Veterinary Physical Exam Template and Checklist

A comprehensive physical exam checklist ensures a thorough and structured approach to veterinary examinations. Here are the key areas to focus on:

1. Initial Observations

• Observe the animal’s posture, gait, and activity level
• Note any unusual behaviors or signs of distress

2. Vital Signs

• Measure and record temperature
• Measure and record heart rate
• Measure and record respiratory rate

3. Head-to-Tail Examination

• Head
  • Check eyes for discharge, redness, or cloudiness
  • Inspect ears for discharge, odor, or redness
  • Examine mouth, teeth, and gums for dental health
• Neck and Throat
  • Palpate for any lumps, swelling, or pain
• Thorax
  • Auscultate heart and lung sounds
• Abdomen
  • Palpate for masses, pain, or distension
• Limbs and Joints
  • Check for range of motion, swelling, or pain
• Skin and Coat
  • Inspect for parasites, lesions, or abnormal hair loss
• Tail and Perineum
  • Check for signs of discomfort or abnormalities

4. Behavior and Neurological Assessment

Assess alertness and responsiveness
Check reflexes and coordination

5. Body Condition and Hydration Status

• Assess body condition score (BCS)
• Check mucous membranes and capillary refill time for hydration status

6. Additional Examinations (if needed)

• Conduct specific diagnostic tests (blood work, urinalysis, imaging) as indicated

7. Record Findings and Plan

• Document all observations and findings
• Formulate a plan for treatment or further diagnostics if necessary

This general checklist ensures a comprehensive examination while providing a structured approach that can be adapted to various veterinary settings.

Using physical exam form templates in veterinary practices offers numerous advantages that enhance the quality of care and streamline the workflow. Below are the key benefits of implementing these templates.

Benefits of Using Physical Exam Templates

Physical exam templates provide a structured and consistent method for documenting patient health, ensuring comprehensive care and improved record-keeping. Here are some specific benefits:

• Consistency: Ensures all critical health parameters are checked and recorded uniformly across all patients.
• Efficiency: Saves time during the exam process by providing a structured format to follow.
• Comprehensive Care: Helps in documenting detailed health records, making it easier to track changes over time.
• Improved Communication: Facilitates better information sharing among the veterinary team, leading to more informed decisions.
• Enhanced Client Trust: Demonstrates professionalism and thoroughness to pet owners, building trust and confidence in the care provided.

How TextExpander Can Help

TextExpander is a powerful tool that can significantly enhance the use of physical exam form templates by streamlining documentation and reducing errors. Here’s how TextExpander can help:

• Quick Access: TextExpander allows for rapid insertion of frequently used phrases, findings, and recommendations into exam forms, making the documentation process more efficient.
• Error Reduction: By using pre-defined snippets, TextExpander minimizes the risk of typographical errors, ensuring accurate and professional documentation.
• Time Savings: TextExpander streamlines the documentation process, allowing veterinarians to spend more time on patient care rather than paperwork.
• Standardization: The tool ensures that all team members use consistent language and terminology, improving overall communication within the practice.
• Customization: TextExpander allows for easy customization of snippets to fit specific needs or update them as protocols change, ensuring the documentation process remains current and relevant.

Example 1: Routine Wellness Check for a Dog

Basic Information

Owner’s Name: Jane Doe
Pet’s Name: Max
Species: Dog
Breed: Labrador Retriever
Age: 5 years
Sex: Male (neutered)
Color: Black
Microchip Number: 123456789

History

Reason for Visit: Annual wellness check
Current Medications: None
Previous Medical History: Vaccinated, no known illnesses
Diet: Dry kibble, twice a day
Allergies: None

Physical Exam

Weight: 30 kg
Temperature: 38.5°C
Heart Rate: 90 bpm
Respiratory Rate: 24 bpm

General Appearance

Body Condition Score (BCS): 5/9
Hydration Status: Normal
Behavior and Mentation: Alert and responsive

Systems Examination

Integumentary: Coat shiny, no lesions or parasites
Musculoskeletal: Normal gait, no lameness
Respiratory: Clear lung sounds
Cardiovascular: No murmurs, strong pulse
Gastrointestinal: Normal abdominal palpation
Urogenital: No abnormalities detected
Neurological: Normal reflexes and responses
Lymphatic: No enlarged lymph nodes

Diagnostics

Blood Work: Complete blood count (CBC) normal
Urinalysis: Normal
Fecal Exam: Negative for parasites
X-Rays: Not indicated

Assessment and Plan

Assessment: Healthy adult dog
Plan/Treatment: Continue current diet, maintain exercise, update vaccines
Medications Prescribed: None

Follow-Up

Next Appointment: One year
Special Instructions: None

Example 2: Sick Cat Visit

Basic Information

Owner’s Name: John Smith
Pet’s Name: Whiskers
Species: Cat
Breed: Domestic Shorthair
Age: 3 years
Sex: Female (spayed)
Color: Gray
Microchip Number: 987654321

History

Reason for Visit: Vomiting and lethargy for 2 days
Current Medications: None
Previous Medical History: Indoor cat, no previous health issues
Diet: Wet food, twice a day
Allergies: None

Physical Exam

Weight: 4 kg
Temperature: 39.2°C
Heart Rate: 160 bpm
Respiratory Rate: 30 bpm

General Appearance

Body Condition Score (BCS): 4/9
Hydration Status: Mild dehydration
Behavior and Mentation: Lethargic but responsive

Systems Examination

Integumentary: Coat dull, mild dandruff
Musculoskeletal: No abnormalities detected
Respiratory: Slightly increased respiratory effort
Cardiovascular: No murmurs, normal pulse
Gastrointestinal: Mild abdominal tenderness
Urogenital: No abnormalities detected
Neurological: Normal reflexes and responses
Lymphatic: Slight enlargement of mandibular lymph nodes

Diagnostics

Blood Work: Elevated white blood cell count
Urinalysis: Normal
Fecal Exam: Pending
X-Rays: Normal abdominal radiographs

Assessment and Plan

Assessment: Suspected gastrointestinal infection
Plan/Treatment: Antibiotics, antiemetics, fluid therapy
Medications Prescribed: Metronidazole, Maropitant

Follow-Up

Next Appointment: 3 days
Special Instructions: Monitor for changes in behavior and appetite

Example 3: Senior Pet Check-Up for a Rabbit

Basic Information

Owner’s Name: Sarah Johnson
Pet’s Name: Thumper
Species: Rabbit
Breed: Holland Lop
Age: 8 years
Sex: Male (neutered)
Color: Brown
Microchip Number: 567890123

History

Reason for Visit: Senior wellness check
Current Medications: None
Previous Medical History: History of dental issues
Diet: Hay, pellets, fresh vegetables
Allergies: None

Physical Exam

Weight: 2.5 kg
Temperature: 38.3°C
Heart Rate: 180 bpm
Respiratory Rate: 50 bpm

General Appearance

Body Condition Score (BCS): 3/9
Hydration Status: Normal
Behavior and Mentation: Calm and cooperative

Systems Examination

Integumentary: Coat thinning, some bald patches
Musculoskeletal: Mild arthritis in hind limbs
Respiratory: Clear lung sounds
Cardiovascular: No murmurs, normal pulse
Gastrointestinal: Normal abdominal palpation
Urogenital: No abnormalities detected
Neurological: Mild weakness in hind limbs
Lymphatic: No enlarged lymph nodes

Diagnostics

Blood Work: Mild anemia, normal renal function
Urinalysis: Normal
Fecal Exam: Normal
X-Rays: Mild osteoarthritis in hind limbs

Assessment and Plan

Assessment: Senior rabbit with mild arthritis and thinning coat
Plan/Treatment: Joint supplements, monitor diet and weight, regular grooming
Medications Prescribed: Glucosamine

Follow-Up

Next Appointment: 6 months
Special Instructions: Monitor mobility and coat condition