History And Physical Flashcards
Signalment
Breed, gender, age, spay/neuter status
Components of a thorough history
- Identify the primary or presenting problem
- completing a medical history
- completing the environmental history
- reviewing the body systems
Questions about primary or presenting problem
When did it begin
Has the problem gotten better or worse?
Has the animal ever experienced this problem before?
What are the characteristics and details of the problem?
Environmental history
Details of ownership: where/when pet was obtained
Diet: brand, how much, how often, any dietary changes, treats, table scraps, access to water
Medications: are preventatives given, how often. Any other meds, supplements, or OTC products, how often.
Environment: outdoor time, attended or unattended. Travel. Socialization, grooming, day care, training, boarding. If caged, bedding/substrate. Does pet hunt, breed, show?
Body systems history/review
Same order should be used in every case. Nose-to-tail or system-by-system approach.
Integumentary system and questions for history
Skin feathers, scales, hair, nails, hooves, horns
Questions: itchiness, irritation, hair/feather loss, lesions, lumps, bumps
Respiratory system and questions for history
Nose, mouth, pharynx, larynx, trachea, bronchi, lungs
Questions: discharge, sneezing, coughing, resp rate/effort
Circulatory system and questions for history
Heart, blood, blood vessels
Questions: energy, coughing, fainting, exercise intolerance
Gastrointestinal system and questions for history
Mouth, esophagus stomach, small and large intestines, anus, liver, gallbladder, pancreas
Questions: digestion, foul breath, change in appetite, vomiting, diarrhea
Urogenital system and questions for history
Kidneys, ureter, urinary bladder, urethra, reproductive organs (penis/prostate/testes or ovaries/uterus/vagina)
Questions: urination (frequency/straining), change in drinking habits, last heat cycle, hx of pregnancy, discharge from penis or vulva
Musculoskeletal system and questions for history
Bones, muscles, tendons
Questions: weight gain/loss, mobility, limping
Nervous system
Brain, spinal cord, nerves
Questions: demeanor, seizures, confusion, lack of response to sights/sounds
Heart-girth tape
When a walk-on scale is unavailable for a horse, this measuring tape can be used around the horse’s chest, around the heart just behind the elbow and converts the circumference into a body weight.
Using a stethoscope for heart rate
Insert ear pieces with tips facing forward. Place diaphragm of stethoscope on the patient’s thorax near the left axilla
Arrhythmia
Abnormal rate heart rate or rhythm
Bradycardia
Abnormally slow heart rate
Tachycardia
Abnormally fast heat rate
Respiratory sinus arrhythmia
Heart rate decreases with exhale and increases with inhale