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Dog & Cat Physical Exams: A Vet Tech Guide

Published on August 20, 2018 by A. Rothstein

Veterinary Technicians will perform routine physical exams each time a dog or cat comes to the veterinarian’s office. They will take or confirm the dog’s or cat’s history and take vital signs. Obtaining vital signs each time the dog or cat visits the vet will help the veterinarian identify when an abnormality is present. During the physical exam, the vet tech will note the body weight, temperature, pulse and heart rate and respiratory rate.

The Dog’s & Cat’s History

Obtaining a complete history of the dog or cat, during the physical exam, is the first step to diagnose or treat the pet. The vet tech should start the physical exam off with an examination of historical information about the dog or cat to better understand their observations and assessment of the pet.

Getting historical information for the dog or cat can be time consuming and a good vet tech can obtain a complete and accurate history. This allows the veterinarian to focus on the pet’s diagnosis and treatment plan. However, obtaining inaccurate information can be more harmful to the dog or cat than no information at all. Inaccurate information can cause unnecessary tests and treatments. This inaccurate information can also lose the pet owner’s trust very quickly. In order to get a complete and accurate history of the dog or cat, the vet tech should first gain the trust and confidence of the pet owner before starting the physical exam.

When asking questions to obtain the history of the dog or cat, during a physical exam, it is best not to use medical jargon as many pet owners will not have an extensive knowledge of medical terminology. Finding the most appropriate words can be important so that the pet owner is not confused or insulted. Open-ended questions are best during the historical review to not lead the pet owner in answering the historical questions one way or another.

Documenting the Historical Information

It is important to properly document the dog’s or cat’s historical information, during the physical exam, for later use during diagnostics and treatment. Make sure to document the information at the time of questioning the pet owner, especially if historical information is transferred to electronic medical records later on. If written manually, the vet tech should make sure to write legibly as the historical information form can be used as a legal document.

Signalment – this includes the dog’s or cat’s age, breed, sex and reproductive status. Understanding this information up front can help a veterinarian understand if the dog or cat is predisposed to certain diseases or disorders based on their signalment.

Environment History – it should be noted when the pet was adopted and where the dog or cat was obtained. If there are any medical problems that precede the ownership of the pet, it should be recorded. It can be important to understand whether the dog or cat has been out of its normal environment or travelling, to understand if they are more likely to have a foreign disease. It is also important to know if the pet stays inside, outside or sleeps in a kennel. This information can give the veterinarian additional clues to possible exposure to disease. The last bit of information in the general management section is the type of food the dog or cat eats and the frequency it is fed. It is important to understand if the dog or cat ate something unusual to their diet before they became sick.

Vaccination History – it is important for the vet tech to record all vaccination history, during the physical exam, to make sure the dog or cat is safe from disease. It is also important to understand the medication that the dog or cat receives to make sure they are free of fleas, ticks and heartworm.

Behavioral Information – the vet tech should note the current state of behavior of the dog or cat, especially if the pet has become more aggressive since the illness. This assessment will allow the vet tech to take necessary precautions.

Animal Interaction Information – the vet tech will want to note any infectious diseases of the pet owner or exposure to other animals in the household.

Allergy History – it is important to note any allergies before administering any medication as an adverse reaction can cause a dog or cat to go into septic shock.

Spay or Neuter? – in addition to the signalment information it is important for the vet tech to note at what age a spay or neuter event occurred to understand if any complications may arise.

Medical History – the vet tech should note any previous medical problems or reoccurrence of problems that may suggest a chronic disease.

Presenting Complaint – the vet tech should note the reason for the dog or cat to visit the veterinarian’s office. If an emergency, it is important to get as much information as you can from the pet owner in a quick and efficient manner. The presenting complaint will be more important in an emergency situation than historical information as the issue may be life threatening. If the pet owner presents more than one complaint, it is important to discuss them separately as they may not all point to only one medical disorder.

Before Symptoms Started – it is important to understand when the dog or cat was last feeling normal, before the symptoms started.

The Evolution – each problem is prioritized in the order it appeared and how long it lasted. A problem that is worsening quickly may warrant a more aggressive treatment.

Quick Systems Review – a full systems review will be performed later; however, the vet tech should ask some questions about each individual system to understand the issues with each. During this time the vet tech can ask about symptoms like coughing and diarrhea, current appetite, energy level and weight loss or weight gain.

Medication Review – all medications should be noted for the dog or cat during the physical exam to understand any complications or conflicts. The medication’s type, dose and frequency, duration, reason for administration and whether it has benefited the dog or cat is important for the vet tech to note.

The Physical Examination

A thorough physical exam serves as the first diagnostic test performed on the dog or cat. The physical exam will be important to confirm and understand the severity of the symptoms of the dog or cat. It is important for the vet tech to perform the physical exam in the same order each time it is administered. This will help the vet tech remember to perform a complete physical exam on each dog or cat, not forgetting any steps along the way.

The physical exam must be properly documented. Use of a standard form should be used to not forget to document any information. The form should include places to record body weight, temperature, pulse rate and respiratory rate.

The physical exam should begin as the dog or cat is in the waiting room, examination room or kennel. This will give the vet tech an overall idea of the dog’s or cat’s state, whether alert and responsive or sluggish and depressed.

Temperature – during the physical exam, the vet tech will want to take the dog’s or cat’s temperature, typically using a rectal probe thermometer. Variations in the pet’s temperature can offer clues to the nature and severity of the dog’s or cats’ condition. An elevated body temperature signifies the presence of infection, inflammation or abnormal tissue growth. Lower than normal body temperature can be an indicator of chronic renal failure, hypothermia or central nervous system disease.

Pulse Rate & Heart Rate – the best place to measure pulse rate and pulse quality is in the medial thigh of the dog or cat. The pulse rate is calculated by counting the number of pulses palpated for 15 seconds and multiplied by 4. Both the pulse rate and heart rate should be identical.

Respiratory Rate – an initial note of respiratory rate and effort should be obtained before any vigorous activity by the dog or cat during the physical exam. The respiratory rate is checked by both visual cues and actually listening to the lung sounds. To calculate the respiratory rate of the dog or cat, count the number of breaths for 15 seconds and multiply by 4. If the dog or cat is expending effort during respiration, further investigation should be done by the vet tech to see if something is obstructing the pet’s airway.

It is important for a vet tech to learn the proper procedures for documenting historical information and vital signs. With this information, the vet tech can work with the veterinarian to create a treatment plan that benefit the dog or cat. The initial physical exam will serve as a baseline for the pet, so it is important to perform the first physical exam while the dog or cat is healthy.

Interested in learning more about giving dogs and cats physical exams? Ready to start working as a veterinary technician? With an associate degree in veterinary technology, you’ll gain the knowledge and skills you need to start an entry-level career as a veterinary technician. Broadview University has been part of the community for more than 40 years, so we’ve developed connections that can help move your career forward. After completing our accredited degree program, you’ll be eligible to sit for the Veterinary Technician National Exam (VTNE). Passing the VTNE allows you to become a Certified Veterinary Technician (CVT), a designation that will give you a competitive advantage when you enter the job market.

Contact us today to learn more about becoming a veterinary technician and working in veterinary technology.

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