Patient History/ Physical Exams
A patient history is a documentation that is divided into 3 parts
1.History of chief complaint
2.Medical history
3. Environmental history
Ways to obtain Patient History:
-Introduce yourself
-Know the client's name and pet
-Avoid talking bad about the pet
-Before examining the animal get a simple check off sheet and fill it out and give another one to the client as well
-Ask questions about the animal's past and if they have medical problems
-When asking questions ALWAYS ask yes or no questions.
-Keep in mind that some breeds are predisposed to certain diseases and also the age and gender of the animal
General Information:
*Age
*Breed dominant breed if mixed
*General Management
*How long has pet been owned
*Where and when did they get the pet
*Previous medical problems if any
*Pet's normal routine
*Has all vaccinations
*Last time that came to vet
Diet History
*Type of food eaten,amount,frequency
*Any changes in diet
*Has animal eaten anything new or unusual
*Has pet gotten into something it wasn't supposed to
*Vaccination history
*Heart worm Prevention
*Flea and tick prevention
Behavior Information
*Normal dog behavior
*Changes in behavior
These are all questions that should be answered by the client
Physical Exams: Things to check
-Eyes
-Ears
-Mouth
-Skin
-Vital Signs TPR
-Lameness
-Weight-over,under, or normal
-Head to tip of tail
General Areas:
1.General Appearance
-Is there a healthy overall appearance?
-Are eyes bright and coat shiny?
-Is animal obese or very thin
2. Integumentary
-Is the coat shiny and full or dull and brittle ?
-Are there any bald patches,rashes,or flaking skin?
3. Muscoskeletal
-History of lameness or visible lameness?
-Broken bones?
4. Circulatory
-Coughing?
-Fainting?
-Dyspnea?
-Murmurs?
5. Respiratory
-Coughing?
-Sneezing?
-Nasal Discharge?
-Exercise tolerance?
-Cyanosis?
6.Digestive
-Eating Normally?
-Diet Changes?
-Ingested any toxins?
-Vomiting or diarrhea?
7. Genitourinary?
-Abnormal discharge ?
-Difficulty urinating or defecating ?
8.Nervous system
-Seizures?
-Changes in behavior?
-Difficulty walking?
-Head tilt?
9.Lymph Nodes
-Enlarged
10.Ears
-Discharge?
-Unusual odor?
-Head shaking?
11.Eyes
-Excessive tearing or discharge?
-Visual deficits
12.Mouth
-Gums and teeth healthy ?
-Mucous membrane moist and pink?
Mostly used equipment
-Stethoscope
-Thermometer
-Petroleum Jelly
-Muzzle
Vital Signs
TPR is temperature,pulse,and heart rate always do temperature last *See TPR tab for more info
CRT
-Capillary Refill Time you are checking for any circulation problems.
-Amount of time it takes for gums to return to normal color after being pressed on
-Normal is less than 2 seconds
-If it takes longer than 2 seconds it can be shocks,dehydration or cardiovascular problems
A patient history is a documentation that is divided into 3 parts
1.History of chief complaint
2.Medical history
3. Environmental history
Ways to obtain Patient History:
-Introduce yourself
-Know the client's name and pet
-Avoid talking bad about the pet
-Before examining the animal get a simple check off sheet and fill it out and give another one to the client as well
-Ask questions about the animal's past and if they have medical problems
-When asking questions ALWAYS ask yes or no questions.
-Keep in mind that some breeds are predisposed to certain diseases and also the age and gender of the animal
General Information:
*Age
*Breed dominant breed if mixed
*General Management
*How long has pet been owned
*Where and when did they get the pet
*Previous medical problems if any
*Pet's normal routine
*Has all vaccinations
*Last time that came to vet
Diet History
*Type of food eaten,amount,frequency
*Any changes in diet
*Has animal eaten anything new or unusual
*Has pet gotten into something it wasn't supposed to
*Vaccination history
*Heart worm Prevention
*Flea and tick prevention
Behavior Information
*Normal dog behavior
*Changes in behavior
These are all questions that should be answered by the client
Physical Exams: Things to check
-Eyes
-Ears
-Mouth
-Skin
-Vital Signs TPR
-Lameness
-Weight-over,under, or normal
-Head to tip of tail
General Areas:
1.General Appearance
-Is there a healthy overall appearance?
-Are eyes bright and coat shiny?
-Is animal obese or very thin
2. Integumentary
-Is the coat shiny and full or dull and brittle ?
-Are there any bald patches,rashes,or flaking skin?
3. Muscoskeletal
-History of lameness or visible lameness?
-Broken bones?
4. Circulatory
-Coughing?
-Fainting?
-Dyspnea?
-Murmurs?
5. Respiratory
-Coughing?
-Sneezing?
-Nasal Discharge?
-Exercise tolerance?
-Cyanosis?
6.Digestive
-Eating Normally?
-Diet Changes?
-Ingested any toxins?
-Vomiting or diarrhea?
7. Genitourinary?
-Abnormal discharge ?
-Difficulty urinating or defecating ?
8.Nervous system
-Seizures?
-Changes in behavior?
-Difficulty walking?
-Head tilt?
9.Lymph Nodes
-Enlarged
10.Ears
-Discharge?
-Unusual odor?
-Head shaking?
11.Eyes
-Excessive tearing or discharge?
-Visual deficits
12.Mouth
-Gums and teeth healthy ?
-Mucous membrane moist and pink?
Mostly used equipment
-Stethoscope
-Thermometer
-Petroleum Jelly
-Muzzle
Vital Signs
TPR is temperature,pulse,and heart rate always do temperature last *See TPR tab for more info
CRT
-Capillary Refill Time you are checking for any circulation problems.
-Amount of time it takes for gums to return to normal color after being pressed on
-Normal is less than 2 seconds
-If it takes longer than 2 seconds it can be shocks,dehydration or cardiovascular problems