1
History and Physical Examination

Gerianne Holzman1 and Lana Bishop2

1 University of Wisconsin, School of Veterinary Medicine, Emerita, Madison, WI, USA

2 Blue Pearl Pet Hospital, Des Moines, IA, USA

The history and physical exam provide the basis for all patient care. Without this information, the veterinarian cannot formulate a correct diagnosis and treatment plan. Veterinary technicians provide an invaluable service in deciphering a client's perception of the 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 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 bladder stones.

History

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 treatment plan. A complete history includes:

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

Figure 1.1 Lateral radiograph of a cat with cystic calculi.

Source: Courtesy of Amy Lang.

Vaccinations

Hospitalized patients may be exposed to many communicable diseases. Suggested canine vaccinations include distemper, adenovirus, parainfluenza, parvovirus, leptospirosis, rabies, and possibly Bordetella and influenza. 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. In an emergency setting, the vaccination records may not be attainable at intake and treatment will still be initiated carefully.

Parasites

Every state reports cases of heartworm disease. Preventative treatment promotes patients' 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. Many intestinal parasites can also be prevented with these medications. Some intestinal parasites can be zoonotic such as giardia.

Diet

Diet affects all aspects of a patient's health. Knowledge of a patient's dietary habits aids treatment plans. For example, young puppies fed 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, clients providing raw food diets might create an in-hospital storage problem and hazard for hospital personnel. Patients undergoing oral or facial 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. There are also many non-traditional diets such as grain free, raw, and home cooked. Nutritional balance may not be obtained with these diets and other health issues can arise from them. Dilated cardiomyopathy (DCM) can be the result of grain-free diets according to the FDA and a study by the University of California, Davis [1].

Allergies

Food allergies are prevalent in the veterinary patient population. Determining a patient's food allergies avoids 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 and recovery. Anesthetic complications include vomiting, diarrhea, cardiac arrhythmias, breathing difficulties, blood pressure changes, and slow recovery. Other previous or ongoing allergic reactions to medications or environmental conditions must also be noted.

Current Medication

A patient's current and prior medication and supplement history influences future treatment plans. For example, patients receiving anti-inflammatory medications need a "wash-out" period (three to seven days) 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 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. If the patient is a working animal, an extensive rehabilitation regimen may be recommended to regain/maintain strength, flexibility, and endurance [2]. The same holds true for an indoor cat versus an outdoor cat. Will the client be able to medicate a mostly outdoor cat postoperatively? Do they have the ability to keep them inside for a short time?

Medical History

A complete medical history begins with confirming the signalment with the owner: age, breed, sex (intact or neutered), and presenting complaint. A preconceived diagnosis may affect physical exam findings; therefore, it is important to ask open-ended questions. (For example, a patient presented with hip dysplasia may actually have a cranial cruciate rupture causing more lameness than poor hip conformation.) Carefully interviewing the client provides the much-needed information to aid in the diagnosis. In addition to the presenting complaint, e.g. 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?" Another example, asking a client "Is Sam vomiting more today?" versus "Did you see Sam eat anything unusual prior to the vomiting?" With the second questions, the client needs to give a more detailed answer providing the clinician with better historical information. Record all prior surgical procedures and outcomes. A patient may present for a second opinion of a recurrent problem. Historical knowledge influences the treatment plan.

Figure 1.2 Old charts: a mnemonic device to remember important aspects of a patient's history.

The current exercise regimen may determine the client and patient's ability or lack of ability to provide appropriate postoperative rehabilitation. This may influence the surgical plan. A mnemonic for obtaining a history is using the old charts method (Figure 1.2).

Client Expectation

Although delicate to obtain, a client's personal situation and expectations (time, financial commitment, lifestyle, recovery, and other obligations) also influence the surgical plan. A client with many commitments may not have the time required for extensive post-op rehabilitation. For this person, a more conservative plan or an inpatient program may better fit the client's lifestyle. In addition, if the patient requires multiple procedures and/or treatments based on the current plan, alternative treatment plans may be more desirable. An example may be an open, traumatic, fracture with bone destruction that the...