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
Murmur
Abnormal swooshing sounds relating to the improper closure of heart values or other cardiac diseases
Character of pulse
Strong - easily palpated
Weak - difficult to palpate
Bounding - excessive pressure
Thready - weak and feels like a small thread moving under your fingers
Using a stethoscope for respiratory rate
Insert ear pieces with tips facing forward. Place diaphragm of stethoscope on the patient’s left lateral thorax at approximately the third rib.
Normal and abnormal lung sounds
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
Mucous membrane colors
Pink: normal
Pale or white: shock
Blue or purple (cyanotic): hypothermia, cardiac or respiratory disease
Red (hyperemic): shock or hyperthermia
Capillary refill time
<2 seconds: normal
> 2 seconds: could indicate cardiovascular dysfunction
Normal TPR dog
T: 99.5-102.5
P: 80-140 (young) / 60-140 (adult)
R: 20-25 (young) / 20-30 (adult)
Normal TPR cat
T: 100.5-102.5
P: 140-200 (young and adult)
R: 20-30 (young) / 20-40 (adult)
Normal TPR horse
T: 99-101
P: 60-80 (young) / 30-50 (adult)
R: 14-15 (young) / 9-10 (adult)
Normal TPR cow
T: 100-102
P: 100-150 (young) / 40-60 (adult)
R: 30-60 (young) / 12-16 (adult)
Normal TPR sheep
T: 101-104
P: 80-120 (young) / 70-80 (adult)
R: 15-20 (young) / 15-40 (adult)
Auscultation
Listening to the body’s various sounds with a stethoscope
Erythroderma
Redness of the skin
Turgor pressure
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%
Rales
Crackling or rattling sounds during inhalation. Four locations should be examined including the right ventral, right dorsal, left ventral and left dorsal.
Pulse deficit
The difference between the heartbeat and pulse beat
Peristalsis
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.
Abdominal palpation
Checks for consistency, size and shape of abdominal organs
Checks for masses and other abnormalities such as pain
Body condition score
Degree of slimness to obesity on a scale of 1-9 where
1-2: underweight
5-6: ideal weight
9: overweight
Muscle condition score
Degree of muscle present on a scale of 1-4
Palpebral reflex
Blink elicited by touching the medial corner of the eye
Menace reflex
Blink elicited by moving an open palm rapidly toward the animal’s eye
Proprioception
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.
Peripheral lymph nodes
Submandibular: pea sized or smaller
Prescapular
Axillary: felt only when enlarged
Inguinal: felt only when enlarged
Popliteal: felt only when enlarged
Conjunctiva
The membrane that covers the eyeball and the inside of the eyelids. Normal color is pink.
Sclera
White of eye
Cornea
Transparent layer that covers the front of the eye
Retina
Inner chamber of the eye
SOAP
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.
