Veterinary Patient History: Key Components

• Good history taking is essential for ultimate diagnosis and aiding the patient.
• Gathering a patient's history helps avoid unnecessary diagnostic work-ups, time delays for therapeutic treatments, and Doctor of Veterinary Medicine workload.
• Complete and accurate information is useful.
• Inaccurate information may lead to unnecessary tests and unneeded treatments.
• Listening skills include listening attentively and utilizing active listening skills, positive body language, eye contact, and proper posture.
• Interrupt if the patient is unstable.
• Asking the right questions involves maintaining an unbiased approach, allowing the client to answer (with guidance as needed), using open-ended questions, and avoiding being judgmental
• Standardized forms can act as part of medical record.

Key Components of Patient History

• Signalment
• Presenting (Chief) Complaint
• Background Information (only for new clients, confirm with current ones)
• Past Medical History (only for new clients, confirm with current ones)
• When Last Normal & Progression of Complaint
• General Questions for Every Client

Signalment

• Date of Birth/Age
• Species
• Breed (description or dominant breed)
• Sex
• Reproductive status (neutered, spayed)

Presenting Complaint

• Reason for visit
• The most critical aspect, especially for the client
• In emergencies handle immediately
• Record multiple complaints separately.

Background Information

• Applies to new clients or confirm information with existing ones
• Where and when acquired
• Preventive medicine details, such as vaccination history, heartworm, and parasite treatment
• Typical behavior
• Household information, including other animals and lifestyle (indoor vs. outdoor)
• Routine and travel history

Medical History

• Only for new clients, confirm with current ones
• Previous illnesses that may contribute to current problems
• All current medications/supplements
• Clarify abnormal laboratory findings

Complaint Progression

• Date of onset and timeline
• If progression is static or dynamic
• Determine if acute or chronic with details on episodes
• Past diagnostics at other practices
• Medications used and patient responses

General Questions for Every Client

• Appetite/drinking habits
• Energy levels
• Current temperament/personality
• Elimination habits
• Diet
• Brand (canned vs kibble, raw, homemade)
• Amount and known/suspected allergies
• Treats/snacks

Physical Exam

• Perform a physical exam to gain information about health status, identify abnormal conditions, monitor recovery from previous conditions, and assess anesthetic risk.

Vital Signs

• Heart rate; the units are beats/minute (bpm); auscultate heart/pulse

Heart Rate Normal Ranges

• Dogs: 70-160 bpm
• Cats: 150-210 bpm

Tachycardia Causes

• Pain
• Hypoxemia
• Anxiety
• Decreased blood volume
• Fever
• Sepsis

Bradycardia Causes

• Heart disease
• Hypothermia
• Endocrine issues, such as hypothyroidism
• Opioids
• Increased anesthetic depth

Heart Auscultation

• Location: Just behind the elbow (~4-6th rib).
• Method: Count beats in 15 seconds multiplied by four for bpm.

Pulse Measurement

• Primarily in dogs using the femoral artery
• Gentle pressure and count pulses like heart rate

Pulse Pressure Description

• Normal
• Absent
• Weak & thready
• Bounding/strong
• Irregular

Mucous Membranes

• Assess blood volume and perfusion
• Normal appearance: Pink and moist

Mucous Membranes Abnormal Colors and Indications

• Dry/tacky indicates dehydration
• Pale indicates anemia
• Brick red indicates vasodilation
• Gray/cyanotic indicates hypoxemia
• Yellow/icteric indicates liver disease

Capillary Refill Time (CRT)

• Assesses blood volume/perfusion
• Normal values are 1-2 seconds
• 2 seconds indicates poor perfusion
• Less than 1 second indicates vasodilation, shock, or hyperthermia

Hydration Assessment Methods

• Using Skin turgor test
• Evaluating eye moisture
• Mucous membrane assessment

Respiration Units

• Breaths/minute (bpm)

Respiration Levels

• Dogs: 8-20 per minute
• Cats: 8-30 per minute

Temperature Normal Levels

• Dogs: 37.5-39 °C (99.5-102.2 F)
• Cats: 38.0-39°C (100.4-102.2 F)

Temperature

• Hold tail at base, wait for the "beep"

Hyperthermia

• Implement cooling measures and monitor closely, use ice-wrapped towels, fans or intravenous fluids

Hypothermia

• Warming measures needed gradually
• Temperature must be brought back up to normal slowly
• Frequently monitor temperature until rectal temperature approaches normal

Temperature Conversion

• °C = (°F - 32) ÷ 1.8
• ° F = (° C x 1.8) + 32

Complete Systems Review PE

• Integument
• Respiratory
• Cardiovascular
• Gastrointestinal
• Urogenital
• Musculoskeletal
• Ears
• Eyes
• Lymph Nodes
• +/- Nervous System

Integument Exam

• Skin
• Coat condition: coarse vs. soft
• Dull, greasy

Skin Appearance

• Alopecia
• Focal, diffuse, or patchy
• Symmetric or asymmetric
• Bruising
• Lump
• Turgor

Papule

• Small, pink, underskin, elevated lesions

Pustule

• Similar in size
• Pink/red base with a white tip
• Filled with pus

Respiratory Nose Exam

• Nose symmetry
• Patency
• Discharge
• Severity/Consistency such as serous, mucoid, purulent, or hemorrhagic

Lung Auscultation

• Listening to the lungs on both sides, ventrally and dorsally
• Lung volume is less in felines than canines

Abnormal Lung Sounds

• Decreased sound: Res. Weakness, pleural space disease
• Increased sound: Loud, harsh lung disease

Respiratory Sounds

• Stertor harsh, like snoring
• Stridor intense
• Crackles similar to a popping sound
• Can be coarse or fine

Circulation Review

• Evaluate Heart valves: Right AV, Pulmonic, Left AV, Aortic

Gastrointestinal System

• Check the oral cavity and palpate for abnormalities in the abdomen.

Rectal Exam

• Evaluates the prostate, anal glands, and checks for possible parasites.