History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Relevant Testing
Test Results 1
Test Interpretation
Differential Diagnoses
Relevant Next Steps
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Quarter horse with external abscess, fever, and cough
Physical Examination
General appearance
: Patient was of good body weight and muscle mass with pectoral abscess on left side.
Vital signs
:
Temperature: 38° C
Pulse: 48 beats/min
Respirations: 16/min
Skin
: Normal except for area of alopecia over pectoral region with dried exudate and draining pus.
HEENT
: Sclera mildly injected, mucous membranes bright pink and moist. No submandibular lymphadenopathy.
Pulmonary
: Regular rate and rhythm with no increased effort. No nasal discharge. Lung sounds are quiet with deep wheeze on right. Occasional cough.
Cardiovascular
: Capillary refill time is normal. Good jugular refill. No murmur or arrhythmia.
Gastrointestinal
:Gut sounds present and unremarkable.
Genitourinary
: Unremarkable
Musculoskeletal
: No pain or swelling of joints. Gait normal. Digital pulses within normal limits.
Neurologic
: No cervical nerve deficits or other abnormalities noted.
Mental status
: Quiet, alert, and responsive.
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