Surgery visit

Finalized

Oct 7, 2025 · Dr. Patricia Reyes

Anaesthetic monitoring

Weight

6.10 kg

Temperature

39.6 °C

Heart rate

135 bpm

Resp. rate

32 rpm

Body condition

5 / 9

Mucous membranes

Pink, moist

Cap. refill

<2 s

Hydration

Normal

Clinical note (SOAP)

Subjective: Admitted for elective neuter.
Objective: Pre-operative exam normal; pre-anaesthetic bloodwork within range; cleared for anaesthesia.
Assessment: Routine elective surgery.
Plan: Procedure completed without complication. Wound check in 10 days. Analgesia dispensed.

Physical examination

General / demeanour

Alert; responsive to handling.

Eyes, ears & nose

No discharge; conjunctiva pink.

Oral & dental

Mucous membranes pink; no oral lesions.

Heart & lungs

No murmurs; lungs clear on auscultation.

Abdomen

Mild discomfort on palpation; no masses.

Skin & coat

Coat unremarkable; no external parasites seen.

Musculoskeletal / gait

Ambulatory; no lameness observed.

Lymph nodes

Within normal limits.

Neurological

Mentation appropriate; no deficits.

Diagnostics & laboratory

CBC

Test	Result	Reference	Flag
PCV / Haematocrit	44 %	37–55	Normal
Haemoglobin	15.1 g/dL	12–18	Normal
WBC	11.8 ×10⁹/L	6–17	Normal
Platelets	312 ×10⁹/L	200–500	Normal

Blood chemistry

Test	Result	Reference	Flag

Charges · ₱4,800

Item	Qty	Unit	Total	Status
Visit fee	1	₱4,800	₱4,800	Done

Medications

Maropitant (Cerenia) · 16 mg

Once daily · 3 days · For nausea and vomiting.

Amoxicillin · 250 mg

Twice daily · 7 days · Give with food.

Follow-up scheduled for Oct 17, 2025