History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Testing
Test Results
Differential Diagnosis
Additional Testing
Additional Test Results
Test Interpretation
Relevant Next Steps
Treatment Orders
Question 1
Question 2
About the Case
Horse with neurologic defects
Physical Examination
General appearance
: Fair body condition, sways while standing
Vital signs
:
Temperature: 37.3° C (99.1° F)
Pulse: 42 beats/min
Respirations: 18/min
Weight: 550 kg (1,213 lbs)
Skin
: Smooth, groomed haircoat with no alopecia
HEENT
: Sclera clear, mucous membranes pink, ears clean. No ocular discharge, submandibular lymphadenopathy, or oral lesions observed.
Pulmonary
: Eupneic with no sneezing or coughing
Cardiovascular
: No murmur or arrhythmia, capillary refill time normal, adequate jugular refill
Gastrointestinal
: Gut sounds present but decreased
Genitourinary
: One episode of posturing to urinate without producing urine was observed, followed by normal urination some time later
Musculoskeletal
: Bilateral hindlimb atrophy, ataxia
Neurologic
: Hindlimb ataxia, facial nerve paralysis (mild muzzle deviation)
Mental status
: Quiet, alert, and responsive
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