NAME: _______________________________ DEADLINE: ________________

DATE SUBMITTED: ______________________ RATING: __________________

EXERCISE NO.
3
HISTORY TAKING AND PHYSICAL EXAMINATION
I: INTRODUCTION

Patient history is one of the most important aspect of proper medical problem
identification. One must resist the temptation of substituting history with diagnostic test kits. It will
guide clinicians and/or veterinarians on the potential problem and will have an idea on which part of
the body that will be given attention during physical examination. Begin with the chief complaint then
pursue this complaint deeper noting additional problems and their chronologic development. Review
each body system and ask question to the owner on any presence of signs that would indicate organ
or system dysfunction. There are usually two techniques in taking history. The first technique is called
the interrogative or cross – examination technique in which is done in a more organized and
chronologic manner. This style is good to honest and dillegent owners because some owners may
answer falsely to spare themselves. The second is the open style technique in which the owner is
asked to describe the pet’s problems. This can be disorganized and lack of chronologic specificity. You
can use both the combination of technique to a more precise history taking.
Physical examination of a patient is important tool in determination of which part of the body
is having a problem. Proper interpretation of laboratory tests involves correlation with the history
and physical examination findings. All body system should be examined giving particular attention to
those system/s in which there are dysfunctions from the history. All abnormalities should be noted
and recorded.
II: Objectives

1. Familiarize history taking and be able to fill up Information form correctly

2. Perform history taking and physical examination thoroughly

III: MATERIALS NEEDED

Thermometer, penlight, stethoscope

Pen, pencil, references

IV: PROCEDURES
1. Get a Protocol form ( Patient and client Information Form ) at the clinic and Perform history
taking and physical examination at the VTH. ( atleast 3 )
2. Attach the legibly filled Protocol form
3. Write legibly ( use black ink )