C09984880 / invoice 10000

Appointment Notes: check up before O goes away FW?????History: Presented for a one-week post-operative check-up following major surgery. The owner is travelling tonight and wanted a check before leaving. The patient is reported to be eating well with regular stools. Activity level is high, described as "running around a lot," making rest difficult. The owner reports no signs of pain. The surgical scar appears clean and not red. The original bandages from surgery are still in place. The patient is shaking in the clinic, which the owner believes is due to nervousness.- Significant history: Major surgery one week ago.- Current medications: Gabapentin - dosage not specified - intermittently once daily for calming. Paracetamol was administered but finished on Sunday.Examination Findings:- Demeanour: Anxious (shaking), quiet Heart Rate: = PR, Respiratory Rate: , MM pink CRT<2s, Temperature: not taken BCS: /9- Eyes: NAD.- Ears:- Oral: WNL.- Nose: NAD.- Peripheral lymph nodes: WNL.- Cardiovascular: regular, no murmur.- Respiratory, breathing: normal effort, auscultation clear.- Urinary/Genital: normal external anatomy.- Skin: Surgical wound is clean, dry, and intact with no erythema noted. Bandages were present and removed during the consultation.- Abdomen: soft, comfortable on palpation.- Rectal examination: not performed- Neurological: Normal mentation, no ataxia, detailed exam deferred.- Musculoskeletal: Nil lameness, normal for ageProblem List:- Post-operative recovery (major surgery one week prior)- Hyperactivity at home post-operatively- Situational anxiety (veterinary clinic)Assessment:Patient presented for a one-week post-operative recheck. The surgical wound is healing well. The main challenge reported is managing high activity levels at home. The patient appears comfortable and pain-free based on the owner's report and clinical assessment.ddx:Plan:Treatment Plan:- In-house: Removed surgical bandages and cleaned the wound.- Continue Gabapentin as needed for sedation to manage hyperactivity.- Discontinue Paracetamol as the patient is not assessed to be painful.Client Communications:- Discussed that the surgical wound is healing appropriately.- Advised to continue Gabapentin to assist with keeping the patient calm during the recovery period.- Educated on signs of pain to monitor for, including squinting eyes or pain on palpation near the surgical site.?????    Vital Signs