History and Physical Examination

Question 1

When is a history taken?

Answer 1

During initial contact with the client and patient.

Question 2

What purposes does taking a history serve?

Answer 2

1. Setting the tone for the appointment.
2. Developing a rapport with the client and patient (friendly, welcoming, pet name, client name, pet gender, client gender).
3. Asking questions about the animal (In terms the client will understand. Avoid leading and judging).
4. Documenting (History or S of SOAP, is a legal document, be legible and accurate).

Question 3

What 12 things are included in a signalment?

Answer 3

1. Management questions (Diet, exercise, sleep habits, outdoor or indoor).
2. Preventative medicine (Vx, dewormer, flea and tick, dental, supplements).
3. Behavior (BAR, QAR, depressed).
4. Household information (surrounded by woods, in the city, summer and winter locale changes).
5. Allergies.
6. Reproductive history (Spayed, neutered, intact, used in breeding, any prior pregnancies).
7. Past medical Hx.
8. Presenting complaint.
9. Last normal day (if applicable).
10. Progression of the symptoms (if applicable).
11. Systems review (Any C/S/V/D).
12. Medications.

Question 4

What is the first part of a physical exam?

Answer 4

Observing the patient in the room (demeanor, gum color, pain signs, mentation, lameness, visual deficits, BCS).

Question 5

What is the second part of a physical exam?

Answer 5

1. TPR.
2. Head to tail check.

Question 6

What is examined with the oropharyngeal system?

Answer 6

Teeth, gingiva, tongue, hard palate, soft palate, pharynx, larynx.

Question 7

What is examined with the eyes?

Answer 7

Eyes, vision, adnexa (tissue surrounding the eye. ex: eyelid).

Question 8

What is examined with the ears?

Answer 8

Pinna, ear canal, eardrum, hearing.

Question 9

What is examined with the respiratory system?

Answer 9

Nares, nasal discharge, upper airway noise (stertor or stridor), auscultation (crackles, wheezes).

Question 10

What is examined with the cardiovascular system?

Answer 10

Mucous membranes (CRT, gum color), pulse quality (strong, weak, thready), auscultation (S1 and S2, murmurs, arrhythmia).

Question 11

What is examined with the GI system?

Answer 11

Palpate abdomen (1-2 hands in companion animals, rectally in large animals, sheep and goats are a middle ground), kidneys (cats only), liver, spleen, LI, SI, bladder.

Question 12

What is examined rectally?

Answer 12

Prostate, urethra, medial iliac lymph nodes, rectal wall, anal sacs, character of stool.

Question 13

What is examined with the urogenital system?

Answer 13

Distal urethra (males only), penis, scrotum, testicles, vagina, vestibule, mammary chain.

Question 14

What is examined with the integumentary system?

Answer 14

Alopecia, scales and crusts, pustules and papules, masses, ectoparasites, pruritus and excoriations (scratches), petechiae (pinpoint) and ecchymoses (paintbrush)*.
*From a clotting issue.

Question 15

Which lymph nodes can be palpated?

Answer 15

Mandibular, prescapular, popliteal, axillary, inguinal.
*Palpable if enlarged.

Question 16

What is examined with the musculoskeletal system?

Answer 16

Lameness, swelling, difficulty rising, pain, ROM loss, atrophy.

Question 17

What is examined with the nervous system?

Answer 17

Mentation, gait, posture, cranial nerves, postural reactions, reflexes.