Creating Your First SOAP Note

🟦 Subjective (Owner-reported information)
🟩 Objective (Physical exam findings)
🟪 Assessment (Your diagnosis)
🟪 Plan (Treatment and follow-up)

This is a wellness examination for Max, a five-year-old male 
neutered beagle.

SUBJECTIVE:
Owner Sarah Johnson reports that Max has been coughing 
intermittently for the past three days. The cough is dry and 
nonproductive. It seems to worsen after exercise or excitement. 
She also notes that his appetite has decreased slightly, eating 
about three-quarters of his normal food intake. No vomiting or 
diarrhea. No lethargy. Activity level is normal otherwise. 
He's current on vaccinations per her records.

OBJECTIVE:
On physical examination, Max is bright, alert, and responsive. 
Body condition score is six out of nine, slightly overweight at 
twenty-eight pounds. Temperature is one hundred one point five 
Fahrenheit, which is within normal limits. Heart rate is one 
hundred ten beats per minute, regular rhythm. Respiratory rate 
is twenty-eight breaths per minute, mildly elevated.

Auscultation of the heart reveals no murmurs or arrhythmias. 
Lung auscultation reveals mild bronchial sounds bilaterally, 
no wheezes or crackles. Tracheal palpation elicits a mild cough.

Oral examination shows moderate tartar accumulation on the molars 
bilaterally. Gingivitis is present, grade two out of four. 
No loose teeth or oral masses noted.

Abdominal palpation reveals no abnormalities, no pain, no masses.

Lymph nodes are normal size and consistency. Skin and coat are 
in good condition, no external parasites visualized.

ASSESSMENT:
Primary diagnosis is infectious tracheobronchitis, commonly known 
as kennel cough, likely viral in etiology given the dry cough and 
tracheal sensitivity. Differential diagnoses include early 
congestive heart failure, allergic airway disease, or foreign body, 
but these are less likely given the acute onset and physical exam 
findings.

Secondary finding is dental disease with moderate tartar and 
gingivitis requiring attention.

The decreased appetite is likely secondary to the respiratory 
discomfort.

PLAN:
I'm recommending supportive care for the kennel cough. Prescribe 
hydrocodone for cough suppression, one five-milligram tablet every 
eight to twelve hours as needed for cough. I'm also starting 
doxycycline one hundred milligrams once daily for seven days to 
cover any secondary bacterial infection.

Recommend strict rest, no dog parks or boarding for two weeks to 
prevent spread and allow recovery.

For the dental disease, I discussed scheduling a dental cleaning 
under anesthesia in the next four to six weeks once the respiratory 
issue has resolved.

Recheck appointment in one week to assess cough progression. 
Advised owner to return sooner if cough worsens, if Max develops 
lethargy, inappetence, or respiratory distress.

Owner was receptive to the plan and has no questions at this time.

🔄 Transcribing audio...
Progress: ████████████████ 100%
Duration: 2:34
Status: Analyzing speech patterns

This is a wellness examination for Max, a 5-year-old male 
neutered Beagle.

Subjective: Owner Sarah Johnson reports that Max has been 
coughing intermittently for the past 3 days. The cough is 
dry and nonproductive. It seems to worsen after exercise 
or excitement. She also notes that his appetite has decreased 
slightly, eating about three-quarters of his normal food 
intake. No vomiting or diarrhea. No lethargy. Activity level 
is normal otherwise. He's current on vaccinations per her 
records.

Objective: On physical examination, Max is bright, alert, 
and responsive. Body condition score is 6/9, slightly 
overweight at 28 lbs...

🧠 Analyzing transcription with GPT-4...

✓ Identified patient: Max (Beagle, 5 years)
✓ Extracted subjective findings
✓ Categorized objective measurements  
✓ Formulating assessment
✓ Generating treatment plan
✓ Checking for drug interactions
✓ Applying Standard SOAP template

Complete! (18 seconds)

🟡 MEDIUM PRIORITY | Diagnosis | 78% Confidence

Bordetella bronchiseptica infection

Consider Bordetella as primary pathogen in kennel cough cases. 
While often viral, Bordetella bacterial component is common. 
Doxycycline covers this well (already prescribed).

Reference: ACVIM Consensus Statement on Canine Infectious 
Respiratory Disease Complex (2020)

[Accept] [Reject]

🟪 HIGH PRIORITY | Risk Factor | 92% Confidence

⚠️ Penicillin allergy - Avoid beta-lactam antibiotics

Patient has documented penicillin allergy. Ensure no cross-reactive 
beta-lactams prescribed. Doxycycline is safe (different class). 
Do not use amoxicillin, cephalexin, or clavamox.

[Accept] [Reject]

🟩 LOW PRIORITY | Suggestion | 65% Confidence

Consider thoracic radiographs if no improvement in 7 days

If cough persists or worsens after 1 week of treatment, thoracic 
radiographs indicated to rule out pneumonia, cardiac disease, or 
masses. Current plan appropriately schedules recheck at 1 week.

[Accept] [Reject]

- Recommended humidifier at home to ease respiratory discomfort
- Suggested honey (1 tsp) for natural cough relief if needed

✓ Medical record saved successfully

Record ID: MR-2026-03-06-001
Patient: Max
Date: March 6, 2026
Status: Finalized
Created by: Dr. Sarah Wilson

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