당사의 AI 스크라이브는 외과 수의사를 위해 특별히 설계되었습니다 — 실시간으로 SOAP 노트를 생성하고 문서화 부담을 줄여줍니다.
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.
완전한 구조로 수술 노트를 받아쓰고 검토.