Patient History and Physical Exam n 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 n Basis for choosing laboratory tests and radiographs (ex: vomiting vs. Regurg) n Provides vital information for making diagnosis

Patient History nMnMay be most important step nAnAsk open ended, not yes and no questions nLnLook for quantitative and descriptive information, not conclusions

Patient History n Chief or current Complaint- briefly n Signalment- age, breed, sex, reproductive status n Geography and ownership- how long owned, where obtained, source, travel

Patient History n Living conditions- indoor/outdoor/pastured, exposed to other animals, how many, what species n Diet- what kind of food, brand, how many meals, how much, treats n Dates of last vaccinations, tests, PE

Patient History n Past medical history- diagnosis, treatment, response n Current medications and supplements n History of current complaint- first symptoms, duration, specific details, what concerns the client

Physical Exam n Begin systematic exam n Always follow the same format n Exception: Avoid obvious areas of distress, check last n Primum non nocere

Vital Signs n Temperature n Pulse n Respiration n Capillary refill time n Weight (Know calculation and how to record) n Pain Score

Temperature n Use same method on patient each time n Rectal, axillary, inguinal, ear probe n Normal temps vary by species and are affected by environment n “Normal” is defined by a range n Many factors affect body temperature

Pulse n Actually, usually the heart rate n Pulse may vary from heart rate, good to check both at same time n Increases and decreases have many causes- excitement, chemical imbalances, temperature, cardiac defect n /Littmann/stethoscope/education/heart-lung- sounds /Littmann/stethoscope/education/heart-lung- sounds

n When using the stethoscope be sure to index between bell and diaphragm mode. n Use bell side for low-frequency sounds. n Use diaphragm for high-frequency sounds. n Bell Mode (low-frequency) Use light contact with tunable chest piece to hear low frequency sounds. n 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 n Observe movement n Feel breath at nares n Listen to lungs n Sometimes can only be rated as panting

Capillary refill time n CRT measures perfusion n Press on nonpigmented mucous membrane- gums, conjunctiva, vulva, penis n Count seconds until pink color returns n Normal is 1-2 seconds

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

Pain Score

Hydration status n Many forms request this- can be difficult to rate. Very subjective. n <5% undetectable n 5-6% skin slightly doughy, MM moist n 6-8% skin tents (slowly back to normal) prolonged CRT n 8-12% severe- skin peaks and stays, CRT 4-5, tongue dry, eyeballs soft and sunken n 12-15% shock, imminent death

Physical Exam Techniques n Inspection- look n Palpation- feel n Percussion- tap n Auscultation- listen

Inspection n Begins first with patient; start to make general observations n Watch while you take patient history n Observe level of consciousness, facial expressions, body condition, posture n Continue using your eyes as you do your systematic exam n Symmetry

Systems to examine n Integument n Respiratory n Cardiovascular n Gastrointestinal n Urogenital n Musculoskeletal n Nervous n Peripheal Lymph Nodes n Ears n Eyes

n Swollen carpus

n Alopecia

n Ear canal

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

Percussion n Tapping and listening to the resulting vibrations n Helps to determine dense solid areas, fluid or gas filled pockets

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

Heart auscultation zones

Lung auscultation zones

History Form n /VSPN/Default.aspx?id=8047&redirect= 1 /VSPN/Default.aspx?id=8047&redirect= 1 n This will provide guidelines for you. N/Default.aspx?id=6695&pid=49&catid=&said= 1http:// N/Default.aspx?id=6695&pid=49&catid=&said= 1

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