History & Physical Flashcards
Examinations help establish a relationship between the vet, the client, and the patient.
Legal requirement in most states.
Necessary for the vet to be able to treat the animal and prescribe medications.
Veterinarian-Client-Patient Relationship (VCPR)
The most common veterinary procedure and the foundation of diagnosis/treatment.
Physical Examination
First step of every vet physical examination.
Provides information that helps the vet evaluate the patient’s physical status, develop a diagnosis, create a treatment plan, and offer a prognosis (outlook) for the patient).
Medical History
Overall patient description.
Includes breed, gender, age, and reproductive status.
Signalment
Key components of a good, thorough history are:
Identifying primary/presenting problem.
Completing a medical history.
Completing the environmental history.
Reviewing the body systems.
The reason for the patient’s visit.
Primary/Presenting Problem
Client Complaint
Details animal’s current living situation.
Including travel history.
Ownership, diet, medications, environment.
Environmental History
Discuss each body system in sequence and record any current or previous problems.
Body Systems History & Body Systems Review
Skin, scales, hair, nails, hooves, horns, feathers.
Integumentary System
Nose, mouth, pharynx, larynx, trachea, bronchi, lungs.
Respiratory System
Heart, blood, blood vessels.
Circulatory System
Mouth, esophagus, stomach, small and large intestines, anus, liver, gallbladder, pancreas.
Gastrointestinal System
Digestive System
Kidneys, ureters, urinary bladder, urethra, reproductive organs.
Male - penis, prostate, testes.
Female - ovaries, uterus, vagina.
Urogenital System
Bones, muscles, tendons, ligaments, joints, connective tissues.
Musculoskeletal System
Brain, spinal cord, nerves.
Nervous System
Science that relates to different parts of an animal’s body.
Anatomy
Science that explains how body parts function individually and collectively.
Physiology
Way to measure a horse’s weight by measuring around the horse’s chest (heart area just behind the elbow) and a conversion char that translates the circumference of horse’s chest into total body weight.
Heart-Girth Tape
Mitral and tricuspid valve closures.
“Lub” (heart sound)
Aortic and pulmonic valve closures.
“Dub” (heart sound)
Abnormal heart rate or rhythm.
Arrhythmia
Abnormally slow heart rate (arrhythmia).
Bradycardia
Abnormally fast heart rate (arrhythmia).
Tachycardia
Heart rate cyclically decreases when the animal exhales and increases when the animal inhales.
Respiratory Sinus Arrhythmia
Abnormal “swooshing” sounds relating to the improper closure of heart valves (or other cardiac diseases).
Murmur
Heart pumps blood through the arteries —> arterial walls expand/contract.
________ is created via this pressure on the arterial walls.
Pulse
Pulse - excessive pressure.
Bounding
Pulse - weak, feels like a small thread moving under your fingers.
Thready
One inhalation and one exhalation.
Breath
Full Respiration
Lung sound - harsh noises that sound like crumpling cellophane paper.
Crackles
Lung sound - high pitched musical noises hear on expiration.
Wheezes
Lung sound - high pitched noises on inspiration OR expiration.
Stridor
Blood flow to organs and peripheral tissues.
Perfusion
MM color indicating shock.
Pale/White
MM color indicating hypothermia or cardiac/respiratory disease.
Blue/Purple (Cyanotic)
MM color indicating shock or hyperthermia.
Red (Hyperemic)
Virals order:
Weight
Heart Rate
Pulse
Respiratory Rate (and Effort)
Mucous Membrane Color
Capillary Refill Time (CRT)
Temperature
Dog Vitals
Temp: 99.5-102.5°F
HR/Pulse: 80-140 (young), 60-140 (adult)
Respiration: 20-25 (young), 20-30 (adult)
Cat Vitals
Temp: 100.5-102.5°F
HR/Pulse: 140-200 (young), 140-200 (adult)
Respiration: 20-30 (young), 20-40 (adult)
Horse Vitals
Temp: 99-101°F
HR/Pulse: 60-80 (young), 30-50 (adult)
Respiration: 14-15 (young), 9-10 (adult)
Cow Vitals
Temp: 100-102°F
HR/Pulse: 100-150 (young), 40-60 (adult)
Respiration: 30-60 (young), 12-16 (adult)
Sheep Vitals
Temp: 101-104°F
HR/Pulse: 80-120 (young), 70-80 (adult)
Respiration: 15-20 (young), 15-40 (adult)
Involves careful visual inspection of each body part and evaluating the animal as a whole.
Observe at a distance noting demeanor, posture, and gait.
Examine appearance for ways to identify any problems.
Observation
Involves touch.
Tissues/structures, something that’s hard that should be soft or something that’s soft that should be hard, texture, if the animal flinches.
Palpation
Involves listening with a stethoscope to the body’s various sounds.
Heart and lungs.
But also sinuses, windpipe, stomach, and intestines.
Auscultation
A comprehensive head-to-tail examination involves each body system:
List them.
Integumentary
Respiratory
Circulatory
Gastrointestinal
Urogenital
Musculoskeletal
Nervous
Lymphatic
Eyes and Ears
Comprises skin, hair, nails, and skin.
Start with coat —> skin —> surface of legs/paws —> turgor pressure.
Integumentary System
Normal elastics of the skin.
Evidence of dehydration.
Turgor Pressure
Check nose/sinuses, mouth (oral cavity), throat, and thorax.
Respiratory System
Crackling/rattling sounds during inhalation.
Rales
Examine mouth (including mucous membranes and CRT), throat, thorax, and pulse.
Circulatory System
Where to feel the pulse:
Femoral artery in small animals.
Facial artery of large animals.
Difference between heartbeat and pulse beat (feel pulse beat while listening to heartbeat).
Notably slower or pulse beat is missing.
Pulse Deficit
Examine mouth (oral cavity), throat (esophagus), abdomen, and rectum.
Gastrointestinal System
Digestive System
Involuntary constriction and relaxation of the muscles of the intestine (or other canal), creating wavelike movements that push the contents of the digestive tract forward.
Peristalsis
Female —> check mammary glands and examine vulva.
Male —> palpate testicles and penis.
Urogenital System
Palpate muscles and leg bones. Examine each joint for range of motion. Apply pressure to the muscles around the spine (moving from neck to tail). Body Condition Score (BCS). Muscle Condition Score (MCS).
Musculoskeletal System
Wasting away.
Atrophy
Degree of slimness or obesity on a scale of 1-9.
Body Condition Score (BCS)
Degree of muscle present on a scale of 1-4.
Muscle Condition Score (MCS)
Evaluate palpebral reflex, menace reflex, and propioception.
Nervous System
Evaluated by touching the medial corner of the eye to elicit a blink.
Palpebral Reflex
Evaluate by moving an open palm rapidly toward animal’s eye (should elicit blinking).
Menace Reflex
Righting reflex.
Flex paw, place it on floor, animal should immediately return paw to its normal position.
Proprioception
Evaluates animal’s palpable peripheral lymph nodes.
Submandibular, prescapular, axillary, inguinal, and popliteal.
Lymphatic System
Lymph node located caudal to the mandible on each side of jaw.
Submandibular Lymph Node
Lymph node located just cranial and dorsal to the shoulder joint.
Prescapular Lymph Node
Lymph node located in the animal’s armpit region.
Axillary Lymph Node
Lymph node located in the inguinal region between the rear legs (groin).
Inguinal Lymph Node
Lymph node located at the caudal aspect of the rear leg behind the stifle (knee) joint.
Popliteal Lymph Node
Don’t nearly fit in any one system, so examined as separate organs.
Eyes & Ears
Membrane that covers the eyeball and the inside of the eyelids.
Conjunctiva
White part of eye.
Sclera
Transparent layer that covers the very front of the eye.
Cornea
For examination/magnification of the eye.
Ophthalmoscope
Ear drum.
Tympanic Membrane
For examination/magnification of the ear.
Otoscope
For examination/magnification of the ear.
Otoscope
What does SOAP stand for?
Subjective
Objective
Assessment
Procedue/Plan
Include the reason the animal is being presented to the vet clinic and observations that can’t be quantified.
Subject to the observation/descriptive powers of the evaluator.
Includes patient history details obtained from the client.
Subjective Data
Quantifiable, data that is/can be measured.
Includes weight, temperature, pulse, respiration, lab data, and details of the physical exam.
Objective Data
Includes possible/probable explanations for the problem (differential diagnosis).
Roadmap for diagnostic testing —> guiding vet’s testing choices.
Assessment
Outlines the plan for treatment and the prognosis.
*Includes any problems that should be monitored, follow-up care instructions to the client, medications prescribed, and other recommendations.
Procedure/Plan
Client’s interactions with the practice (most are with he vet).
*Animal’s recovery/health depend on the client’s ability to administer follow-up care.
Client Education