Veterinary Clinical Examination Guide
Translated by
ScribdTranslationsVeterinary Clinical Examination Guide
Translated by
ScribdTranslationsUniversity of Antioquia
Faculty of Agricultural Sciences
School of Veterinary Medicine
Introduction to Veterinary Practice
Veterinary Clinical Examination
Professor Dubel Balvin Escobar
Veterinary Semiotics
The veterinary clinical examination is a tool that allows the clinician to organize a
methodically shapes the evaluation process of each patient.
As we have seen before, there are as many clinical specialties as there are species of
animals can be worked, this condition allows each clinician to create a format of
clinical examination that adapts to the conditions deemed important or relevant for
your work.
Although differences in the formats of the clinical examination may arise, it is important
emphasize the fact that the procedure to reach a good diagnosis is similar for
all species.
Among other aspects, the clinician must take into account to analyze very well all those
important aspects such as:
▪ The environment in which the animal operates, due to the direct relationship that
exists between environmental conditions, biotic and abiotic factors and the way
how different diseases behave.
▪ The behavioral characteristics of the animal, since an adequate
The interpretation of the animal's ethology collaborates significantly with a correct
diagnostic interpretation.
These are just two of the aspects to consider in order to perform well.
clinical examination. Other aspects such as performing a correct general physical examination and
by systems, and the choice of appropriate diagnostic aids to reach the diagnosis
more accurate.
For a better understanding of the clinical examination methodology, each student will read
at least two documents of veterinary clinical examination and subsequently it will be placed in
common in a group of 4 students the readings done. From this sharing,
You will receive a guide in which we will try to define the differences and benefits that create existence.
in each methodology, subsequently through a socialization in the classroom
They will address questions and concerns.
NOTE: very important Read the Clinical Examination Document Oriented to the Problem
ECOP.
University of Antioquia
Faculty of Agricultural Sciences
School of Veterinary Medicine
Subject Organic Systems (Semiology)
Problem-oriented clinical record
Dr. Jorge Padilla Sánchez
The Problem-Oriented Clinical Record (POCR) is a medical system that
it allows for the rational and sequential organization of the information obtained from a
patient to formulate a diagnosis and record the clinical evolution.
The ECOP was developed by the doctor in human medicine Lawrence lo Weed, at the beginning of the
sixties, to support the hospital clinical teaching of surgeons. A few years
later, this data sorting system was adopted in veterinary medicine with the
same purposes. Currently, the system is used in many educational institutions around the
world.
The methodology described in the ECOP has not only been applied to medical sciences, but
also to other professions; for example, in engineering, where it is known as
analysis system
Unlike traditional systems for organizing a clinical file, in which the
Basic data vary between patients, there is no list of problems, there is no system of
association of diagnostic or therapeutic plans with each identified problem, the notes of
progress are not listed or related to each problem; the ECOP defines in the four
points that consist of an arrangement that guarantees a good diagnosis.
The ECOP consists of four fundamental parts that revolve around
identification of the problems presented by the patient. The four parts are:
PARTS OF THE SYSTEM MEDICAL ACTIONS
Basic data. Gather information.
2. List of problems. Decide what is wrong.
3. Initial plan. Find something to do.
4. Progress notes. Follow up on each decision made.
The following will describe what each of the parts that make up this consists of.
system, to later give an example of its use.
Basic data
The basic data includes the information obtained from the medical history and the physical examination.
and some laboratory tests (complete blood count, general urine examination and
coproparasitological examination.
List of problems
A problem is defined as the attitudes or abnormalities that are generated in a
sick individual and require treatment or diagnostic evaluation. A problem can
being a sign of an abnormality in laboratory tests, a diagnosis, a
physiological abnormality or a physical finding.
The list of problems consists of a numerical relationship of each problem that the
the patient presents or has presented. At the doctor's discretion, the problems may be
divided into 2 different lists:
1. The list of top-priority problems or problems that affect quality
life
2. The list of secondary, self-limiting, temporary problems.
The identified problems are listed in order of importance, on a sheet that
attached to the file at the front and serves as an index or table of contents
(also called Master List).
The list of issues can be increased or modified according to the resolution of
each one of them.
Do not try to guess the possible causes of the problems listed. Continue with the
system and make diagnostic and treatment plans.
Initial plan
Each identified problem must be analyzed from a diagnostic point of view and
therapeutic.
The diagnostic plan (Pdx)
Each problem is structured as follows:
The probable causes are listed in order of greatest to least likelihood.
producing the problem. These probable causes can be considered as the
differential diagnoses.
To help remember the possible causes of disease, use the word 'DAMNIT'
as key:
D = Degenerative conditions.
A = Autoimmune disorders.
M = Metabolic disorders.
N = Neoplastic conditions.
I = Inflammatory conditions (infectious and non-infectious).
T = Traumatic conditions.
For each possible cause of the problem, select tests or laboratory exams or
cabinet, as specific as possible, that helps you to verify or dismiss the(s)
proposed cause(s).
Remember that to suggest the possible causes, it is necessary to know the diseases that
interpret the information obtained from the basic data.
Today there are commercial computerized systems that assist in the
statement of the possible causes.
The therapeutic plan (Prx)
Each problem must be evaluated according to the need for treatment.
From a diagnostic standpoint, the ideal plan is to avoid treatment until
know the specific cause of the problem. This eliminates the variables produced by the
treatment both in the clinical picture and in the complementary tests and expands the
the clinician's ability to assess the significance of laboratory and imaging results.
It is evident that in patients who require emergency treatment or in those where the
the diagnosis is established based on the response to therapy, the therapeutic plan is
priority.
Progress notes
The problems identified in a patient should be re-evaluated at appropriate intervals.
(minutes, hours or days), according to their severity.
To properly track each issue, draw conclusions and propose
diagnostic plans (Pdx) and therapeutic plans (Prx), progress notes are required
organized in such a way as to facilitate their analysis.
The correct scheme for sorting the observations is described below.
subjective and objective aspects of the clinical state regarding each identified problem in the
patient. With this information, additional diagnostic plans are established, or the
therapeutic plans.
Tracking scheme / progress notes.
S Subjective data refers to clinical signs, history, and observations from the owner.
OObjective data. It refers to listing the relevant results of the physical examination.
laboratory tests and X-rays.
I Interpretation of the data. Evaluation of the subjective and objective data of the problem.
P Plan. For each problem according to the observations of the previous points.
the plan of (Pdx) and (Prx) must be reviewed and updated.
Summary
a) Obtain complete and valid basic data (observations).
b) Develop a complete list of problems.
c) Project a diagnostic plan (Pdx) and therapeutic plan (Prx) for each problem.
d) In your dx plan, do not exaggerate the interpretation of the observations obtained in the
basic data.
e) Establish hypotheses about the possible causes for each problem.
f) If necessary, obtain additional data with laboratory tests.
they help them accept or reject their proposals of possible: causes of the problem. Do not try
to guess.
g) Review the diagnostic or therapeutic plan at appropriate intervals based on the
reevaluation of the course of clinical signs and test results
additional laboratory or office equipment.