History of Present Illness
Review of Systems
Past Medical History
Relevant Next 1
Physical Examination
Relevant Testing
Test Results
Differential Diagnoses
Relevant Next 2
Treatment Orders
Question 1
Question 2
About the Case
Horse with facial laceration
Physical Examination
General appearance
: Healthy weanling of appropriate weight.
Vital signs
:
Temperature: 37.6° C (99.7° F)
Pulse: 45 beats/min
Respirations: 20/min
Weight: 222 kg (490 lb)
Skin
: 2-cm laceration lateral and caudal to lateral canthus of left eye, with dried blood.
HEENT
: Sclera white, mucous membranes appear pink. No ocular or nasal discharge. No blepharospasm. No crepitus or pain upon palpation of periocular region. Eyelid margins are intact. Fundic exam unremarkable. No cervical lymphadenopathy.
Pulmonary
: Regular rate and rhythm with no increased effort. No cough or nasal discharge. Lung sounds normal.
Cardiovascular
: Capillary refill time is normal. No jugular distension, murmur, or arrhythmia.
Gastrointestinal
: Gut sounds present and unremarkable.
Genitourinary
: Unremarkable
Musculoskeletal
: No pain or swelling of joints. Gait normal.
Neurologic
: No cervical nerve deficits or other abnormalities noted. Menace response is intact
Mental status
: Bright, alert, and responsive.
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