History of Present Illness
Differential Diagnoses
Review of Systems
Past Medical History
Physical Examination
Testing
Test Results
Lab Interpretation
Relevant Next Steps
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
About the Case
Labrador retriever with lethargy and anorexia
Physical Examination
General appearance
: Lethargic, responsive
Vital signs
:
Temperature: 40.1° C (104.2° F)
Pulse: 110 beats/min
Respirations: 30/min
Weight: 28.6 kg (63.0 lb)
Skin
: Hair coat normal
HEENT
: Mucous membranes pale; mild mandibular and prescapular lymphadenopathy
Pulmonary
: Eupneic with no abnormal lung sounds
Cardiovascular
: Capillary refill time >2 seconds; no arrhythmias or pulse deficits
Gastrointestinal
: Gut sounds present but decreased; abdomen soft and nonpainful
Genitourinary
: Urination not observed
Musculoskeletal
: No abnormalities
Neurologic
: Not evaluated
Mental status
: Quiet but responsive
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