AI-kirjurimme on suunniteltu erityisesti Kirurgia eläinlääkäreille — luo SOAP-merkinnät reaaliajassa ja vähentää dokumentaatiotaakkaa.
Kenny, a 4-year-old neutered male mixed-breed dog, was presented for a surgical repair of a ruptured cranial cruciate ligament (CCL) in the left stifle. After confirming the diagnosis through orthopedic examination and radiographs, a lateral fabellar suture (extracapsular stabilization) was elected. Kenny was fasted overnight and admitted the morning of surgery. A pre-anesthetic examination was unremarkable. Anesthesia was induced with propofol and maintained with isoflurane inhalant gas. The affected limb was clipped and aseptically prepared. The procedure was completed without complication. Postoperative radiographs confirmed appropriate implant placement. Kenny recovered uneventfully and was placed on appropriate analgesia. An e-collar was applied, and postoperative instructions were reviewed with the owner at discharge.
Pre-surgical physical exam revealed moderate muscle atrophy and joint effusion in the left stifle. Positive cranial drawer and tibial thrust were present. No abnormalities were noted in the contralateral limb. Cardiothoracic auscultation was normal; mucous membranes were pink with CRT <2 seconds. Abdominal palpation and general neurologic function were within normal limits.
Sanele ja tarkista kirurgiset merkinnät täydellisellä rakenteella.