Introduction & Physical Examination

Purpose of Medical Record

1. Basis for patient care

2. Referrals

3. Legal evidence of care of the patient

Major categories of disease

• Degenerative

• Anomaly

• Metabolic

• Neoplastic & Nutritional

• Inflammatory, Infectious, and Immune-mediated

• Trauma and Toxicity

• Vascular

POMR means

Problem-Oriented Medical Record

POMR provides?

Clear problem identification

Basic components of POMR / Weed System

• Data base

• Problem identification

• Plan formulation

• Progress notes

Data base includes

• Chief complaint

• Patient profile

• History

• Review of old records

• Physical examination

• Laboratory data

Plan formulation includes

• Diagnostic section

• Therapeutic section

• Client education

Progress notes include

• Subjective data

• Objective data

• Assesment of problem

• Plans

The first component of database

History

Second and most important component of database

Physical examination

Second step in clinical problem solving

Problem identification

Problems are numbered consecutively and dated chronologically on separate form called:

MPL or Master Problem List

Master Problem List includes:

• Symptoms

• Sign

• Physiologic Abnormality

• Physical Finding

• Abnormal Laboratory Test

• Diagnosis

After the problems are identified and listed on the MPL, the next step is:

Plan Formulation

Plan Formulation purpose:

Dictates the medical action for the first 24-48 hours

3 components of plan formulation

1. Diagnostic section

2. Therapeutic section

3. Client education section

It is intended to resolve or help. This provides a method to audit the logic of treatment.

Therapeutic section

Describes the information given to clients about their animal’s problems , diagnostic tests, cost, and prognosis

Client education section

4 types of DDB

• Minimum

• Maximum

• Comprehensive

• Problem-specific

These are free nerve endings especially abundant in the skin, cornea, anus, periosteum, joint capsule, muscles, tendons and meninges

Nociceptors

3 types of nociceptors characterized by responsiveness

• Extreme heat

• Excessive mechanical stress

• Chemicals

  • Serotonin

  • Bradykinin

  • Histamine

  • Prostaglandins

  • Leukotrienes

  • Proteolytic enzymes

Classification of Pain

• Acute of Physiologic Pain

• Chronic or Clinical Pain

• Musculoskeletal Pain

• Visceral Pain

• Neurologic Pain

• Ischemic Pain

• Referred Pain

Results stem from minimal tissue damage that triggers high-threshold sensory nerve fibers. Pain is typically well-localized, short-lived and stimulates reflexive responses

Acute or Physiologic pain

Results from intense or prolonged stimuli from tissue damage, extended discomfort, and abnormal sensitivity. It induces physiologic, metabolic, and immunologic alterations that promote illness and death.

Chronic or Clinical Pain

Joint surfaces and periosteum contain abundant nociceptors, and focal stimulation may cause intense pain or a waxing and waning pain.

Musculoskeletal Pain

Primary consequence of Musculoskeletal Pain

Lameness

This contains a lower density of nociceptors and more widespread tissue involvement is necessary to elicit pain.

• Stimuli include ischemia, distention of hollow viscus, chemical damage to visceral surfaces, spasm of smooth muscle, and stretching of ligaments.

Visceral pain

The only nervous structure that has abundant nociceptors

Meninges

Pain that is manifested in a site considerable distance from the primary lesion is called referred pain.

Referred pain

Common cause of pain in spinal column (cervical and back pain)

1. Intervertebral disk disease

2. Diskospondylitis

3. Fractures /luxations

4. Meningitis

5. Caudal cervical spondylomyelopathy

6. Lumbosacral stenosis

Common cause of muscle pain

1. Polymyositis

2. Ischemic myoneuropathy

3. Exertional rhabdomyolysis

Common cause of Joint/long bones pain

1. Arthritis

2. Fractures

3. Osteomyelitis

4. Neoplasia

Common cause of pain in abdominal cavity

1. Acute Pancreatitis

2. Pyelonephritis

3. Renal and ureteral calculi

4. Gallbladder disease

5. Peritonitis

6. Torsion/volvulus (spleen, stomach, and intestine)

Common cause of pain in thoracic cavity

1. Pleuritis

2. Pericarditis

Common cause of referred pain to the abdomen

1. Disk disease

2. Meningitis

3. Diskospondylitis

Common cause of referred pain to the back

Abdominal cavity diseases

Common cause of perianal pain

1. Fractured tail

2. Perianal fistulas

3. Rectal strictures/foreign bodies

4. Anal sac abscess/impaction

5. Rectal trauma

Two essential components of practicing medicine

• History

• Physical examination

It is frequently key in determining the cause of an illness, its significance, treatmen options and even prognosis.

History

It is the second and most important component of the database.

Physical examination

Two types of physical examination

• Routine physical exam

• Emergency physical exam

Elements of history

1. Obtaining facts

2. Diet and appetite

3. Drinking, urination, and defecation patterns

4. Geographic history

5. Describe home environment

6. Chronology of the sequence of events

7. Initial abnormal signs and their progression

8. Changes in body weight

9. Vaccinations and medications

10. Animals present condition

A good physical examinations can:

1. Detect minor abnormalities before they become serious problems

2. Identify major organ dysfunction without extensive and expensive medical tests

How to do physical examinations

• Gain trust

• Restraints

• Away from the animal or back off

• Thorough and consistent

• Experiences help

• Record

Physical examination process

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

Inspection of the animal should involve observation of the following:

• General appearance

• Body condition / state of nutrition

• Mentation / level of consciousness

• Posture and gait

• Hydration status

In inspecting general appearance, it is important to note:

Symmetry, note any asymmetry and difference in size or shape or extremities

What to observe in inspecting posture and gait

Limping, incoordination or unsteadiness and abnormal limb placement

How is hydration status reported

• Adequate, marginal, or inadequate

First sign of dehydration

Loss of skin elasticity (skin turgor)

Skin may tent more in certain breeds, what are these?

Sharpei and Basset Hounds

It is the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath.

Palpation

Locations of Lymph Nodes

• Submandibular

• Prescapular

• Axillary

• Inguinal

• Popliteal

Abdominal palpation is divided into three, what are these:

• Cranial abdomen

• Mid abdomen

• Caudal abdomen

Organs present upon cranial abdominal palpation

• Stomach

• Liver

• Spleen

• Area of pancreas

• Small intestines

Organs present upon mid abdominal palpation

• Spleen

• Kidneys

• Small intestines

Kidneys is usually not palpable in what animal?

K9

Upon palpation, what shape is the bladder on dogs?

Pear-shaped

Upon palpation, what shape is the bladder on cats?

Spherical

What is the purpose of tapping fingers or hands quickly and sharply against parts of the animal’s body?

• Locate organ borders

• Identify organ shape and position

• Determine if an organ is solid or filled with fluid or gas

Two types of percussion

1. Direct or immediate percussion

2. Indirect or mediate percussion

It is the striking of the part under examination directly with the finger or a plexor, without the intervention of another finger or pleximeter.

Direct percussion

It is a percussion performed by using the fingers of one hand as a plexor and those of the opposite hand as a pleximeter

Indirect percussion

Drum-like sounds heard over air filled structures during the abdominal examination

Tympanitic

It is said to sound similar to percussion of puffed up cheeks

Hyperresonant (pneumothorax)

The sound produced by percussing a normal chest

Normal resonance / resonant

Lower than normal percussion sounds

Impaired resonance

Similar to percussion of a mass such as a liver

Dull

Involves listening for various lung, heart, and bowel sounds with a stethoscope

Auscultation

What is usually heard in the yellow triangle (left side)

• Mitral

• Atrial

• Pulmonic

What is usually heard in the yellow circle (right side)

Tricuspid

In respiratory auscultation, listen for noisy breathing at mouth and nares without stethoscope, then auscultate at least four different areas of the chest, including?

Right and left ventral, right and left dorsal lung fields

musical sounds-low or high pitched

Rhonchi

Continuous high pitched hissing heard more often on expiration occur with small airway diseases such as asthma

Wheezes

This may indicate pleural space disease (pleural effusion) or space - occupying lesions

Absence of breathe sounds

This lung sound may indicate pneumonia, or consolidation

Dull lung sound

May be heard when fluid in the lungs

Rales / crackles

Where do you auscultate when you want to listen to the mitral valve

Left 4th-6th (PMI) intercostal space just above the sternal border

Where do you auscultate when you want to listen to the pulmonic valve

Left 2nd-4th intercostal space above sternal border

Where do you auscultate when you want to listen to the aortic valve

Left 3rd-5th intercostal space at mid thorax

Where do you auscultate when you want to listen to the tricuspid valve

Right 3rd-5th intercostal space at mid thorax

S1 should be:

Loud, long, low pitch

S1 indicates

Closure of the atrioventricular valves

S2 indicates

Closure of the semilunar valves

Three or four sounds instead of two

Arrhythmia

Slight increase in heart rate during inspiration and decrease with expiration. More common in the dog than in the car

Sinus arrhythmia

Prolonged series of audible vibrations during normally silent part of cardiac cycle. Often heard as a soft, swooshing sound.

Murmur

This heart sound may be a result of fluid in the chest – if having difficulty hearing the heartbeat do not assume it is just you – it never hurts to get a second opinion

Muffled heart sounds

Examples of arrhythmia

• Sinus arrhythmia

• Atrial fibrillation

• Heart block

• Premature ventricular contractions

• Gallop rhythm

Part of stethoscope that is best for higher pitched sounds, like- breath sounds and normal heart sounds

Diaphragm

Part of stethoscope that is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. used for the detection of bruits, and for heart sounds

Bell