Transcript Patient History and Physical Exam

Patient History and
Physical Exam
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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
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May be most important step
Ask open ended, not yes and no
questions
Look for quantitative and descriptive
information, not conclusions
Patient History
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Chief or current Complaint- briefly
Signalment- age, breed, sex,
reproductive status
Geography and ownership- how long
owned, where obtained, source, travel
Patient History
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Living conditionsindoor/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
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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
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Begin systematic exam
Always follow the same format
Exception: Avoid obvious areas of
distress, check last
Primum non nocere
Vital Signs
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Temperature
Pulse
Respiration
Capillary refill time
Weight (Know calculation and how to
record)
Pain Score
Temperature
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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
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Actually, usually the heart rate
Pulse may vary from heart rate, good to
check both at same time
Increases and decreases have many causesexcitement, chemical imbalances,
temperature, cardiac defect
http://solutions.3m.com/wps/portal/3M/en_GB
/Littmann/stethoscope/education/heart-lungsounds
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When using the stethoscope be sure to index between bell and
diaphragm mode.
Use bell side for low-frequency sounds.
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Use diaphragm for high-frequency sounds.
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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.
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Respiration rate
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Observe movement
Feel breath at nares
Listen to lungs
Sometimes can only be rated as panting
Capillary refill time
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CRT measures perfusion
Press on nonpigmented mucous
membrane- gums, conjunctiva, vulva,
penis
Count seconds until pink color returns
Normal is 1-2 seconds
Weight
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Best to write kg and lbs in record
Dose for ideal body weight
Be sensitive to owners
Pain Score
Hydration status
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Many forms request this- can be difficult
to rate. Very subjective.
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<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
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Physical Exam Techniques
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Inspection- look
Palpation- feel
Percussion- tap
Auscultation- listen
Inspection
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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
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Integument
Respiratory
Cardiovascular
Gastrointestinal
Urogenital
Musculoskeletal
Nervous
Peripheal Lymph Nodes
Ears
Eyes
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Swollen carpus
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Alopecia
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Ear canal
Palpation
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Both light and deep
Most sensitive touch with finger tips
Back of hand best to rate temperature
Percussion
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Tapping and listening to the resulting
vibrations
Helps to determine dense solid areas,
fluid or gas filled pockets
Auscultation
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Sounds created by body
Listen with and without instruments
Respiratory system
Cardiovascular system
Gastrointestinal systems
Heart auscultation zones
Lung auscultation zones
History Form
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http://www.vin.com/Members/CMS/Misc
/VSPN/Default.aspx?id=8047&redirect=
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This will provide guidelines for you.
• http://www.vin.com/MEMBERS/CMS/Misc/VSP
N/Default.aspx?id=6695&pid=49&catid=&said=
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