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AS

Dr. Andrea Salazar

Owner Admin

Max

Surgery visit

Finalized

Apr 7, 2025 · Dr. Patricia Reyes

View anaesthetic chart

Weight

13.10 kg

Temperature

39.6 °C

Heart rate

105 bpm

Resp. rate

30 rpm

Body condition

5 / 9

Mucous membranes

Pink, slightly tacky

Cap. refill

~2 s

Hydration

Mildly dehydrated (~5%)

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

TestResultReferenceFlag
PCV / Haematocrit44 %37–55Normal
Haemoglobin15.1 g/dL12–18Normal
WBC11.8 ×10⁹/L6–17Normal
Platelets312 ×10⁹/L200–500Normal

Blood chemistry

TestResultReferenceFlag

Charges

No charges yet.

Medications

Metronidazole · 200 mg

Twice daily · 5 days

Amoxicillin · 250 mg

Twice daily · 7 days · Give with food.

Follow-up scheduled for Apr 17, 2025
ALT62 U/L10–100Normal
ALP94 U/L20–150Normal
BUN18 mg/dL7–27Normal
Creatinine1.1 mg/dL0.5–1.8Normal
Glucose92 mg/dL70–110Normal
Total protein6.4 g/dL5.4–7.5Normal

Other

TestResultReferenceFlag
Abdominal ultrasoundMild gastric wall thickening; no foreign body or effusion—Normal