Nationale, anamnesis, status presens Flashcards
Signalment/ nationale
Name and address of owner
Permanent data of animal
Transient data of animal
Examples of permanent data of the animal
Species Breed Sex Colour Blood group Permanent defects e.g missing limbs Type of coat Forms of ears- pendulous, erect or cropped State of tail- natural vs docked
Examples of transient data of the animal
Age Body weight Height at withers Brand marks Microchip
Anamnesis/ History includes
Inquiries concerning the animal
Inquiries concerning the environment
Inquiries concerning the animal
Health state Previous vet and other interventions Reproductive state Productivity Transport
Inquiries concerning the animal: health state
How long has the animal been ill
Abnormalities observed
Any changes since the observation
Same or any other symptoms previously observed
Inquiries concerning the animal: previous vet and other interventions
Treatments
Immunizations- N.B check rabies vaccine with mouth/pharynx related problems
Dewormings
Previous surgeries
Interventions by others e.g enema, PO treatment, assistance during calving
Inquiries concerning the animal: Reproductive state
Female: estrus, partuition, contraceptives- pyometra
Male: mating
Neuters
Inquiries concerning the environment
Health state of the animal population
Husbandry
Nutrition
Inquiries concerning the environment: health state of the animal population
How many/ species of animals kept together
How many are ill
Previous diseases/symptoms and number infected
Any lab or instrumental exams performed
General epidemiological, parasitic state of the herd
Inquiries concerning the environment: Husbandry
Housing: indoor- plants. Outdoor- insecticides, rat poisin
Hygiene standards
Changes in people managing the animals
Inquiries concerning the environment: Nutrition
Quality and quantity of food
Feeding technology
Water intake
Faeces and urine
*Check the diet for up to a year previously, protein sources should be known
Status praesens= current state
*the order is important
- General impression
- Basic clinical values
- Skin
- Lymph nodes
- Mucous membranes
- Respiratory system
- CV system
- GI
- Urinary
- Genital
- Spleen and haematopoietic
- Hormonal
- Locomotion
- Nervous system
General impression: cat vs dog
Dog- let them walk around
Cat- keep in cage for as long as possible
General impression: areas to assess
Body size Body shape and developmental state Nutritional condition General condition, grooming Consciousness and behaviour Posture Locomotion Obvious abnormalities
General impression: Nutritional condition
Muscle
Thickness of SC tissue
BCS
BCS
Used to range from 1-5 now ranges from 1-9
Obese-overweight-normal-underweight-very thin-cachectic/emaciated
General impression: General condition, grooming
Hair Fleece Footpads Claw Hoof
General impression: consciousness and behaviour (general demeanor) 1
- Bright, alert- normal response to ext stimuli
- Dull, apathy- retarded response to ext stimuli
- Sopor- sleepiness
- Stupor- extreme delay in response to ext stimuli
- Coma- Unconsciousness, does not respond to even painful stimuli
General impression: consciousness and behaviour (general demeanor) 2
- Nervous, tense- increased response to ext stimuli. Alert, but normal movement
- Restlessness- constant movement, usually caused by pain
- Mania- compulsive abnormal behaviour, vigorous licking and head pressing
- Frenzy- actions are now uncontrolled
General impression: consciousness and behaviour (general demeanor) - Pathologic behaviour
Self- mutilation
Compulsive: head-pressing, walking in circles, mania
Convulsions, tail-chasing, fly biting
Aggression
General impression: Posture
Position of: Head Ears Neck Trunk Spinal column Legs Tail Weight
General impression: Posture if standing
Weight bearing equally on all legs
Legs not over or under extended
General impression: Posture- spinal column
Arched, sagging- kyphosis, lordosis, scoliosis
Abduction of elbows
Stiff, extended neck
Lying on sternum/ side/ recumbent
Sitting position
General impression: Locomotion/ Gait
Lameness, stilted gait, exaggerated flexion, stumbling, goose-stepping- could indicate meningitis/ ataxia
Frequency: constant, intermittent or increased with exercise
General impression- obvious abnormalities
of spinal cord?
Lordosis- upwards
Kyphosis- downwards
“Praying “ position- chronic pain e.g pancreatitis
What are the basic clinical values
Temperature
Heart rate
Breathing rate/ minute
Normal temp in the dog
38.2- 39.1
Normal temp in cats
38.5-39.3
Normal heart rate/ pulse
Consider: at clinic the animal is more nervous
Pulse in dogs in the clinic vs at home
Clinic: 60-70 — 140(180)
At home: 60–70
Pulse in cats in the clinic vs at home
Clinic: 140 — 180 (200)
At home: 120–130
Breathing rate/ minute
Clinic: <40
At home: <30
Sleeping: <25
What increases temp?
Sun, work, excitement, feeding, heating
Fever, inflamm, abnormalities of heat centre
Unregulated hyperthermia- heat stroke, uncontrolled muscle contraction (maybe in seizures?)
What decreases temp?
Cooling Few days before calving Exhaustion Cachexia Opened anus Hypovolaemic shock Barbiturate toxicosis
*changes in temp depend on species, breed, age, sex, condition NOT SIZE!
What factors influence pulse?
Species, breed, temperment, excitement, age, sex, training
Where do we take the pulse?
The A femoralis medial thigh
Increase of breathing rate per minute
Tachypnoea, polypnea Fever Narrowing/ Obstruction of airways Decreased breathing surface Obstruction of diaphragm Painful systemic disease Central nervous irritation- encephalitis, epilepsy Decreased O2 of blood- anemia, CO toxicosis
Tachypnoea, polypnea: narrowing/ obstruction of airways
Inflamm FB Larynx paralysis Edema Tracheal hypoplasia or collapse Neoplasm Bronchitis
Tachypnoea, polypnea: decreased breathing surface
Pneuomonia Lung edema Neoplasm Abscess Pneumo, hydro, haemo thorax Pleuritis
Tachypnoea, polypnea: obstruction of diaphragm
Tetanus
Ascites
Gastric torsion
Meteorism
Decrease of breathing rate per minute
Oligopnoe, bradypnoe
Encephalitis between the excited periods
Brain edema
Toxicosis
