History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Testing
Test Results
Test Interpretation
Differential Diagnosis
Relevant Next Steps
Additional Test Results
Treatment Orders
Question 1
About the Case
Horse with a mass near left eye
Physical Examination
General appearance
: Unremarkable. Body condition score of 5 out of 9.
Vital signs
:
Temperature: 37.6°C
Pulse: 42/min
Respirations: 30/min
Weight: 473 kg (964 lbs)
Skin
: Hair coat normal. Mass (2.5 cm x 2.5 cm) noted near medial canthus of left eye with purulent discharge.
HEENT
: Blepharospasm of left eye
Pulmonary
: Eupneic with no abnormal lung sounds
Cardiovascular
: No murmurs or arrhythmias heard.
Gastrointestinal
: Gut sounds ausculted, normal feces.
Genitourinary
: Urination not observed.
Musculoskeletal
: Unremarkable
Neurologic
: Not examined
Mental status
: Bright, alert, and responsive
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