Week Three: History and Physical Examination Flashcards
Who are the SBVM?
Advocate/protect public from veterinarians
Keep track of vets licenses
Discipline vets
State Board of Veterinary Medicine
What is included in a signalment?
- Age
- Breed
- Sex
- Repro. status
Congenital diseases are more likely to be diagnosed in who?
Very young patients than in very old patients
What is SOAP?
Subjective
Objective
Assessment
Plan
What is “subjective”
Information supplied by client (presenting complaint from the client and the pertinent medical history)
Include annotations of vaccination status, repro status, diet, elimination abnormalities, exercise level and any current meds
What is “objective”
Irrefutable information, actual observation, or tests performed
Results of the physical examination, lab tests, or similar “hard data” information
What is “assessment”
What the client is told the problem is
Dx is written if final diagnoses is known
What is tentative? (TDx)
If diagnosis is almost certain, but is waiting for test results
What is differential (DDx)
If there could be several diseases or conditions under consideration, the most likely choice first, the next most likely choice listed next, and so on
What is Dx Open
if the clinician has no diagnosis and needs further study or workup to complete
What is “plan”
Actions the clinician wants to take to resolve the problem or cure the disease
(“put him on steroids”, “trim nails”)
What types of questions do you ask?
Open ended rather than leading questions (let the client fill in the information themselves)
“Has he been drinking more water than usual?” is an example of what kind of question?
Close ended
What is a last normal?
The last time the animal was normal
What goes in the general management spot?
- How long has the pet been owned and from where obtained?
- Amy previous medical problems
- any recent travel
- Where is the pet kept
- diet
What is V/D
Vomitting/diarrhea
What is C/S?
Coughing/sneezing
What is PUPD?
Polyuria and polydypsia
Pyometra occurs most commonly _______ to ______ following a heat cycle
Two weeks to two months
What is pyometra?
Pus in uterus
What is TPR?
Pulse, respiration, temperature
Where is body temperature most accurately measured?
Rectally
Where else can you measure temperature besides rectally?
Axillary or aural
When is an elevated body temperature (hyperthermia) usually occurred?
The presence of infection, inflamation, or neoplasia
What is the temperature of a heat stroke?
> 107F
What is the temperature of severe hypothermia?
<90F
What is the normal body temperature of a dog?
- o to 102.2
101. 5 +-1
What is the normal body temperature of a cat?
100.0 to 102.2
F to C (equation)
F-32/1.8
C to F (equation)
C*1.8+32
How should a pulse be described?
- Weak
- Moderate
- Strong
How do you take a pulse?
Peripheral arterial pulses should be palpated to determine pulse rate and pulse quality in every single patient (femoral)
What is a pulse deficit?
Absence of a palpable pulse or significant change in pulse quality with an audible heartbeat
What is pulse pressure?
Pressure you feel when palpating a pulse
Difference between systolic and diastolic arterial pressure
A weak peripheral pulse might equal what?
Poor perfusion caused by poor cardiac output
How do you take a heart rate?
15 seconds X 4
6 seconds X 10
30 seconds X 2
What is the normal heart rate for a dog?
60-160 beats per minute
smaller breeds and puppies can have rates up to 200 bpm
What is the normal heart rate for a cat?
140-220 bpm
What does an increased inspiratory effort mean?
Upper airway issue
What does an increased expiratory effort mean?
Obstructive disease
What is the normal respiration rate of a dog?
16-32 breaths per minute
What is the normal respiration rate of a cat?
20-42 breaths per minute
What do you need to note for general appearance?
- Behavior
- Mentation (state of mind)
- Respiratory effort
- Evidence of ataxia
- Asymmetry
- Swelling
- Body condition (very thin-overweight)
What is BAR?
Bright/alert/responsive
What is QAR?
Quiet, alert, responsive
What should you note/examine for integumentary?
Hair, skin, nails, foot pads
What is alopecia?
Hair loss
What should you examine for musculoskeletal?
- Lameness
- Swelling
- Difficulty rising
- Pain
- Walking-observation
- Assymetry of limbs
- Limbs and the vertebral column
- Joints (range of flexion)
Things to look at and record for circulatory (heart)
- Heart rate
- Rhythm
- Sounds
How to auscultate the heart
- Pulmonic, aortic, and mitral valves on left side
- Tricupsid valve (right side)
What is a sinus arrhythmia?
Pause in heart beat
What should you examine for respiratory?
- Rate and effort
- Nares
- Nasal discharge
- Sneezing
- Stertor or stridor (upper airway disease)
What are stenotic nares?
Small nostrils
What do inspiratory crackles mean?
Fluid in the alveoli (pulmonary edema)
What is a lack of lung sounds in the ventral lung fields in a standing animal?
Pleural effusion (fluid settles in the ventral areas)
What does a lack of lung sounds in the dorsal lung fields can indicate what?
Pneumothorax (air rises to the dorsal areas)
What do you examine in the gastrointestinal?
From mouth to anus:
- Flip the lip
- Palpate to feel
- Look at anus
How should you palpate?
Begin in one section (cranial-dorsal)
Should move slowly and methodically through all sections of the abdomen
Note any pain, swelling, firmness or fluid within each section
What should you look for during urogenital?
- Distal urethra
- Vestibule
- Testicles
- Mammary chains in sexually intact female cats and dogs
- Palpate for heat, swelling, masses or discharge
What should you look for when examining eyes?
- Examine eyelids
- Examine external and internal structures of the eyes
- Look for redness, swelling, masses, ect.
What is entropion?
Eyelids curling in
What is ectropion?
Eyelids curling out
What is icterus?
Yellowing
What is the sclera?
White/clear part
What is the nictitating membrane?
Third eyelid
What is conjunctiva?
Red part of eye
What is the cornea?
Colored part of eye
What should you look at when examining the ears?
Pinnae
-Swelling, focal swelling, diffuse thickening, redness, alopecia, crusting, excoriation, petechiation
Vertical canal
-Discharge, thickening, swelling, masses, hirsuite, foreign material
Aural discharge
-Amount, mild/moderate/severe
What should you examine during the nervous system?
-Subjective visual examination Mentation Visual acuity, menace, pupillary light reflex Gait, lameness Head tilt Circling Weakness, paralysis, muscle tone Anal sphincter tone
What are the cranial nerves?
I. olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Accessory XII. Hypoglossal
What are the peripheral lymph nodes that can be palpated in a normal patient?
- Mandibular
- Prescapular
- Popliteal
What should you look for for lymph nodes?
Normal lymph nodes are round to oval, slightly moveable, firm but slightly compressable
Abnormal is enlarged, firm, wam, and potentially painful on palpation
How should you palpate lymph nodes?
Palpate by gently isolating between your thumb and index finger
Left and right should be palpated simultaneously
