Vaccination visit

Finalized

Sep 11, 2024 · Dr. Andrea Salazar

Weight

9.60 kg

Temperature

38.4 °C

Heart rate

120 bpm

Resp. rate

26 rpm

Body condition

4 / 9

Mucous membranes

Pink, moist

Cap. refill

<2 s

Hydration

Normal

Clinical note (SOAP)

Subjective: Routine puppy visit for the final vaccine doses. Eating and playing well.
Objective: BAR. Normal vitals, ideal body condition. Full physical examination performed — no abnormalities detected.
Assessment: Healthy — fit for vaccination.
Plan: 5-in-1 3rd dose and primary anti-rabies given. Booster due in one year.

General / demeanour

Bright, alert and responsive. Good body condition.

Eyes, ears & nose

Eyes clear, no discharge. Ear canals clean. Nose moist.

Oral & dental

Mild tartar on the upper premolars; gums pink. Dental cleaning advised within the year.

Heart & lungs

No murmurs on auscultation; lungs clear bilaterally.

Abdomen

Soft and non-painful on palpation; no organomegaly.

Skin & coat

Coat glossy, good density. No lesions or external parasites.

Musculoskeletal / gait

Normal gait; full range of motion, no joint pain.

Lymph nodes

All peripheral lymph nodes normal in size.

Neurological

Mentation normal; cranial nerve and postural reactions intact.

No charges yet.

No medications prescribed.