physical examination
The most common veterinary procedure and the cornerstone of diagnosis and treatment.
The vet tech may also be responsible for:
Interviewing the client for the presenting/primary problem or client complaint; taking the body systems history; interpreting the animal's body systems review.
presenting/primary problem; client complaint
The reason the animal is being seen by the veterinarian.
body systems history
Detailed questions about the body systems involved in the presenting problem.
body systems review
A review of the body systems to note any additional problems the animal may have.
Before the physical exam, the vet tech must:
Gather and prepare any necessary supplies, and know the appropriate methods and degrees of restraint for each species, procedure, and individual animal.
medical history
The first step of every veterinary physical exam. It can suggest a diagnosis or testing, x-rays, or other procedures needed to obtain a diagnosis.
When taking a history:
Start with yes or no questions, then move to more specific, open-ended questions that require a detailed answer.
signalment
The overall patient description, including species, breed, age, gender, and whether or not the animal is neutered.
A good history involves:
Identifying the presenting problem, taking a medical history, taking the environmental history, and reviewing the body systems.
Regarding the primary problem:
Record: the primary problem and the signs and symptoms the animal presents. Ask: When did the animal begin to show symptoms? How quickly did they progress? Improved or worsened? Any changes in routine or environment around the onset of symptoms?
More basic history questions:
Ask about previous health problems and how they were treated. Ask for dates of vaccinations and tests and if another vet has seen the animal. Arrange for the transfer of records if needed.
Environmental history topics to ask about:
Food: type, amount, frequency, any changes. Supplements, flea/tick prevention, heartworm preventative. Water: type, amount, testing. Indoor/outdoor pet. Origin of pet, travel history, expected performance.
Body systems history and review - step 1:
Acquire the body systems history. Ask detailed questions about the body system involved in the presenting problem.
Body systems history and review - step 2:
Perform a body systems review: Ask about other problems noticed and ask questions to encourage elaboration.
Body systems history and review - step 3:
Integumentary system: (skin and attached structures) Ask about itching, scratching, hair loss, lumps, growths/removal, previous issues, changes in environment.
Body systems history and review - step 4:
Head and neck: Ask about ears, eyes, nose, mouth, teeth, history of problems.
Body systems history and review - step 5:
Respiratory system: Ask about coughing, exercise, sneezing, runny nose, lethargy, gums, traveling and exposure to other animals.
Body systems history and review - step 6:
Cardiovascular system: Ask about lethargy, fainting, heart disease, murmurs, heartworms/testing, chest x-ray.
Body systems history and review - step 7:
Gastrointestinal system: Ask about vomiting/diarrhea and frequency, color, blood/mucus, volume, relation to mealtime, contain food, constipation, parasites, overdosing on grain or grass, ingesting garbage/compost, deworming.
Body systems history and review - step 8:
Urinary system: Urine color, smell, frequency, control, straining, drinking habits, trauma or infection, bladder or kidney stones.
Body systems history and review - step 9:
Reproductive system: Ask about neutering, breeding, ease of birth, health of offspring, false pregnancies, breast tumors, STDs, semen evaluation, discharge or smell.
Body systems history and review - step 10:
Musculoskeletal system: Ask about physical activities/sports, exercise, history of trauma, broken bones, torn tendons/ligaments/tissues, dislocations, lameness, stiffness.
Body systems history and review - step 11:
Central nervous system: Ask about seizures and frequency, duration, intensity, distance between, poisons, vaccinated against distemper and rabies, odd posturing, difficult normal behaviors, sensory function, disk issues.
Vitals to collect before the exam:
Weight, temperature, heart rate, respiration rate.
Taking a temperature with a rectal mercury thermometer:
1. Wipe clean with alcohol. 2. Shake mercury down as far as possible. 3. Coat the end with petroleum jelly. 4. Insert one inch into the rectum for one minute. 5. Remove, read and record. 6. Wipe clean with alcohol.
Taking a temperature with a digital thermometer:
1. Wipe clean with alcohol. 2. Turn it on. 3. Coat the end with petroleum jelly. 4. Insert one inch into the rectum until it beeps. 5. Remove, read and record. 6. Wipe clean with alcohol.
Taking a temperature with an ear thermometer:
1. Press the on button and swing arm out into position. 2. Put a probe cover on and insert into the ear. 3. Aim probe at the ear drum and press the on button again to take the temperature, wait for the beep. 4. Remove, read, record. 5. Discard probe cover
Taking a heart rate:
Listen to the heart with a stethoscope or with a finger on a pulse. Count the number of beats in a 15 second period and multiply that number by 4 to determine bpm.
Taking a respiratory rate:
Count the number of respirations (full breath in and out again) in 30 seconds and multiply the result by 2 to find respirations per minute.
palpation
Examining body parts by touch.
auscultation
Listening for sounds produced within the body.
systematic examination
Examining one body system in its entirety before moving on to the next.
head-to-tail examination
Allows an overall impression of the animal's outward appearance, general behavior, demeanor, and gait, evaluation of most of the superficial musculoskeletal and nervous systems.
The thorax is visually divided into:
9 quadrants. Listen to each one when doing an exam.
The abdomen is visually divided into:
3 sections. Palpate each one when doing an exam.
The heart is divided into:
4 zones, each corresponding with a valve. Listen to each one when doing a physical exam.
The four zones the heart is divided into:
The mitral valve, the aortic valve, and the pulmonary valve (left side of thorax), and the tricuspid valve (right side of thorax).
Gut sounds in a large animal are caused by:
peristalsis. Listen for one minute to the abdomen of a large animal to determine the number of sounds per minute. There should be one to two per minute.
palpebral reflex
The reflex elicited by touching the medial corner of the eye. The animal should immediately blink.
menace reflex
The reflex elicited by moving a hand toward the animal's eye. The animal should immediately blink.
penlight test
Direct the beam of a penlight into the eye to constrict the pupil, then move the beam away and the pupil should dilate to its pre-exam state.
proprioception
The righting reflex. Flex the animal's paw or hoof and place it on the exam table or floor. The animal should immediately return the paw or hoof to its normal position.
Lymph nodes to check:
Submandibular: caudal to the mandible on both sides of the jaw. Prescapular: just cranial and dorsal to the shoulder joint. Axillary: located in the arm pit region. Inguinal: located in the inguinal region between the rear legs. Popliteal: located at the
SOAP
Subjective, Objective, Assessment, Procedure or Plan. Stands for the sections of the progress notes.
subjective data
Includes the reason the animal is at the vets, observations, non-quantifiable information about the animal, such as outlook.
objective data
Quantifiable information. Includes weight, temperature, pulse, lab data, and anything else that can be precisely calibrated.
assessment
Includes possible or probable explanations for the problem. Also includes the diagnosis. Only the veterinarian uses this section.
procedure or plan
Outlines the plan for treatment. Includes any problems that should be monitored, follow-up care instructions, meds prescribed, etc. Only the veterinarian uses this section.
client education
A general term that covers many of the client's interactions with the practice. Informing the client during and after the exam, explaining postoperative care instructions, going over a prescription to make sure the client knows how much medication to give
opthalmoscope
An instrument used to visualize the interior chamber of the eye, where signs of disease or trauma can sometimes be seen.
otoscope
An instrument used to inspect the ear of an animal.
choana
A slit-like opening on the roof of a bird's mouth.
intervertebral disk disease
Disintegrated cushions between the vertebrae.
keel
The breastbone of a bird.
nares
The nostrils.
neuro hammer
An instrument used by the veterinarian to check an animals reflexes.
papillae
A pimple-like structure that can be found in an ear canal, choana, etc.
papule
A hard, pimple-like skin bump.
perfuse
To pump; in an animal, the body's ability to pump blood.
pulmonary edema
Fluid accumulation in the lungs.
pulse difference
A distinct difference between when the heart beats and the point at which the pulse beat can be felt. The pulse should be felt immediately after the heart beats.
rales
Abnormal crackling sounds in the lungs.
When auscultating the heart:
Note these four things: heart rhythm, heart sounds, heart rate, and pulse deficits.