History And Physical Flashcards

1
Q

Signalment

A

Breed, gender, age, spay/neuter status

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2
Q

Components of a thorough history

A
  • Identify the primary or presenting problem
  • completing a medical history
  • completing the environmental history
  • reviewing the body systems
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3
Q

Questions about primary or presenting problem

A

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?

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4
Q

Environmental history

A

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?

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5
Q

Body systems history/review

A

Same order should be used in every case. Nose-to-tail or system-by-system approach.

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6
Q

Integumentary system and questions for history

A

Skin feathers, scales, hair, nails, hooves, horns

Questions: itchiness, irritation, hair/feather loss, lesions, lumps, bumps

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7
Q

Respiratory system and questions for history

A

Nose, mouth, pharynx, larynx, trachea, bronchi, lungs

Questions: discharge, sneezing, coughing, resp rate/effort

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8
Q

Circulatory system and questions for history

A

Heart, blood, blood vessels

Questions: energy, coughing, fainting, exercise intolerance

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9
Q

Gastrointestinal system and questions for history

A

Mouth, esophagus stomach, small and large intestines, anus, liver, gallbladder, pancreas

Questions: digestion, foul breath, change in appetite, vomiting, diarrhea

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10
Q

Urogenital system and questions for history

A

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

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11
Q

Musculoskeletal system and questions for history

A

Bones, muscles, tendons

Questions: weight gain/loss, mobility, limping

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12
Q

Nervous system

A

Brain, spinal cord, nerves

Questions: demeanor, seizures, confusion, lack of response to sights/sounds

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13
Q

Heart-girth tape

A

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.

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14
Q

Using a stethoscope for heart rate

A

Insert ear pieces with tips facing forward. Place diaphragm of stethoscope on the patient’s thorax near the left axilla

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15
Q

Arrhythmia

A

Abnormal rate heart rate or rhythm

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16
Q

Bradycardia

A

Abnormally slow heart rate

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17
Q

Tachycardia

A

Abnormally fast heat rate

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18
Q

Respiratory sinus arrhythmia

A

Heart rate decreases with exhale and increases with inhale

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19
Q

Murmur

A

Abnormal swooshing sounds relating to the improper closure of heart values or other cardiac diseases

20
Q

Character of pulse

A

Strong - easily palpated

Weak - difficult to palpate

Bounding - excessive pressure

Thready - weak and feels like a small thread moving under your fingers

21
Q

Using a stethoscope for respiratory rate

A

Insert ear pieces with tips facing forward. Place diaphragm of stethoscope on the patient’s left lateral thorax at approximately the third rib.

22
Q

Normal and abnormal lung sounds

A

Normal: smooth and breeze-like

Abnormal:
Crackles - harsh noises that sound like crumpling cellophane
Wheezes - high pitched musical noises heard on expiration
Stridor - high pitched noises on inspiration or expiration

23
Q

Mucous membrane colors

A

Pink: normal

Pale or white: shock

Blue or purple (cyanotic): hypothermia, cardiac or respiratory disease

Red (hyperemic): shock or hyperthermia

24
Q

Capillary refill time

A

<2 seconds: normal

> 2 seconds: could indicate cardiovascular dysfunction

25
Q

Normal TPR dog

A

T: 99.5-102.5

P: 80-140 (young) / 60-140 (adult)

R: 20-25 (young) / 20-30 (adult)

26
Q

Normal TPR cat

A

T: 100.5-102.5

P: 140-200 (young and adult)

R: 20-30 (young) / 20-40 (adult)

27
Q

Normal TPR horse

A

T: 99-101

P: 60-80 (young) / 30-50 (adult)

R: 14-15 (young) / 9-10 (adult)

28
Q

Normal TPR cow

A

T: 100-102

P: 100-150 (young) / 40-60 (adult)

R: 30-60 (young) / 12-16 (adult)

29
Q

Normal TPR sheep

A

T: 101-104

P: 80-120 (young) / 70-80 (adult)

R: 15-20 (young) / 15-40 (adult)

30
Q

Auscultation

A

Listening to the body’s various sounds with a stethoscope

31
Q

Erythroderma

A

Redness of the skin

32
Q

Turgor pressure

A

Normal elasticity of the skin. Measured by time it takes for skin to return to normal after lifting and twisting (usually between the shoulder blades). Correlates to level of dehydration.

0-1 second: less than 5%
2-4 seconds: 5-8%
5-10 seconds: 8-10%
10-30 seconds: 10-12%

33
Q

Rales

A

Crackling or rattling sounds during inhalation. Four locations should be examined including the right ventral, right dorsal, left ventral and left dorsal.

34
Q

Pulse deficit

A

The difference between the heartbeat and pulse beat

35
Q

Peristalsis

A

Involuntary constriction and relaxation of the muscles of the intestine or another canal, creating wavelike movements that push the contents of the digestive tract forward.

One or two gut sounds per minute is normal in a large animal.

36
Q

Abdominal palpation

A

Checks for consistency, size and shape of abdominal organs
Checks for masses and other abnormalities such as pain

37
Q

Body condition score

A

Degree of slimness to obesity on a scale of 1-9 where

1-2: underweight

5-6: ideal weight

9: overweight

38
Q

Muscle condition score

A

Degree of muscle present on a scale of 1-4

39
Q

Palpebral reflex

A

Blink elicited by touching the medial corner of the eye

40
Q

Menace reflex

A

Blink elicited by moving an open palm rapidly toward the animal’s eye

41
Q

Proprioception

A

Righting reflex when an animal’s paw is flexed and placed on the exam table or floor. Animal should immediately return the paw or hoof to its normal position.

42
Q

Peripheral lymph nodes

A

Submandibular: pea sized or smaller

Prescapular

Axillary: felt only when enlarged

Inguinal: felt only when enlarged

Popliteal: felt only when enlarged

43
Q

Conjunctiva

A

The membrane that covers the eyeball and the inside of the eyelids. Normal color is pink.

44
Q

Sclera

A

White of eye

45
Q

Cornea

A

Transparent layer that covers the front of the eye

46
Q

Retina

A

Inner chamber of the eye

47
Q

SOAP

A

Subjective Data: reason animal presents to clinic. Information that is observed and described

Objective Data: Quantifiable data such as weight, temp, pulse, respiration, laboratory data, and details of the physical exam of each body system

Assessment: Differential diagnoses, possible or probable explanations for the problem. Guides diagnostic testing. Includes diagnosis.

Procedure or Plan: treatment plan, problems that need monitoring, follow-up care instructions, rxs, and other recs.