10 Common Veterinary Medicine SOAP Note Examples

Create Your Veterinary Medicine SOAP Note in 2 Minutes

Start with 3 free SOAP notes. No credit card required.

Type Your NoteRecord Note

This page provides 10 comprehensive SOAP note examples commonly encountered in veterinary practice. Each example follows standard documentation guidelines and includes appropriate CPT codes.

Cases

1. Canine Annual Wellness Exam
2. Feline Upper Respiratory Infection
3. Canine Acute Gastroenteritis
4. Feline Chronic Kidney Disease
5. Canine Orthopedic Injury
6. Feline Diabetes Mellitus
7. Canine Dermatitis
8. Feline Hyperthyroidism
9. Canine Dental Disease
10. Emergency Trauma Assessment

1. Canine Annual Wellness Exam

Description

Comprehensive annual wellness examination for an adult dog, including preventive care and health screening.

SOAP Note

Patient Information

• Name: Max
• Species/Breed: Canine/Labrador Retriever
• Age: 5 years
• Sex: Male Neutered
• Weight: 32.5 kg

Date of Visit: 09/01/2024

Subjective

Owner reports Max is doing well overall. Eating and drinking normally, regular exercise routine with daily walks. No vomiting, diarrhea, or changes in appetite. Current on monthly heartworm and flea/tick prevention. Owner notes occasional scratching but no excessive licking or chewing. Diet consists of commercial adult maintenance dry food.

Objective

• Vital Signs:
  • Temperature: 101.8°F
  • Heart Rate: 88 bpm
  • Respiratory Rate: 24/min
  • MM: Pink, CRT < 2 sec
  • Body Condition Score: 5/9
• Physical Examination:
  • General: Alert, bright, responsive
  • Musculoskeletal:
    • Gait normal
    • No lameness
    • Good muscle condition
  • Cardiovascular:
    • Regular rhythm
    • No murmurs
    • Strong pulses
  • Respiratory:
    • Clear lung sounds
    • Normal effort
  • Dermatologic:
    • Coat healthy
    • No parasites
    • Mild interdigital erythema
  • Oral Cavity:
    • Mild tartar
    • Gingivitis Grade 1/4
    • All teeth present
• Diagnostic Tests:
  • Heartworm test: Negative
  • Fecal flotation: Negative

Assessment

1. Healthy Adult Dog
   • Good body condition
   • Age-appropriate status
2. Mild Dental Disease
   • Early periodontal disease
   • Preventive care needed
3. Mild Interdigital Dermatitis
   • Early stage
   • Environmental cause likely

Plan

1. Preventive Care:

   • Annual vaccinations updated
   • Heartworm prevention continued
   • Flea/tick prevention renewed
   • CPT Code: 95115

2. Recommendations:

   • Dental cleaning scheduled
   • Paw cleaning routine
   • Weight maintenance
   • Exercise continuation

3. Client Education:

   • Dental home care
   • Nutrition review
   • Senior care preparation
   • Parasite prevention

4. Follow-up:

   • Annual exam
   • Dental cleaning in 1 month
   • Call if dermatitis worsens

2. Feline Upper Respiratory Infection

Description

Evaluation and treatment of an acute upper respiratory infection in a young adult cat.

SOAP Note

Patient Information

• Name: Luna
• Species/Breed: Feline/Domestic Shorthair
• Age: 2 years
• Sex: Female Spayed
• Weight: 4.2 kg

Date of Visit: 09/02/2024

Subjective

Owner reports 3-day history of sneezing, nasal discharge, and decreased appetite. Luna is indoor-only cat but recently boarded at kennel 1 week ago. Eating about 50% of normal amount, drinking water normally. No vomiting or diarrhea. Current on FVRCP vaccination. No previous history of URI.

Objective

• Vital Signs:
  • Temperature: 103.2°F
  • Heart Rate: 180 bpm
  • Respiratory Rate: 36/min
  • MM: Pink, CRT < 2 sec
• Physical Examination:
  • General:
    • BAR but subdued
    • Mild dehydration (5%)
    • BCS 5/9
  • Respiratory:
    • Bilateral serous nasal discharge
    • Mild conjunctivitis
    • Occasional cough
    • Clear lung sounds
  • Oral Cavity:
    • Mild ulceration on tongue
    • Decreased appetite
    • No gingivitis
  • Lymph Nodes:
    • Mild submandibular lymphadenopathy
    • Other nodes normal
• Point of Care Testing:
  • FeLV/FIV: Negative
  • PCV/TS: 42%/7.2 g/dL

Assessment

1. Upper Respiratory Infection
   • Likely viral etiology
   • Moderate severity
   • Post-boarding onset
2. Mild Dehydration
   • Secondary to decreased intake
   • Clinically stable
3. Oral Ulceration
   • Secondary to viral infection
   • Contributing to inappetence

Plan

1. Treatment:

   • Subcutaneous fluids
   • Broad spectrum antibiotics
   • L-lysine supplement
   • CPT Code: 95024

2. Medications:

   • Amoxicillin-clavulanate 62.5mg BID x 10 days
   • Terramycin ophthalmic ointment BID
   • L-lysine 500mg daily

3. Supportive Care:

   • Humidification
   • Nasal decongestant
   • Appetite stimulation
   • Stress reduction

4. Follow-up:

   • Recheck in 5 days
   • Call if worsening
   • Monitor appetite/hydration
   • Isolation from other cats

3. Canine Acute Gastroenteritis

Description

Evaluation and treatment of acute vomiting and diarrhea in an adult dog.

SOAP Note

Patient Information

• Name: Charlie
• Species/Breed: Canine/Golden Retriever
• Age: 3 years
• Sex: Male Neutered
• Weight: 29.8 kg

Date of Visit: 09/03/2024

Subjective

Owner reports acute onset of vomiting (6 episodes) and diarrhea (watery, no blood) over past 24 hours. Patient got into garbage two days ago. Decreased appetite but still drinking water. No known toxin exposure. Current on vaccinations. No previous GI issues. Usually healthy, active dog.

Objective

• Vital Signs:
  • Temperature: 102.4°F
  • Heart Rate: 112 bpm
  • Respiratory Rate: 28/min
  • MM: Pink, slightly tacky
  • CRT: 2.5 seconds
• Physical Examination:
  • General:
    • Mild dehydration (7%)
    • Alert but less energetic
    • BCS 5/9
  • Gastrointestinal:
    • Mild abdominal discomfort
    • No masses palpable
    • Borborygmi increased
  • Hydration Status:
    • Mild skin tenting
    • Tacky mucous membranes
    • Normal urine output
• Point of Care Testing:
  • Parvo snap test: Negative
  • PCV/TS: 48%/7.0 g/dL
  • Blood glucose: 95 mg/dL
  • Electrolytes: Na+ 148, K+ 3.8

Assessment

1. Acute Gastroenteritis
   • Dietary indiscretion
   • Moderate dehydration
   • Stable vital signs
2. Rule Out:
   • Foreign body
   • Pancreatitis
   • Infectious causes

Plan

1. Treatment:

   • IV fluid therapy
   • Anti-emetic medication
   • GI protectants
   • CPT Code: 95024

2. Medications:

   • Maropitant 1mg/kg SC
   • Famotidine 0.5mg/kg IV
   • Metronidazole 15mg/kg BID

3. Supportive Care:

   • NPO for 12 hours
   • Bland diet introduction
   • Fluid therapy plan
   • Monitoring parameters

4. Follow-up:

   • Recheck tomorrow
   • Call if worsening
   • Diet transition plan
   • Monitor hydration

4. Feline Chronic Kidney Disease

Description

Management of chronic kidney disease in a senior cat presenting for routine monitoring.

SOAP Note

Patient Information

• Name: Milo
• Species/Breed: Feline/Maine Coon Mix
• Age: 12 years
• Sex: Male Neutered
• Weight: 5.1 kg (down from 5.4 kg)

Date of Visit: 09/04/2024

Subjective

Owner reports Milo drinking more water than usual and using litter box frequently. Appetite good with renal diet. Some weight loss noted despite good appetite. Energy level stable. Taking medications as prescribed. No vomiting. Previously diagnosed with IRIS Stage 2 CKD six months ago.

Objective

• Vital Signs:
  • Temperature: 101.8°F
  • Heart Rate: 168 bpm
  • Respiratory Rate: 32/min
  • MM: Pink, CRT < 2 sec
• Physical Examination:
  • General:
    • Alert, responsive
    • Mild muscle loss
    • BCS 4/9
  • Cardiovascular:
    • Grade 2/6 systolic murmur
    • BP: 155/95 mmHg
  • Oral:
    • Mild gingivitis
    • Dental tartar
  • Hydration:
    • Well hydrated
    • Skin turgor normal
• Laboratory Results:
  • Creatinine: 2.8 mg/dL (↑)
  • BUN: 42 mg/dL (↑)
  • Phosphorus: 4.5 mg/dL
  • K+: 3.9 mEq/L
  • USG: 1.025
  • SDMA: 16 μg/dL (↑)

Assessment

1. Chronic Kidney Disease
   • IRIS Stage 2
   • Stable but progressive
   • Mild azotemia
2. Concurrent Issues
   • Mild hypertension
   • Dental disease
   • Weight loss

Plan

1. Treatment:

   • Continue renal diet
   • Blood pressure monitoring
   • Fluid therapy assessment
   • CPT Code: 95024

2. Medications:

   • Continue benazepril 0.5mg/kg daily
   • Add amlodipine 0.625mg daily
   • Potassium supplementation

3. Monitoring:

   • Monthly blood pressure
   • Q3 month bloodwork
   • Weight tracking
   • Hydration status

4. Follow-up:

   • Recheck in 2 weeks
   • BP monitoring
   • Bloodwork review
   • Diet assessment

5. Canine Orthopedic Injury

Description

Evaluation and treatment of acute hind limb lameness in an active adult dog.

SOAP Note

Patient Information

• Name: Rocky
• Species/Breed: Canine/Border Collie
• Age: 4 years
• Sex: Male Neutered
• Weight: 20.4 kg

Date of Visit: 09/05/2024

Subjective

Owner reports acute onset right hind limb lameness following agility training yesterday. Patient was jumping and landed awkwardly. Non-weight bearing on affected limb. No previous orthopedic issues. Active dog who regularly participates in agility competitions. No known trauma other than described incident.

Objective

• Vital Signs:
  • Temperature: 101.6°F
  • Heart Rate: 96 bpm
  • Respiratory Rate: 24/min
  • MM: Pink, CRT < 2 sec
• Orthopedic Examination:
  • Gait Analysis:
    • Grade 4/4 lameness RH
    • Non-weight bearing
    • Toe-touching only
  • Right Stifle:
    • Positive cranial drawer
    • Positive tibial thrust
    • Joint effusion present
    • Pain on manipulation
  • Other Joints:
    • Hip range normal
    • No crepitus
    • No other swelling
• Neurological:
  • Proprioception intact
  • Reflexes normal
  • Pain sensation normal
• Imaging:
  • Radiographs: Stifle effusion
  • No obvious fractures
  • Good joint alignment

Assessment

1. Cranial Cruciate Ligament Rupture
   • Complete tear suspected
   • Right stifle
   • Acute onset
2. Secondary Issues
   • Joint effusion
   • Muscle tension
   • Pain/inflammation

Plan

1. Treatment:

   • TPLO surgery recommended
   • Pain management
   • Rest/restriction
   • CPT Code: 95024

2. Medications:

   • Carprofen 2.2mg/kg BID
   • Gabapentin 10mg/kg TID
   • Ice therapy protocol

3. Activity Restriction:

   • Strict rest
   • Leash walks only
   • No jumping/running
   • Crate rest advised

4. Follow-up:

   • Surgical consultation
   • Pre-op bloodwork
   • Activity modification
   • Pain monitoring

6. Feline Diabetes Mellitus

Description

Routine monitoring visit for a diabetic cat with recent insulin dose adjustments.

SOAP Note

Patient Information

• Name: Oliver
• Species/Breed: Feline/Domestic Longhair
• Age: 9 years
• Sex: Male Neutered
• Weight: 6.2 kg

Date of Visit: 09/06/2024

Subjective

Owner reports improved energy and reduced water consumption since last insulin adjustment. Maintaining good appetite. Using litter box normally. Blood glucose curves at home ranging 120-280 mg/dL. No hypoglycemic episodes noted. Currently receiving 3U ProZinc BID. Owner reports consistent timing of insulin and meals.

Objective

• Vital Signs:
  • Temperature: 101.4°F
  • Heart Rate: 164 bpm
  • Respiratory Rate: 28/min
  • MM: Pink, CRT < 2 sec
• Physical Examination:
  • General:
    • Bright, alert
    • Good muscle condition
    • BCS 6/9
  • Hydration:
    • Well hydrated
    • Skin turgor normal
  • Systems Review:
    • Clear lung sounds
    • Normal heart sounds
    • No peripheral neuropathy
• Laboratory Results:
  • Fructosamine: 380 μmol/L
  • Blood Glucose: 185 mg/dL
  • Urinalysis:
    • USG: 1.035
    • Glucose: Negative
    • Ketones: Negative

Assessment

1. Diabetes Mellitus
   • Well regulated
   • Good glycemic control
   • Stable weight
2. Concurrent Issues
   • Mild obesity
   • Otherwise healthy
   • Good compliance

Plan

1. Treatment:

   • Continue ProZinc 3U BID
   • Maintain feeding schedule
   • Weight management
   • CPT Code: 95024

2. Monitoring:

   • Home glucose curves
   • Monthly weight checks
   • Quarterly fructosamine
   • Urine monitoring

3. Client Education:

   • Diet compliance
   • Exercise plan
   • Hypoglycemia signs
   • Monitoring protocol

4. Follow-up:

   • Recheck in 3 months
   • Call if changes noted
   • Glucose curve review
   • Weight monitoring

7. Canine Dermatitis

Description

Evaluation and treatment of chronic allergic dermatitis with secondary bacterial infection.

SOAP Note

Patient Information

• Name: Bella
• Species/Breed: Canine/West Highland White Terrier
• Age: 6 years
• Sex: Female Spayed
• Weight: 8.2 kg

Date of Visit: 09/07/2024

Subjective

Owner reports increased scratching and licking over past month, particularly feet and abdomen. History of seasonal allergies. Currently on monthly flea prevention. Diet unchanged (grain-free kibble). Previous response to steroids but symptoms returned. Sleep disrupted by scratching. No other pets in household showing signs.

Objective

• Vital Signs:
  • Temperature: 101.8°F
  • Heart Rate: 92 bpm
  • Respiratory Rate: 24/min
  • MM: Pink, CRT < 2 sec
• Dermatologic Examination:
  • Distribution:
    • Erythema: paws, ventrum
    • Lichenification: axillae
    • Alopecia: scattered
  • Lesions:
    • Hot spots: right flank
    • Excoriations: multiple
    • Papules: ventral abdomen
  • Other Findings:
    • Malassezia overgrowth
    • Secondary pyoderma
    • Moderate pruritus
• Diagnostic Tests:
  • Skin scraping: Negative
  • Cytology: Cocci, yeast
  • DTM culture pending

Assessment

1. Atopic Dermatitis
   • Moderate severity
   • Seasonal component
   • Chronic condition
2. Secondary Issues
   • Bacterial pyoderma
   • Malassezia dermatitis
   • Self-trauma

Plan

1. Treatment:

   • Multimodal approach
   • Infection control
   • Allergy management
   • CPT Code: 95024

2. Medications:

   • Cephalexin 22mg/kg BID x21d
   • Prednisone taper protocol
   • Antifungal shampoo 2x/week

3. Environmental:

   • Hypoallergenic diet trial
   • Weekly bathing
   • Flea control
   • Environmental changes

4. Follow-up:

   • Recheck in 2 weeks
   • Allergy testing discussion
   • Monitor response
   • Long-term planning

8. Feline Hyperthyroidism

Description

Monitoring visit for a senior cat with recently diagnosed hyperthyroidism on methimazole therapy.

SOAP Note

Patient Information

• Name: Sophie
• Species/Breed: Feline/Domestic Shorthair
• Age: 14 years
• Sex: Female Spayed
• Weight: 3.8 kg (up from 3.5 kg)

Date of Visit: 09/08/2024

Subjective

Owner reports improvement in hyperactivity and vocalization since starting methimazole 2 weeks ago. Appetite remains increased but less ravenous. Water consumption decreased. No vomiting or diarrhea. Tolerating oral medication well. Sleep patterns improving. Using litter box normally.

Objective

• Vital Signs:
  • Temperature: 101.6°F
  • Heart Rate: 188 bpm (down from 220)
  • Respiratory Rate: 32/min
  • MM: Pink, CRT < 2 sec
• Physical Examination:
  • General:
    • Improved body condition
    • Less agitated
    • BCS 3/9
  • Cardiovascular:
    • Gallop rhythm resolved
    • BP: 145/85 mmHg
  • Thyroid Palpation:
    • Left lobe: 4mm
    • Right lobe: 5mm
• Laboratory Results:
  • T4: 3.8 μg/dL (improved)
  • BUN: 28 mg/dL
  • Creatinine: 1.4 mg/dL
  • ALT: 65 U/L
  • CBC: WNL

Assessment

1. Hyperthyroidism
   • Responding to treatment
   • Partial improvement
   • Stable side effects
2. Monitoring
   • Weight gain positive
   • Heart rate improved
   • Renal function stable

Plan

1. Treatment:

   • Continue methimazole 2.5mg BID
   • Monitor weight
   • Cardiac assessment
   • CPT Code: 95024

2. Diagnostics:

   • Recheck T4 in 2 weeks
   • Monitor kidney values
   • BP monitoring
   • Cardiac evaluation

3. Client Education:

   • Medication compliance
   • Monitoring parameters
   • Diet management
   • Side effect watch

4. Follow-up:

   • Recheck in 2 weeks
   • Dose adjustment plan
   • I-131 discussion
   • Long-term options

9. Canine Dental Disease

Description

Comprehensive oral examination and treatment planning for advanced periodontal disease in a senior dog.

SOAP Note

Patient Information

• Name: Bailey
• Species/Breed: Canine/Yorkshire Terrier
• Age: 10 years
• Sex: Female Spayed
• Weight: 3.2 kg

Date of Visit: 09/09/2024

Subjective

Owner reports halitosis and difficulty eating hard kibble. Occasionally pawing at mouth. No obvious pain but more selective with food choices. Previously diagnosed with periodontal disease but no professional cleaning in 2 years. No other health issues. Current on vaccinations.

Objective

• Vital Signs:
  • Temperature: 101.4°F
  • Heart Rate: 112 bpm
  • Respiratory Rate: 24/min
  • MM: Pink, CRT < 2 sec
• Oral Examination:
  • Periodontal Disease:
    • Grade 3-4/4 generalized
    • Severe calculus buildup
    • Gingival recession
    • Mobile teeth: 304, 308, 404
  • Specific Findings:
    • Furcation exposure #208
    • Abscess suspected #309
    • Worn enamel multiple teeth
  • Soft Tissues:
    • Gingivitis severe
    • Oral mass 5mm right maxilla
    • Ulceration present
• Pre-Anesthetic Screen:
  • CBC/Chemistry: WNL
  • ECG: Normal sinus
  • Chest radiographs clear

Assessment

1. Severe Periodontal Disease
   • Multiple teeth affected
   • Secondary infection
   • Chronic progression
2. Oral Mass
   • Requires biopsy
   • Rule out neoplasia
   • Local invasion possible

Plan

1. Treatment:

   • Dental cleaning/extractions
   • Mass biopsy
   • Pain management
   • CPT Code: 95024

2. Anesthetic Protocol:

   • Pre-medication plan
   • IV catheter/fluids
   • Monitoring parameters
   • Recovery protocol

3. Client Education:

   • Procedure risks
   • Post-op care
   • Home dental care
   • Diet modifications

4. Follow-up:

   • Schedule procedure
   • Biopsy results review
   • Recovery monitoring
   • Dental care plan

10. Emergency Trauma Assessment

Description

Emergency evaluation of a cat following motor vehicle trauma with multiple injuries.

SOAP Note

Patient Information

• Name: Shadow
• Species/Breed: Feline/Domestic Shorthair
• Age: 3 years
• Sex: Male Neutered
• Weight: 4.5 kg

Date of Visit: 09/10/2024

Subjective

Patient presented after witnessed motor vehicle accident 30 minutes ago. Indoor/outdoor cat. No previous medical issues. Current on vaccinations. Owner reports cat was conscious but unable to walk after accident. No loss of consciousness observed. Normal behavior prior to incident.

Objective

• Vital Signs:
  • Temperature: 99.8°F
  • Heart Rate: 200 bpm
  • Respiratory Rate: 45/min
  • MM: Pale pink, CRT 3 sec
  • Blood Pressure: 90/60 mmHg
• Primary Survey:
  • Respiratory:
    • Increased effort
    • Harsh lung sounds right
    • Suspect pneumothorax
  • Cardiovascular:
    • Tachycardia
    • Weak femoral pulse
    • Shock signs present
  • Neurological:
    • Alert but subdued
    • Pupils equal/responsive
    • Pain response all limbs
• Secondary Survey:
  • Right hind limb deformity
  • Abrasions multiple sites
  • Chest wall crepitus
  • Mild epistaxis
• FAST Ultrasound:
  • Small volume free fluid abdomen
  • Pneumothorax confirmed
  • Cardiac contractility fair

Assessment

1. Polytrauma
   • Pneumothorax
   • Suspected pelvic fracture
   • Shock state
2. Critical Status
   • Respiratory compromise
   • Cardiovascular instability
   • Multiple injuries

Plan

1. Stabilization:

   • IV catheterization
   • Fluid resuscitation
   • Thoracocentesis
   • CPT Code: 95024

2. Diagnostics:

   • Full body radiographs
   • Blood work panel
   • Coagulation profile
   • ECG monitoring

3. Treatment:

   • Oxygen therapy
   • Pain management
   • Shock protocol
   • Wound care

4. Follow-up:

   • Continuous monitoring
   • Surgical planning
   • Critical care protocol
   • Owner updates