Patient History and Physical Exam Flashcards
Use a __, ___ system for obtaining historical information to ensure nothing is ___
consistent, organized, overlooked
ask___ended questions
open
useless unless ___ down
written
medical record is a __ document
legal
signalment
age, breed, sex, reproductive status
Background information
general management (normal diet, routine, medical problems)
preventative medicine (vaccination, heartworm, flea/tick)
behavioral
household
allergy
presenting complaint
the most important information to be addressed in the history - in emergency situations, should be the first thing you obtain
medications
type, dose, frequency, duration, reason, beneficial
PE
the first and most important diagnostic test - starts w/ pt in its surroundings
TPR
K9 - HR(60-160), RR (10-30), temp (100.5-102.5)
feline - HR (140-210), RR (10-30), temp (100.5 - 102.5)
Oropharyngeal system
examine teeth for discoloration, fracture, excessive tartar formation
eyes
note ocular discharge, in regards to color, severity, and location
cornea
if scratched, will show up as cloudy
ears
palpation of the pinna, eval for symmetry, inside - crusting, swelling, redness, alopecia, horizontal canal and ear drum, redness, swelling, masses, discharge
respiratory
auscultation begins with the chest piece over the trachea
