Assignment Objectives:

1.1 Identify the importance of a thorough veterinary physical examination

1.2 Define presenting problem and signalment

1.3 Describe the significance and key components of a medical and environmental history

1.4 Use interviewing techniques

1.5 Roleplay each aspect of a body systems history and a body systems review

The cornerstone of every diagnosis and treatment is the physical examination. Veterinary technicians are permitted to perform physical examinations. The veterinarian usually then reviews and confirms the findings.

The vet tech may also be responsible for additional procedures, including...

Interviewing the client for the presenting problem (the reason the animal is at the vet)
Taking its body systems history (detailed questions about the body systems involved in the presenting problems)
Interpreting the animal's body systems review (a review of the body systems to not any additional problems the animal may have.

Medical History - the first step of every veterinary physical examination. It can be the most important part because it may suggest a diagnosis or show specific laboratory tests, x-rays and other procedures required to obtain a diagnosis.

Signalment- the overall patient description. Isn't considered part of the history but it can help to determine what is wrong with the animal.

Key Components of a good, thorough history are...

Identifying the primary presenting problem
Taking medical history
Taking environmental history
Reviewing the body systems

The primary or presenting problem also referred to as the client complaint; is what brings the animal into the veterinarian; the problem the owner has observed.

Primary Problem & Medical History Questions:

When did the animal begin to show that something was wrong?
How quickly did the symptoms progress?
Has the animal gotten worse?
What about any changes in the animals routine around the onset of the signs?
Has the animal's diet, living situation or exertion level changed?

Environmental History Questions:

What does the animal eat?
How do you feed the animal? Once or twice a day?
How big is each meal?
What nutritional products does the animal eat? Does it get any supplements?
Is the animal on prevention? If so, what kind?
Is the animal on parasite heartworm preventative? If so, what kind?
What, if any recent changes have occurred in the animal's diet?
What is the animals exposure to water? Does it drink tap water?

Also, ask about housing, substrates, bedding ect.

Where did the animal come from? Breeder, resucue, pet store?

Body Systems History & Review

Discuss each body system in sequence and record any current or previous problems. Use the same order to approach any case to ensure consistency.

Aquire the body systems history. Ask detailed questions about the body system (or systems) involved in the presenting problems. For instance, if the animal presents with a sore leg, asked detailed questions about the musculoskeletal system
Perform body systems review. Take inventory of the body systems to note any additional problems the animal may have. A good place to start the body systems review is to ask the owner, "What other problems have you noticed?" Then proceed through the body systems with brief, open-ended questions that prompt the owner to describe further abnormalities.
Review the integumentary system. The integumentary system is the skin and attached structures, such as hair. Ask questions about itching. Where does the animal scratch? How long has the animal been scratching? Does the scratching seem to vary by season? Is the animal experiencing hair loss? When did it occur, and how is it distributed on the body? Has the animal's environment changed in any way- a new carpet, new laundry detergent or bedding, different floor cleaner, for instance? Any lumps or bumps on the skin? Any previous lumps removed? How were previous skin problems treated, and how did the animal respond? Do any other animals in the household have the same problem?
Review the head and neck. The review of the head and neck includes discussing the eyes, ears, nose, and mouth. Has the animal been shaking its head? Does it tilt its head? Are its eyes clear? Do they tear excessively? Does the animal squint or scratch at its eyes? Does the animal seem to see normally? Any history of nosebleeds? Any coughing, gagging or difficulty eating? Are the teeth clean? Have any teeth been lost or extracted?
Review the respiratory system. The respiratory system takes in oxygen and releases carbon dioxide. The chief symptom of a respiratory problem is a cough. However, some coughs, especially coughs that occur primarily at night, can signal heart disease. When does the animal cough most? Does it cough after exercise or exertion? Does the cough clear the respiratory system? Does the animal sneeze or have a runny nose? Sneezing and nasal discharge are also important symptoms of respiratory disease. Some animals with respiratory problems become sluggish. Have there been any changes in the animal’s running or playing habits? Sometimes an abnormal respiratory tract causes the animal’s gums to turn dark blue or purple, so check gum color as part of your systems review. Exposure to toxins, fungus, bacteria, viruses, and environmental irritants may all cause respiratory problems. Has the animal been exposed to other animals? Has it traveled recently, and if so, where? Was it recently boarded?
Review the cardiovascular system. The cardiovascular system circulates blood. Because decreased vigor or breathing problems can indicate either respiratory or cardiovascular problems, or both, these body systems reviews tend to overlap. Has there been any change in the animal’s ability to perform everyday tasks (such as climbing stairs)? Has the animal ever fainted? Is its breathing ever labored? Cardiovascular (heart) disease can cause coughing because a malfunctioning heart affects the blood pressure balance in the lungs, causing fluid to leak from blood vessels into the lungs. Enough of this leakage can literally drown an animal in its own fluids. This fluid accumulation, or pulmonary edema, could indicate heart disease. Other signs include fainting, labored breathing, and fluid accumulation in the abdomen.
Your cardiovascular systems review should include the following questions: Has the animal ever been diagnosed with heart disease? If so, how was it treated? How did the animal respond? Has the animal ever been tested for heartworms? What was the test result? Has anyone examining the animal ever detected a heart murmur? Has the animal ever had a chest x-ray?
Review the gastrointestinal system. The gastrointestinal (GI) system is complex. Its many problems, however, have two main symptoms: vomiting and diarrhea (constipation is also a sign of GI system disease). Describing these signs precisely may assist diagnosis, so detail is extremely important. If the animal is vomiting, you need to know: How often? How much volume? When does the vomiting occur relative to meals? What’s the consistency and color of the vomit? Does it contain undigested or partially digested food?

If there’s diarrhea, what’s its consistency and color? What’s the volume of stool passed? Is there blood or mucus in the diarrhea? How often is the animal having diarrhea? The questions concerning volume, consistency, color, and frequency also apply to an animal suffering constipation.

Don’t forget to take a dietary history as well. What does the animal eat? How much food is the animal given, and how frequently? For the large-animal patient, has the animal overeaten a particular item, such as grain or green grass? What’s the animal’s exposure to toxins? Some of these can cause vomiting or diarrhea. What about the animal’s exposure to garbage? For a small-animal patient, does the owner routinely feed it table scraps?

What about intestinal parasites? Has the animal ever been diagnosed with parasites, and if so, how was it treated? When was the animal last screened for parasites in its feces? What routine deworming program does the owner have in place?
Urinary system. Urinary tract problems can be difficult to assess. Ask questions about both drinking and urinating habits. What does the urine look like? How does it smell? How frequently does the animal urinate? Is there any pus or blood in the urine? Does the animal seem able to urinate when it wants to, or is there dribbling of urine? Can the animal hold its urine all night, or all day while the family is gone? Does the animal strain to urinate or seem to pass small amounts of urine very frequently? What about the animal’s drinking habits? When does the animal tend to drink? What’s its daily intake? Has the owner noticed any increase or decrease in water intake?

It’s important to ask if the animal has ever suffered urinary tract trauma or infection. How was the urinary tract disease treated? Has the animal ever had bladder or kidney stones? Were the stones removed? If stones were removed, were they analyzed? If so, what was their makeup?
Reproductive system. The first question on your reproductive system review is: Has the animal been neutered? If it has, your reproductive system review is simple, because you can skip all of the following questions that you must ask if the animal is intact. Has the animal been bred? Did it produce live, healthy offspring? For the female, was delivery of the young difficult? What about false pregnancies? Has the animal ever had breast tumors? Has the animal been tested for sexually transmitted diseases, such as brucellosis? For the male, has its semen ever been evaluated? Has it ever had discharge from the penis or problems with the scrotum?
Musculoskeletal system. Problems of the musculoskeletal system can often be diagnosed just from the systems review, combined with a thorough physical examination. Particular activities can cause specific orthopedic problems. What’s the animal’s expected performance or use? Is it a working animal? Is it a racing animal? Certain breeds are also prone to specific orthopedic problems. Do the signs and symptoms disappear completely, or do they still come and go? If there’s lameness, when did it first occur? Was the onset sudden or gradual? Is it better at some times than others? Does it seem worse after the animal rests, or after activity? Does it affect more than one limb? Is there any history of broken bones, torn tendons or ligaments, or dislocations? If so, how were the injuries treated? What was the outcome of therapy?
Central nervous system (CNS). The central nervous system carries nerve impulses to and from the brain. The most common sign of a CNS problem is a seizure, a short circuit in the brain that makes the animal lose control over its body. In most seizures, the major muscle groups of the body spasm while the animal loses awareness of itself and its surroundings. Seizures aren’t painful, but they can be frightening to witness. Witnessing the seizure, however, greatly helps diagnosis. An animal that has seizures will often have a normal physical examination. It’s especially important to take a thorough history of an animal with CNS problems.

How often do the seizures occur? How long does each seizure last? How violent are the muscle contractions? Does the animal lose control of bladder or bowel function? How does the animal act between seizures? Do the seizures seem linked to a particular activity, such as eating? Has the animal possibly been exposed to poisons? Has the animal been vaccinated against diseases that affect the CNS, such as rabies and distemper? Has the animal’s behavior changed? Does the animal have any problem eating, drinking, swallowing, walking, balancing, or running? Does the animal exhibit any unusual posturing, such as arching of the back?

Ask about the animal’s senses. Has the owner observed any change in the animal’s ability to hear, see, or smell? Has the way the animal responds to external stimuli changed with the onset of the CNS symptoms?

Another CNS disorder is intervertebral disk disease, deteriorated cushions between the vertebrae, or bones of the spine. Sometimes a disk ruptures and presses on the spinal cord and nerves. Symptoms of intervertebral disk disease vary from intense pain to complete paralysis. Has the animal suffered intervertebral disk problems? How were they treated? How did the animal respond? Did the animal return to normal function after the disorder? How has the animal functioned since?

Once you have gathered information about the body system involved with the primary problem or presenting complaint, you'll want to conduct a body systems review.

Give the client a chance to describe any additional abnormalities by proceeding through the remaining body systems logically.

Self-Check:

1. Without a physical exam on an animal, you can't arrive at a diagnosis.

2. If an animal presented with a sore leg, you would check its musculoskeletal system.

3. If a dog presented with a cough, you check the dog's respiratory system and its cardiovascular system.

4. If you want to learn what a pet eats, its exposure to water, and its travel situation, you'll take an environmental history.

5. If the owner tells you the dog is scratching a lot, you need to check the dog's integumentary system.

6. Which of the following are components of the signalment?

a. coat color, eye color, and weight

b. breed, eye color, and gender

c. breed, gender, age, and reproductive status

d. age and coat color

7. Taking a good history is critical part of the physical examination because a good history

a. determines the cause of the presenting problem

b. confirms the client's diagnosis

c. narrows the focus of testing and diagnosis

d. reassures the client that the animal is receiving the best care

8. Which statement is true of the animal patient's history?

a. the presenting problem is the only focus of the history

b. the animal's living situation (indoor or outdoor) has little bearing on the history

c. previous medical problems and the animals's response to therapy should be included in the history

d. a history of coughing suggests a problem with only the respiratory tract

9. What helps the veterinarian evaluate the patient's physical status, develop a diagnosis, and offer a prognosis? A Medical- History

10. Why is it so important to ask non-leading, open-ended questions when interviewing a client about the animal's medical history? Allow you to obtain detailed information about the patient. You'll gain more useful, specific info from asking these questions vs yes or no questions.

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