History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Extra Question
Testing
Test Results
Differential Diagnosis
Relevant Next Steps
Treatment Orders
Question 1
Question 2
About the Case
Dog with a swollen left elbow
Physical Examination
General appearance
: Older dog with body condition score of 7 out of 10
Vital signs
:
Temperature: 37.8°C (100.0°F)
Pulse: 60/min
Respirations: 28/min
Weight: 59.8 kg (132.0 lbs)
Skin
: Unremarkable
HEENT
: Sclera white, mucous membranes appear pink. No cervical lymphadenopathy.
Pulmonary
: Regular rate and rhythm with no increased effort. No cough or nasal discharge. Lung sounds normal.
Cardiovascular
: Capillary refill time is 1 to 2 seconds. Pulse strong and synchronous. Irregular rhythm with no murmur.
Gastrointestinal
: Gut sounds present and unremarkable.
Genitourinary
: Unremarkable
Musculoskeletal
: Left elbow has substantial swelling around joint and decreased range of motion in flexion. There is minimal pain on deep palpation of the proximal radial head.
Neurologic
: Unremarkable
Mental status
: Bright, alert, and responsive
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