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1

Orderof the documentation of the examination results

SIGNALEMENT /NATIONALE (patient ID) 
name and address of the owner 
permanent data of the animal 
transient data of the animal
ANAMNESIS (history) 
STATUS PRAESENS (current state)

2

SIGNALEMENT (NATIONALE)

OWNER
- name and address, (phone, e-mail) 
PERMANENT data of the ANIMAL
- species, breed, sex, colour, colour pattern, nose impression, blood group, marks, (chestnuts, whorl, permanent blemishes or defects) 
TRANSIENT data of the ANIMAL
- age, body weight, brand marks microchip, tattoos, ear tags, (name) withers height

3

HISTORY I. Inquiries concerning the animal

-Health state
1. How long has the animal been ill?
2. What kind of abnormalities has the owner observed? 3. Were there any change in the state of the animal since the observation of the disease?
4. Were the same or any other symptoms previously observed? If yes, at what time? 
-Previous veterinary and other interventions
1. Veterinary interventions (previous treatments, immunizations, operations, diagnostic processes-e.g. thoracocentesis, abdominocentesis)
2. Interventions by other people (enema per rectum, per os treatment, sounding, assistance during calving etc.)
-Reproductive state
1. Female animal: oestrus, parturition, pseudogravidity, contraceptives
2. Male animal: mating
3. Neutering 
-Productivity 
-Transport

4

HISTORY II. Inquiries concerning the environment

-Health state of the animal population
1. How many and what kind of animals are kept together with the sick animal?
2. How many of them are ill? Were there any similar or different diseases previously observed among them? Is there any loss from the population? If yes, its degree?
3. Were any laboratory or instrumental examinations performed?
4. General epidemiological, parasitic state of the group/herd?
-Husbandry
1. Housing
2. Hygienic conditions
3. Possibility of the ingestion of toxic materials
4. Change of the person who works with the animal
-Nutrition
1. Quality and quantity of the food
2. Feeding technology, way of eating
3. Water intake: amount, way of drinking
4. Feces (stool), urine 
-Change of the owner (sale and purchase)-

5

STATUS PRAESENS

1. General impression
2. Basic clinical values
3. Skin
4. Lymph nodes
5. Mucous membranes
6. Respiratory system
7. Cardiovascular system
8. Gastrointestinal system
9. Urinary system
10. Genital system
11. Spleen and haemopoetic system
12. Hormonal glands
13. Locomotion system
14. Nervous system

6

1. General impression

-Body size (height, body weight) 
-Body shape and developmental state, matures (skeleton, muscles)
-Nutritional condition:
Body condition score BCS 5 BCS 9 (4-5=ideal)
obese-overweight-normal-underweight-very thin 
-General condition, grooming (hair, fleece, footpads, claw, hoof) 
-Consciousness
1) bright, alert: normal response to external stimuli, obvious interest in surroundings 
2)dull /apathy: reaction to normal stimuli is retarded, suppressed 
3)sopor: sleepiness 
4)dummy, stupor: advanced degree of failure to respond remains standing, capable of movement 
5)comatose: responds to painful stimuli, otherwise unresponsive
6)coma: unconscious, fails to respond to even a painful stimuli
-behavior (general demeanor) (breed, physiologic variations w/ age, sex, state of health)
1)nervous, tense, excited, anxious: Increased responsiveness to external stimuli. Alert, but normal movement
2) restlessness: movement is almost constant, usually caused by pain (colic= lying down, rolling, getting up again, kicking belly)
3)mania: extreme form of abnormal behaviour, aberrations seem compulsive, vigorous licking, head pressing. frenzy: animal’s action are uncontrolled
4)Pathologic behavior: Self mutilation; Compulsive actions: head-pressing, walking in circle, mania; Convulsion, tail chasing, fly biting ; Aggression
-Posture= Position of head, ears, neck, trunk, spinal, legs, tail, weight balance 
1) If standing :
-Weight bearing equally on all legs & Legs may not be under/over extended 
-Spinal column : Arched, sagging back (kyphosis, lordosis=sag, scoliosis=arch) ; abduction of elbows ;Stiffly extended neck 
2)Lying on sternum/side, recumbent; opistotonus 
3)Sitting position= pathological in horse
-Locomotion (gait) 
-Obvious abnormalities

7

General impression Normal result

The physique concerning the body size, shape and matures is according to age, sex and breed specificity. Nutritional condition is good (upper range of breed specific weight) and general condition is good with good muscling. The groomed state of the animal is very good, the hair coat is shiny and clean. The behavior of the dog is conscious and alert and a little excited showing panting and restlessness. Posture, gait and movements are physiological with head held high, tail straight-out and putting weight on all four limbs. Steps are equal length and powerful walk showing no signs of limping, circling or other lesions concerning locomotion.

8

Basic Clinical Values

Temperature °C 
Dog: 38,2-39,1
Cat: 38,5-39,3
≈ determined by excitement, physical exertion & temperament, not by size 
Pulse / minute 
Dog: 60-70 -140 (180)-clinic 60-70 -home 
Cat: 140-180 (200) -clinic 120-130 -home
Breathing rate / minute 
Clinic: <40 at home: <30 sleeping: <25

9

Breathing rate 

Tachypnoe, polypnoe
-fever 
-narrowing / obstruction of the airways (nose:inflammation, foreign body, larynx paralysis, oedema, trachea hypoplasia, collapse, inflammation, oedema, neoplasma, macro or microbronchitis)
-decreased breathing surface (pneumonia, lung oedema, neoplasma, abscess, pneomothorax, hydrothorax, haemothorax, pleuritis) 
-obstacle of the movement of the diaphragm (tetanus, ascites, gastric torsion, meteorism) 
-systemic painful disease 
-central nervous irritation (encephalitis, epilepsy)
-decreased oxygen level of the blood (anaemia, methaemoglobinaemia, CO toxicosis)
↓Oligopnoe, bradypnoe
• encephalitis between the excited periods, brain oedema, toxicosis

10

Temperature °C

Increased:
- sun, work, excitement, feeding, heating
- fever, inflammation, irritation of the heat centre
- heat stroke, muscle contraction (unregulated hyperthermia)

Cat=> always check temp as catecholamine rece[tor numbers change according to it, and giving fluid therapy may be lethal

Decreased:
- cool, 1-1,5 day before calving, exhaustion, cachexia, opened anus
- hypovolemic shock, barbiturate toxicosis 
- species, breed, age, sex, condition

11

Pulse / minute (heart rate)

dog, cat: a. femoralis
species, breed (not size), temperament, excitement!, age, sex, training