Examination Form

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After we document what breed your pet is, along with its age and gender, we follow the following protocol during an exam:

Background

  • Vaccine history
  • Prior diseases and their treatment
  • Diet
  • Allergies
  • Current medication
  • Current problem

Exam Findings

  • Mental status
  • Temperature
  • Heart rate
  • Respiratory rate
  • Mucous membrane color
  • Capillary refill time
  • Current and previous weight
  • Skin
  • Musculoskeletal (bones)
  • Respiratory system
  • Oral cavity
  • Eyes
  • Abdomen
  • Lymph nodes
  • Ears
  • Heart
  • Neurologic system
  • Urogenital system

This is an example of our exam form in a poodle that has not eaten well (anorexia) for 3 days and is straining to urinate. We will explain the findings below.

The abbreviations with the V, D, C, and S that are circled means this little guy is not vomiting or coughing or sneezing, and does not have diarrhea.

BAR- Bright, alert, and responsive

Temp- Temperature is 102.5 fahrenheit (normal)

HR- Heart rate is 180 beats per minute (high normal). This dog is uncomfortable which adds to this heart rate

RR- Respiratory Rate  is 30 breaths per minute (normal)

MM- Mucous membranes are pink (normal)

CRT- Capillary refill time (normal)

His weight today is 10#, last time we saw him it was 9#

Skin– normal

M/S- Musculoskeletal. Bones and muscles palpate normal

Respir- lungs sound normal with the stethoscope

Mouth- abnormal. He has tartar on his teeth causing mild gingivitis

Eyes- normal

Abdomen- normal upon palpation

Lymph nodes– normal

Ears- normal

Heart- abnormal. He has a Grade II/VI systolic heart murmur

Neurologic (CNS) exam- normal

U/G- urogenital. This is abnormal because small stones are palpated in his bladder and urethra.

TDX- tentative diagnosis. This is our working diagnosis a the moment, and will be confirmed with diagnostic tests.

Stage 1 PD is stage 1 periodontal disease

Urolithiasis– bladder stones

Mitral regurgitation- Turbulence of blood flow through a valve that separates the left atrium from the left ventricle.

Heart Dz- heart disease secondary to the mitral murmur

Our bladder stone page talks all about this problem.  We see bladder stones in a wide variety of species, except birds. They get something similar called eggs!

To see the surgery on the dog above follow our Facebook link from the home page (or click here for Facebook) and scroll down. His name is Barnacle, so you know his mother is a boater.

If you want to learn more about how our doctors make a diagnosis follow the Diagnostic Process link.