VT120 Lesson

History

  • Current and past medical history plays a crucial role in creating a treatment plan.
  • It is essential to obtain an organized history of the patient.
  • Key considerations while obtaining the history:
    • Ask pertinent questions related to current and historical problems.
    • Avoid leading questions to prevent generating inaccurate information.
    • Inaccurate information can lead to unnecessary diagnostics and treatment.
    • You may need to ask questions multiple times to clarify and confirm accuracy.
    • It is important to keep the client focused on the specific problem or problems at hand.

Information

  • Patient history includes, but is not limited to:

    • Signalment:
    • Definition: Age, gender, breed, and reproductive status of the pet.
    • Importance: Certain disease processes appear more commonly in specific signalments; thus, confirming signalment is critical.
    • Problem List:
    • Definition: A list of current and previous illnesses.
    • Importance: Helps visualize the progression of acute and chronic illnesses.
    • Benefits: Provides a visual aid for veterinarians and technicians to manage any new problems that may arise.

  • General Environment:

    • Factors to assess:
    • Duration the pet has been with the family.
    • Pet lifestyle and behavior.
    • Diet and any recent changes to the environment or household.
    • Importance of home environment: Factors may include:
    • Health status of other household members.
    • Addition of new members in the household.
    • Recent relocations of the client and exposure to new areas (e.g., parks, camping).
    • Introduction of new plants in the household.
    • Behavioral considerations: Important to inquire about when the pet was last acting normally.

  • Preventive Care Status:

    • Definition: Current vaccine status and parasite prevention status.
    • Risks: Pets not vaccinated or overdue on vaccinations are at higher risk for certain viruses and diseases. Additionally, lack of current parasite preventives increases risk for specific diseases.

  • Past Medical History:

    • Items to include:
    • Allergies, diagnoses, previous and current treatments.
    • Importance of a complete medication list: Essential for generating treatment plans, as medications can interact with one another, leading to adverse effects on pets.

Physical Exam

  • The physical exam assesses all body systems, evaluating the patient from nose to tail.
  • As a technician, you perform the initial examination, aiding the veterinarian in identifying abnormalities.
  • Key components of the physical exam include:

TPR - Temperature, Pulse, Respiration

  • Purpose: Serves as a quick reference for the patient's status.

EENT - Ears, Eyes, Nose, Throat

  • Definition: Assessment of the oropharyngeal system, dentition, and periodontal disease status.
  • Key evaluations:
    • Nose and Throat: Assess for swellings, masses, and other abnormalities around the mouth.
    • Ear Examination: Includes visual assessment of pinnae, ear canal, and otoscopic evaluation of the tympanic membrane.
    • Eye Examination: Evaluates swelling, discharge, vision clarity, and abnormalities (e.g., ulcers, abrasions). An ophthalmoscope is utilized to view internal eye structures.

Respiratory System

  • Assessment: Evaluation of breathing rate and effort.
  • Technique: Auscultation (listening) of lung sounds for airway disease.
  • Norms: Normal breath sounds describe clear inhalation without crackles or wheezes.

Cardiovascular System

  • Assessment: Evaluates heart rate, rhythm, and sound.
  • Techniques include:
    • Mucus membrane color evaluation and capillary refill time assessment, typically via the mouth.
    • Cardiac auscultation for identifying heart murmurs.

Gastrointestinal System (GI)

  • Also known as abdominal palpation.
  • Evaluates not just the GI tract but also organs such as the liver and spleen.

Urogenital System

  • Evaluation of the urinary tract and genitalia.
  • Key technique: Palpation of kidneys and bladder, visual examination of distal urethra and genitalia for abnormalities.

Integumentary System

  • Assessment: Evaluates hair, skin, and nails.
  • Considerations:
    • Hair coat - Assess for dullness or dryness.
    • Nails - Check for dryness or brittleness.
    • Evaluate for any hot spots, masses, or signs of parasites.

Lymph Nodes

  • Locations to palpate:
    • Under the salivary glands (mandibular lymph nodes).
    • In front of the scapulae (prescapular lymph nodes).
    • At the caudal hind limbs at the stifle level (popliteal lymph nodes).
  • Technique: Palpate both sides simultaneously for comparison in size and shape.
  • Abnormal sizes may indicate disease processes or illness.

Musculoskeletal System

  • Assessment usually occurs as the patient walks in the exam room.
  • Evaluate for:
    • Lameness and swelling.
    • A more thorough examination may proceed if the patient presents specific lameness concerns.

Nervous System

  • This is a subjective evaluation focusing on:
    • Mentation (mental state), gait, and visual acuity.
    • Signs to observe include excessive leaning on walls, circling, head tilt, limb use, and any seizure activity.