PATIENT HISTORY

I. Signalment A. Age B. Breed C. Sex 1. Neutered or intact Chief complaint A. The reason the client is bringing the pet into the hospital B. Why the owner feels the pet is sick or injured History of present problem or illness A. Example is vomiting 1. How long has the dog been vomiting? 2. Is the dog eating? 3. Is it having any diarrhea/coughing/sneezing? 4. Have you changed diet? Past medical history A. Previous illness? B. Previous surgery? C. On any medication or treatment? Current health status A. Vaccine history B. Indoor/outdoor pet C. Other pets D. Environment E. Diet F. Toxin exposure Vitals A. Weight B. Temperature C. Pulse D. Respiration

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Diagnostic tests and treatments Behavior and mentation 1. Stupor. ect Vitals 1. Capillary refill time (Crt) 2 . Auscultation SOAP-ACRONYM S – Subjective a. Neuro. Tentative diagnosis P – Plan a. Palpation 3. BAR. Inspection 2. Weight 3. Complaint and history O – Objective a. TPR 2. QAR. Depressed.Physical Exam Techniques 1. Mucous membrane color (MM) 4. Physical exam A – Assessment a. Percussion 4.

Scabs B. Eye discharge Epiphora Tearing Symmetrical pupils and PLR Conjunctiva Redness Cataracts White cornea Nuclear sclerosis Cornea Clear Eyes Ears 1. Oiliness B. 4. 2. Alopecia A. 2. Masses Erythema A. Hair loss Pruritus A. Itching Skin lesions A. Wax 3. B. Clean or dirty A. Ear mites B. 4. Inflammation Seborrhea A. Odor 2. Scabs Fleas and ticks 1. A. 6. 3. 3. A. 6. Blood 2.Skin 1. 5. A. 5. Painful 3 . A. Black 1.

2. 3. Cat . Palpate larynx A. Blue – cyanotic D. Wheezes 1. Brick Red – sepsis or warm shock F.160-240 beats/min. Muffled 1. Icteric – Jaundice or liver disorder E. 4. Pink – normal B. Fluid B. Nasal discharge 2. Dog – 16-24 breaths per min. Cat – 16-30 breaths per minute Cardiovascular 1. Vesicular Sounds – Lungs and Alveoli 5. Dog – 70-180 beats/min.Respiratory System 1. Shows blood pressure Femoral pulse 4 . Crackles 1. Types of lung sounds 1. Pale to White – anemia or poor perfusion C. Pleural effusion D. Normal heart rates A. B. Ascultate lungs A. B. Coughing 3. Bronchial Sounds – Trachea and larynx 2. Petechia – coagulopathy or bleeding disorder CRT (Capillary Refill Time) A. Brown – methemoglobinemia ( Acetomenophin toxicity ) G. MM Color (Mucosa Membrane) A. Sneezing A. Normal respiration rates A. Constricted bronchi C. Elicit cough 4.

Redness and swollen gums 2. Pain 5 . Distended stomach 1.Facial 3. Tongue A. Symmetrical 1. Heart beat not the same with femoral pulse Gastrointestinal 1. XII – Hypoglossal nerve B. Gingivitis 1. Swallow reflex 1. VII .5. Ventral to sternum 2. Left 5 intercostal space 1. Pulse deficit 1. Pendulous 1. Excessive salivation 1. Aorta th C. Fluid D. Facial paralysis a. pulmonic valve th B. Teeth A. IX – Glossopharyngeal nerve 2. Tricuspid valve E. Right 4th intercostal space 1.Vagus 3. Palpate abdomen A. Ascultate heart A. Acute abdomen 1. Large liver or spleen C.Accessory C. Bloat B. Left 3rd intercostal space 1. X . Mitral valve D. Calculus and loose teeth B. Left 4 intercostal space 1. XI .

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Symmetry 3. Symmetrical pupils 1. Anal and tail tone G. Testicles 1. Uncorordinated gait B. Should be small and symmetrical A. Mandibular B. Anus A. Conscious proprioception ( CP ) of 4 legs E. Inguinal popliteal Musculoskeletal 1. Male A. Muscle atrophy A. Breast tumors Lymph nodes 1. Prescapular C. Fecal appearance Reproductive 1. Shows dysplasia and arthritis Nervous system A. Ataxia 1. Axillary D. Spinal Pain F. Mammary glands 1. Possible pyometra if intact female B. Symmetrical prostate 2. Mental depression or stupor C. Vulvar discharge 1.4. Sciatic and patellar reflexes 7 . Nystagmus D. Limping 2. Female A. Mentation 1. Anal sacs B. Rectal 1. Flexing and extension A. Cryptorchid 2.

Body Condition Scoring 1. Cachexia (Emaciated) a. Weakness. muscle atrophy. Generally referred to emaciated 2nd to Cancer b. Symptoms 1. anorexia. lethargy. edema and anemia. 8 . wasting and physical debilitation.

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deficating or vomiting before cleaning 1. Sanitation A. NPO – nothing per os ( nothing orally ) B. Heated cage or incubator 2. Rocal. Note on record if urinating. Kidney or Liver-low protein=K/D and L/D 4. Vital signs A. Blood with mucous-colitis c. Temperature < 99o 10 . Yellow-bile c. Puppies. Black tarey-melena b. Food b. Daily 1. Saliva and flem-coughing. Vomit a. drinking.kittens or pregnancy-high protein=P/D or A/D III. Diabetes-no sugar=W/D 3. Gastrointestinal-bland diet=I/D or D/D 5. Parvosal. Clean cages. and towels with disinfectant a. Bloody urine a. Feces a. Hypothermia (Cold) 1. Heating pads or bottles 3. Bloody-GI ulcer d. Diarrhea 3. Eating. V?D?C?S 2. Diet types 1.HOSPITAL PATIENT CARE Observation A.cardiac and respiratory B. Heart disease-low sodium=H/D 2. Cystitis 2. Bleach IV. Minimum daily TPR B. Behavior changes a. Active or depressed II. bowels. Feeding A.

flush with heparnized saline q 4-6 hours to prevent clotting 2. Flush catheter with 0. Erythema c. E-collar C. Decubital ulcers (Bed sores) 1. Check daily for patency. Infection is seen within 3-4 days post surgery a.9% Nacl C. Discharge 3. pressure sores and edema Treatment care A. Due to pressure points 2. cellulitis or edema around the elbow or joint a. Infection b. redness. Dehiscence-incision and suture break down 4. Sutures 1. IV catheters 1. Blown catheter-SQ fluids 3. Swelling b. Record urination volume and color D. E-collar to prevent self-trauma 11 . Not changing bedding. Urine scald or rash 1. Check leg and foot for swelling. Urinary catheters A.V. Keep cages padded with frequent bedding changes B. Paralyzed or recumbent patients that cannot stand 3. Closed system (Attached to bag) E. Check suture site daily for discharge and inflammation 2. patient laying in urine and feces C. Fever e. Recumbent patients A. VI. Jugular catheters should not stay in any longer than 5 days (5-7 in practice) B. pain. IV catheters should not be left in longer then 3 days (3-5 in practice) 4. Check to see if flowing(Patent) and not obstructed B. Turn q 2 hours from side to side to prevent pneumonia. Pain d.

E. Abscess b. Drain removal 2-3 days d. H. G. Tracheostomy tube a. Flow rate 1-3 liters 2. Make sure set up correctly Chest tubes 1. Check toes for swelling and loss of circulation (Cold) 4. Seroma c. Warm compress tid for 3-5 minutes Oxygen-4 minutes of hypoxia can cause brain damage 1. Should not exceed 90 ml/kg/hr (Pulmonary edema) Drains 1. Risk pneumothorax and infection (Pyothorax) 2. Suction and clean out q 4-6 hours 1. Nasal oxygen a. Monitor patient from over heating and humidity in oxygen cage 3. Mucous blocks breathing 3. Bandages 1. Wrap bandages in plastic bag to prevent wetness Intravenous fluids 1. Monitor fluids for correct rate and volume 2. Make sure 3-wat stop cock is closed to prevent air entering the chest cavity 3. F. Penrose-check daily for draining. Ventilator a.D. Causes tissue scalding and ulceration 2. Heimlich chest valve 12 . Check bandage daily for wetness from urine or feces a. E-collar to prevent chewing 3. Check for correct fluid type and additives (Spikes) 3.clean and flush a. Ivac machine is set up correctly for rate and volume 4. Suction tubes a.