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