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

II.

III.

IV.

V.

VI.

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

Skin
1. 2. 3.

4. 5.

6.

Alopecia A. Hair loss Pruritus A. Itching Skin lesions A. Scabs B. Masses Erythema A. Inflammation Seborrhea A. Oiliness B. Scabs Fleas and ticks 1. 2. A. 3. 4. A. 5. A. B. 6. A. Eye discharge Epiphora Tearing Symmetrical pupils and PLR Conjunctiva Redness Cataracts White cornea Nuclear sclerosis Cornea Clear

Eyes

Ears 1. Odor 2. Clean or dirty A. Black 1. Blood 2. Ear mites B. Wax 3. Painful

Respiratory System 1. Sneezing A. Nasal discharge 2. Coughing 3. Palpate larynx A. Elicit cough 4. Ascultate lungs A. Crackles 1. Fluid B. Wheezes 1. Constricted bronchi C. Muffled 1. Pleural effusion D. Types of lung sounds 1. Bronchial Sounds Trachea and larynx 2. Vesicular Sounds Lungs and Alveoli 5. Normal respiration rates A. Dog 16-24 breaths per min. B. Cat 16-30 breaths per minute Cardiovascular 1. Normal heart rates
A. B. Dog 70-180 beats/min. Cat - 160-240 beats/min.

2.

3. 4.

MM Color (Mucosa Membrane) A. Pink normal B. Pale to White anemia or poor perfusion C. Blue cyanotic D. Icteric Jaundice or liver disorder E. Brick Red sepsis or warm shock F. Brown methemoglobinemia ( Acetomenophin toxicity ) G. Petechia coagulopathy or bleeding disorder CRT (Capillary Refill Time) A. Shows blood pressure Femoral pulse

5.

Ascultate heart A. Left 3rd intercostal space 1. pulmonic valve th B. Left 4 intercostal space 1. Aorta th C. Left 5 intercostal space 1. Ventral to sternum 2. Mitral valve D. Right 4th intercostal space 1. Tricuspid valve E. Pulse deficit 1. Heart beat not the same with femoral pulse

Gastrointestinal 1. Teeth A. Calculus and loose teeth B. Gingivitis 1. Redness and swollen gums 2. Tongue A. Symmetrical 1. XII Hypoglossal nerve B. Swallow reflex 1. IX Glossopharyngeal nerve 2. X - Vagus 3. XI - Accessory C. Excessive salivation 1. Facial paralysis a. VII - Facial 3. Palpate abdomen A. Distended stomach 1. Bloat B. Large liver or spleen C. Pendulous 1. Fluid D. Acute abdomen 1. Pain

4.

Anus A. Anal sacs B. Rectal 1. Symmetrical prostate 2. Fecal appearance

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

Body Condition Scoring

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

HOSPITAL PATIENT CARE

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

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V.

VI.

Recumbent patients A. Decubital ulcers (Bed sores) 1. Due to pressure points 2. Paralyzed or recumbent patients that cannot stand 3. Keep cages padded with frequent bedding changes B. Urine scald or rash 1. Not changing bedding, patient laying in urine and feces C. Turn q 2 hours from side to side to prevent pneumonia, pressure sores and edema Treatment care A. IV catheters 1. Check daily for patency, flush with heparnized saline q 4-6 hours to prevent clotting 2. Check leg and foot for swelling, pain, redness, cellulitis or edema around the elbow or joint a. Infection b. Blown catheter-SQ fluids 3. IV catheters should not be left in longer then 3 days (3-5 in practice) 4. Jugular catheters should not stay in any longer than 5 days (5-7 in practice) B. Urinary catheters A. Check to see if flowing(Patent) and not obstructed B. Flush catheter with 0.9% Nacl C. Record urination volume and color D. Closed system (Attached to bag) E. E-collar C. Sutures 1. Check suture site daily for discharge and inflammation 2. Infection is seen within 3-4 days post surgery a. Swelling b. Erythema c. Pain d. Fever e. Discharge 3. Dehiscence-incision and suture break down 4. E-collar to prevent self-trauma

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D.

E.

F.

G.

H.

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

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