Post on 24-Dec-2015
transcript
Patient History and Physical Exam
Remember the impression you are making– Know patient and client info before entering
the room– talk to owner not animal, well dressed,
professional in manner– Introduce yourself and explain
Basis for choosing laboratory tests and radiographs (ex: vomiting vs. Regurg)
Provides vital information for making diagnosis
Patient History
May be most important step Ask open ended, not yes and no
questions Look for quantitative and descriptive
information, not conclusions
Patient History
Chief or current Complaint- briefly Signalment- age, breed, sex,
reproductive status Geography and ownership- how long
owned, where obtained, source, travel
Patient History
Living conditions- indoor/outdoor/pastured, exposed to other animals, how many, what species
Diet- what kind of food, brand, how many meals, how much, treats
Dates of last vaccinations, tests, PE
Patient History
Past medical history- diagnosis, treatment, response
Current medications and supplements History of current complaint- first
symptoms, duration, specific details, what concerns the client
Physical Exam
Begin systematic exam Always follow the same format Exception: Avoid obvious areas of
distress, check last Primum non nocere
Vital Signs
Temperature Pulse Respiration Capillary refill time Weight (Know calculation and how to
record) Pain Score
Temperature
Use same method on patient each time Rectal, axillary, inguinal, ear probe Normal temps vary by species and are
affected by environment “Normal” is defined by a range Many factors affect body temperature
Pulse
Actually, usually the heart rate Pulse may vary from heart rate, good to
check both at same time Increases and decreases have many causes-
excitement, chemical imbalances, temperature, cardiac defect
http://solutions.3m.com/wps/portal/3M/en_GB/Littmann/stethoscope/education/heart-lung-sounds
When using the stethoscope be sure to index between bell and diaphragm mode.
Use bell side for low-frequency sounds.
Use diaphragm for high-frequency sounds.
Bell Mode (low-frequency)Use light contact with tunable chest piece to hear low frequency sounds.
Diaphragm Mode (high-frequency)Turn the chest piece over, index to the opposite side and use firm pressure to hear high-frequency sounds.
Respiration rate
Observe movement Feel breath at nares Listen to lungs Sometimes can only be rated as panting
Capillary refill time
CRT measures perfusion Press on nonpigmented mucous
membrane- gums, conjunctiva, vulva, penis
Count seconds until pink color returns Normal is 1-2 seconds
Hydration status
Many forms request this- can be difficult to rate. Very subjective.
<5% undetectable 5-6% skin slightly doughy, MM moist 6-8% skin tents (slowly back to normal) prolonged
CRT 8-12% severe- skin peaks and stays, CRT 4-5,
tongue dry, eyeballs soft and sunken 12-15% shock, imminent death
Inspection
Begins first with patient; start to make general observations
Watch while you take patient history Observe level of consciousness, facial
expressions, body condition, posture Continue using your eyes as you do your
systematic exam Symmetry
Systems to examine
Integument Respiratory Cardiovascular Gastrointestinal Urogenital Musculoskeletal Nervous Peripheal Lymph Nodes Ears Eyes
Palpation
Both light and deep Most sensitive touch with finger tips Back of hand best to rate temperature
Percussion
Tapping and listening to the resulting vibrations
Helps to determine dense solid areas, fluid or gas filled pockets
Auscultation
Sounds created by body Listen with and without instruments Respiratory system Cardiovascular system Gastrointestinal systems
History Form
http://www.vin.com/Members/CMS/Misc/VSPN/Default.aspx?id=8047&redirect=1
This will provide guidelines for you.• http://www.vin.com/MEMBERS/CMS/Misc/
VSPN/Default.aspx?id=6695&pid=49&catid=&said=1
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