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
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Patient History and Physical Exam n Remember the impression you are making –Know patient and client info before entering the room –talk to owner not animal,
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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 conditions- indoor/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 causes-
excitement, chemical imbalances, temperature, cardiac defect
This will provide guidelines for you.• http://www.vin.com/MEMBERS/CMS/Misc/
VSPN/Default.aspx?id=6695&pid=49&catid=&said=1
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