Auscultation
The act of listening to internal sounds of the body
signalment
patient's identity, species, breed, age, sex, reproductive status
Rx
Medication
Sx
abbreviation for "symptoms"
Dz
Disease
Hx
History
PE
Physical Exam
NE
Not Examined
HR
Heart Rate
BPM
Beats per minutes (contractions)
T
Temperature - take rectal - 99.5-102.9 for cats and dogs
Dyspnea
difficult or labored breathing. A feeling of discomfort or effort associated with breathing and may manifest as rapid, shallow, or otherwise abnormal breathing patterns.
Tachypnea
abnormally rapid rate of breathing. Means something is wrong. Characterized by quick and shallow breaths, often resulting in an increased respiratory rate.
Hyperventilation
breathes at an abnormally rapid rate, often resulting in deeper and faster breaths than what is necessary for normal respiration. This rapid and deep breathing leads to a reduction in the levels of carbon dioxide (CO2) in the bloodstream, which can have various physiological effects.
Hypocapnia
Caused by hyperventilation. is a medical condition characterized by abnormally low levels of carbon dioxide (CO2) in the bloodstream.
Hypoventilation
abnormally slow or shallow rate of breathing, resulting in reduced airflow into the lungs and inadequate oxygen exchange
hypercapnia
caused by hypoventilation. elevated level of carbon dioxide (CO2) in the bloodstream. It occurs when there is an excess of carbon dioxide compared to the normal range.
ventilatory failure
respiratory failure
VCPR
Veterinarian-Client-Patient Relationship
V/D/C/S
Vomit/diarhea/coughing/sneezing
Supplies for the exam
thermometer, lubricant,scale,pen,watch, chart, restraint equipment, stethoscop, otoscope, opthalmoscope, exam gloves, reflex hammer, cotton balls, penlight
Physical Exam - Mental Status
alert, focused, responsive
Physical Exam - Conformation
body shape, limping
Physical Exam - body condition score
4 or 4-5 is ideal score.
Physical Exam - Neurological problems
Wobbling, unable to control movemetn
Physical Exam - Overall assessment
weak, labored breathing, etc.
Vital Signs
Wt - Weight
TPR - temperature, pulse, respiration
MM color - mucos membrane color
CRT - Capillary refill time
BCS
Body Condition
Patient Parameters/Vital Signs/Patient Vitals (what you do at the beginning of the
Name, session, date and then the following:
T
P
HR
R
MM
CRT
Wt
___
1. Observe (looks like..., acts like, how it moves)
2. Mental State
3. Body Condition Score
4. Neurological
5. Overall General Appearance
P - Pulse K9 and feline
Pulse (K9 70-140) (Feline 140-220)
Temperature K9 and feline
Temperature - take rectal - 99.5-102.9 for cats and dogs
R - Respiratory K9 and feline
Respiratory (K9 20-40,PANT) (Feline, 20-50)
Endothermic
regulated body temp internally - human
Ectothermic
regulates body temperature through environment - lizard
Hypothermia
temp below normal -
Hyperthermia
temp above normal
Gum Assessment
- Oxygenation (blue)
- Liver issues (yellow)
- Blood supply (pale/white)
- Shock/ decreased BP (pale/white)
- Infection (muddy red)
- Hydrations (moist)
Pyrexia
Fever (105 is dangerous for cats and dogs)
crackles
sounds in the lungs - also "rails"
Pulse Deficit
heart rate and pulse don't match - probably Arrhythmia:
Arrhythmia
heart rate and pulse don't match
Respiratory Observation
Scale of 0-2. - Healthy is 0 = no effort
Tachypnea
abnormally rapid breathing rate
Dyspnea
struggle breathing
apnea
stop breathing
hyperventilation
rapid breathing
hypocapnia
carbon dioxide (CO2) levels in the bloodstream are abnormally low.
hypoventilation
really slow breathing
hypercapnia, ventilatory failure
high levels of carbon dioxide in the blood
Gingiva
gums
Dental Exam
- Lift Lip
- look for tartar
- stains
- odors
- broken teenth
- gingival hyperplasia
gingival hyperplasia
Abnormal growth or bump on the gums
Head Exam
- eyes
- ears
- nose
- face
- head
Eye Exam
- Ophthalmoscope
- PLR (Pupil Light Reflex)
Abnormal Eyes
- redness
- swelling
- discharg
- anisocoria
- nystagmus
- proptosis
Anisocoria
pupils are not the same size
Nystagmus
rapid, repetitve movement of the eyes
Proptosis
Bulging eyes
Otoscope
Ears, nose, and throat flashlight and magnifying glass
Abnormal Ears
- discharge
- redness
- odor
- Aural hematoma
Abnormal Nose
- discharge
- foreign objects
- swelling
- Epistaxis
Body Systems
- Integumentary
- Nervous
- Musculoskeletal
- Urogenital
Nervous System
- Proprioception - pet in a standing position and, flip over one paw so that it is knuckled on the ground
- pupil reflexes
- gait
- other reflexes - knee jerk, toe pinch, wheelbarrow
Musculoskeletal System
- bones
- joints
- muscles
Abnormal Musculoskeletal
- swelling
- heat
- pain
- muscle
- atrophy
- limping
Abdominal Cavity
- stomach
- intestines
- internal organs (liver, pancreas, spleen)
Abnorminal Abdominal Cavity
- masses
- Distension (swelling)
- Pain
- bruising
- diarhea
- foreign body
- ingestion
Urogenital System
- kidneys
- bladder
- external genitals
- mammary glands
- rectal
Abnormal Urogenital System
- masses
- pain
- swelling
- abnormal milk discharge
- discharge
- inflammation
- Abscessed anal glands
- urinary abnormalities
triage
assess and prioritize
carnassial tooth
most common to get a cavity
SOAP
"SOAP" stands for a systematic method of organizing and documenting patient information and clinical notes.
S - Subjective
O - Objective
A - Assessment
P - Plan