History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Question 1
Testing
Test Results
Question 2
Differential Diagnosis
Relevant Next Steps
Treatment Orders
Question 3
Question 4
About the Case
Dog straining to urinate
Physical Examination
General appearance
: Body condition score 5 out of 10
Vital signs
:
Temperature: 37.8°C (100.0°F)
Pulse: 71/min
Respirations: 32/min
Weight: 39.5 kg (87.1 lb)
Skin
: Unremarkable
HEENT
: Unremarkable
Pulmonary
: No cough or nasal discharge. Lung sounds are normal.
Cardiovascular
: Capillary refill time is 1–2 seconds. Pulses are strong and synchronous. No arrhythmia or murmur noted.
Gastrointestinal
: Rectal exam reveals enlarged, nonpainful prostate.
Genitourinary
: Large bladder palpated
Musculoskeletal
: Unremarkable
Neurologic
: Unremarkable
Mental status
: Bright, alert, and responsive
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