1. CW 107-2 Chapter 1: Assessing the Patient’s Health Course Work 107

2. I. Medical Health History A. The Medical History (Hx) includes 1. Date of examination 2. Signalment a. Age b. Sex c. Breed 3. Chief complaint (CC) a. This is the reason the client brought the patient to the veterinarian. 4. Past medical history… a.k.a. Post history- is the patient’s previous illnesses. Course Work 107

3. I. Medical Health History 5. Current health status…a.k.a. Present history- is the patient’s current illness. 6. Family history a. Health of dam, sire, and littermates. 7. Vaccination history 8. Travel history 9. Diet history 10. Environmental history Course Work 107

4. I. Medical Health History B. Questioning the client 1. First listen to the client explain what she perceives to be the problem; this is known as the chief complaint (CC). 2. Follow with additional questions 3. Start with general questions then get more specific 4. Questions should be asked in such a way that is unbiased. 5. Ask questions one at a time. 6. Direct eye contact should be made with the client as much as possible. Course Work 107

5. II. The Physical Examination (PE) A. The veterinary technician must possess the following: 1.Sensitivity 2. Attentiveness to detail 3. Completeness of method Course Work 107

6. II. The Physical Examination (PE) B. Methods for gathering information 1. Observation - Look for abnormalities such as swellings, lameness, and asymmetrical body parts. 2. Palpation - Feeling with hands for abnormalities. 3. Auscultation - Using a stethoscope to listen to heart, lung, and gastrointestinal sounds. 4. Percussion - Striking a part of the body with short, sharp blows of the fingers in order to determine the size, position and density of the underlying parts by the sound obtained. Course Work 107

7. II. The Physical Examination (PE) C. Characteristics of a clinically healthy animal 1. Bright 2. Alert 3. Responsive 4. Vital signs should be within normal limits 5. No signs of lameness Course Work 107

8. III. Steps of the Physical Exam A. It is important to create a pattern and stick to it when performing physical exams. For example start at the head and proceed to examine all the organ systems back to the tail. 1. Examination head and neck a. Eyes b. Ears c. Nose d. Skin e. Teeth Course Work 107

9. III. Steps of the Physical Exam 2. Mouth a. Capillary refill time(CRT) i. Visualize the gingival mucous membranes by lifting the lips. ii. Apply gentle pressure with the thumb onto the mucous membranes. iii. The resultant area is pallor when the thumb is removed. iv. Note the time to return of normal mucous membrane color. v. This assesses the degree of hydration. Course Work 107

10. III. Steps of the Physical Exam 3. Throat a. Look down throat for potential foreign objects that could be lodged. b. Palpated larynx and trachea for abnormalities. 4. Observe the symmetry and posture of all the structures of the head. a. Is there a head tilt? b. Is there pain? c. Any swellings of the head or face? Course Work 107

11. III. Steps of the Physical Exam 5. Examination of the Spinal cord a. The spinal cord is palpated from the atlas all the way to the last caudal vertebrae. i. Look for signs of tenderness or pain. 6. Examination of the forelimbs a. Palpate from the dorsal scapula to the distal phalanges. i. Look for pain, heat, or swellings. 7. Examination of the thorax. Course Work 107

12. III. Steps of the Physical Exam 8. Auscultate the heart. a. Listen for murmurs. b. Take the pulse. c. Can be signs of mitral valve regurgitation or pulmonic stenosis. 9. Auscultate the lungs. a. Listen for crackles and wheezes. b. Take the respiratory rate. c. Can show signs of pneumonia or congestive heart failure. Course Work 107

13. III. Steps of the Physical Exam 10. Examine the abdomen. a. Palpate the abdomen. b. Feel for masses. c. Look for signs of tenderness or pain. d. Auscultate to listen for gastrointestinal sounds. i. If no gurgling sounds heard the intestines could be blocked or not functioning properly. 11. Examine the hind legs. a. Palpate from the pelvis to the distal phalanges. i. Look for pain, heat, or swellings. Course Work 107

14. III. Steps of the Physical Exam 12. Examine the reproductive organs and rectal area. a. Observe the organs. b. Note the size, shape, and number of organs. i. Male dogs can have a retained testical either unilateral or bilateral. ii. Females with small vulvas could be predisposed to dystocia (difficulty birthing). Course Work 107

15. III. Steps of the Physical Exam 13.Examine all areas of the skin. a. Alopecia(hair loss) b. Rash c. Irritated areas with signs of scratching i. These signs could be caused from: i. Allergies ii. Parasites iii. Infections iv. Endocrine dysfunction such as Addison disease or hyperthyroid. 14. Take a rectal temperature. Course Work 107