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How to Perform a Physical Exam

When does the physical exam begin? The exam starts the moment the patient is presented to you.

What do we mean? Take your time to observe the patient prior to physically touching the patient.
There is a lot to learn from observing. Is the patient timid or social, BAR, anything unusual in their gait/ posture, shaking their head, scratching, these are just a few of many things you can pick up just by observing your patient. Please remember, they are YOUR patients as well as the veterinarian’s.

When should a technician do a physical exam? You should perform a physical prior to placing any patient under anesthesia, even if the veterinarian already has performed an exam.

At least once daily on all hospitalized patients, preferably prior to any treatments. It’s not always possible to observe them walking around but you need to observe them in their cages. Often you will see something others will not.

It is always best to perform the examination in the same order every time, this way you are less likely to miss anything. Starting from the tip of the nose and working your way to the tip of the tail (if there is one) will ensure you have examined the entire patient.

  • General Appearance 
    • B.A.R./Q.A.R
    • Timid/Outgoing
    • Lameness
    • Normal/Abnormal
  • Nose
    • Discharge- Clear/Colored
    • Skin Color
    • Integrity-Moist/Dry
    • Wounds
  • Eyes
    • Conjunctiva-White/Red/Yellow
    • Discharge-Clear/Discolored/Mucus
    • Lids-open/Blepharospasm/Entropion/Ectopic celia/Masses
    • Lens- Clear/Cloudy
    • Use an Otoscope to examine the eardrum
  • Ears 
    • Color-Red/Pink/White/Yellow
    • Odor- Normal/Abnormal
    • Discharge-None/White and Creamy/Black and Greasy/Black Coffee Grounds/Green and or Yellow
    • Pinna-Normal/Ulcerated/Crusty/Red/Thickened/Masses
  • Mouth
    • Lips-Color/Irritation/Drooling/Odor/Masses
    • Teeth-Plaque/Cracks/Broken/Missing/Odor
    • Gums-Pink/Red/White/Masses
    • Tongue-Pink/Red/Pale/Blue/Purple/Masses
    • Throat-Tonsils-Size
    • Odor/Foreign Bodies/Masses

 

  • Cranial Lymph Nodes
    • Mandibular/Prescapular/Axillary
    • Size/Shape/Texture
  • Front Legs
    • Palpate-Shoulders/Foreleg/Elbows/Carpus/Paw/Pads/Toe Nails
    • Legs are Straight (Breed Specific)/Pain/Skin/Masses
  • Body Wall
    • Palpate-Spine/Abdominal Wall
    • Coat Condition/Skin Disease/Masses
  • Rear Legs
    • Palpate-Hips/Long Bones/Patellae/Stifle/Hocks/Tarsus/Paw/Pads/Toe Nails
    • Legs are Straight (Breed Specific)/Pain/Skin/Luxating Patellae/Masses
  • Heart and Lungs
    • Heart-Rate and Rhythm/Murmurs/Pounding/Quiet
    • Listen to all four chambers
    • Lungs-Respiratory Rate/Sounds-Harsh/Quiet/Wet/Wheezing
    • Listen to Right and Left Lobes
  • Temperature 
    • Normal 101-103 F
    • Temperatures in hospital are not always accurate due to the stress level of the patient. Take temperature if possible; DO NOT get bitten over taking a temperature.

References:
Small Animal Physical Diagnosis and Clinical Procedures – McCurnin and Poffenbarger
Clinical Textbook for Veterinary Technicians – McCurnin and Bassert
Veterinary Nursing – Lane and Cooper