History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Relevant Testing
Test Results 1
Differential Diagnoses
Relevant Next Steps
Test Interpretation
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Dalmatian with Bite Wounds
Physical Examination
General appearance
: Older dog with multiple non-healing wounds. Body Condition Score of 5.
Vital signs
:
Temperature: 38.6° C
Pulse: 74 beats/min
Respirations: 18/min
Skin
: Normal except for multiple wounds concentrated on dorsal neck and thorax. The wounds are open and have exudate and areas of necrosis and dehiscence.
HEENT
: Sclera white, mucous membranes appear pink. 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.
Mental status
: Quiet, alert, and responsive
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