SOAP note
- S Subjective
- Polydipsia for about two weeks, especially at night. Appetite unchanged.
- O Objective
- Good general condition, mucous membranes pink, T 38.4 °C. Abdomen soft, non-painful.
- A Assessment
- Polydipsia of unclear origin. Further work-up recommended.
- P Plan
- Bloodwork and urinalysis today; schedule results review and follow-up.
Lisa Hoffmann
Client letter · Luna
Dear Ms. Hoffmann,
Thank you for visiting with Luna. Luna has been drinking more than usual for about two weeks. Today's exam was unremarkable; we took a blood sample to investigate further.
Please bring a urine sample tomorrow morning. We'll be in touch as soon as the lab results are in.
Kind regards
Dr. Anna Weber
Sonnenhof Animal Hospital · Internal Medicine
Referral: Luna, Labrador Retriever, 8 y
Dear colleagues,
We are referring Luna for further work-up of polydipsia and polyuria present for two weeks. Clinical exam unremarkable, bloodwork from 14 Oct attached.
Clinical question: hyperadrenocorticism? Please perform an ACTH stimulation test and abdominal ultrasound.
Kind regards
Dr. Anna Weber



