History of Present Illness
Review of Systems
Past Medical History
Relevant Next Steps 1
Physical Examination
Relevant Testing
Test Results 1
Diagnosis
Relevant Next Steps 2
Test Results 2
Differential Diagnoses
Treatment Orders
Question 1
Question 2
About the Case
Lethargic dog with anorexia and pain
Physical Examination
General appearance
: Thin male who appears fatigued and older than stated age; in no apparent respiratory distress.
Vital signs
:
Temperature: 38.2° C (100.7° F)
Pulse: 140 beats/min
Respirations: Panting
Weight: 7.0 kg (15.4 lb)
Skin
: Hair coat normal. Small, firm mass palpated near 10
th
rib on right side.
HEENT
: Eyes and ears normal. Mucous membranes pink and moist. No ocular discharge, submandibular lymphadenopathy, or oral lesions observed.
Pulmonary
: Eupneic, with no abnormal lung sounds.
Cardiovascular
: Grade III/VI apical murmur, capillary refill time normal, no arrhythmias or pulse deficits.
Gastrointestinal
: Mass in area of right anal sac that does not express fluid. Enlarged sublumbar lymph nodes palpated. Gut sounds present but decreased. Normal feces expressed during exam.
Genitourinary
: Urination not observed.
Musculoskeletal
: Stiffness of neck on lateral flexion.
Neurologic
: Conscious proprioception deficits and mild ataxia of both hind limbs.
Mental status
: Quiet, alert, and responsive.
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