Veterinary History and Physical Examination Notes

A comprehensive set of flashcards covering key terms and concepts related to obtaining patient history and performing physical examinations in veterinary medicine.

Patient History

Questions about the patient’s medical background, symptoms, lifestyle, and family history to understand overall health.

Physical Exam

Assessment through inspection, palpation, percussion, and auscultation to detect signs of illness.

Medical History

The most crucial step in diagnosing and developing a treatment plan for a patient.

Signalment

A short description of the animal which includes details like breed, age, sex, and reproductive status.

Primary Exam

The initial physical examination mainly conducted by the veterinarian, but veterinary technicians may also perform it.

Medical History Components

Includes identifying the primary problem, medical history, environmental history, and reviewing body systems.

Open-ended Question

A question that requires more than a yes or no answer and encourages detailed responses.

Closed-ended Question

A question that can typically be answered with a simple yes or no.

Presenting Complaint

The reason a client brings their animal to the veterinary clinic, confirmed during the initial visit.

Environmental History

Details regarding the animal’s current living conditions that may affect its health.

Vital Signs (TPR)

Temperature, Pulse, and Respiratory rate, indicating an animal's health status.

Capillary Refill Time (CRT)

A measure of the time taken for color to return to mucous membranes after pressure is applied.

Hydration Status

An assessment of water balance in the body; dehydrated animals show dry mucous membranes.

Attitude Assessment

Evaluation of an animal's level of mental awareness and engagement with its surroundings.

Heart Rate

The number of heartbeats per minute, measured via auscultation or palpation of pulses.

Normal Vital Signs

Standard reference ranges for animals' temperature, pulse, and respiration rates.

SOAP 

A method of organizing medical records that includes Subjective, Objective, Assessment, and Procedure.

Integumentary

Includes skin, scales, hair, nails, hooves, horns, and

feathers

Respiratory

Respiratory Includes nose, mouth, pharynx, larynx, trachea, bronchi, and lungs

Circulatory

Includes heart, blood vessels, and blood.

Gastrointestinal

Includes mouth, Urogenitalesophagus,stomach, small and large intestines, anus, liver, gallbladder, and pancreas

Urogenital

Includes kidneys, ureters, bladder, urethra, and reproductive organs.

Musculoskeletal

Includes bones, joints, muscles, tendons, ligaments and connective tissue

Nervous

Includes brain, spinal cord, and nerves 

Arrhythmia

is a condition characterized by an irregular heartbeat, which can be too fast or too slow, affecting the heart's ability to pump blood effectively.

Bradycardia

refers to an abnormally slow heart rate, typically defined as fewer than 60 beats per minute, which can lead to insufficient blood flow to the body.

Tachycardia

refers to an abnormally fast heart rate, typically defined as exceeding 100 beats per minute, which may result in symptoms like palpitations or dizziness.

Respiratory Sinus Arrhythmia

is a condition where the heart rate varies with the respiratory cycle, speeding up during inhalation and slowing down during exhalation, and is often considered a normal physiological response.