History & Physical

History and Physical

• The history and the physical examination are crucial steps in treating patients.
• Recording medical history and performing physical exams are essential to treating animals humanely, safely, and effectively.
• Client education and effective communication with the client are also discussed.
• Key learning objectives include identifying the importance of thorough veterinary examinations and medical and environmental history.
• Explain the role of the body systems reviewed during physical examinations and how each system is examined.
• Understanding SOAP format components for medical records.
• Learning how to effectively communicate with clients to provide client education.
• A quiz on history and physical procedures is required for course completion. An average of 70% is needed to pass.

The Complete Examination

• Animals are required to have a complete physical examination every visit or, according to age or chronic conditions, more than once a year.
• Physical exams assess overall health and help to identify potential health problems in the early stages.
• Thorough physical examinations help establish a veterinarian, client, and patient relationship (VCPR) for animal treatment.

The Medical History

• The medical history is the first step in every veterinary physical exam.
• The history helps in diagnosing a patient or suggests possible diagnoses.
• Diagnosing is a responsibility of the vet, as only a vet can legally determine the causes of animal symptoms.
• Medical history helps assess the animal's physical state, devise a diagnosis, and predict possible or probable outcomes (prognosis).
• This includes the patient's treatment plan.
• Fear Free is a practice that incorporates emotional well-being into the medical history.

Signalment

• Signalment is a concise summary of the animal including breed, sex, age, and reproductive status.
• Signalment is a helpful tool for quickly assessing a patient's key characteristics.
• Key components of a thorough history include the presenting problem, medical history, environmental history, and body systems review.
• Understanding the animal's travel history is relevant to the environmental history.

Client Communication

• Clients should be approached with a calm, confident, and pleasant demeanor.
• Use neutral language and open-ended questions during client conversations.
• Confirming the presenting problem is important when a client brings an animal for an examination.
• Ensure questions are open ended to elicit more information when talking to a client.

Environmental History

• The environmental history provides details about the animal’s current living environment.
• Questions about ownership, diet, medications, travel history, and environments are addressed.
• Veterinary technicians often assist during environmental history documentation.
• Review, confirmation, and documentation of prior medical issues, treatments, vaccinations, and diagnostics is essential for established patients.
• For new patients, client records should be reviewed.

Preparing for a Physical Examination

• This section is an open link to additional information.

Body Systems History & Body Systems Review

• The body systems history and review document the current or past problems of each body system.
• Following a consistent, organized approach to the examination is important.
• If a client reports a specific issue or problem, further questions should be asked.

The Physical Examination

• The physical examination is a crucial process.
• Vital statistics are collected, and descriptions of the various bodily systems are documented.

The Physical Exam and Vital Statistics

• Physical examinations of animal patients and vital statistics are important.
• Collecting vital statistics (weight, heart rate, respiratory rate, mucous membrane color, capillary refill time, and body temperature) is discussed.
• The integration of physical examinations with history might create a diagnosis and may also offer guidance in selecting diagnostic tests.
• Collecting vitals should be performed in the order of least to most invasive (weighting before temperature).

Weight

• Recording accurate animal weights is vital and helps to identify any changes in health.
• An infant scale can be used to weigh animals that weigh less than 20 pounds.
• For heavier animals, a platform scale is recommended.

Heart Rate

• Auscultating (listening to heart sounds) is a crucial method for finding heart rate.
• Palpating (feeling) a pulse to check on the proper correspondence of heartbeats to pulse is also important.

Respiratory Rate

• Respiratory rates are measured in breaths per minute.
• The method of counting breaths is described.
• Abnormal lung sounds are described, including crackling sounds (rales), high-pitched musical noises (wheezes), and stridor (high pitched noises).

Capillary Refill Time

• Capillary refill time (CRT) reflects peripheral tissue perfusion.
• CRT should be less than two seconds.
• Steps to assess CRT (firm pressure on mucous membranes, and noting the time it takes for color return) are detailed.

Temperature, Pulse, and Respiratory Rates

• Body temperature, pulse, and respiratory rates are vital statistics for assessing overall health in animals.
• Digital thermometers are used for obtaining temperature.

The Examination

• Veterinary technicians may assist during the physical exam but the vet determines the diagnosis.
• The physical examination follows a systematic order (head to tail).
• Methods used include observation, palpation, and auscultation (listening to with a stethoscope).

Integumentary System

• The examination should assess skin, hair, nails/hooves/horns, and scales.
• The coat should be checked for abnormalities.
• Skin color, condition, and abnormalities are noted.
• Pads and paws should be assessed for moisture, color changes, and other abnormalities.

Checking the Turgor Pressure

• Turgor pressure is the measure of elasticity and integrity of the skin.
• Turgor pressure reflects dehydration levels. A table describes how long it takes for the skin to return to normal, indicating the amount of dehydration present.

Respiratory System

• Respiratory system examination starts with the nose and mouth.
• The nose is examined for discharge, sneezing, and other abnormalities.
• The oral cavity is examined for masses, obstructions or foreign bodies, and elongation of soft palate, among others.
• The throat is palpated for masses or any cough or sneezing
• Thorax auscultation is performed to assess air flow.

Circulatory System

• The color of mucous membranes (normally a moist pink color) is checked.
• Capillary refill time (CRT) is assessed and recorded.
• Jugular veins are examined for pulsing.
• The heart is auscultated for abnormalities in rhythm and sounds.
• The pulse is examined for strength and synchronization with the heartbeat.

Gastrointestinal System

• The oral cavity is examined for healthy teeth, gum abnormalities, masses, foreign bodies, and mouth obstructions.
• A physical examination of the throat/esophagus is performed for abnormalities.
• The abdomen is examined for consistency, size, shape, masses, and any signs of pain during palpation.
• Gut sounds are auscultated, especially in large animals, and checked for abnormalities which follow a specific pattern, but if there are less than 1 to 2 sounds per minute, a possible abnormal condition will need to be brought to the vet's attention.

Urogenital System

• The female's mammary glands are examined for abnormalities, discharge, enlargement or growth.
• The vulva is examined for discharge, swelling, or irritation.
• The male's testicles, penis, its shape and smoothness are palpated to check for abnormalities.

Musculoskeletal System

• Muscles are palpated for atrophy, heat, pain, and any masses.
• The leg bones are palpated for fractures and masses.
• Each joint is moved through its full range of motion, and sounds and any loss of motion are assessed.
• Pressure should be applied to the muscles near the spine to observe for pain or abnormalities.

Nervous System

• Palpated reflex observations (eyes), like the palpebral (blinking) reflex and menace reflex are performed
• The pupil's reaction to light is checked.
• Proprioception or the righting reflex is performed.
• Observation of the animal's demeanor, and behavior for abnormalities.

Lymphatic System

• Lymph nodes (submandibular, prescapular, axillary, inguinal, and popliteal) are palpated for abnormalities.

Eyes and Ears

• Eyes are examined for discharge/swelling and any abnormal appearance (e.g., rolled lashes, or other)
• The conjunctiva membrane and sclera are assessed.
• Corneas are checked for cloudiness.
• Retinas are examined using an ophthalmoscope.
• Ear canals, and surfaces are visually checked for masses, growths, discharge, color abnormalities, and swellings

Equipment Needed for a Physical Examination

• Proper use of equipment (ophthalmoscope, otoscope, stethoscope) is essential for accuracy and efficiency of the exam. Cleaning and proper maintenance procedures are described.

The Medical Record

• Medical records are a legal document, containing animal current medical conditions, health histories, and other related materials.
• Records are organized in a chronological way, and details are included: owner info, animal details, diagnostic tests, detailed examination notes, treatment and prognosis, instruction to the owners or patients, copied notes on communications between the vet clinic and client.

Using the SOAP Format

• SOAP (Subjective, Objective, Assessment, and Plan) is a widely used method for documenting medical care.
• Subjective, objective, and assessment are the client's view including observations, while Procedure or Plan focuses on treatment plans, prognosis, and any medication needs.

Educating the Client

• Client education involves communicating with clients clearly and efficiently. The goal is to provide clients with the information and support needed.
• This includes nutrition, behavior, aftercare instructions, and general information about the animal's health.