History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Testing
Test Results 1
Relevant Next Steps
Test Results 2
Diagnosis
Treatment Orders
Additional Test Results
Follow-up
Question 1
Question 2
About the Case
Disoriented cat with stumbling gait
Physical Examination
General appearance
: Normal appearing cat
Vital signs
:
Temperature 38.5° C (101.3° F)
Pulse 240 beats/min
Respirations: 28/min
Weight: 5.1 kg (11.3 lbs)
Skin
: Hair coat normal.
HEENT
: Eyes appear normal but distant vision seems impaired. Left ear was normal and right ear had mild, dark crusting.
Pulmonary
: Eupneic, with no abnormal lung sounds.
Cardiovascular
: Capillary refill time <2 seconds, no arrhythmias or pulse deficits.
Gastrointestinal
: Gut sounds present.
Genitourinary
: Urination not observed, small bladder palpated.
Musculoskeletal
: No abnormalities.
Neurologic
: Cranial nerves unremarkable. Mild mydriasis OD. Pupillary light reflex (PLR) intact but slow. No pathologic nystagmus. Mild delayed hopping on right pelvic limb. Continuously moves around room along walls.
Mental status
: Quiet
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