History taking is done by the technician or veterinarian to report on how the pet has been doing at home since the last assessment.
A pet’s temperament can have a significant influence on how thorough the examination may be without sedation. For example, some pets may strongly resent their mouth being opened, or require a muzzle to be safely handled without sedation. If the owner declines a sedated examination, certain areas may need to be assessed while the pet is sedated at another time, or even anesthetized—as is the case with some feral cats.
There is no single profession-wide standardized checklist used to perform an evaluation of pets, but each veterinarian develops their own favored order of systems evaluation, and has their own tips and tricks for assessing each.
For example, some veterinarians prefer to start at the front and work back while others have a favored order, carried out system by system. Whatever a veterinarian selects in his/her own practice, the physical examination covers the following:
- Weight and body condition
- TPR (temperature, pulse, respiration)—Temperature may not be taken in all patients
- Gait (way of moving)
- Brightness of eyes
- Activity level, reflexes
- Haircoat, nails, skin and anal glands—including external parasite check, hydration
- Ears and eyes- including ophthalmoscope exam of eyes, scope visualization of ear canals
- Circulatory system—pulse, gum color, stethoscope check of heart sounds
- Respiratory system—breathing sounds via stethoscope exam, respiratory pattern, discharges from nose, air flow of nostrils, tracheal rub
- Digestive system—from the oral cavity to the exit point, including dental, guts and general abdomen, liver, and rectum
- Urinary and reproductive system—check exit points for the systems, palpate the uterus (if present), testes (if present), bladder, kidneys, and the prostate gland of mature male dogs
- Bones, joints, muscles—check joint mobility/position, swelling, pain, and muscle loss
- Glands—check lymph nodes, thyroid lobes, spleen
Many practices offer the client a “report card” or a take home report detailing the results of the professional exam. This is a great way for you to learn about your pet’s particular quirks and problems. Often, the checklist allows the practitioner to simply place a checkmark where no abnormal findings are identified, and place comments where problems are noted. Other practices provide a brief written summary following the examination which may be included at the bottom of the invoice, along with any reminders for follow up or recommendations for treatment and testing.
You may request a summary of the examination findings for your home medical records, and if you have any questions about any part of the examination, the time at the end of the appointment is ideal for this process. Otherwise, if you find yourself left with questions when you get home, contact your veterinary practice. Your veterinarian or a licensed technician should be able to address those hanging questions.