2 days, with decreased appetite and occasional vomiting (3x in 24h). No diarrhea. Drinks water normally. No known toxin exposure. Up to date on vaccinations and heartworm prevention. No recent dietary changes. OBJECTIVE Weight: 28.4 kg (stable from last visit) Temp: 39.4°C (mild pyrexia) HR: 96 bpm RR: 24 breaths/min CRT: <2 seconds MM: Pink, moist Physical Examination: - Body condition score: 5/9 - Attitude: Mildly depressed - Hydration: Mildly dehydrated (~5%) - Abdomen: Mild pain on deep palpation cranial abdomen; no masses palpated - Lymph nodes: Within normal limits - CV/Respiratory: No abnormalities detected - Musculoskeletal: Normal gait and stance ASSESSMENT 1. Acute gastroenteritis — most likely etiology 2. Mild dehydration secondary to vomiting 3. Mild pyrexia — monitoring DIAGNOSTIC PLAN 1. CBC/Chemistry panel ordered 2. Abdominal radiographs — 2-view TREATMENT PLAN 1. Maropitant (Cerenia) 60mg PO q24h x 3 days 2. Metronidazole 375mg PO q12h x 5 days 3. Bland diet (boiled chicken and rice) x 5 days, then gradual transition 4. Subcutaneous fluids: 200ml Hartmann's administered in clinic 5. Recheck in 48h or sooner if vomiting continues or worsens CLIENT COMMUNICATION Owner educated on signs to monitor: continued vomiting, bloody stool, lethargy worsening. Instructed to call if no improvement in 24h. Owner verbally understands discharge plan.