canine physical exam and SOAP approach

overall for any species how should physical exam be done

the same way every time

- could be systems approach

- could be nose to tail approach

canine normal temp

100-102.5

canine normal pulse

70-160

canine normal respiration

10-24

distance exam observations

behavior, musculoskeletal, skin changes, neurological

ataxia

incoordination (drunk walk)

signs of a "green dog"

wiggly body, willing to greet, ears neutral position

signs of a "yellow dog"

hiding, whale eyes, ears back, tail tucked, lip licking

signs of a "red dog"

growling, barking, lip curling, lunging

what do you have to be careful of when assessing dog behavior

tail wagging

ear exam looks at what

- entire vertical and horizontal "L shaped" canal and ear drum

- ensure to note any discharge or debris

what should be done with ear discharge

sampled

eye exam should look at

- pupillary light reflex (PLRs)

- cornea (white)

- lens (internal)

- conjunctiva (pink tissue surrounding)

mouth exam should look at

- tartar/ calculus present

- any fractures in teeth

- gingivitis

- masses

- gum color (should be pink

nose exam should look at

discharge, stenotic nares, airflow

what are stenotic nares

narrowing of the nares of a dogs nose especially in brachiocephalic breeds that restrict airflow entering

neurologic exam incudes

mentation of dog, reflexes, cranial nerve assessment, palpation of spine, distance exam

what type of dogs should have spinal palpation done

long backed breeds

heart exam

auscultation of heart on both sides of chest listing for normal or abnormal sounds (murmurs)

point of maximum intensity in dogs

4-6 rib space

lung exam

- listening to lungs in all quadrants listing for abnormal sounds

- wheezes, crackels, absent of sounds (fluid present)

abdominal palpation

- assessing internal organs

- gently pressing hands on either side of abdomen and compress inwards and upward working cranial to caudal

palpable organs

spleen, intestines, liver, +/- stomach, kidneys and bladder

musculoskeletal exam

gait exam with palpation of joints with extension and flexion

crepitus/ crunching of joint meaning

arthritis

for gait exam what is the lameness saying

down on sound (referring to the head)

integument exam

assessing the skin for masses, parasites and palpating lymph nodes

palpable lymph nodes

submandibular, prescapular, popliteal

reproductive and urinary tract exam

looks at vulva, uterus (surgically), and bladder

color change in urine means

females: bladder infection or bladder stones

males: bladder stones or prostate

pyrometra

pus filled uterus

purpose of SOAP approach

identify problems, collect data, assessment, plan

Subjective

influenced based on feeling or opinion and NO FACTS

- based on complete history form presenting complaint via open ended questions

Objective

NOT feelings or opinion but rather FACTS

- information gathered through physical exam and diagnostic works

- do NOT analyze or interpret any of the diagnostics yet

Assessment

evaluation/interpretation of your patients

- putting together problems found in previous steps trying to come up with what is wrong

Plan

how to treat the disease or problem

- includes diagnostic plan, therapeutic plan and client/owner education