Vet science

Patient History and Signalment Assessment

  • Questioning Techniques in Clinical History:

    • Open-Ended Questions: Questions structured to allow the client to provide any answer as long as it remains on topic, providing detailed context regarding the patient's condition.

    • Closed-Ended Questions: Questions requiring specific, binary, or concise answers, such as a simple "yes or no".

  • Patient Signalment Components:

    • Signalment consists of baseline demographic details that uniquely identify the patient:

    • Name

    • Sex

    • Reproductive status (e.g., intact, neutered male, spayed female)

    • Age

    • Breed

    • Species (e.g., K-9/canine, feline, equine)

  • Standard Signalment Formatting:

    • Case Example: A canine patient named Bagel presented for vomiting after consuming a sock. He is a Labrador Retriever who was neutered at 6 months6\text{ months} of age, and his last visit was approximately 3 years3\text{ years} ago.

    • Written Signalment Format: Bagel, Lab, K-9, neuter male, 4 years old.

  • Comprehensive Patient History Contents:

    • Complete patient signalment

    • Current medications

    • Chief complaint and timeline of symptoms

    • Baseline normal findings versus abnormal changes reported by the owner

Physical Examination Fundamentals and Procedure

  • Observational Physical Assessment:

    • Behavior and general appearance are assessed visually prior to physically touching or handling the patient.

  • TPR (Temperature, Pulse, Respiration) Sequence:

    • Temperature (temp\text{temp}) is taken last during the TPR sequence to avoid agitation early in the examination.

  • Integumentary System Scope:

    • System encompasses the outer protective boundary and associated mucosal boundaries, including evaluation of the eyes, ears, nose, mouth, skin, and coat.

  • Physical Measurement Conversions and Standards:

    • Equine Height Measurement: One hand equals 4 inches4\,\text{inches}.

    • Weight Conversion: 1 kg=2.2 lb1\,\text{kg} = 2.2\,\text{lb}.

Cardiovascular and Respiratory System Evaluation

  • Pulse Assessment:

    • Anatomic Evaluation Site: Femoral artery, located in the inner thigh of small animals.

    • Equine Evaluation Sites: Vessels used to determine pulse rate, pulse pressure, and pulse quality in horses include the facial artery, mandibular artery, and digital arteries.

    • Pulse Quality Descriptors: Evaluated and classified as strong, weak, or uneven.

    • Pulse Deficit: Defined as the absence of a palpable arterial pulse (or a significant alteration in pulse quality) occurring simultaneously with an audible heartbeat during auscultation.

  • Thoracic Auscultation:

    • Left-Sided Cardiac Auscultation (Dog): Cardiac valves evaluated on the left side of the chest comprise the Pulmonic valve, Aortic valve, and Mitral valve.

    • Pulmonary Auscultation: Each quadrant of the lungs must be auscultated through at least 2 to 32\text{ to }3 full respiratory cycles of inspiration and expiration.

    • Obtaining Respiratory Rate: Determined visually by watching breathing motion/thoracic excursions.

    • Open-Mouth Breathing: Open-mouth breathing is always considered abnormal in cats and horses.

Vital Signs and Normal Species Reference Ranges

  • Normal Heart Rates:

    • Dog: 60−120 bpm60 - 120\,\text{bpm}

    • Cat: 140−220 bpm140 - 220\,\text{bpm}

    • Horse: 28−40 bpm28 - 40\,\text{bpm}

  • Normal Respiratory Rates:

    • Dog: 15−30 breaths/min15 - 30\,\text{breaths/min}

    • Cat: 16−40 breaths/min16 - 40\,\text{breaths/min}

    • Horse: 10−14 breaths/min10 - 14\,\text{breaths/min}

  • Normal Body Temperatures:

    • Dog: 100.0−102.5∘F100.0 - 102.5^\circ\text{F}

    • Cat: 101.5−102.5∘F101.5 - 102.5^\circ\text{F}

    • Horse: 99.0−101.5∘F99.0 - 101.5^\circ\text{F}

    • Severe Hyperthermia: Classified as a body temperature significantly above normal body temperature limits.

Mucous Membrane Evaluation and Diagnostic Reflexes

  • Mucous Membrane Evaluation Sites:

    • Assessment locations include the gums (gingiva), inner pinnae/ears, vulva, and eyelids (conjunctiva).

    • Capillary Refill Time (CRT): Normal CRT value is less than 2 seconds2\,\text{seconds}.

    • Color Clinical Indications:

    • Red: Indicates fever or infection (hyperemia).

    • Pale: Indicates dehydration, anemia, or poor perfusion.

    • Blue: Indicates cyanosis or lack of oxygen.

    • Yellow: Indicates jaundice (icterus).

  • Clinical Diagnostic Findings and Reflexes:

    • Petechiae: Pinpoint bruising visible inside the pinnae, indicative of a primary hemostatic defect such as thrombocytopenia.

    • Halitosis: Bad breath resulting from diseases of the oral cavity.

    • Ectropion: Position of the lower eyelid rolling outward away from the eye.

    • Entropion: Position of the lower eyelid rolling inward toward the eye.

    • Corneal Ulcers: Fluorescein staining is required for visual identification of a corneal ulcer.

    • Anisocoria: Term for the presence of unequal or different pupil sizes in a patient.

    • Palpebral Reflex: Reflex elicited by tapping lightly on the medial and lateral canthus of the eyes.

    • Menace Response: Tested by gesturing/tapping outside of the eye to observe blinking response.

  • Mentation and Neurological Assessment:

    • Mentation Abbreviations: BAR (Bright, Alert, Responsive), QAR (Quiet, Alert, Responsive), Lethargic.

    • Conscious Proprioception (CP): Neurological test performed by flipping the paw pads over to assess if and how quickly the patient corrects back to normal anatomic position.

  • Abdominal Palpation and Pathology:

    • Abdominal Palpation: Kidneys can be routinely palpated on abdominal palpation in cats, but not in dogs.

    • Pyometra: Infection of the uterus that most commonly occurs after a heat cycle.