History and Physical Examination PDF

History and Physical Examination This initial contact with the client and patient can set the tone for the entire appointment  Extremely important part of the patient visit  A good, thorough history can free up the veterinarian to accomplish other tasks  Must be complete and accurate  History...

History and Physical Examination This initial contact with the client and patient can set the tone for the entire appointment  Extremely important part of the patient visit  A good, thorough history can free up the veterinarian to accomplish other tasks  Must be complete and accurate  History  Developing rapport      Friendly and welcoming Introduce yourself Explain what your doing Know client’s name, pet’s name, and gender Asking questions       Understanding/respectful owner Tailor to client’s understanding Clarify nature of current/previous problems Ask open-ended questions Avoid leading Avoid judgement History  Documenting   History form or under “S” in SOAP Legal document      Mistakes crossed out (not scribbled over)/initialed MISTAKE LS Legible and accurate Use appropriate medical terminology Remember the major focus is the presenting complaint but general background info is also important History  Signalment     Age Breed Sex Reproductive status Information  Background info  General management        How long has pet been owned Where/When it was obtained Previous medical problems Litter mates dx w/problems Travel Where is the pet kept Nutritional hx   Changes, fed anything unusual, got into something Preventive medicine   Vaccinations Heartworm, flea/tick Information  Background info (cont)  Behavioral info    Household info     Other pets ill Human illnesses Exposed to other animals Allergy history    What is normal Changes in behavior since ill Medications/food Previous blood transfusions Repro history    If spayed/neutered ask when If intact ask about recent breeding/last been bred Last heat cycle Information  Past pertinent medical history   Presenting complaint    Recurrent problems May be more than one Last normal Progression    Order in which problems appeared How long it lasted Better, worse, unchanged Information  Systems review          Coughing Sneezing Vomiting Diarrhea Polyuria Polydipsia Appetite Energy level Weight loss/gain Information  Medications        Type, dose, frequency Duration/reason for giving Helping patient Vitamins Supplements Topical medications Shampoos Information  It is important for the technician to observe the patient at presentation and repeatedly throughout the hospital stay in order to assess changes in patient status and report to the veterinarian   Technician observation of patient/monitor changes will guide nursing process Has attitude or mentation changed? Is the patient showing signs of pain? Is the pet’s gum color changing? Physical Exam    Most important diagnostic test Perform some evaluation of every system Visual inspection from a distance-subjective assessment       Mentation – BAR, QAR, dull, depressed, nonresponsive Increased RR or effort Lameness, ataxia present Visual deficits Swelling/asymmetry Body condition score (BCS)     1 out of 5 1=emaciated/thin 5=obese/fat 3/5 is ideal body wt. Physical Exam  Temperature, pulse, and respiration (TPR) Rectal Temperature ⁰F Heart Rate Respiratory Rate *Dog 100.0-102.2 60-160 bpm 16-32 bpm *Cat 100.0-102.2 140-220 bpm 20-42 bpm 99.0-101.5 28-44 bpm 6-16 bpm Cow 100.4-103.1 40-80 bpm 10-30 bpm Goat 101.5-104.0 70-90 bpm 15-30 bpm Sheep 102.0-104.0 70-90 bpm 15-30 bpm *Horse Physical Exam  Elevated Temperature  Fever (pyrexia) or hyperthermia    Infection, inflammation, neoplasia Mild elevation secondary to stress/anxiety Significant true hyperthermia     Heat stroke Certain drugs > 107 o F =organ dysfunction start gradual cooling mechanisms Decreased Temperature  Hypothermia  Impaired thermoregulation in ill patient   Chronic renal failure, hypothyroidism, CNS dz <90 o F requires immediate attention Physical Exam  Peripheral arterial pulses    Palpate to determine pulse rate/quality Femoral artery Auscult heart while palpating pulses   Should be identical Pulse deficit=absence of palpable pulse or change pulse quality w/audible heartbeat   Indicates abnormal heart rhythm ECG warranted Physical Exam  Peripheral arterial pulses (cont)  Pulse pressure=pressure feel when palpating pulse   Represents difference between systolic & diastolic arterial pressures Weak, moderate, strong    Weak=poor perfusion d/t decreased cardiac output (CHF or hypovolemia) or increased peripheral resistance (shock) Strong=bounding, tall, hyperkinetic; early septic shock, anemia, patent ductus arteriosus Evaluate blood pressure warranted Physical Exam  Respiratory rate/effort   Evaluate prior to stressful manipulation Visually then by auscultation  Increased inspiratory effort   Upper airway problem esp if noise (laryngeal paralysis) Increased expiratory effort  Small airway obstructive disease (asthma) Physical Exam   Oropharyngeal system  Teeth  Gingiva  Tongue  Hard and soft palate  Pharynx and larynx Lift lips/open mouth   Loss of appetite, difficulty chewing, halitosis Periodontal dz common Physical Examination  Eyes  Vision Walking exam room  Menace reflex  Drop cotton ball in front  Eyes  Adnexa  Physical Exam Swelling, redness, discharge, XS tearing, squinting  Globe-symmetric, enlarged, protruding, sunken  Conjunctiva, sclera, nictitating membrane, cornea  Physical Exam  Internal structures of eye  Iris-colored part of the eye   Swelling, discoloration, irregularity, masses Pupil-opening of iris     Lens-normally cannot see w/o special equipment   Constricted/dilated-What are the medical terms for these words? Anisocoria-different size pupils PLR Opacity-lenticular sclerosis vs cataract Anterior chamber-behind cornea in front iris   Should be clear Cloudiness, pus, blood Physical Exam Ears  Pinnae Canals Eardrum  Physical Exam  Respiratory   Nares Nasal discharge      Symmetry Severity Character Upper airway noise  Sneezing, stertor or stridor Auscultation  Crackles-inspiratory presence of fluid w/in alveoli (pulmonary edema)  Wheezes-inspiration &/or expiration air moving through a narrowed airway (feline asthma)  Lack lung sounds-ventral lung fields (pleural effusion); dorsal lung fields (pneumothorax); mass or lung consolidation Physical Exam Lung Auscultation  Cardiovascular (CV) system  Mucous membranes  Capillary refill time   Color    Perfusion status Pale-anemia; poor perfusion Hyperemia-stress; early septic shock Pulse quality  Strong, weak, thready Physical Examination  Cardiovascular (CV) system  Auscultation    Heart rate S1-Closure of mitral & tricuspid valves S2-Closure of aortic & pulmonic valves   Murmurs-turbulent blood flow (swishing)     “Lub-Dub” Cardiac dz, anemia, normal some young animals Graded I-VI/VI Arrhythmias Jugular veins   Normally pulsation doesn’t extend beyond 1/3 up neck Distended vein further up the neck=elevated central venous pressure (pericardial effusion or pulmonic stenosis) Physical Examination Location of Heart Valves Cardiac Sounds-Normal Cardiac Sounds-Mitral Murmur Cardiac Sounds-Aortic Stenosis  Gastrointestinal system (abdominal palpation)  Two-handed vs. one-handed technique  Six quadrants to evaluate   Pain, swelling, firmness, fluid Palpable structures      Liver (not palpable if normal) Spleen Kidneys (cat) Bladder Small and large intestine  Stomach usu not palpable if empty Physical Examination Location of Gastrointestinal Organs  Rectal examination        Physical Exam Perianal area/anus Prostate Urethra Medial iliac lnn. (enlarged) Rectal wall Anal sacs-5 & 7 o’clock Character of stool  Urogenital Distal urethra  Penis  Scrotum and testicles  Vagina and vestibule  Mammary chains  Physical Examination  Integument-hair, skin (include footpads/nails), SQ tissues           Alopecia Scales and crusts Flaking Odor Pustules and papules Masses Ectoparasites Pruritis and excoriations Petechiae/Ecchymoses Erythema Physical Exam  Lymph nodes  Palpable     Submandibular lnn. Prescapular lnn. Popliteal lnn. Axillary/Inguinal (if enlarged) Physical Examination Lymph Nodes  Musculoskeletal system        Lameness Swelling Difficulty rising Pain Asymmetry Loss of range of motion Atrophy Physical Examination  Nervous system  Mentation  BAR, QAR, dull, obtunded, stuporous, comatose Vision  Gait and posture    Ataxia-uncoordinated movement Muscle tone    Subjective Include anal sphincter tone Atrophy Physical Examination  Nervous system  Presenting complaints may be neurological        Behavior changes Depression Lethargy Blindness Head tilt Circling Lameness/weakness/paralysis Physical Examination  Nervous system (cont)  Cranial nn.   Review in McCurnin’s or Anatomy book Postural reactions   Conscious proprioception Limb strength-hop Physical Examination Physical Examination  Nervous system (cont)  Reflexes    Forelimb-Withdrawal, bicep/triceps reflex Hindlimb-Withdrawal, patellar/cranial tibial reflex Cutaneous trunci-spinal segments   Pinch skin on either side lateral thorax Paralyzed animal   Test sensation in limbs by pinching toes w/hemostat  Cry or try to bite  Pulling leg back doesn’t indicate normal sensation but indicates intact pedal reflex Pinch anal mucosa contraction of anal sphincter (perineal reflex) Physical Examination  Questions????