History and Physical Key Terms Flashcards
1
Q
The most common veterinary procedure and tells more about a patient than any other diagnostic tool
A
Physical Examination
2
Q
What does VCPR stand for?
A
Veterinarian Client Patient Relationship
3
Q
What are the 5 VT responsibilities during the physical exam?
A
- Vitals
- Restraining Patient
- Interviewing client for presenting problem
- Body Systems History
- Body Systems Review
4
Q
The detailed questions about the body systems involved in the presenting problem
A
Body Systems History
5
Q
The overview of the body systems to note any additional problems the animal may have
A
Body Systems Review
6
Q
The first step of an exam
A
Medical History
7
Q
Takes into account the patient’s emotional wellbeing such as fear triggers, treat preferences, where and how they like or dislike being handled, and behavioral nutraceuticals and/or meds that have worked in the past
A
Emotional Medical Record
8
Q
What types of questions should you ask when interviewing the owner in order to get the most detailed response possible and avoid yes/no answers
A
Open-Ended Questions
9
Q
The overall but concise patient description used to share basic facts about the animal to the vet
A
Signalment
10
Q
What 4 pieces of info are included in the Signalment?
A
- Age
- Gender
- Breed
- Reproductive Status (neutered or not)
11
Q
What are the 5 key components of a thorough history?
A
- Identify the presenting problem
- Completing a medical history
- Completing an environmental history
- Completing an emotional history
- Reviewing the body systems
12
Q
What should the VT say to the client upon entry to the exam room if the presenting problem is:
- known at client arrival
- unknown at client arrival
A
- Confirm and reiterate the problem - “Hi, Mrs. Jones. I see Marley is here to see Dr. Smith today because he has been scratching his ears.”
- Ask the client - “Hi Mrs. Jones. Tell me why Marley needs to see Dr. Smith today.”
13
Q
What 4 things should the VT ask once the presenting problem is confirmed?
A
- When did this problem begin?
- Has the problem gotten better or worse?
- Has the animal ever experienced this problem before?
- What are the characteristics and details of the problem?
14
Q
Details about the animal’s current living situation
A
Environmental History
15
Q
What 4 things should the VT ask the client regarding patient environmental history?
A
“Oh dam that’s how you live?”
1. Ownership Details
2. Diet
3. Environment
4. Medications
16
Q
The Circulatory System includes what 3 things?
A
- Heart
- Blood
- Blood Vessels
17
Q
The Respiratory System includes what 7 things?
A
- Nose
- Mouth
- Pharynx
- Larynx
- Trachea
- Bronchi
- Lungs
18
Q
The Integumentary system includes what 8 things?
A
- Skin
- Scales
- Hair
- Paws
- Hooves
- Feathers
- Horns
- Nails
19
Q
The Musculoskeletal System includes what 6 things?
A
- Bones
- Muscles
- Tendons
- Ligaments
- Connective Tissues
- Joints
20
Q
The Gastrointestinal System includes what 8 things?
A
- Mouth
- Esophagus
- Stomach
- Intestines
- Anus
- Liver
- Gallbladder
- Pancreas
21
Q
The Urogenital System includes what 5 things?
A
- Kidneys
- Ureters
- Bladder
- Urethra
- Reproductive Organs
22
Q
The Nervous System includes what 3 things?
A
- Brain
- Spinal Cord
- Nerves
23
Q
What are the 6 Vital Statistics you must collect at the beginning of every physical exam?
A
- Weight
- HR
- RR
- Mucous Membrane Color
- CRT
- Temperature
24
Q
What type of scale do you use for dogs/cat > 20 lbs?
A
Platform Scale
25
What type of scale do you use for dogs/cats < 20 lbs?
Infant Scale
26
What type of scale do you use for small animals < 2 lbs?
Gram Scale
27
What type of scale do you use for horses and other farm animals?
Walk-On Scale
28
If a walk-on scale is not available, what is another way to determine the weight of a horse?
Heart-Girth Tape
29
Listening with a stethoscope to the body's various functions
Auscultation
30
Feeling with your hands and/or fingers
Palpating
31
How do you calculate Heart Rate?
HR (beats per min) = # beats over 15 sec x 4
32
What is the "lub" sound caused by in a normal heart beat?
The mitral and tricuspid valves closing
33
What is the "dub" sound caused by in a normal heart beat?
The aortic and pulmonary valves closing
34
An abnormal heart rate or heart rhythm
Arrythmia
35
Abnormally slow heart rate
Bradycardia
36
Abnormally fast heart rate
Tachycardia
37
When the HR increases when the animal inhales and decreases when the animal exhales
Respiratory Sinus Arrythmia
38
An abnormal sound caused by the improper closure of the heart valves or other cardiac diseases - causes a "whooshing" sound
Murmur
39
How do you calculate pulse rate?
PR (pulse beats per minute) = # pulse beats over 15 sec x 4
40
Where can you find the femoral artery for palpation?
Palpate the medial thigh where the femur bone meets the trunk of the body
41
The heart rate should be synchronous with what?
Pulse Rate
42
How do you note the Character of the pulse?
Whether it is:
- Strong = easily palpated
- Weak = difficult to palpate
- Bounding = excessive pressure
- Thready = weak and feels like a small thread moving under your fingers
43
What is considered 1 Full Respiration?
1 breath = 1 inhalation + 1 exhalation
44
Where do you place the diaphragm of the stethoscope when auscultating for heart rate?
Thorax near the left axilla
45
Where do you place the diaphragm of the stethoscope when auscultating for respiratory rate?
Left side of the thorax - approximately the 3rd rib
46
What are the 2 methods to determine respiration rate?
1. Auscultation
2. Visualization
47
What are the 4 Lung Fields?
1. Left Dorsal
2. Left Ventral
3. Right Dorsal
4. Right Ventral
48
When auscultating the lung fields, what 3 things are you noting?
1. Depth - deep breaths vs shallow?
2. Effort - effortless or difficult to breathe?
3. Character - smooth or abnormal?
49
Abnormal Character of Respiration - harsh noises that sound like crumpling cellophane paper
Crackles
50
Abnormal Character of Respiration - high pitched musical noises heard on exhalation
Wheezes
51
Abnormal Character of Respiration - high pitched noises on inhalation or exhalation
Stridor
52
How do you calculate respiratory rate?
RR (breaths per minute) = # breaths over 15 seconds x 4
53
Reflection of the perfusion and peripheral tissues
Capillary Refill Time (CRT)
54
What should the CRT be?
< 2 seconds
55
How do you determine CRT?
Press down on the gums until blanched > count how many seconds it takes for them to return to normal color
56
How far in should a rectal thermometer be placed?
1 inch
57
99.5 -102.5 is the normal temperature for what species?
Dogs
58
100.5 -102.5 is the normal temperature for what species?
Cats
59
99 - 101 is the normal temperature for what species?
Horses
60
100 - 102 is the normal temperature for what species?
Cows
61
101 - 104 is the normal temperature for what species?
Sheep
62
80 - 140 is the normal HR/PR for what species?
Young Dog
63
140 - 200 is the normal HR/PR for what species?
Young and Adult Cat
64
60 - 80 is the normal HR/PR for what species?
Young Horse
65
100 - 150 is the normal HR/PR for what species?
Young Cows
66
80 - 120 is the normal HR/PR for what species?
Young Sheep
67
60 - 140 is the normal HR/PR for what species?
Adult Dog
68
30 - 50 is the normal HR/PR for what species?
Adult Horse
69
40 - 60 is the normal HR/PR for what species?
Adult Cow
70
70 - 80 is the normal HR/PR for what species?
Adult Sheep
71
20 - 25 is the normal RR for what species?
Young Dog
72
20 - 30 is the normal RR for what species (young)?
Young Cat
73
14 - 15 is the normal RR for what species?
Young Horse
74
30 -60 is the normal RR for what species?
Young Cow
75
15 - 20 is the normal RR for what species?
Young Sheep
76
20 - 30 is the normal RR for what species (adult)?
Adult Dog
77
20 - 40 is the normal RR for what species?
Adult Cat
78
9 - 10 is the normal RR for what species?
Adult Horse
79
12 - 16 is the normal RR for what species?
Adult Cow
80
15 - 40 is the normal RR for what species?
Adult Sheep
81
Who is primarily responsible for physical exams?
Veterinarian
82
What are the 6 most common Integumentary System abnormalities?
1. Lesions - alopecia, lumps, bumps
2. Papules
3. Crusting
4. Scabs
5. Erythroderma
6. Fleas/Flea Dirt
83
What 4 things are you checking in the Integumentary System?
1. Hair Coat
2. Skin
3. Paw pads and nails
4. Turgor Pressure
84
Unit of time used to measure the elasticity of the skin
Turgor Pressure
85
What do the results of Turgor Pressure indicate?
Level of Dehydration
86
How do you measure Turgor Pressure?
1. Lift a patch of skin between the shoulder blades
2. Twist and release
3. Measure the length of time it takes the skin to return to normal
4. Length of time = Turgor Pressure
87
Ratio of Turgor Pressure to Dehydration:
0-1 sec = ____ % dehydration
< 5%
88
Ratio of Turgor Pressure to Dehydration:
2-4 sec = ____ % dehydration
5 - 8%
89
Ratio of Turgor Pressure to Dehydration:
5-10 sec = ____ % dehydration
8 - 10%
90
Ratio of Turgor Pressure to Dehydration:
10-30 sec = ____ % dehydration
10 - 12%
91
If masses, lesions or papules are observed, what 4 things do you record?
1. Location on the body
2. Location on or under the surface of the skin
3. Size
4. Shape
92
External parasites like fleas
Ectoparasites
93
Redness of the skin
Erythroderma
94
What 4 things are you checking in the Respiratory System?
1. Nose/Nostrils
2. Mouth
3. Throat
4. Lungs
95
What are some common Respiratory System abnormalities?
- Discharge
- Swelling
- Masses
- Foreign Objects
- Rales
- Elongation of the Palate
96
What are you listening for when auscultating the thorax?
Even air flow in and out of the lungs in all 4 quadrants
97
Crackling or ratting sounds during inhalation
Rales
98
Soft palate fluttering when the animal breathes
Elongated Palate
99
What 4 things are you checking in the Circulatory System?
1. Mouth - mucous membrane color and CRT
2. Throat
3. Thorax - heart auscultation
4. Pulse Beat
100
What are you listening for when auscultating the throat?
Even air flow
101
What are you listening for when auscultating the heart?
Valve PMI (Point of Maximal Intensity)
102
How do you determine if there is a Pulse Deficit?
Feeling the pulse beat while listening to the heart
103
The difference, if any, between the heartbeat and the pulse beat
Pulse Deficit
104
What 4 things are you checking in the Gastrointestinal System?
1. Mouth - mouth cavity, teeth, gums
2. Throat - esophagus
3. Abdomen
4. Rectum
105
When palpating the abdominal organs, what 3 things are you noting?
1. Consistency
2. Size
3. Shape
106
The involuntary constriction and relaxation of the muscles of the intestines, creating wavelike movements that push the contents of the digestive tract forward
Peristaltis
107
What 5 things are you checking in the Urogenital System? (3 female/2 male)
Female:
1. Internal Sex Organs
2. Mammary Glands
3. Vulva
Male:
1. Testicles
2. Penis
108
What are some common abnormalities in the Urogenital System?
- Masses
- Discharge
- Enlargement
- Lumps
109
What 4 things do you palpate the testicles for?
1. Presence
2. Size
3. Shape
4. Consistency
110
What 2 things do you palpate the penis for?
1. Shape
2. Smoothness
111
What 5 things are you checking in the Musculoskeletal System?
1. Muscles
2. Leg Bones
3. Joints/Toes
4. Spine
5. Body Condition Score (BCS) or Muscle Condition Score (MCS)
112
What 4 things do you palpate the muscles for?
1. Atrophy
2. Enlargement
3. Heat
4. Pain
113
What 3 things do you palpate the leg bones for?
1. Fractures
2. Pain
3. Masses
114
What 4 things do you feel and listen for when moving the joints/toes through their full ranges of motion?
1. Crackling
2. Popping
3. Sounds of Pain
4. Loss of Motion
115
How do you evaluate the spine during a physical exam?
Apply pressure to the muscles around the spine from neck to tail
116
The degree of slimness or obesity on a scale from 1-9
Body Condition Score (BCS)
117
The degree of muscle present on a scale from 1-4
Muscle Condition Score (MCS)
118
What 3 things are you checking in the Nervous System?
1. Eye Reflexes
2. Pupils
3. Foot Reflexes
119
What are normal vs abnormal Pupil reactions during their test?
Normal - pupil dilates to its pre-exam state
Abnormal - any lack or delay of constriction or dilation
120
What 2 reflexes do you test for in both eyes during a physical exam?
1. Palpebral Reflex
2. Menace Reflex
121
Touching the medial corner of the eye to elicit a blink
Palpebral Reflex
122
Moving an open palm rapidly toward the animal's eye to elicit a blink
Menace Reflex
123
The reflex to right the foot once being put in a flexed position
Proprioception
124
How do you test paw/hoof reflexes?
Test their proprioception
125
What is an abnormal response during a proprioception test?
Delay or lack of righting the foot
126
What are the 5 peripheral lymph nodes palpated and compared in the Lymphatic System?
1. Submandibular
2. Axillary
3. Inguinal
4. Popliteal
5. Prescapular
127
Lymph node located caudal to the mandible on each side of the jaw
Submandibular Lymph Node
128
Lymph node located cranial and dorsal to the shoulder joint
Prescapular Lymph Node
129
Lymph node located in the animal's armpit region
Axillary Lymph Node
130
Lymph node located in the region between the rear legs
Inguinal Lymph Node
131
Lymph node located at the caudal aspect of the rear leg behind the stifle joint
Popliteal Lymph Node
132
When comparing the lymph nodes to one another what 3 things are you comparing for?
1. Size - enlargement
2. Consistency
3. Pain
133
Scientific name for the knee joint
Stifle Joint
134
What 5 things are you checking in the Eyes?
1. Eyelashes / Lids
2. Conjunctiva
3. Sclera
4. Cornea
5. Retina
135
When discharge is observed in the eye(s), what 3 things do you note?
1. Color
2. Consistency
3. Location - left, right or both eyes
136
What 3 things are you checking in the Ears during a physical exam?
1. Base of Ear / Ear Pinna
2. Ear Canal
3. Tympanic Membrane
137
What are some common abnormalities when evaluating the ears during a physical exam?
- Masses
- Fluid
- Alopecia
- Discoloration
- Irritation
- Discharge
138
Device used to check the ears during a physical exam
Otoscope
139
Device used to check the eyes during a physical exam
Ophthalmoscope
140
The membrane that covers the eyeball and the inside of the eyelids
Conjunctiva
141
The white part of the eye
Sclera
142
The transparent layer that covers the very front of the eye
Cornea
143
A layer at the back of the eyeball containing photosensitive cells that trigger nerve impulses that pass via the optic nerve to the brain
Retina
144
A legal document containing all pertinent info about the animal's current medical condition, medical history, and anything else that applies to the animal's health
Medical Chart / Medical Record
145
Who does the medical record belong to?
The vet hospital or the owner of the practice
146
In what order are medical records organized?
Reverse-Chronological Order
147
What is on the first page of the medical record/chart?
Master Problem List
148
The most widely accepted format that divides a physical exam medical note into 4 sections
SOAP Format
149
What does SOAP stand for?
S - Subjective Data
O - Objective Data
A - Assessment
P - Plan
150
Section of the medical record for info that's subject to observational and descriptive powers of the evaluator
Subjective Data
151
What SOAP section includes:
- Reason the animal is at the vet
- Patient history details
- observations of the animal that can't be quantified
Subjective Data Section
152
What SOAP section includes:
- Weight
- Temperature
- Pulse
- Respiration
- Lab Data
- Details of each body system's physical exam
Objective Data Section
153
Section of the medical record containing info that is quantifiable - can be and is measured
Objective Data Section
154
Section of the medical record that guides the vet's diagnostic testing choices - is only used by the vet
Assessment Section
155
What SOAP section includes:
- differential diagnoses
- patient diagnoses
Assessment Section
156
What SOAP section includes:
- Prognosis
- Problems to be monitored
- Follow up care instructions for client
- Medications prescribed
- Other recommendation
Plan Section
157
What are 4 common topics for Client Education?
1. Nutrition
2. Behavior
3. Postoperative Care
4. Wellness Information
158
General term that covers many of the client's interactions with the practice
Client Education
159
What are 4 examples of Vet-Client interactions considered to be Client-Education?
1. Talking informatively to the client during and following the examination
2. Explaining postoperative care instructions when discharging a surgical patient
3. Reviewing a prescription to make sure the client knows how much medication to give and when
4. Answering the client's questions
160
Who is primarily responsible for client-education?
Veterinarian
161
What 2 things can you do to be a successful VT?
1. Listen to what the vet says to clients
2. Learn about the topics the vet considers important
162
How long do you auscultate the abdomen when checking the gastrointestinal system and what do you record?
Listen for 1 full minute
Record how many gut sounds you hear
163
How many gut sounds should you hear per minute during abdominal auscultation of a large animal?
1-2 gut sounds
