Chapter 1 History and Physical Examination
Veterinarians are faced with many diagnostic challenges on a daily basis. By far the most important diagnostic tool that veterinarians possess is their ability to obtain a complete history and perform a thorough physical examination. This information, when accurately interpreted, lays the foundation for a logical diagnostic and therapeutic plan. A systematic and thorough history and physical examination prevents unnecessary diagnostic testing and needless cost to the owner.
GENERAL HISTORY
Obtain both objective and subjective information when collecting the history.
• Objective data consist of the signalment, environment, diet, and medical history. For a patient’s first visit, determine the length of ownership and the place of origin.
• Subjective data include a description of the primary complaint and a historical overview of the patient’s general health. The owner often may not realize how a seemingly unimportant observation may be related to the primary problem. Tailor specific questions to the individual case.
Signalment
• The signalment consists of the patient’s age, species, breed, and gender. Note whether the patient is intact or neutered. The patient’s breed will sometimes become a key factor when formulating differential diagnoses. Congenital or hereditary disorders should be considered. For example, familial renal disease should be a primary differential for a young Shih Tzu presenting with polydipsia and polyuria. In other cases the disease process may not be congenital or hereditary, but it may be more prevalent in certain breeds than others. For example, a small-breed dog that presents with lameness that is localized to the hip is more likely to have avascular necrosis of the femoral head (Legg-Perthes disease) than hip dysplasia.
Environment
• Gather environmental information as a routine part of the patient’s history. In many circumstances, where the pet is kept provides a vital clue in diagnosis.
• Determine whether the pet is free roaming or confined to a yard or house. If the patient is confined to a yard, ask the owner if the yard is fenced, if the pet is chained, and if an escape has been possible in the recent past. The free-roaming or recently escaped pet may have had access to toxins or have been subject to trauma, which is less likely for an indoor pet. For example, in a dyspneic patient, diaphragmatic hernia ranks higher on the differential diagnosis list for a free-roaming pet than for a strictly indoor pet.
• Determine the geographic origin of the pet and any record of recent travels. This becomes paramount if the patient has been exposed to diseases endemic to certain regions but not prevalent in the current environment, such as systemic mycoses and vector-borne diseases.
• Determine the pet’s water source. This may be important if the pet has access to contaminated outdoor water, toilet-bowl water treated with deodorants or cleansers, or if the pet has limited access to water.
• Question the owner if there has been any potential exposure to toxins such as antifreeze, pesticides, or insecticides if the patient’s clinical presentation is indicative of intoxication. Exposure to houseplants or outdoor vegetation may also provide a clue. For a vomiting or anorexic patient, questions should include access to potential ingested foreign bodies.
Dietary History
• Always include dietary information in the routine database. Question the owner about the patient’s appetite and noticeable weight gain or loss. Also note whether the owner watches the pet eat.
Preventive Health Care Status
• Record all previous vaccinations received and the dates of each. Avoid simply asking if the patient is current on vaccinations because many clients are unfamiliar with vaccination recommendations. Inform the client about what vaccinations are available as well as the indications and booster intervals for each (see Chapter 7).
• For a feline patient, discuss the subjects of feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV), including the dates and results of previous testing. Exposure to stray cats or cats known to be FeLV-positive or FIV-positive may also be relevant. History of previous cat fight wounds may warrant repeat testing for FIV. However, if the patient has been previously vaccinated for FIV, then further FIV testing will be invalid since the FIV test is an antibody test.
Prior Medical History: Previous Illnesses and Surgeries
• Often the patient’s prior or ongoing health problems play a role in its presenting ailment; therefore, review the information previously recorded in the medical record and discuss previous problems managed by other veterinarians.
• Record the dates of the previous illness or surgery, followed by a brief description of the problem, how it was managed, and the response to treatment.
• Discern the relevance of prior illnesses before obtaining extensive details; otherwise, the history may become unnecessarily lengthy and confusing.
Primary Complaint
• Use the history to identify and localize the primary problem. Much of this information is subjective, based mostly on the owner’s interpretation of the pet’s clinical signs and behavior. Be aware that some owners are extremely observant of their pet and others are not. Prompt owners to describe the pet’s behavior and clinical signs in their own words. An astute clinician collects all data and subjectively analyzes this information in context of an owner’s perceptivity.
• Encourage the owner to describe the patient’s problem from its onset so that a chronologic picture is obtained.
• Avoid leading questions that might result in a deceptive history. For example, ask if there has been any change in frequency of defecation. Do not ask if the patient is defecating more frequently than normal.
• Determine the last period of normalcy or the duration of the clinical signs. This will help determine how acute or chronic the problem may be and will guide the ranking of differential diagnoses. Some differentials are more likely for an acute problem; others are more likely for a chronic problem. For example, intestinal intussusception or an intestinal foreign body are likely differentials for a puppy presenting with an acute episode of persistent vomiting. A gastric foreign body or inflammatory bowel disease are more likely in a similar patient with chronic intermittent vomiting. The onset and severity of the illness influences how rapidly or aggressively the problem should be approached.
• Determine the progression of the clinical signs. Once again, this may help not only in formulating a list of differentials but also in developing a treatment plan. For example, a patient presenting with a history of seizures is managed more aggressively when the seizures are increasing in frequency and length than when they have been the same for months or years.
• Question the owner as to any intervening signs that might provide a clue to the most likely differential diagnosis. For example, a cat with chronic diarrhea and intermittent episodes of fever is considered a more likely candidate for infectious disease than for dietary intolerance.
• Attempt to further define and localize the problem. For example, characterize diarrhea as originating in the small or large bowel before proceeding to a diagnostic or therapeutic plan. Ask questions regarding frequency, appearance (color and consistency), and presence or absence of straining to help localize this problem. Specific questions oriented by body systems follow in the next section.
• Determine treatments and response. For example, a dog presenting with pruritus unresponsive to previous treatment with corticosteroids is a more likely candidate for food allergy dermatitis than for atopy. Record what medication was given, the dose, the duration of treatment, and the level of response observed.
HISTORY ORIENTED BY BODY SYSTEMS
For a complete history, include a system-by-system review of the patient’s general health. This can be accomplished by the experienced clinician as the physical examination is performed. The novice may prefer to obtain the entire history before proceeding with the physical examination. Develop a consistent and systematic method. One method is to begin with questions concerning the patient’s head and proceed caudally, as demonstrated in the following text. It is left to the clinician’s discretion as to how in-depth the client is questioned about systems that do not appear to affect the primary complaint. Apply the general principles described in the previous section in the approach to all body systems (e.g., onset and duration).
Eyes
• Ask if any ocular discharge has been noted. If so, describe the discharge (serous, mucoid, or mucopurulent) and determine if it has been unilateral or bilateral.
• Determine if ocular pain or discomfort is present as indicated by blepharospasm, face rubbing or pawing, or photophobia. These signs may be seen with anterior uveitis, glaucoma, corneal ulcerations, or foreign bodies.
• Ask if the owner has noticed a color change in the pet’s eye. This change can occur with anterior uveitis and iriditis, in which hyphema may be present or the iridial color may be altered. A localized pigment change in the iris may occur with an iris cyst or melanoma.
Head, Neck, Ears, Nose, and Oral Cavity
• Inquire about head shaking, ear scratching, and otic discharge or odor that may indicate the possibility of otitis or a foreign body in the ear. Determine if any loss of hearing has been evident.
• Ask if any nasal discharge has been present. Note the character of any nasal discharge (serous, mucoid, mucopurulent, or hemorrhagic) and whether it has been unilateral or bilateral. Note any history of sneezing, nose rubbing, nasal asymmetry, or stridor.
• Request information relating to the oral cavity, such as odor, difficulty eating or drinking, abnormal swellings involving the gingiva or tongue, and changes in gingival pigmentation. Ask if there has been any change in the patient’s ability to vocalize. The patient’s voice can be affected either by a mass in the laryngeal region or by laryngeal paralysis.
Cardiopulmonary System
• Ask if cough, exercise intolerance, weakness, or fainting have been observed. These may indicate cardiopulmonary disease.
• Syncope is a transient loss of consciousness that may be precipitated by exercise in patients with underlying cardiac disease (see Chapter 148). During a syncopal episode the patient usually demonstrates very little motor movement. The episode typically lasts less than a minute, and usually the patient returns to normal within a short period of time. Seizures vary greatly in severity. They are often preceded by a preictal phase during which the patient may be anxious or disoriented. The actual seizure usually involves a loss of consciousness and active motor activity such as tonic-clonic limb movements and rapid jaw movements. The postictal phase may last from minutes to days. The patient may be either overly agitated or depressed during this time. Seizure disorders are discussed in Chapter 127.
• Characterize coughing as productive or nonproductive, moist or dry, and harsh or honking. Some owners may confuse a productive cough with vomiting; therefore, ask whether abdominal heaving occurs prior to the production of fluid or foam or whether coughing and gagging are more typical. Yellow or green fluid is indicative of vomitus. The circumstances surrounding the cough are often relevant. For example, cough associated with tracheal collapse is often elicited with excitement or pulling on the patient’s collar. Coughing secondary to congestive heart failure may be exacerbated with the pet in a sternal position. Is the pet routinely exposed to cigarette smoke? This can play a role in chronic bronchitis or feline asthma.
• Determine if dyspnea has been observed. It may be difficult for an owner to differentiate between heavy panting and true dyspnea. Ask if the pet is breathing the same during the exam as it was at home. Also inquire if the pet seems reluctant to exercise or lie down, as would be expected with most dyspneic animals. Open-mouth breathing for a cat is always considered abnormal except when it is excessively stressed. See also Chapter 142.
Digestive System
Most problems related to the digestive system are clinically manifested as anorexia, regurgitation, vomiting, diarrhea, constipation, weight loss, or a combination of these. Determine which clinical sign is being exhibited, because the owner may incorrectly interpret what is observed. For example, owners often assume that their pet is constipated if it is observed straining to defecate, when diarrhea may be the actual cause. Ask specific questions to differentiate between vomiting and regurgitating. Regurgitation is characterized as a passive ejection of ingested material from the esophagus. It typically occurs soon after a meal is eaten. The regurgitated material is usually undigested and tubular in form. Vomiting frequently involves an abdominal heave movement or retching. Time of vomiting in relation to eating should be noted and is variable depending on the underlying disorder. Vomitus is not tubular in form and may consist of froth, fluid, yellow-green bile, food, or ingested foreign material. Include the following specific information in approaching a digestive system problem:
• Review dietary history, as previously described. Specifically ask about treats or access to garbage.
• Has any vomiting been noted (onset, frequency, progression)?
• Has the owner actually observed the pet vomiting? In a multi-pet household, verify that it is the presenting patient that is actually vomiting.
• Has the owner witnessed the patient defecating, and are there any abnormalities?
• What volume of stool is typically produced? Small amounts of stool produced frequently are indicative of large bowel disease, and larger amounts of stool produced less frequently are more typical of small bowel disease.
• Does the animal strain while defecating? Straining is typical of diseases localized to the colon, rectum, or anus.
Urinary System
Often, the owner complaint may be that the pet is urinating excessively. The following questions help distinguish whether excessive urination is due to polyuria or pollakiuria:
• Is the pet urinating inside the house (i.e., having “accidents”)?
• Are these urinations observed? (The owner should verify that this is the pet having the accidents versus another pet in the household.)
• Does the owner know if the accidents occur while the animal is awake or asleep? If the owner has not observed the act, there may be other clues to pursue. Where has the owner found the accidents (where the pet sleeps, next to a door, etc.)? A patient that is experiencing urinary incontinence may be dribbling urine while resting in its sleeping area. Dogs that are well house-trained may urinate close to an outside door if they are unable to hold their urine until allowed access to the outside yard. Another clue to urinary incontinence is the presence of urine on the pet’s perineal region or rear legs.
• Has there been any change in frequency of urination? If the patient is urinating frequent small amounts (pollakiuria), then differentials should include lower urinary tract disorders such as cystitis, urolithiasis, and neoplasia.
• Does the animal appear to strain while urinating? (This is typical of lower urinary tract disease.)
• What quantity of urine is produced? Larger quantities of urine are indicative of polyuria, which occurs with a large number of underlying metabolic disorders (renal disease, liver disease, diabetes, mellitus, diabetes insipidus, hyperadrenocorticism, hypercalcemia, etc.).
• Has the owner noticed any blood in the urine? If so, is it before, during, or after urination? Bleeding only at the beginning of urination is more likely to be from the urethra. Hematuria present throughout the urination is most typical of bleeding of renal origin. Blood seen at the end of urination usually originates from the urinary bladder. Remember to consider the genital system as a potential source for the blood, as with prostatic disease or vaginal masses.
Genital System
Females
• Note any vulvar discharge and describe the amount, consistency, color, and odor. This type of discharge may be valid for spayed pets as well as intact ones.
• If the patient is intact, ask the following questions:
• When did the owner last observe a heat cycle for the patient? Was it a normal cycle? How long did it last?
• Has the pet been intentionally bred or is there any possibility of an accidental breeding? Is there any previous history of pregnancy? If so, were there any complications (e.g., dystocia, abortions, mastitis, metritis, etc.)?
Swelling or Masses
Ask if any abnormal masses or swellings have been observed that have not been previously mentioned. Note the location, how long the mass or swelling has been present, and any change in appearance, character, or size. If the patient has not been examined in your practice before, ask if the mass has been previously sampled by either a fine needle aspirate or a surgical biopsy. Obtain a fine needle aspirate from masses that have not been previously investigated.
Skin
An accurate and detailed history is essential for successful management of dermatologic problems. Remember that some systemic disease processes may manifest themselves in cutaneous changes, such as hyperadrenocorticism or systemic lupus erythematosus (SLE). Some clinicians prefer to have the owner fill out a standardized dermatologic history form prior to specific questioning. Include the following questions on such a form, or directly ask the owner:
• Where does the pet seem to be most pruritic? Many atopic and food-allergic patients may rub their faces and lick their feet excessively. Flea-allergic patients predominantly chew the dorsal tail-base region.
• If the pet is pruritic, how severe is it? Have the owner grade the degree of pruritus on a scale of 1 to 10, with 10 being the most severe. This helps subsequent evaluation of treatment response.
• Is the skin problem continuous or seasonal? If seasonal, then determine when the pet is most severely affected.
• Has the owner noticed fleas? What flea products have been used? Has the pet been on monthly preventive treatment? If so, which product?
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