History of Present Illness
Relevant Next Steps 1
Review of Systems
Past Medical History
Physical Examination
Relevant Testing
Test Results 1
Test Interpretation
Differential Diagnoses
Relevant Next Steps 2
Test Results 2
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Rottweiler with severe bilateral epistaxis
Physical Examination
General appearance
: Abnormal, dull, blood on nasal planum.
Vital signs
:
Temperature: 36.8° C
Pulse: 72 beats/min
Respirations: 16/min
Weight: 42 kg (92.5 lbs)
Skin
: Unremarkable
HEENT
: Sclera clear, mucous membranes pale pink, no ocular discharge, ears clean, no submandibular lymphadenopathy, and no oral lesions observed. Mild bilateral epistaxis.
Pulmonary
: Eupneic with mildly increased bronchovesicular sounds. No sneezing or coughing.
Cardiovascular
: No murmur or arrhythmia, capillary refill time decreased, sluggish jugular refill.
Gastrointestinal
: Gut sounds present and unremarkable.
Genitourinary
: Intact male: both testicles descended.
Musculoskeletal
: Limited exam because patient was sedate and not ambulating.
Neurologic
: Unremarkable
Mental status
: Quiet, sleeping, slow responses.
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