History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Relevant Testing
Test Results 1
Differential Diagnoses
Relevant Next Steps
Test Results 2
Test Interpretation
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
14-yr-old dog unable to walk
Physical Examination
General appearance
: Ambulatory but severely ataxic. Patient has normal body condition.
Vital signs
:
Temperature: 38.2° C
Pulse: 150/min
Respirations: 35/min
Weight: 9.9 kg (21.8 lb)
Skin
: Small skin tag on right lower eyelid
HEENT
: Moderate black discharge from left ear. Mass palpated at ventral cervical region. Mucous membranes pink and moist.
Pulmonary
: Normal respiration pattern with mildly increased bronchovesicular sounds. No sneezing or coughing.
Cardiovascular
: No murmur or arrhythmia, capillary refill time normal, good jugular refill, and no pulse deficits.
Gastrointestinal
: Gut sounds present and unremarkable. Moderate dental calculus.
Genitourinary
: Unremarkable
Musculoskeletal
: Generalized muscle atrophy throughout both hind limbs.
Neurologic
: Left head tilt with wide head excursions. Ambulatory with severe ataxia. Delayed to absent conscious proprioception of pelvic limbs.
Mental status
: Quiet, alert, and responsive.
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