Foundations of Veterinary Technology: History and Physical PDF

Foundations of Veterinary Technology / History and Physical History and Physical © 2024 PF High School, LLC Page: 1 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu In...

Foundations of Veterinary Technology / History and Physical History and Physical © 2024 PF High School, LLC Page: 1 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical History and Physical The history and the physical examination are the first, and often the most important, steps in treating a patient. Your studies discuss the different components required when recording medical history and performing a thorough physical examination. Your study material provides information on how to assist the veterinarian and the animal patient in ways that are humane, safe, and effective. Your studies also discuss client education and how to effectively communicate with a client. By the end of this lesson, you’ll be able to: Identify the importance of a thorough veterinary physical examination and medical and environmental history Explain the body systems that are reviewed during physical examinations and how they’re examined Identify the components required for medical records and for using the SOAP format Identify how to effectively communicate to clients when providing client education In this lesson, you’ll be graded on: Lesson Quiz: History and Physical There's one required quiz at the end of this lesson. You need an overall average of 70% to successfully complete this course. © 2024 PF High School, LLC Page: 2 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Complete Examination Animals have a complete physical examination every time they visit a veterinary hospital or clinic. This helps identify problems and builds a relationship with the client. You’ll study the components involved with a physical exam including identifying the medical history and client communication. Proceed through this lesson. There’s no textbook reading for this lesson. © 2024 PF High School, LLC Page: 3 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Complete Physical Examination Each patient who visits the clinic or is hospitalized must have a complete physical examination. Outpatients are normally scheduled for one complete examination each year, sometimes more as they age or if chronic conditions are present. Annual examinations are vital to identifying any potential problems with the patient. A thorough physical examination often reveals health problems before any symptoms appear. Hospitalized patients are examined at least daily to monitor their progress and document their condition. These examinations help establish a relationship between the veterinarian, the client, and the patient. This relationship is known as the VCPR, veterinarian-client-patient relationship. This is a legal requirement in most states and is necessary for the veterinarian to be able to treat the animal and prescribe medications. The most common veterinary procedure, and foundation of diagnosis and treatment, is the physical examination. While veterinary technicians are permitted to perform physical examinations, the veterinarian is primarily responsible for this task. If the veterinary technician performs the physical exam, the findings are conveyed to the veterinarian without making a diagnosis. For example, the veterinary technician may report that the gums are inflamed. Upon confirmation of inflamed gums, the veterinarian would make a diagnosis of gingivitis. If the veterinary technician is assisting the veterinarian with the physical exam, the veterinary technician may be responsible for collecting vital signs and restraining the patient. The veterinary technician may be responsible for additional procedures, including: Interviewing the client for the presenting problem or concern (the reason the animal is at the veterinarian) Taking the animal’s body systems history (detailed questions about the body systems involved in the presenting problems) Interpreting the animal’s body systems review (a review of the body systems to note any additional problems the animal may have) Prior to the examination, the technician must gather and prepare any supplies and equipment necessary to perform the examination, such as a stethoscope, thermometer, otoscope, and ophthalmoscope. © 2024 PF High School, LLC Page: 4 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Whether you perform the physical examination with the help of a veterinary assistant or assist the veterinarian in performing the examination, you’ll need to know the proper type and degree of restraint each species, procedure, and individual animal requires. © 2024 PF High School, LLC Page: 5 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Medical History The medical history is the first step of every veterinary physical examination. It can be the most important step, because it may suggest a diagnosis, or prompt specific laboratory tests, x- rays, and other procedures required to obtain a diagnosis. Only the veterinarian is qualified and legally permitted to make a diagnosis or identify the cause of an animal’s symptoms. The medical history provides information that helps the veterinarian evaluate the patient’s physical status, develop a diagnosis, offer a prognosis (or outlook) for the patient, and create a treatment plan. Fear Free Fear Free techniques can be incorporated into the medical history by making sure to not to overlook a patient’s emotional well-being. Fear Free provides an Emotional Medical Record template(https://fearfreepets.com/emotional-medical-record-and-fas-scale/) to members. The Emotional Medical Record takes into account the patients’ emotional well-being, such as their fear triggers, treat preferences, where and how they like or dislike being handled, and behavioral nutraceuticals and/or medications that have worked for them in the past. For access to the Emotional Medical Record, veterinary technician students can take the Fear Free Veterinary Certification Program for free by enrolling here(https://fearfreepets.com/fear-free-student-and-faculty-application/). © 2024 PF High School, LLC Page: 6 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Signalment The signalment is the overall patient description. Signalment isn’t considered part of the history, but it can help to determine what’s wrong with the animal and is a concise way of sharing basic facts about the animal with the veterinarian. The signalment includes the breed, gender, age, and reproductive status (whether the animal has been neutered). For example, you might say Otis is a three-year-old neutered male domestic shorthair cat. Sometimes a sign or symptom, combined with the signalment, suggests certain ailments. For instance, the cause of a young animal’s intestinal blockage is far more likely to be a swallowed foreign object since young animals are less discriminating about what they eat. The key components of a good, thorough history are: Identifying the primary or presenting problem Completing a medical history Completing the environmental history Reviewing the body systems © 2024 PF High School, LLC Page: 7 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Client Communication Always approach the client with a pleasant, calm, and confident demeanor. It’s important to use time efficiently without rushing the client. Talking to a Client When you’re speaking with a client, use neutral language and non-leading, open-ended questions. This technique will require the client to give you a detailed response instead of yes or no answers. For example, you’ll get more information asking, “How often do you feed Daisy?” and “How many cups of food do you feed Daisy per day?” than you will asking, “Does Daisy eat more than she used to?” The owner may respond to the first two questions by saying, “Well, I usually feed her twice a day. I give Daisy about three cups of food a day, split between the two feedings.” However, the owner can simply respond “yes” or “no” to the third question. Client Complaint The primary or presenting problem, also referred to as the client complaint, is the reason for the patient’s visit to the veterinary clinic. The presenting problem will often be confirmed at the time the client schedules the appointment. If this is the case, the veterinary technician should confirm and reiterate the problem. For example, “Hi, Mrs. Jones. I see Marley is here to see Dr. Smith today because he has been scratching his ears.” If the presenting problem is unknown upon client arrival at the clinic, you may instead say, “Hi Mrs. Jones. Tell me about why Marley needs to see Dr. Smith today.” Once the presenting problem has been confirmed, the veterinary technician will proceed by asking: When did this problem begin? Has the problem gotten better or worse? Has the animal ever experienced this problem before? © 2024 PF High School, LLC Page: 8 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical What are the characteristics and details of the problem? (For example, if the patient has diarrhea, what does it look like? Is there a sense of urgency?) For established patients, prior medical problems, treatments, vaccinations, and diagnostics should be confirmed. If the patient is new to the clinic, the client should ideally send previous medical records. Environmental History The environmental history details the animal’s current living situation. The veterinary technician should ask the following questions: Details of Ownership Where did you obtain this pet? When did you obtain this pet? Diet Tell me what brand of food your pet eats. How much? How often? Have there been any dietary changes? Do you feed treats, table scraps, or raw foods? Does your pet have access to clean, fresh water at all times? Medications Do you give your pet heartworm and ea/tick prevention? Does your pet receive these medications year-round? Do you give your pet any other medications, supplements, or over-the-counter products? If yes, what are the doses and frequency? Environment Does your pet spend time outdoors? If yes, is the pet attended or unattended? Has your pet traveled recently? Does your pet socialize with other pets or go to the groomer, day care, training, or boarding facilities? If your pet lives in a cage, what type of bedding material or substrate is provided? Is your pet expected to perform for the purposes of hunting, breeding, or showing? © 2024 PF High School, LLC Page: 9 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Preparing for a Physical Examination Open Link © 2024 PF High School, LLC Page: 10 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Body Systems History and Body Systems Review A body systems history and body systems review discuss each body system in sequence and record any current or previous problems. Use the same order or approach in every case to ensure consistency. Typically, a nose-to-tail or system-by-system approach is used. If the client reports any problems or concerns with a body system, follow-up questions about the details, duration, and character should ensue. Here’s an example of a system-by-system review. Select each item to learn more. Integumentary system Integumentary system: skin, scales, hair, nails, hooves, horns, and feathers Open-ended question: “How are your pet’s skin, hair, nails, hooves, or feathers?” Closed-ended follow-up question: “Have you noticed any itchiness, irritation, hair or feather loss, lesions, lumps, or bumps?” Respiratory system Respiratory system: nose, mouth, pharynx, larynx, trachea, bronchi, lungs Open-ended question: “How is your pet’s breathing?” Closed-ended follow-up question: “Have you noticed any nasal discharge, sneezing, coughing, increased respiratory rate or effort?” Circulatory system Circulatory system: the heart, blood, and blood vessels Open-ended question: “How is your pet’s energy?” (Animals with cardiac or circulatory disease typically have reduced stamina.) Closed-ended follow-up question: “Have you noticed any coughing, fainting, or exercise intolerance?” Gastrointestinal system Gastrointestinal system (a.k.a. digestive system): mouth, esophagus, stomach, small and large intestines, anus, liver, gallbladder, and pancreas Open-ended question: “How is your pet’s digestion?” Closed-ended follow-up question: “Have you noticed any foul breath, change in appetite, vomiting, or diarrhea?” Urogenital system Urogenital system: kidneys, ureters, urinary bladder, urethra, reproductive organs (male – penis, prostate, testes; female – ovaries, uterus, vagina) © 2024 PF High School, LLC Page: 11 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical ( p ,p , ; , , g ) Open-ended question: “How is your pet’s urination?” Closed-ended follow-up questions: “Have you noticed any change in frequency or amount of urination? Any straining to urinate? Change in drinking habits? For intact females, when was the last heat cycle? Has there ever been a pregnancy? Any discharge from the vulva? For breeding males, has there been any difficulty with impregnation? Any discharge from the penis?” Musculoskeletal system Musculoskeletal system: bones, muscles, tendons, ligaments, joints, connective tissues Open-ended question: “How are your pet’s weight and mobility?” Closed-ended follow-up questions: “Has there been any weight gain or loss, limping, or difficulty with everyday movement?” Nervous system Nervous system: brain, spinal cord, nerves Open-ended question: “How is your pet’s demeanor?” Closed-ended follow-up questions: “Have there been any seizures, confusion, lack of response to sights or sounds?” Once you start asking open-ended questions instead of “yes” or “no” questions, taking a thorough history and doing a body systems review becomes automatic. This review helps the veterinarian. It highlights key points for the physical examination and narrows the focus of laboratory testing. As the veterinary technician, you can make a tremendous difference for the patients whose histories you take by knowing what questions to ask the client and how to ask them. Vet Tech Connection Knowledge of veterinary anatomy and physiology is essential for veterinary technicians. Veterinary anatomy is the science that relates to different parts of an animal’s body. Physiology explains how those body parts function individually and collectively. The information presented in this course is an introduction to the information you'll study in your Anatomy and Physiology courses. As a veterinary technician, you'll use and apply your knowledge in anatomy and physiology to perform physical exams, take patient vitals, monitor anesthesia, and provide treatments. © 2024 PF High School, LLC Page: 12 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical © 2024 PF High School, LLC Page: 13 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Quick Check Which body system are the kidneys a part of? Urogenital system Gastrointestinal system Integumentary system Musculoskeletal system Lesson 2 Section 1 Practice Question 1 Which of the following responsibilities is only for a veterinarian to complete and not the veterinary technician? Question 2 It’s important to know how to speak to a client and how to ask questions. Which of the following questions meets best practices for interviewing a client? Question 3 Which body system includes hooves and horns? Answers Question 1: While veterinary technicians are permitted to perform physical examinations, the veterinarian is primarily responsible for this task and only the veterinarian can make a diagnosis. © 2024 PF High School, LLC Page: 14 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Question 2: “How many times a day do you feed Auggie?” is a better question to ask because it involves the client providing more information than a “yes” or “no” response. Question 3: Integumentary system includes skin, scales, hair, nails, hooves, horns, and feathers. © 2024 PF High School, LLC Page: 15 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Practice: The Examination Open Link © 2024 PF High School, LLC Page: 16 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Key Points The most common veterinary procedure is the physical examination. Veterinary technicians are permitted to perform physical examinations, but the veterinarian typically reviews and con rms the ndings. Properly executed restraint is humane and crucial to the safety of both the animal and the sta members. The medical history is the rst step of every veterinary physical examination. The medical history provides information to help the veterinarian evaluate the patient’s physical status, develop a diagnosis, create a treatment plan, and o er a prognosis. When interviewing clients, make sure to ask questions that require the client to give you a detailed response. The signalment is the overall patient description and includes the breed, gender, age, and reproductive status (whether the animal has been neutered). The key components of thorough history taking are identifying the primary or presenting problem, taking a medical history, taking the environmental history, and reviewing the body systems. The environmental history is the animal’s current living situation and includes the travel history. © 2024 PF High School, LLC Page: 17 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Physical Examination The physical examination for an animal patient is important. Your study material discusses some of the responsibilities involved in the physical examination such as collecting vital statistics, the heart rate, the respiratory rate, taking the temperature, and reviewing the body systems. Proceed through this lesson. There’s no textbook reading for this lesson. © 2024 PF High School, LLC Page: 18 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Physical Exam and Vital Statistics The physical examination tells you more about an animal patient than any other single diagnostic tool. There are different parts to the physical exam of an animal. Part of the exam is collecting vital statistics. This includes weight, heart rate, respiration rate, mucous membrane color, capillary refill time, and body temperature. The combination of physical examination and history may yield a definitive diagnosis. At the very least, the physical examination guides decisions about diagnostic testing, whether the test involves laboratory analysis or diagnostic imaging. The veterinarian examines the animal thoroughly and systematically, observing, touching, and listening to the animal’s body. Before this examination begins, you may be charged with the task of collecting the animal’s vital statistics. The vital statistics include weight, temperature, heart rate, pulse, and respiration rate. You’ll also need to prepare the equipment needed for the physical examination. Vital signs include weight, heart rate, respiration rate, mucous membrane color, capillary refill time, and body temperature. When collecting vitals, always begin with the least invasive procedure (weighing) and end with the most invasive procedure (taking the temperature). This ensures that an animal won’t become unnecessarily stressed while taking the temperature, resulting in a potential inability to accurately assess the heart rate and respiration. © 2024 PF High School, LLC Page: 19 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Weight It’s important to weigh an animal every time it visits the veterinarian and to record this weight accurately in the medical chart. Unintended weight loss or gain can be a sign of illness, and weight changes aren’t always apparent just from looking at an animal. Many animals with thick coats can gain or lose several pounds without much change in appearance. For cats and dogs less than 20 pounds, it’s recommended to use an infant scale. If an infant scale isn’t available, it’s acceptable to use a platform scale. For challenging cats, it’s also acceptable to weigh the cat in the carrier, remove the cat from the carrier, weigh the carrier without the cat, and subtract the second number from the first to arrive at the cat’s weight. For horses you may use a walk-on scale. If a walk-on scale is unavailable, you can use a heart- girth tape, a customized tape measure. Place the heart-girth tape around the horse’s chest, in its heart area just behind the elbow (thus measuring its “heart girth”). This tape has a conversion chart that translates the circumference of the horse’s chest into total body weight. Dogs For dogs greater than 20 pounds, the use of a platform scale is recommended. © 2024 PF High School, LLC Page: 20 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Cats Cats can usually be weighed using an infant scale. Small Animals For small animals weighing less than two pounds, it may be helpful to use a gram scale or kitchen scale. © 2024 PF High School, LLC Page: 21 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Heart Rate The heart rate is obtained via auscultation, or listening to, the heart sounds with a stethoscope. Ideally, the veterinary technician will auscultate the heart while simultaneously palpating (feeling) the femoral pulse to ensure that the heart beats heard directly correspond with the pulses felt. Here are the steps to properly use a stethoscope: 1. Insert the earpieces into your ears with the tips facing forward, toward your nose. 2. Placethe diaphragm of the stethoscope on the patient’s thorax (chest) near the left axilla (armpit). In small animals, the heart may be heard most clearly in this location. 3. Count each beat over a 15-second timeframe and multiply this number by 4. The result is the number of beats per minute. 4. Listenfor normal and abnormal heart sounds. In small animals, the normal heart sounds include a “lub dub.” The “lub” correlates with the mitral and tricuspid valve closures, while the “dub” correlates with the aortic and pulmonic valve closures. a. Arrhythmia – abnormal rate or rhythm i. Bradycardia – abnormally slow heart rate ii. Tachycardia – abnormally fast heart rate iii. Respiratory Sinus Arrhythmia – heart rate cyclically decreases when the animal exhales and increases when the animal inhales b. Murmur – abnormal “swooshing” sounds relating to the improper closure of heart valves or other cardiac diseases c. Other – Mu ed sounds or challenges in hearing the heartbeat should be brought to the veterinarian’s attention right away. 5. Disinfect the earpieces and diaphragm after use. Vet Tech Connection Heart murmurs occur when there’s turbulent blood flow through the heart valves and can result from any disease that affects the heart. When performing a physical exam and collecting a patient’s vital signs, veterinary technicians may be the first to hear a heart murmur in their patients. Murmurs create a “swoosh” or “woosh” sound that can be identified upon auscultation. In veterinary medicine, several factors influence how heart murmurs are characterized, and graded based on how loud they are, or their intensity. The Merck Veterinary Manual describes how heart murmurs intensity is classified. © 2024 PF High School, LLC Page: 22 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical An animal’s heart rate and pulse rate should be identical, but they are not the same thing. As the heart pumps blood through the arteries, the arterial walls expand and contract. A pulse is created via this pressure on the arterial walls and may be palpated with your fingers. Here are the steps to palpate the animal’s femoral pulse: 1. With a few fingertips (but not the thumb), locate the femoral artery by palpating the medial (inner) thigh, where the femur bone meets the trunk of the body. 2. Apply moderate digital pressure until a consistent pulsation is felt. 3. Count the number of pulses over 15 seconds and multiply this number by 4 to determine the pulses or beats per minute. 4. Notethe synchronicity of the pulse with the heartbeat. There should be a pulse for every heartbeat. A mismatch is cause for concern and should be brought to the veterinarian’s attention. 5. Note the character of the pulse. a. Strong – easily palpated b. Weak – di cult to palpate c. Bounding – excessive pressure d. ready – weak and feels like a small thread moving under your ngers Reference Links:- Stethoscope A stethoscope is used to check the animal’s heart rate and heart sound quality. © 2024 PF High School, LLC Page: 23 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Femoral Pulse The animal’s pulse should match its heartbeat. © 2024 PF High School, LLC Page: 24 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Respiratory Rate Your next vital statistic is the respiratory rate, expressed as breaths per minute. A breath, or full respiration, is one inhalation and one exhalation. Respiration may be determined by auscultation or direct visualization. Here are the steps to auscultate a respiratory rate: 1. Insert the earpieces into your ears with the tips facing forward, toward your nose. 2. Placethe diaphragm of the stethoscope on the patient’s thorax (chest) on the left lateral side at approximately the third rib. 3. Count each breath over a 15-second timeframe and multiply this number by 4. The result is the number of breaths per minute. 4. Auscultate 4 lung fields in total for depth, effort, and character: right ventral, left ventral, right dorsal, left dorsal. 5. Note the respiratory depth and effort. a. Is the animal taking deep or shallow breaths? b. Is it e ortless or di cult for the animal to breathe? 6. Listen for normal and abnormal lung sounds and character of respirations. Inhalations and exhalations should sound smooth and almost breeze-like. a. Crackles – harsh noises that sound like crumpling cellophane paper b. Wheezes – high pitched musical noises heard on expiration c. Stridor – high pitched noises on inspiration or expiration d. Di culty in hearing air ow in any lung eld is a cause for concern and should be brought to the veterinarian’s attention right away. 7. Fordirect visualization, observe the number of times the animal’s chest/ribcage moves in and out over a 15-second period. Multiply the result by 4 to obtain the breaths per minute. When counting respiratory rate, the veterinary technician should also observe respiratory effort and note if the animal is excited, panting, or having difficulty breathing. Next, determine the mucous membrane color. This is a rough indicator of perfusion, or blood flow to the organs and peripheral tissues. Mucous membranes should be a bubble-gum pink color in dogs and a slightly lighter pink color in cats. Here are the steps to determine the mucous membrane color: 1. Observe the color of the mucous membranes of the mouth, the gums. 2. For fractious patients, or if the mouth is inaccessible, you may observe the mucous membrane color of the third eyelids or conjunctiva, the vulva, or the prepuce. 3. Abnormal colors 1. Pale or white – shock 2. Blue or purple (cyanotic) – hypothermia, cardiac or respiratory disease © 2024 PF High School, LLC Page: 25 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical 3. Red (hyperemic) – shock or hyperthermia The capillary refill time (CRT) also reflects the perfusion of peripheral tissues. The CRT should be less than two seconds. A CRT greater than two seconds is cause for concern and should be brought to the veterinarian’s attention right away, as it could indicate cardiovascular dysfunction. Here are the steps to assess the CRT: 1. Firmly depress the mucous membrane with your ngertip. is is most easily accomplished on the gums. 2. Allow the gums to blanch or turn white. is action forces all of the blood from the capillaries. 3. Remove your nger and observe the gums as blood ows back into the capillaries, and the gums return to their original color. 4. Count the number of seconds from when you release pressure from the gums to when the color returns to the gums. © 2024 PF High School, LLC Page: 26 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Quick Check Which of the following is considered full respiration? One inhalation with one exhalation, and another inhalation One inhalation One inhalation and one exhalation © 2024 PF High School, LLC Page: 27 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Temperature, Pulse, and Respiratory Rates An animal’s temperature can be an important barometer of its overall health. Many illnesses, including bacterial infections, viral infections, and certain types of cancer, will elevate body temperature. Keep in mind that excitement commonly increases temperature one or two degrees above normal. To take a temperature with a digital thermometer, follow these steps: Step 1 Wipe the thermometer clean with alcohol. Step 2 Turn the thermometer switch to the “on” position. Step 3 If available, place a cover slip over the thermometer. Then, coat the end of the thermometer with lubricating jelly to ease insertion. Step 4 Insert the thermometer one inch into the rectum until a beeping sound is heard, indicating that the temperature has been recorded. Step 5 Remove the thermometer; read and record the result. Step 6 Remove the cover slip and wipe the thermometer clean with alcohol. The general rule for taking a large animal’s temperature is to insert the thermometer one inch into the rectum for one minute. Large-animal rectal thermometers are available for this purpose. Remember when using these thermometers that you’re reading core body temperature, and this may not be the same as the rectal temperature if the animal’s body temperature is fluctuating rapidly. It takes time for the rectal temperature to catch up to a change in the core body temperature. The following table provides the normal temperature, pulse, and respiratory rates for domestic animals. © 2024 PF High School, LLC Page: 28 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The following interactive further discusses temperature, pulse and respiratory rate. External Reference(https://lessons.pennfoster.edu/savi/INY00129/story.html) © 2024 PF High School, LLC Page: 29 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Examination Once vital signs have been observed and recorded in the medical chart, the veterinarian begins the examination. The typical physical examination proceeds systematically from head to tail. A comprehensive examination evaluates everybody system, preferably by region. Some veterinarians evaluate the area of the presenting problem first; others save the presenting problem for last to avoid overlooking other problems the owner may have missed. While the veterinary technician may perform a physical exam, this responsibility primarily belongs to the veterinarian, especially for annual exams. Select each tab to learn more about the examination. Observation Observation involves careful visual inspection of each body part and evaluating the animal as a whole. The exam starts by observing the animal from a distance and noting demeanor, posture, and gait (manner of walking). The veterinarian examines appearance for ways to identify any problems, including correct sizes, colors, opacity, and transparency. Palpation Palpation involves touch; how do the various body tissues and structures feel? Is something soft that should be hard, or hard that should be soft? Is the texture what it ought to be: rough, smooth, lumpy, flat? Does the animal flinch when the veterinarian touches certain areas? Auscultation Auscultation involves listening with a stethoscope to the body’s various sounds. The sites typically associated with a stethoscope are the heart and lungs, but veterinarians also listen to the sinuses, the windpipe, the stomach, and the intestines. © 2024 PF High School, LLC Page: 30 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The veterinarian is looking to answer certain questions: Are these sounds normal? If not, what’s the nature of the abnormality? What might explain it? Could the explanation be causing or contributing to the animal’s problem? Is the explanation a separate problem? The first step in the systematic examination is to view the animal from head to tail to get an overall impression of its outward appearance and gait. In this preliminary head-to-tail examination, the veterinarian observes the superficial musculoskeletal and nervous systems. Indicators for these systems include how the animal moves down a length of hallway or around the exam room and whether there’s an abnormal gait, pronounced limp, or dragging of limbs. All of an animal’s legs should be the same size, length, shape, and thickness. Note whether the animal displays any pain when it gets up and ask the owner if any pain is evident after play. The veterinarian must observe the animal’s general behavior and note its demeanor: does the creature seem alert, responsive, aggressive, or lethargic? All abnormalities and the animal’s overall bearing should be recorded. Then, the examination can move to the individual body systems. Lesson 2 Section 2 Practice Question 1 Which of the following means an animal has an abnormally fast heart rate? Question 2 Which of the following means an animal has an abnormally slow heart rate? Question 3 Which of the following colors of mucous membrane could indicate cardiac disease? Answers Question 1: Tachycardia is when an animal has an abnormally fast heart rate. Question 2: Bradycardia is when an animal has an abnormally slow heart rate. Question 3: If the mucous membrane appears blue or purple, it could indicate hypothermia, cardiac disease, or respiratory disease. © 2024 PF High School, LLC Page: 31 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical © 2024 PF High School, LLC Page: 32 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Practice: Collecting Vital Sign Information Open Link © 2024 PF High School, LLC Page: 33 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Integumentary System The first system is the integumentary system, which comprises skin, hair, nails, and/or scales. The integumentary exam will start with the animal's coat and should involve the use of a flea comb to check for ectoparasites (external parasites). A normal coat is typically soft and completely covers the body. The coat needs to be observed for any abnormalities, such as brittleness, oiliness, stiffness, or alopecia (hair loss). If alopecia is observed, record a description of the affected areas in the patient’s record. Be sure to describe the appearance of the alopecia itself, for example, symmetrical, patchy, random. Of course, the coat of the legs should be observed, in addition to that of the head and main body. Once the coat is examined, the veterinarian will examine the skin, which should be colored a healthy light pink free of erythema (redness of the skin), rawness, flea dirt, lesions, papules (pustules), bruises, and masses on the skin. When areas of alopecia are found, the skin color and condition (normal, crusty, scabbed, and so on) should be recorded. When masses, lesions, or papules are found, record their location on the body, their location (on or under the surface of the skin), and their size and shape. The surface of the legs and paws are also part of the integumentary system and must be examined as well. The pads of the paw and nails should be examined for moisture, discoloration, and other visible abnormalities. © 2024 PF High School, LLC Page: 34 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical © 2024 PF High School, LLC Page: 35 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Checking the Turgor Pressure The final step of the integumentary examination is evaluation of the turgor pressure, or normal elasticity of the skin, for evidence of dehydration. Turgor pressure is measured by lifting a patch of skin and twisting it. When the skin is released, the length of time it takes for the skin to return to normal is measured and recorded. This length of time serves as the level of turgor pressure. The following table shows the percentage of dehydration present based on various levels of turgor pressure. Turgor is usually assessed on the skin between the shoulder blades. Ratio of Turgor Pressure to Dehydration Level: Turgor Pressure % Dehydration 0-1 second Less than 5% 2-4 seconds 5-8% 5-10 seconds 8-10% 10-30 seconds 10-12% The most common abnormalities seen when examining the integumentary system are lesions (alopecia, lumps, and bumps), papules, crusting, scabs, erythroderma, fleas, and flea dirt. © 2024 PF High School, LLC Page: 36 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Respiratory System The respiratory system examination starts with the nose and mouth before moving to the throat and thorax. The veterinarian will examine the nose for discharge, inspect the size and state of the nostrils, and watch for any sneezing or coughing. Any discharge should be described in the patient’s record, noting which nostril the discharge is coming from, and the substance’s color and consistency. The veterinarian will examine the nostrils for narrowing/thickening and palpate the bridge of the nose for lumps and soft areas and to elicit coughing or sneezing. From the nose and sinuses, the exam moves to the oral cavity. The veterinarian will then open the animal’s mouth to examine the tonsils, pharynx, and soft palate. These areas should be studied for swellings, masses, ulcerations, foreign objects, and elongation of the palate. The soft palate will flutter when the animal breathes. Now, the examination moves to the throat. The veterinarian will palpate the throat to elicit coughing and/or sneezing, as well as to feel for lumps and masses. The throat should also be auscultated with a stethoscope to listen for the even flow of air as the animal breathes. © 2024 PF High School, LLC Page: 37 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Next, the veterinarian will auscultate the thorax with a stethoscope to listen for the even flow of air both in and out of the lung fields. The primary objective of lung auscultation is to catch any respiratory noises as the animal breathes. The animal should ideally be standing for this procedure. The veterinarian will listen in at least four locations: right ventral, right dorsal, left ventral, and left dorsal. Any abnormality in the tone or flow of air in or out of the lungs, such as rales (crackling or rattling sounds during inhalation), should be noted and described. Note any abnormalities in the patient’s record, including the quadrant and side where they’re detected, as well as the patient’s respiratory rate. © 2024 PF High School, LLC Page: 38 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Circulatory System Examination of the circulatory system starts at the mouth. The veterinarian will start by studying the color of the mucous membranes, which are normally a moist pink, and describe any variation from this in the patient’s record. In addition to membrane color, capillary refill time should be checked, and the result recorded. Capillary refill time is checked by pressing on the gums until they turn white (blanching or disrupting blood flow), then releasing the pressure to allow blood flow to return. Upon release, time how long it takes for the gums to return to their original color. This is normally two seconds or less and is a rough measure of circulation quality. The examination now moves to the throat, where the jugular veins are examined for pulsing. If the jugular veins are pulsing, this should be recorded in the patient’s records. Moving along to the thorax, the veterinarian will auscultate the heart for abnormalities in rhythm and sound. Auscultation in this area involves listening to the point of maximal intensity (PMI) of each of the heart’s valves: pulmonic, mitral, tricuspid, and aortic. Any abnormalities, such as swishing sounds, should be noted on the record, along with the valve in which it seems to be loudest. The veterinarian may also obtain a heart rate again during auscultation. The pulse, found in the femoral artery of small animals and facial artery of large animals, will be checked for strength and count. Any abnormality in the pulse beat should be recorded in the patient’s record. Pulses should be strong and synchronous, matching the beats of the heart. The veterinarian will be checking the animal for a pulse deficit, the difference, if any, between the heartbeat and pulse beat. A pulse deficit is ascertained by feeling the pulse beat while listening to the heartbeat. Both beats should occur at the same time; if not, the pulse beat should run immediately after the heartbeat. If the pulse beat is notably slower than the heartbeat, or if the pulse beat is missing, a pulse deficit exists. Any pulse deficit should be recorded in the patient’s record. © 2024 PF High School, LLC Page: 39 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Gastrointestinal System Examination of the gastrointestinal system begins at the mouth. The veterinarian will examine the oral cavity for healthy teeth and gums and observe for tartar, dental problems (such as fractured teeth, missing teeth, or misaligned teeth), and gum problems, specifically the color and general appearance of the gums (note the presence of pus, redness, or swelling). Both sides of the mouth are examined. The veterinarian will also check the oral cavity for masses, foreign bodies, and obstructions. Any abnormalities are recorded in the patient’s record. The throat is palpated for masses, obstructions, or foreign bodies in the esophagus. An abdominal exam follows the throat exam. With small animals, the veterinarian will palpate the cranial and caudal abdomen, gently but firmly pressing the fingers toward each other to feel the abdominal organs. The key is to apply enough pressure to feel these organs but not so much pressure that the animal tenses the abdomen. The abdominal organs should be palpated for consistency, size, and shape. But as with the oral cavity and throat, the veterinarian will also be palpating for masses and other abnormalities, such as pain upon palpation. Any pain can be localized by palpating the abdomen and noting the area (and organ, if possible) in which pressure causes discomfort. Existing pain or too heavy a palpation can cause an animal to tense its abdomen, making the exam more difficult. Abdominal palpation is a technique that takes practice to perfect. Because large animals have such large organs that are difficult to palpate, the veterinarian will use a stethoscope to auscultate the abdomen for gut sounds. This can also be done for small animals. Abdominal gut sounds are caused by peristalsis, the involuntary constriction and relaxation of the muscles of the intestine or another canal, creating wavelike movements that push the contents of the digestive tract forward. An examiner should hear one to two gut sounds per minute in a large animal and must listen for a full minute to obtain and record an accurate number of sounds. © 2024 PF High School, LLC Page: 40 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Finally, the veterinarian will examine the rectum for evidence of discharge, masses, enlarged anal glands, and/or anal infections. © 2024 PF High School, LLC Page: 41 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Urogenital System Most of the female urogenital system is examined during abdominal palpation. The female’s mammary glands need to be checked for masses, discharge, enlargement, and/or growths. The veterinarian will examine the vulva for discharge, swelling, and irritation. A male’s testicles should be palpated for presence, size, shape, and consistency. The veterinarian will also palpate the penis to check its shape and smoothness, as well as to detect any masses, lumps, or discharge. Record any abnormalities in the patient’s record. Palpating the Mammary Glands The veterinarian or technician palpates the mammary glands. A Dog Being Examined for Tumors The veterinarian or technician examines the genitalia for tumors, cysts, and prolapsed or redundant tissue. © 2024 PF High School, LLC Page: 42 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Musculoskeletal System The veterinarian will palpate the muscles of the body for atrophy (wasting away), enlargement, heat, and pain. The leg bones are palpated for fractures, pain, and masses. Each joint should be moved through its full range of motion. As the joints are exercised, the veterinarian will both feel and listen for crackling, popping, and sounds of pain and observe any loss of motion. An animal’s toes are included in the joints and should also be evaluated. The veterinarian will apply pressure to the muscles around the spine, moving from the neck to the tail and observing any signs of pain. Any abnormalities are recorded in the patient’s record. A body condition score (BCS) and muscle condition score (MCS) should also be obtained. The BCS represents the degree of slimness or obesity on a scale of 1–9, while the MCS represents the degree of muscle present on a scale of 1–4. For the assessment form for the BCS and MCS refer to BCS & MCS(https://www.aaha.org/aaha-guidelines/life-stage-canine-2019/nutritional- assessment/body-and-muscle-condition-score/). © 2024 PF High School, LLC Page: 43 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Nervous System During the physical examination, the veterinarian will perform a perfunctory review of the animal’s nervous system. The eyes are examined for palpebral and menace reflexes. Evaluate the palpebral reflex by touching the medial corner of the eye to elicit a blink. Both eyes should be tested. The menace reflex is evaluated by moving an open palm rapidly toward the animal’s eye. This should also elicit blinking. For an accurate menace reflex evaluation, the palm should never come in contact with the animal. Any blinking delay is recorded in the patient’s record. A light is used to evaluate the eye pupils. Direct the light toward the eye to constrict the pupil, then pull the light back. The pupil should dilate to its pre-exam state. Any lack or delay of constriction or dilation should be recorded in the patient’s record. Proprioception, or the righting reflex, should be present in each of the four paws or hooves. The veterinarian will flex the animal’s paw and place it on the exam table or floor. The animal should immediately return the paw or hoof to its normal position. If the animal doesn’t right its foot or delays in doing so, this should be noted in the record. © 2024 PF High School, LLC Page: 44 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Lymphatic System The lymphatic system exam evaluates an animal’s palpable peripheral lymph nodes, specifically the submandibular, prescapular, axillary, inguinal, and popliteal lymph nodes. External Reference(https://lessons.pennfoster.edu/savi/INY00130/story.html) © 2024 PF High School, LLC Page: 45 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Eyes and Ears The eyes and ears don’t fit neatly in any one system, so they’re examined as separate organs. The veterinarian will examine the eyes for signs of infection or irritation. First, they’re observed for discharge and swelling. Any eye abnormalities should be recorded in the patient’s record. Any discharge should be evaluated for color, consistency, and location (for example, left, right, or both eyes). The eyelashes and lids are observed for abnormal appearance (for example, lashes rolled toward the eyeball or pulled away from the eyeball). The conjunctiva, the membrane that covers the eyeball and the inside of the eyelids, is observed for color; its normal color is pink. The sclera, or white part of the eye, is also evaluated for color; its normal color is white. The cornea, which is the transparent layer that covers the very front of the eye, is observed for clarity. Any cloudiness of the cornea should be recorded, including its specific location. The retina is examined with an ophthalmoscope. © 2024 PF High School, LLC Page: 46 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The veterinarian will examine the ears via palpation and visual observation. Palpate the base of the ear and the ear pinna for masses and fluid. Also observe for alopecia, discoloration, and swelling. Lifting the ear pinna allows the veterinarian to observe the ear canal for discharge, discoloration, and irritation. Take a swab of any discharge you find for later lab analysis. The interior of the ear canal is then evaluated with an otoscope, taking note of any growths, masses, discharge, or wax buildup. The otoscope should also be used to evaluate the tympanic membrane (ear drum). A healthy tympanic membrane appears as an intact, milky-colored surface. If it isn’t intact, this fact should be recorded. When performing a nose-to-tail exam, multiple body systems are often assessed simultaneously. For example, opening the mouth allows for examination of respiratory, circulatory, and digestive elements. All of these elements are examined by opening the mouth one time instead of opening the mouth three separate times for each body system. © 2024 PF High School, LLC Page: 47 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Equipment Needed for a Physical Examination Take a closer look at the equipment the veterinarian uses during the physical examination and how you can keep it clean and in good working order. Prior to a physical examination, the veterinary technician may be responsible for ensuring that the examination room and the equipment needed to perform the examination are functional, clean, and ready for the veterinarian’s use. The ophthalmoscope and otoscope both consist of two parts: the body and the head. The body of each holds a rechargeable battery, which is the power source for the light located in the head of the instrument. The head of each instrument contains a lens for magnifying the body part. A variety of cone sizes are available to be used with the otoscope to localize the viewed area. Ophthalmoscope The veterinarian or technician uses the ophthalmoscope to examine the inner chamber of the eye. Ophthalmoscope Base The ophthalmoscope can also be used without any attachments. © 2024 PF High School, LLC Page: 48 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Charging an Ophthalmoscope An ophthalmoscope should be recharged after the veterinarian is done with it. Otoscope Attachments The otoscope comes with different size ear cones. © 2024 PF High School, LLC Page: 49 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The batteries of the ophthalmoscope and otoscope should be recharged whenever they aren’t in use. This is done by removing the head and plugging the battery into a power source. The magnification area of the head and the cones can be cleaned with a diluted solution of disinfectant and water. The diaphragm of the stethoscope can also be cleaned with this solution. Cleaning the Exam Equipment Clean the magnification area of the head and scope with a diluted solution of disinfectant and water. Cleaning the Diaphragm of the Stethoscope Clean the diaphragm of the stethoscope with the same type of solution. If you’re assisting a large-animal veterinarian, you’ll also need to help prepare the equipment and learn how to keep it clean. Instead of working in an examination room, however, you’ll probably be working on-site at a farm. © 2024 PF High School, LLC Page: 50 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Often, you’ll spend the day traveling from farm to farm. In this case, it’s very important not to carry germs from one farm to another. Most mobile veterinary vans include the equipment and water necessary for cleaning your boots before entering a new farm. Thoroughly remove any debris from your boots with a scrub brush. Lesson 2 Section 2 Practice Question 1 Which of the following is considered a part of the integumentary system? Question 2 What’s turgor pressure? Question 3 What’s the purpose of testing an animal’s turgor pressure? Answers Question 1: The first system is the integumentary system, which comprises skin, hair, nails, and/or scales. Question 2: The final step of the integumentary examination is evaluation of the turgor pressure, or normal elasticity of the skin. Question 3: You evaluate the turgor pressure of an animal for evidence of dehydration. © 2024 PF High School, LLC Page: 51 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Practice: The Body Systems Open Link © 2024 PF High School, LLC Page: 52 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Key Points The physical examination tells more about an animal patient than any other diagnostic tool. A veterinary technician may have the task of collecting the animal’s vital statistics, such as weight, heart rate, respiration rate, mucous membrane color, capillary re ll time, and temperature. Animals are typically weighed with a oor scale, table scale, or walk-on scale or with a heart-girth tape. Heart rate and respiration rate are obtained via auscultation which also allows for the identi cation of abnormal heart and lung sounds. Mucous membrane color and CRT are indicators of perfusion. Temperature is taken with a rectal digital thermometer and should be taken last because it's the most invasive vital statistic to obtain. A comprehensive, head-to-tail examination evaluates each body system including: integumentary, respiratory, circulatory, gastrointestinal, urogenital, musculoskeletal, nervous, and lymphatic systems and the eyes and ears. Prior to a physical examination, the examination room and the equipment needed to perform the examination must be functional, clean, and ready for the veterinarian’s use. © 2024 PF High School, LLC Page: 53 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Medical Record A medical chart contains important information regarding the animal’s current and previous medical conditions and history. You’ll study how to complete a medical record and how to use the SOAP format. Your study material also discusses the different components of a medical record or chart. Information on these charts include observation and measurable data. Proceed through this lesson. There’s no textbook reading for this lesson. © 2024 PF High School, LLC Page: 54 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Take a Break Keep going! Did you know? A rooster’s crow can be as loud as a running chainsaw. To protect their hearing, roosters tilt their head back so that a bit of soft tissue completely covers their ear canal, like a built- in ear plug. © 2024 PF High School, LLC Page: 55 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Medical Record The medical record, or medical chart, is a legal document belonging to the veterinary hospital or owner of the practice. Any time a veterinarian sees an animal, someone records information in the animal’s medical record. Medical Records The purpose of the medical record is to record all pertinent information about the animal’s current medical condition, the animal’s medical history, and anything else regarding the animal’s health. To protect the animal, the owner, and the veterinary practice, the medical record must be complete, current, and accurate. The sections of a medical record include the: Owner’s identity and contact information Animal’s name, species, breed, color, gender, age, and microchip if present Diagnostic testing and results Detailed examination notes, including diagnoses, treatments, and prognoses Dates of vaccination Copies of instructions to the owner for follow-up care All notes of communication between the clinic and the client Medical Record Organization While medical records must be legible and orderly, it’s the veterinarian’s job to determine their format and layout. This format varies from practice to practice but should be consistent within a practice. Your job is to learn your particular practice’s medical chart design so that you can retrieve information and follow patient-care instructions quickly and efficiently. If not electronic, veterinary medical charts typically follow full-page formats. Full-page charts are 81⁄2-by-11-inch pages, fastened to the inside of a folder by a two-prong folding clip. Medical records are usually put together in reverse chronological order, the oldest information at the bottom, the newest on top. This information, as in human medical records, is most often problem-oriented. Each problem that an animal has is worked up logically and completely, and the results are recorded in the medical chart. The first page of the medical chart is usually the master problem list. This page serves as an index or table of contents for the rest of the record. It may list abnormalities the owner has noticed, abnormal laboratory test results, or a complete diagnosis. The master problem list directs you to something specific in the medical chart. It also lists vaccinations (often abbreviated as vax history) and other routine procedures. The Medical Record Download the blank medical record template(https://courses.portal2learn.com/content/enforced/32846- VET104_RS_1/VET102LB/html/../Medical%20Record.docx) and fill it out as demonstrated, using a pet of your own or a friend’s as an example. © 2024 PF High School, LLC Page: 56 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical © 2024 PF High School, LLC Page: 57 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Using the SOAP Format The widely accepted format, SOAP, divides a physical exam medical note into four sections. Each time a patient is evaluated or each day an animal is hospitalized, the progress notes should be written and categorized following the SOAP format notation. Any notations that are made in the record should follow this format. SOAP is an acronym for: Subjective Objective Assessment Procedure or Plan Subjective Data Subjective data include the reason the animal is being presented to the veterinary clinic and observations of the animal and its condition that can’t be quantified. The patient history details obtained from the client are part of this section. The subjective data section is for information that’s subject to the observational and descriptive powers of the evaluator. Objective Data Objective data is quantifiable. It can be and is measured. This is information that doesn’t depend on any observational and descriptive powers higher than the ability to take a reading and record it. Objective data about the animal include weight, temperature, pulse, respiration, laboratory data, and details of the physical exam of each body system. Assessment The assessment section of the progress notes includes possible or probable explanations for the problem, called differential diagnoses. Assessment becomes the roadmap for diagnostic testing, guiding the veterinarian’s testing choices. The assessment section also includes the patient’s diagnosis. © 2024 PF High School, LLC Page: 58 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Only the veterinarian uses the assessment section. The Procedure or Plan The procedure or plan section of the SOAP format outlines the plan for treatment as well as the prognosis. This section includes any problems that should be monitored, follow-up care instructions to the client, medications prescribed, and other recommendations. It takes practice to get in the habit of entering and retrieving information from the problem- oriented medical chart and to use the SOAP format. However, your reward is the consistency and continuity of information that stems from proper organization. An organized method of entering and retrieving information in the medical record is the only way to ensure that animals receive the quality of care they deserve. Learning how to keep your veterinary practice’s medical charts helps the animals in your care. It also helps you become a more valuable veterinary technician. Download the blank SOAP template(https://courses.portal2learn.com/content/enforced/32846- VET104_RS_1/VET102LB/html/../New%20SOAP%20Sample%201.docx) and fill it out using a pet of your own or a friend’s as an example. Lesson 2 Section 3 Practice Question 1 Who’s the owner of a medical record or medical chart? a. e veterinary technicians b. e patient’s owner c. e veterinary hospital or owner of the practice d. e administration team of the practice Question 2 The first page of a medical chart a. provides a summary of what needs to be done the next visit. b. serves as a summary of the patient’s most recent visit and tests and/or results of those tests. c. provides the owners contact information and the patient’s information. d. serves as an index or table of contents for the rest of the record. Question 3 SOAP is an acronym for a. subjective, opinion, assessment, and purpose. b. subjective, objective, ailment, and procedure or plan. © 2024 PF High School, LLC Page: 59 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical c. subjective, objective, ailment, and purpose. d. subjective, objective, assessment, and procedure or plan. Answers Question 1: The medical record, or medical chart, is a legal document that belongs to the veterinary hospital or owner of the practice. Question 2: The first page of the medical chart serves as an index or table of contents for the rest of the record. Question 3: SOAP is an acronym for subjective, objective, assessment, and procedure or plan. © 2024 PF High School, LLC Page: 60 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Practice: Medical Records and SOAP Open Link © 2024 PF High School, LLC Page: 61 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Key Points The medical record, or medical chart, is a legal document containing all pertinent information about the animal’s current medical condition, medical history, and anything else that applies to the animal’s health. The medical record, or medical chart, belongs to the veterinary hospital or owner of the practice. Medical records are typically put together in reverse chronological order: the oldest information at the bottom and the newest on top. SOAP is an acronym formed by the rst letters of the words subjective, objective, assessment, and procedure or plan; this stands for the sections of the progress notes. Subjective data includes the reason the animal is being presented to the veterinary clinic and observations of the animal and its condition that can’t be quanti ed. Objective data is quanti able which means it can be measured. The assessment section of the progress notes includes possible or probable explanations for the problem, and the procedure or plan. Each major problem on the master problem list should have its own SOAP entries. © 2024 PF High School, LLC Page: 62 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Educating the Client Client education allows the client to understand an animal’s problems and aid in solving them. You’ll study what your role is in client communication, and how to communicate clearly and effectively. The veterinary technician listens to, and supports, the conversations the veterinarian has with the client. Proceed through this lesson. There is no textbook reading for this lesson. © 2024 PF High School, LLC Page: 63 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Client Education Client education is a general term that covers many of the client’s interactions with the practice. Most of these interactions are with the veterinarian. Though much of the veterinary healthcare team’s job is examining the animal and prescribing a course of treatment, another crucial step in the animal-care process is educating the client. The animal’s recovery and health also depend on the client’s ability to administer follow-up care. Without effective education, the client may neglect or misunderstand the animal’s follow-up care, possibly undoing all the veterinary team’s work and endangering the animal all over again. Some veterinarian-client interactions that are considered client education include: Talking informatively to the client during and following the examination Explaining postoperative care instructions when discharging a surgical patient Reviewing a prescription to make sure the client knows how much medication to give and when Simply answering the client’s questions is client education. Common topics for client education include nutrition, behavior, postoperative care, and wellness information. Other popular concerns include reproduction, puppy and kitten care, basic husbandry and management, and medication instructions. Though the veterinarian shoulders the primary responsibility for client education, a busy practice must rely on the veterinary support staff to assist. As a veterinary technician, you may explain to the client what the veterinarian is doing during the examination or follow-up the veterinarian’s client information with supplementary education. For example, if a veterinarian has recommended that a cat be put on a particular nutritional formulation, your job may be to discuss the formulation’s particular benefits with the owner. Although the veterinarian is the only member of the veterinary team able to write a prescription, the veterinary technician may be the one who explains to the owner the directions for administering the medication or the best way to get a dog to swallow a pill. © 2024 PF High School, LLC Page: 64 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical The Role of the Veterinary Technician in Client Education A successful veterinary technician listens to what the veterinarian says to the clients and learns the topics that the veterinarian considers important. Being able to educate clients makes you a more valuable resource to the practice because it allows the veterinarian to move on to other clients or do other things that only a veterinarian can do. For example, you can educate clients about their pet’s nutrition. As a veterinary healthcare team member, you’ll have access to self-study courses to help you understand the nutritional products your veterinarian recommends. When you’ve successfully completed such a course, you can follow up the veterinarian’s nutritional recommendation by making sure clients know why that particular formulation is best for their pets. Nutritional requirements vary by species and life stage. A puppy’s nutritional requirements, for instance, differ greatly from those of a geriatric dog. Many illnesses also change an animal’s nutritional requirements. You can see that this is an important area of client education. You may be able to help answer a client’s basic management and husbandry questions. Perhaps this is the client’s first experience with a particular breed of animal. With your veterinarian’s help, you can learn the appropriate answers to questions about proper shelter, housing, exercise, feeding, fencing, water requirements, and many other topics. The time you take educating clients is time you save the veterinarian, and also time that builds client loyalty, animal safety, and your value to the veterinary practice. The more you know about client education topics, the more you can improve the lives of the animals you encounter, the practice’s relationship to their owners, and your relationship to the practice. In your career as a veterinary technician, you may find yourself working with many different personalities. However, you should never discuss with a client anything of a personal nature about the veterinarian or any member of the veterinary staff. Remember that you’re part of a © 2024 PF High School, LLC Page: 65 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical team. To be viewed as a valuable member of your team, you should maintain a confidential, professional demeanor. Lesson 2 Section 4 Practice Question 1 What’s meant by the term “client education”? Question 2 Who’s primarily responsible for client education? Question 3 Who has authority to write prescriptions? Answers Question 1: Client education refers to the veterinary team providing the client with the proper knowledge they need for their pet and answering any of their questions. Question 2: The veterinarian holds the primary responsibility for client education. However, a busy practice must rely on the veterinary support staff to assist. Question 3: The veterinarian is the only member of the veterinary team able to write a prescription, the veterinary technician may be the one who explains to the owner the directions for administering the medication. © 2024 PF High School, LLC Page: 66 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Practice: Client Education Open Link © 2024 PF High School, LLC Page: 67 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Key Points Client education is a general term that covers many of the client’s interactions with the practice. Educating the client during the physical examination is crucial, as the animal’s recovery and health often depend on the client’s ability to administer follow-up care. Common topics for client education include nutrition, behavior, postoperative care, and wellness information. A good veterinary technician listens to what the veterinarian says to the clients and learns the topics that the veterinarian considers important. As a professional in the veterinary eld, you should maintain a con dential, professional demeanor no matter how close your relationships with clients become. © 2024 PF High School, LLC Page: 68 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical Reminder: Before Your Lesson Exam Before taking your lesson exam, try taking the pre-assessment again. It will help you identify topics to review. You can go back through any of your study material to review any concepts you’re still unsure of. When you feel you’re ready, then take your lesson exam. © 2024 PF High School, LLC Page: 69 of 71 © 2024 Career Step, LLC © 2024 Education Holdings 1, LLC © 2024 Sokanu Interactive Foundations of Veterinary Technology / History and Physical More Practice: History and Physical e physical examination is the foundation of diagnosis and treatment in veterinary medicine and the basis for the VPCR, veterinarian-client-patient relationship. While it may be performed by both veterinarians and veterinary technicians, only veterinarians may diagnosis an animal. Signalment refers to the