Maddie
Tuesday, September 8, 2026 at 8:41 AM
Subjective
Chief Complaint
Judy brought in her 10-week-old puppy, Maddie, for her second round of vaccinations.
History
- Maddie is active, eating well, and playing well.
- House training is progressing fairly well.
- Owner has been keeping Maddie in their yard to limit exposure until fully vaccinated.
- Maddie has been dewormed once but not on a monthly schedule yet.
- Owner is feeding Maddie a third of a cup of food twice daily, recently split into smaller meals with water added.
- Maddie has no history of vomiting, diarrhea, coughing, or sneezing, though she occasionally gets hiccups.
- Bowel movements and urination are normal.
- Owner is interested in starting heartworm prevention next month.
- Owner plans to spay Maddie at 6 months of age.
Objective
Vital Signs
- Temperature: 101.8°F (38.8°C)
- Weight: 4.6 kg
- Heart Rate: 140 bpm
- Respiratory Rate: 28 breaths/min
- Capillary Refill Time: < 2 seconds
- Body Condition Score: BCS 5/9
Physical Exam
- Eyes: Clear with no discharge
- Ears: Clean with no discharge or erythema AU.
- Oral: Deciduous teeth present and erupting normally; normal occlusion.
- Cardiovascular: Normal heart rate, sinus rhythm, no murmurs. Strong and synchronous pulses bilaterally.
- Respiratory: Clear lung fields bilaterally, no crackles or wheezes.
- Abdominal: No organomegaly or mass effects. No pain on palpation.
- Lymphatic: No peripheral lymphadenopathy.
- Coat and Skin: Healthy hair coat and skin, no ectoparasites seen.
- Musculoskeletal: Ambulation normal, no lameness observed.
- Neurological: Normal neurologic exam with normal mentation. No proprioceptive deficits or overt ataxia; normal cranial nerve exam.
- Neck and Thyroid: No cervical masses; thyroid not palpable.
- Reproductive and Urinary: Normal external genitalia, no discharge or inflammation.
- Mammary: No significant findings
- Rectal: Not examined
Assessment
- Maddie is a healthy 10-week-old puppy presenting for her second round of vaccinations.
- No current signs of illness or abnormalities on physical examination.
- Owner is appropriately managing house training and feeding, though grazing behavior is noted.
- Owner is cautious about exposure to other animals and wildlife until vaccinations are complete.
Plan
- Administered the 10-week distemper-parvo combination vaccine in the right shoulder.
- Discussed potential vaccine reactions, including lethargy, localized pain, swelling, hives, vomiting, diarrhea, and rare anaphylactic reactions.
- Scheduled follow-up vaccinations at 13 and 16 weeks, with rabies vaccine planned for 16 weeks.
- Discussed additional vaccines, including Bordetella (kennel cough) and leptospirosis, based on potential exposure risks.
- Recommended monthly deworming until 6 months of age.
- Advised starting heartworm prevention at the next visit.
- Encouraged continued nail trimming and desensitization to handling of paws, mouth, and other body parts.
- Owner to monitor for any vaccine reactions and report if severe symptoms occur.