History of Present Illness
Review of Systems
Past Medical History
Question 1
Physical Examination
Testing
Test Results
Test Interpretation
Differential Diagnosis
Relevant Next Steps
Treatment Orders
Additional Test Results
Question 2
Question 3
About the Case
Australian Shepherd with mammary mass
Physical Examination
General appearance
: Older dog, stiff when ambulating.
Vital signs
:
Temperature: 38.2°C (100.7°F)
Pulse: 88 beats/min
Respirations: 36 breaths/min
Weight: 24.5 kg (54.0 lbs)
Skin
: Hair coat normal except over the largest mammary mass, which is ulcerated and bleeding. The largest mass is 10 x 5 x 5 cm and is in the left 5
th
gland. There are also four soft, subcutaneous masses and three small (<3 cm) mammary masses in the right 3
rd
and 4
th
glands and left 4
th
gland.
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
: No murmur, arrhythmias, or pulse deficits. Capillary refill time is normal.
Gastrointestinal
: Anal sacs full but able to be expressed completely.
Genitourinary
: Urination not observed.
Musculoskeletal
: Stiffness of hind limbs.
Neurologic
: No deficits.
Mental status
: Bright, alert, and responsive.
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