Basic consulting room techniques

Chapter 2

Basic consulting room techniques

The first time you find yourself alone in the consulting room with worried clients and their beloved animal can be terrifying. Knowing that you know how to do all the most common and most basic procedures that are likely to be presented will give you confidence. Appearing confident and competent in front of the client is the art of veterinary medicine as opposed to the science of veterinary medicine. If you are confident, the client will trust you and the animal will also respond positively.

Procedure: Basic clinical examination

When carrying out a clinical examination you must develop a logical, methodical, systematic approach and always stick to it. Always remember that ‘common things are common’ – the dog that walks into the surgery salivating is probably suffering from car sickness or dental problems not rabies!

Remember that your consultation should take about 10 minutes (depends on practice protocols) so time is of the essence – you have a lot to achieve in a short time!

1. History – This must be taken early on in the consultation process and should be as detailed as possible.

    The history should include:

• Client’s details – name, address and telephone number. Some practices may also take the email address. These details may have been taken by the receptionist and will appear on your computer screen in the consulting room. Find out the animal’s name and use it! Get the sex of the animal right – if you consistently refer to him rather than to her, this is what the client will pick up on not on whether you have made the diagnosis of the century!

• Patient details – species, breed, age, vaccination status, any previous medical history, how long they have had him / her. Weigh the animal – this will be useful for calculating dose rates, but is also a useful measure of health. In any animal on a diet this is a useful measure of progress. All these details may already be on the computer screen in front of you, but checking the facts is a good way of getting into a conversation.

• Presenting sign – this is the symptom that has made the client get off the sofa and bring the dog to the surgery. It will be the most obvious sign to them (e.g. the dog is drinking a lot, diarrhoea, vomiting, scratching, etc.) although not necessarily the most significant diagnostically. Ask questions to develop your understanding of this presenting sign (Box 2.1), then ask questions about other relevant symptoms as you begin to extract the facts and widen your knowledge of the patient, e.g. diet, how much, when was it last wormed or defleaed.

2. Initial examination – First stand back and observe. Delay your thorough clinical examination for a short time. As soon as you start to touch the animal you destroy some of the evidence; for example, the heart rate and respiratory rate may rise if the animal is nervous. Observe the animal’s behaviour, including such things as the respiratory rate, as it stands on your table. Look at the animal’s general demeanour. This may be done at the same time as you are taking the client’s details – as you become more experienced you will find that you can multitask!

3. Clinical examination – This must be done in a logical order to avoid missing a piece of evidence (Fig 2.1). Develop your own system and follow it every time. For example, you could start by examining all structures on the head, then progress to the trunk, then the legs and finally the perineum; or you could examine the respiratory system, the digestive system, etc.; or you could examine the parts of the animal alphabetically. It does not matter how you do it, but you must develop your own system and stick to it. In this way you should not miss anything significant. Always make notes and record your findings, both normal and abnormal.

    It is a good idea to start with the basic assessment of temperature, pulse and respiration, check the mucous membranes and the palpable lymph nodes (Table 2.1). This provides essential clinical information and extra thinking time. (Note how clients always start to talk when you are listening to the chest!)

Suggested format for a clinical examination – in a routine 10-minute consultation you will not be able to complete as much detail as is suggested below. Listen to the history and from this you will get an idea of which area to focus on; for example, if the owner says the dog has diarrhoea then look at the digestive system. However, keep an open mind and do not completely rule out the other systems.

Examine the following systems making notes about the indicated parameters.

• Respiratory system:

1. Action: Note the respiratory rate.

    Rationale: Identify one area and watch it move over a period of 15 seconds then multiply by 4.

2. Action: Auscultate the chest using a stethoscope.

    Rationale: Listen to several areas to locate specific problems.

3. Action: Percussion of the chest.

    Rationale: To identify areas of consolidation.

4. Action: Check the colour of the mucous membranes.

    Rationale: To check for levels of oxygenation.

5. Action: Listen to the patient breathing.

    Rationale: Note whether any noise occurs during inspiration or expiration.

6. Action: Note any evidence of dyspnoea.

    Rationale: Inspiration or expiration?

7. Action: Elicit a cough.

    Rationale: By gently squeezing the larynx, note the type – dry and hacking or moist and productive.

8. Action: Nasal discharge.

    Rationale: Unilateral or bilateral?

9. Action: Check lymph nodes around pharyngeal area.

    Rationale: To check for areas of infection.

• Digestive system:

1. Action: Note any faeces on thermometer or around the anus.

    Rationale: Look at colour and smell. Note the presence of blood.

2. Action: Examine lips, inside of the mouth and teeth.

    Rationale: Check for colour, ulceration, injury and presence of gum or dental disease.

3. Action: Check tongue and smell the breath.

    Rationale: Look for injury, ulceration, etc. A smell of pear drops indicates ketosis; foul smell may indicate gingivitis.

4. Action: Check pharyngeal lymph nodes.

    Rationale: For signs of infection.

5. Action: Check salivary glands.

    Rationale: For signs of mucocoele.

6. Action: Palpate the abdomen.

    Rationale: Take note of any pain, very hard or soft areas, guarding.

7. Action: Observe the patient’s stance.

    Rationale: Arched back, praying stance, guarding.

8. Action: Obtain a faecal sample.

    Rationale: Note colour, form and frequency. Faecal egg count will identify worm infestations.

9. Action: Ask owner or obtain a sample of vomit.

    Rationale: Note colour, smell and contents. Note timing in relation to eating.

• Eyes – always examine in a darkened room:

1. Action: Note any evidence of photophobia, chemosis, blepharospasm and epiphora.

    Rationale: These clinical signs may indicate eye problems that require further investigation.

2. Action: Check conjunctiva.

    Rationale: Look for inflammation and infection. Slight dullness could indicate ‘dry eye’. Look for ulcers – use fluorescein stain.

3. Action: Check eyelids – remember to evert them as well.

    Rationale: Look for injury and foreign bodies.

4. Action: Check eyeballs.

    Rationale: Look for bruising, haemorrhage.

5. Action: Look at both eyes together and compare them.

    Rationale: Both eyes should look the same and function together.

6. Action: Check pupil size.

    Rationale: Should be the same.

7. Action: Check pupillary light response.

    Rationale: Pupil constricts in response to bright light.

8. Action: Check menace reflex.

    Rationale: Eyeball should pull back into orbit in response to a fast approaching object such as a hand.

9. Action: Check the lens.

    Rationale: Using an ophthalmoscope – look for evidence of cataracts.

10. Action: Check patency of the tear ducts.

    Rationale: Use fluorescein stain.

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Jul 24, 2016 | Posted by in SMALL ANIMAL | Comments Off on Basic consulting room techniques
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