History and Physical Examination

Chapter 1
History and Physical Examination

The history and physical exam provide the basis for all patient care. Without this information, a diagnosis and treatment plan cannot be formulated by the veterinarian. Veterinary technicians provide an invaluable service in deciphering a client’s perception of a problem while determining their true concerns. These may not be the same as the patient’s actual medical condition. For example, a client brings a pet in for behavioral problems of urinating in the house. The client thinks the cat is “mad” because it is left alone for many hours. The client’s concern is for the cat to stop urinating in the house. Questions are asked about litter pan behavior, urine color, and the cat’s attitude. The patient shows pain on abdominal palpation and a distended bladder. After consultation with the surgeon, it is decided to perform abdominal radiographs on this patient. Radiographs show the cat has cystic calculi (Figure 1.1). After discussing medical versus surgical options with the client, it is decided to surgically remove the stones.


Figure 1.1 Lateral radiograph of a cat with cystic calculi.

(Amy Lang, University of Wisconsin Veterinary Care, Madison, WI. Reproduced with permission from Amy Lang).


Surgical patients may present with many or no other medical conditions other than the original complaint. A careful medical history contributes to the patient’s diagnosis, prognosis, and care. A complete history includes:

  • Vaccinations
  • Heartworm testing/preventative
  • Diet
  • Allergies
  • Current medication
  • Patient’s lifestyle
  • Medical and surgical history


Hospitalized patients may be exposed to many communicable diseases. Suggested canine vaccinations include Distemper, Adenovirus, Parainfluenza, Parvovirus, Leptospirosis, Rabies, and possibly Bordatella. Feline vaccinations include viral Rhinotracheitis, Calicivirus, Rabies, and Panleukopenia. Care is taken to protect unvaccinated emergency patients with minimal inter-patient contact. Hospital policy and local regulations dictate vaccination requirements.


Every state reports cases of heartworm disease. Preventative treatment promotes patient good health. Patients with active or prior heartworm disease pose an anesthetic risk. The client is quizzed to determine the status of heartworm testing and preventative. Flea infestation is avoided in the veterinary hospital with appropriate prevention; therefore, determining a client’s use of flea and tick preventative is imperative.


Diet affects all aspects of a patient’s health. Knowledge of a patient’s dietary habits aids treatment plans. For example, young puppies fed with a high calcium diet can succumb to developmental orthopedic conditions. Obesity causes stress to most body systems including heart, lungs, and joints. Determining if a patient’s feeding schedule is free choice or meal feeding aids in formulating weight management plans. Between-meal snacks contribute to obesity. Maintaining a patient’s current diet while hospitalized avoids gastrointestinal upset from food change. However, client-provided, raw food diets might create an in-hospital storage problem and hazard for hospital personnel. Patients undergoing oral surgery may need a softened diet, postoperatively. Crushing a normal diet of dry kibble and soaking for a short time in water maintains the animal’s normal diet.


Food allergies are prevalent in the veterinary patient population. Determining a patient’s food allergies avoid gastrointestinal problems while hospitalized. Unidentified medication allergies can cause very serious complications during hospitalization, surgery, and recovery. Obtaining information on past sedation and anesthetic episodes provides guidelines for future needs. Patients with a history of a poor response to anesthesia must be more closely monitored during any surgical procedure. Anesthetic drug complications include vomiting, diarrhea, cardiac arrhythmias, breathing difficulties, blood pressure changes, and slow recovery. Other allergic reactions to medications or environmental conditions must also be noted.

Current medication

A patient’s current and prior medications, and other supplements and history influences future treatment plans. For example, patients receiving anti-inflammatory medications need a “wash-out” period prior to starting a different anti-inflammatory drug to avoid gastrointestinal problems including stomach ulceration. Medications for many medical conditions influence the choice of perioperative drugs. Dietary supplements, such as glucosamine chondroitin, calcium, and vitamins, affect patients’ health and food needs.

Patient’s lifestyle

Clients have different expectations for patients leading a sedentary life versus working or service animals. If a dog’s main job is to sit on the couch most of the day, recovery from a ruptured cranial cruciate ligament (CCL) and its attending arthritis is much different from a search and rescue animal. If a patient lives in a city dwelling apartment, it will have different experiences during recovery than a dog, living in the country, with acres of freedom. The same holds true for an indoor cat versus an outdoor cat. Will the client be able to medicate a mostly outdoor cat postoperatively?

Medical history

A complete medical history begins with the signalment: age, breed, sex (intact or neutered), and presenting complaint. A preconceived diagnosis may affect physical exam findings. (E.g., a patient presented for hip dysplasia may actually have a cranial cruciate rupture causing more lameness than poor hip conformation.) Carefully interviewing the client provides much information to aid in the veterinarian’s diagnosis. In addition to the presenting complaint, for example, lameness, the entire patient is taken into consideration with inquiries into coughing (C), sneezing (S), vomiting (V), diarrhea (D), increase in thirst or urination –polyuria/polydipsia(PU/PD), and appetite(A). These parameters are easily recorded in the medical record as C, S, V, D, PU/PD, and A with notations made accordingly. Note all current and previous medical problems as they may influence the surgical experience. Form questions to prevent leading a client into a specific “yes or no” answer. For instance, asking a client “Is Lily more lame today?” provides a yes or no answer as opposed to asking, “When do you see Lily’s lameness increase?” With the second question, the client needs to give a more detailed answer providing the clinician with better historical information. Record all prior surgical procedures. A patient may present for a second opinion of a recurrent problem. Historical knowledge influences a treatment plan.

Current exercise regimen determines the client and patient’s ability or lack of ability to provide appropriate postoperative rehabilitation. While delicate to obtain, a client’s personal situation – time, finances, other obligations – also influences the surgical plan. A client with many commitments may not have the time required for extensive postop rehab. For this person, a more conservative plan betters fit the client’s lifestyle. A mnemonic for obtaining a history is using the OLD CHARTS method (Figure 1.2).


Figure 1.2 OLD CHARTS: a mnemonic device to remember important aspects of a patient’s history.

Physical exam

A complete physical exam covers the patient from the tip of the nose to the tip of the tail. Failure to recognize patients’ underlying medical problems can lead to devastating consequences. (The extent of the exam performed by a veterinary technician varies with individual veterinary practices.) A complete physical exam includes the following parameters:

  • Temperature, pulse, respiration (TPR), and weight
  • Body condition score (BCS)
  • General appearance
  • Attitude
  • Locomotion
  • Head and Face
  • Oral pharynx
  • Lymph nodes
  • Integument
  • Musculoskeletal
  • Perineum
  • Abdominal cavity
  • Respiratory
  • Cardiovascular
  • Nervous system

Use of a paper or electronic physical exam form serves as a reminder to examine all body systems. See an example of a useful physical exam form in Figure 1.3.


Figure 1.3 An example of a physical exam form used at the UW Veterinary Care, Madison, WI.

(Ruthanne Chun, University of Wisconsin Veterinary Care. Reproduced with permission of Ruthanne Chun.).

Temperature, pulse, respiration, and weight

Obtain a TPR and weight at every visit. Clients appreciate knowing if their pet’s TPR is in the normal range (Table 1.1). Knowledge of a patient’s pre-surgical TPR influences the anesthetic protocol. Changes in TPR affect intraoperative and postoperative care. Accurate weight provides proper medication dosing. Monitoring obese patients aids in weight management.

Table 1.1 Normal feline and canine TPR.

Parameter Feline Canine
Temperature 101–102.5 °F 101–102.5 °F
Pulse 160–240 beats/min 70–160 beats/min
Respiration 20–30 breaths/min 10–39 breaths/min

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Dec 15, 2022 | Posted by in NURSING & ANIMAL CARE | Comments Off on History and Physical Examination

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