Module 2: Breeds, Signalment, History, and Physical Exam

Why is signalment important?

1. Predilection of specific diseases

2. To identify the animal (e.g., the right procedure for the right patient)

3. For legal purposes (i.e., the signalment is the legal documentation in the medical record that identifies the animal)

Information included in signalment

• species

• breed

• age

• sex (including reproductive status)

Why is history important

1. lays the foundation for a logical diagnostic and therapeutic plan

2. promotes communication and helps clinic personnel develop a rapport with the owner

3. establishes client knowledge level and helps form client trust

Basic Guidelines for Signalment and Hisotry

1. introduce yourself

2. take only as much history as the condition of the patient allows

3. if in critical condition take directly to treatment area for stabilization before obtaining history > be familiar with your clinic’s policy regarding emergencies

4. always write the history down

5. be polite and maintain level of professionalism

6. if there is more than one owner present try to include both or all of them into the conversation

7. bond with the patient while talking to the client

8. always keep control of the conversation

9. always let the owner tell you a few sentences then ask specific questions to clarify the history