Patient History and Physical Exam

Remember the impression you are making– Know patient and client info before entering

the room– talk to owner not animal, well dressed,

professional in manner– Introduce yourself and explain

Basis for choosing laboratory tests and radiographs (ex: vomiting vs. Regurg)

Provides vital information for making diagnosis

Patient History

May be most important step Ask open ended, not yes and no

questions Look for quantitative and descriptive

information, not conclusions

Patient History

Chief or current Complaint- briefly Signalment- age, breed, sex,

reproductive status Geography and ownership- how long

owned, where obtained, source, travel

Patient History

Living conditions- indoor/outdoor/pastured, exposed to other animals, how many, what species

Diet- what kind of food, brand, how many meals, how much, treats

Dates of last vaccinations, tests, PE

Patient History

Past medical history- diagnosis, treatment, response

Current medications and supplements History of current complaint- first

symptoms, duration, specific details, what concerns the client

Physical Exam

Begin systematic exam Always follow the same format Exception: Avoid obvious areas of

distress, check last Primum non nocere

Vital Signs

Temperature Pulse Respiration Capillary refill time Weight (Know calculation and how to

record) Pain Score

Temperature

Use same method on patient each time Rectal, axillary, inguinal, ear probe Normal temps vary by species and are

affected by environment “Normal” is defined by a range Many factors affect body temperature

Pulse

Actually, usually the heart rate Pulse may vary from heart rate, good to

check both at same time Increases and decreases have many causes-

excitement, chemical imbalances, temperature, cardiac defect

http://solutions.3m.com/wps/portal/3M/en_GB/Littmann/stethoscope/education/heart-lung-sounds

When using the stethoscope be sure to index between bell and diaphragm mode.

Use bell side for low-frequency sounds.

Use diaphragm for high-frequency sounds.

Bell Mode (low-frequency)Use light contact with tunable chest piece to hear low frequency sounds. 

Diaphragm Mode (high-frequency)Turn the chest piece over, index to the opposite side and use firm pressure to hear high-frequency sounds.

Respiration rate

Observe movement Feel breath at nares Listen to lungs Sometimes can only be rated as panting

Capillary refill time

CRT measures perfusion Press on nonpigmented mucous

membrane- gums, conjunctiva, vulva, penis

Count seconds until pink color returns Normal is 1-2 seconds

Weight

Best to write kg and lbs in record Dose for ideal body weight Be sensitive to owners

Pain Score

Hydration status

Many forms request this- can be difficult to rate. Very subjective.

<5% undetectable 5-6% skin slightly doughy, MM moist 6-8% skin tents (slowly back to normal) prolonged

CRT 8-12% severe- skin peaks and stays, CRT 4-5,

tongue dry, eyeballs soft and sunken 12-15% shock, imminent death

Physical Exam Techniques

Inspection- look Palpation- feel Percussion- tap Auscultation- listen

Inspection

Begins first with patient; start to make general observations

Watch while you take patient history Observe level of consciousness, facial

expressions, body condition, posture Continue using your eyes as you do your

systematic exam Symmetry

Systems to examine

Integument Respiratory Cardiovascular Gastrointestinal Urogenital Musculoskeletal Nervous Peripheal Lymph Nodes Ears Eyes

Swollen carpus

Alopecia

Ear canal

Palpation

Both light and deep Most sensitive touch with finger tips Back of hand best to rate temperature

Percussion

Tapping and listening to the resulting vibrations

Helps to determine dense solid areas, fluid or gas filled pockets

Auscultation

Sounds created by body Listen with and without instruments Respiratory system Cardiovascular system Gastrointestinal systems

Heart auscultation zones

Lung auscultation zones

History Form

http://www.vin.com/Members/CMS/Misc/VSPN/Default.aspx?id=8047&redirect=1

This will provide guidelines for you.• http://www.vin.com/MEMBERS/CMS/Misc/

VSPN/Default.aspx?id=6695&pid=49&catid=&said=1

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