Small Animal Internal Medicine for Veterinary Technicians and Nurses

Linda Merrill, Linda Merrill

• Editorial: Wiley-Blackwell
• Año: 2012
• ISBN:
  9781118318256
• Edición: 1
• Categoría: Medicine
• Categoría: Veterinary Medicine

Small Animal Internal Medicine for Veterinary Technicians and Nurses is the first comprehensive resource on internal medicine written for the veterinary technician. Organized by body system, each chapter discusses pertinent diseases, from clinical signs, diagnostic testing, and prevalence to treatment options and nursing considerations. Published in association with the Academy of Internal Medicine for Veterinary Technicians, this book offers both a thorough grounding in the foundations of internal medicine for students and new veterinary technicians and detailed, advanced information suitable for experienced veterinary technicians.

Coverage includes an overview of neurological disorders and discussion of the surgical, emergency, and nursing considerations for each condition. This complete reference, which includes a companion website with quizzes, images, and video clips, is essential reading for veterinary technician students, practicing technicians, and those studying for the AIMVT specialty exam.

Chapter 1

Physical Examination

Editor: Peter J. Bondy, Jr.
Author: Marcella D. Ridgway

The initial consultation appointment for the internal medicine patient is vital not only from the standpoint of evaluating the patient’s history and performing a complete physical examination but also to establish a positive and effective relationship with the pet owner. In the setting of a specialty referral practice, it is important to recognize that the referring veterinarian (RDVM) is the primary client and should always be included as an essential component of the relationship with the pet owner that has been referred. A solid foundation for this relationship with the RDVM and the pet owner can be established even before the actual appointment. Many specialty referral practices provide a Web site where veterinarians can find referral protocols and pet owners can readily access information about the hospital. This information may include how the patient should be managed before the appointment (e.g., 12-h fast), what to expect during the referral appointment, and some biographical material about the specialist(s) and the veterinary health-care team that will be evaluating the pet. Pamphlets or other written materials provided to the RDVM, which can be given to the pet owner at the time of the referral, are also useful. To nurture good relationships with referring veterinarians, it is particularly important to maintain frequent communications. This can be achieved in several ways: prompt follow-up on cases, participation in local veterinary medical association activities, hosting continuing education programs, distributing newsletters with updates about the specialty practice, arranging for new specialists joining the practice to meet referring veterinarians in person, and, above all, by supporting the relationship of the RDVM and the pet owner through positive communications and by ensuring that the pet owner’s visit is otherwise as positive as possible. It can be quite helpful to have short referral forms for the RDVM to fill out online or on paper summarizing the RDVM’s impressions about the case, including suspected diagnoses, and results of diagnostic tests that have already been completed. This short, simple form can be tremendously helpful in assuring that the RDVM’s reasons for referral are addressed and that miscommunication of such information by the pet owner does not mislead the specialist as to the reason for the visit. The specialist and the RDVM are reliant upon each other to achieve the best care for the pet and the pet owner.

Charting

The SOAP charting system (subjective, objective, assessment, and plan) is the standard approach to formulating the medical record. It is a technique of organizing thoughts so that any person picking up the record will understand what the clinician was and is thinking. The medical record is subpoenable by a court of law, and by law, if it is not written in the record, then it does not exist. Understanding the importance of the medical record is paramount to good medical practice.

S (for subjective) includes the history and other data which cannot be measured in a repeatable manner across different evaluators, such as physical exam findings of patient attitude. This may be recorded and may present documentation in narrative form. Ask targeted questions and document what the owner says, in their own words, without paraphrasing. The O (for objective) includes information that can be graded or other­wise quantified such as body weight and heart rate and also includes laboratory data. The A is the assessment, which is a summary and interpretation of the clinical signs and the diagnosis or the differential diagnosis (list of tentative diagnosis). Once the list of differential diagnosis has been established, the clinician forms the plan (P), or how to prove which of the suspect diseases is the actual perpetrator. The plan is divided into three components: the treatment plan (Tx), the diagnostic plan (Dx), and the client education component (CE).

Goals of the Consultation Appointment

The specific goals of the initial consultation appointment are to

1. build trust with the client and with the pet;

2. establish the client’s primary concerns;

3. understand the course of events, diagnostic steps, and treatments prior to referral;

4. carefully evaluate the patient;

5. build a problem list and prioritize problems;

6. consider differentials for each problem on the problem list;

7. establish a diagnostic and/or treatment plan; and

8. communicate patient management plans, associated risks, and costs to the client.

The veterinarian and technician/nurse can consider this list together and determine roles and responsibilities within this framework. These may vary according to the nature of the condition (emergency vs. chronic disease), experience level of the technician(s), or relationships among caregivers.

Build Trust with the Client and with the Patient

Remember this may be the first time that they have come to a specialty hospital. They may have already seen several other veterinarians and it is likely their pet has a serious problem. Recognize that clients are probably distressed by needing to establish yet another new relationship with veterinary caregivers and by the fact that their pet is ill and has a complex disease or an elusive diagnosis that has prompted the referral visit. Working to make the clients feel welcomed and that they are in the hands of capable veterinary professionals is important. This really starts with the receptionist, from the initial phone call to the impression as they walk in the door for the first time. Confidence, consideration, and efficiency on the part of support staff are key in getting consultation visits off to a positive start.

Minimize waiting times—this is a period of uncertainty and discomfort for the client. If they are left with unstructured time to worry about their pet and the visit itself, their anxiety levels may be heightened. Provide something for them to do while waiting; let them know what period of time they can expect to wait and be certain to update them if there will be any delays. Prompt notification of the arrival of the client to the appropriate staff can facilitate the timeliness of the appointment process and can reassure the owner that they are being cared for.

Know the pet and the owner name and greet them both in a welcoming manner. Look the client in the eye, greet them professionally, and introduce yourself by name and position. Invite the client into the exam room, invite them to sit, and ask them to place their pet on the floor or on the table as appropriate. In these initial few minutes, clearly delivered, friendly directions from you will help to build confidence.

Unless this is an emergency, avoid immediately examining the patient. Allow the pet to acclimate to the room while you initiate conversation with the client. Key pieces of information about the patient, such as mentation, respiratory character, ambulation, and vision are often best assessed by a hands-off examination, which can be completed at this time.

Establish the Client’s Primary Concerns

Try to use open-ended questions such as “What made you first take Fluffy to your local veterinarian?” rather than “What seems to be the problem?” In the latter situation, the client is tempted to take on the role of doctor and is likely to paraphrase their RDVM’s assessment rather than their own concerns.

Understand the Course of Events and Diagnostic Steps Prior to Referral

Information from the referring veterinarian should be available prior to the consultation, but ask the clients for their own chronological assessment of the course of events. They may admit to seeing another veterinarian or they may add important information omitted from the referred history. It is helpful to work from a history and physical exam checklist to avoid overlooking any details that may eventually prove to be important. After an initial relaxed inquiry of the patient’s history, the history form should be checked to ensure that all the details of vaccination, heartworm or retrovirus testing, current medications, previous treatments for the current illness, and prior medical problems have been recorded.

History Acquisition

History acquisition may be considered to include two phases. The first phase is acquisition of a general history, which covers information that is pertinent to every patient. The second is a targeted history, in which information pertinent to specific problems of an individual patient is addressed in greater detail (e.g., more careful questioning about exposure to stagnant water sources in a patient in which leptospirosis is being considered as a differential).

In the general history, it is important to determine the reason for the clients’ visit so that their presenting concerns are always addressed even if more significant problems are identified in the referral information or subsequently during the referral visit. Signalment should be determined as a significant factor to be considered in developing appropriate differential diagnoses. Clients should be questioned carefully about preexisting conditions and current medications, keeping in mind that clients may inadvertently omit information about very chronic or common conditions (e.g., osteoarthritis in an older dog) or medication that they give so routinely they may fail to consider it a medication (e.g., heartworm prevention). It is particularly important to determine what treatments, if any, the patient has received for the current illness and what response was noted. Specific information (exact date administered and product used) about vaccinations should be determined as some conditions (e.g., immune-mediated hemolytic anemia, immune-mediated throm­bocytopenia, polyneuropathy) have been chronologically asso­ciated with vaccination. An accurate travel history helps in assessing the risk of exposure to diseases that are regional in occurrence (e.g., systemic fungal diseases, tick-borne diseases, high altitude disease). Complete information about the patient’s diet, including specific types or brands and specific amounts fed, as well as any supplements or treats that the pet receives, should be obtained. It is important to ask open-ended questions that do not “lead” the client into giving a particular answer and to be nonjudgmental when obtaining this information (clients sensing criticism of how they care for their pet may not accurately report historical information) in order to obtain an accurate history.

Evaluate the Patient: Physical Examination

The physical examination begins before ever touching the patient by observing the general demeanor of the animal and how it moves about and interacts with the environment. In fact, hospital receptionists, kennel personnel, and other nontechnical staff can provide important preliminary or monitoring information through their observations and should be advised that their input is welcomed and valuable in providing the best care for patients. This general assessment of patient attitude contributes to the evaluation of vision, mentation, and ambulation. It also allows for a general assessment of the patient’s personality, which can lead to an adjustment in technique for aggressive or fearful patients. It is important to know what constitutes a normal physical examination and to recognize breed, age, sex, and species variations. The key to consistent performance of a thorough and useful physical examination is establishing a well-organized and systematic approach that is employed routinely in evaluating patients, whether for their first visit or for reevaluation. This will safeguard against overlooking some physical abnormalities because of distractions or focusing too soon on a particular area of interest suggested by the client or on a preliminary observation of the patient. A logical system is to work from “nose to tail,” although with patients of uncertain temperament, delaying examination of the mouth and head until the examiner is better acquainted with the patient may be advantageous. Additionally, postponing the parts of the physical examination that are likely to be objectionable to the patient, such as rectal examination or palpation of a painful limb, until the end of the examination is advisable. Body temperature, respiratory rate, and pulse are best determined when the patient is the most relaxed, which may be early in the exam for some patients, especially cats, and later in the exam for others.

Body temperature is usually determined via rectal thermometer; although otic devices are available, normal ranges have been routinely established for rectal temperature. Respiratory rate can often be determined before beginning a hands-on exam by observation of thoracic wall motion. Heart rate is determined by thoracic auscultation or direct chest wall palpation, and pulse rate may be determined by digital pressure over the femoral artery, or the digital artery. Recording both a heart rate and a pulse rate will determine if a pulse deficit is present.

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