Medical Record
The information gathered by means of the physical examination (see Fig. 1.2) is compiled and correlated with the data obtained during the history (see Fig. 1.1). A problem list should be formulated through the physical examination and anamnesis, leading to the development of a differential diagnosis list, a specific diagnostic plan, and a proposed course of therapy (Fig.
1.6). Prognosis can also be assessed with the information now in the examiner’s hands. Accurate recording of the abnormalities noted during the examination should become part of the medical record and can prove valuable in following the course of the case. In addition, with each complete and accurate physical examination performed, the practitioner becomes more skilled in the procedure, adapting it to fit his or her needs, and using his or her time more efficiently. With the number of diagnostic tests available to the profession today, the information gained from the physical examination will allow the examiner to pick the tests that are specific for those disorders suspected, which saves the practitioner time and the client money.As has been noted earlier, temporal and economic constraints sometimes preclude the performance of a complete physical examination. This is especially true when called to investigate a population-based disease/disorder case. In these instances, the practitioner needs to use aspects of the physical examination procedure outlined previously in order to arrive at a reliable presumptive diagnosis that can then be investigated further via the diagnostic plan. The affected population can be observed for signs of disease as previously described. The practitioner can look for evidence of pain, condition of the hair coat, body condition score, and variations in height or size or even shape of the affected animals along with their normal counterparts.
Increased respiratory effort or rate can be noted from a distance, as can be discharges from body orifices. Mentation status can also be assessed. An effort should be made to try and determine the course of the disease on the basis of the signs of pain and/ or disease noted. For example, in the case of a neonatal calf disease problem, the veterinarian would begin with the newborn and look for evidence of the disease/disorder while progressively observing older calves. Doing the investigation in this order would allow for determination of the onset of the disease (i.e., at what age group do you begin to see signs of the disease?), would allow one to determine progression of the disease as the calves age, and would allow one to get an idea of resolution of the disease process and allow for determination of any aftereffects of the disease. This same principle can also be applied to older ruminants, as one can begin with the animals that have just recently been through parturition and end with those that are approaching the end of gestation. While doing this, the veterinarian can also observe the feed bunks, the pens, the water troughs, etc. and gain great insight that could lead one to conclude that the disease process is primarily one that is management induced rather that pathogen induced.