Key Point: Foundational knowledge of anatomy and
physiology is important for the veterinary personnel to
complete a thorough and appropriate physical examination.
V.2.2
Exam Room Observations:
Utilizing Signalment and Physical Exam
to Create a Diagnosis
A Case Study of Jethro:
⮞ Dull and listless
⮞ Wanted to lie down
⮞ Normal respiratory rate
⮞ Slight discharge of mucus from eyes
⮞ No obvious wounds or injuries
⮞ Seemed hesitant to stand after lying down
⮞V.2.2 PowerPoint: Exam Room Observations: Utilizing Signalment and Physical Exam to Create a Diagnosis
Observations in the Exam Room
Physical Exam
⮞ Eyes slightly sunken
⮞ Third eyelids protruding
⮞ Mucoid ocular discharge
⮞ Gums pale pink and dry
⮞ Capillary refill time: two seconds
⮞ External lymph nodes normal
⮞ Heart: Normal rate and rhythm
⮞ Heart rate: 80 bpm
⮞ Lungs clear
⮞ Respiratory rate: 24
⮞ Arched back posture
⮞ Temperature: 102.1 F
⮞ Skin and hair coat normal
⮞ No apparent pain: Extension and flexion of front and rear legs
⮞ Abdomen slightly sunken
⮞ No abnormal neurologic signs
⮞ No head tilt
⮞ Pupils equal: Normal light reflexes
⮞ Bladder empty
⮞ No stool palpated in colon
⮞ Pain more in cranial abdomen
⮞ Could not palpate kidneys well
⮞V.2.2 PowerPoint: Exam Room Observations: Utilizing Signalment and Physical Exam to Create a Diagnosis
Assessment
Listless behavior
Vomiting
Painful cranial abdomen
Arched back
Dehydrated
Pancreatitis???
Gastritis???
Hepatitis???
Foreign body???
Back injury and pain???
Determine Differential Diagnoses
⮞V.2.2 PowerPoint: Exam Room Observations: Utilizing Signalment and Physical Exam to Create a Diagnosis
The Plan
Treatment
⮞ Start IV fluids to treat dehydration
⮞ Provide pain relief
⮞ Monitor vomiting: Control with medication if needed
Diagnostic tests
⮞ Complete blood count
⮞ Blood chemistry
⮞ X-rays
⮞ Ultrasound
Client education
⮞ Explain what symptoms should be treated immediately
⮞ Explain what the differential diagnoses are
⮞ Explain how diagnostic tests will be used to narrow the list of differential diagnoses
⮞V.2.2 PowerPoint: Exam Room Observations: Utilizing Signalment and Physical Exam to Create a Diagnosis
What Is the Plan?
⮞ Complete blood count:
🢖 Normal red blood cell numbers
🢖 Normal white blood cell numbers
🢖 Hematocrit or packed cell volume a little elevated
⮞ Blood chemistry:
🢖 Albumin: slightly elevated
🢖 Amylase and Lipase: slightly elevated
🢖 Liver enzymes: slightly elevated
⮞ X-rays and ultrasound:
🢖 Suspicion of possible foreign body on x-ray confirmed by ultrasound
⮞V.2.2 PowerPoint: Exam Room Observations: Utilizing Signalment and Physical Exam to Create a Diagnosis
Diagnostic Test Results
Client education
Client is informed about the suspicion of a foreign body in the abdomen and permission for an exploratory laparotomy is sought.
Outcome
Jethro undergoes successful exploratory surgery, and a two-inch length of corn cob is removed from his intestine. Recovery is uneventful.
Lesson learned by owner:
Keep trash and compost secure!
⮞V.2.2 PowerPoint: Exam Room Observations: Utilizing Signalment and Physical Exam to Create a Diagnosis
Jethro’s Outcome