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80 Cards in this Set

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What are the differences between a patient history and signalment?
A patient history is a description of current status while signalment is a description of unchanging specifics about an individual animal.
How long should it take to acquire a patient history?
It should take 5 minutes to acquire a patient history.
What are the three components to acquiring medical information?
Acquiring medical information is composed of: obtaining patient's history, performing a physical exam, and results from lab findings.
What are the two objectives of veterinary personnel at the initial stage of a clinic visit?
The two objectives at the initial stage of a clinic visit are: to collect information about past and present conditions, and to establish a doctor/client relationship.
What are three major factors that are required for a good history?
A good history depends on mechanics, interpersonal skills, and experience.
What are the five components of the mechanics in a patient history?
The five components of the mechanics in a patient history are: signalment, chief complaint or presenting issue, vaccination status, FeLV/HWT status, and specific history questions.
What are the nine specific history questions to be asked?
The nine specific history questions are: environment, appetite and diet, attitude, vomiting and diarrhea, coughing and breathing, water consumption, urinary habits, seizures, and lameness.
Which two of the nine specific history questions may not be asked if not applicable?
The two of the nine specific history questions that may not be asked are: seizures and lameness.
What five pieces of information should be obtained about the chief complaint?
Questions that should be asked about the chief complaint are: onset or duration, prior episodes as well as therapy and response, progression in symptoms, current medications and response, and past prognosis or treatments.
What questions should be asked about environment?
Environmental questions should include inquiries about living arrangements of the animal, such as indoor or outdoor, as well as other animals that share the living quarters.
What questions should be asked about appetite and diet?
Appetite and diet inquiries should be to determine if the animal's habits are currently normal for him, or whether appetite has increased or decreased.
What questions should be asked about attitude?
Attitude questions should determine whether animal is alert, bright, depressed, listless, or has had changes in behavior.
What questions should be asked about vomiting and diarrhea?
Vomiting and diarrhea questions should inquire about the description of substance, whether onset is in relation of eating, and frequency.
What questions should be asked about coughing, sneezing, and breathing?
The owner should be asked if they have noticed any difficulties in breathing.
What questions should be asked about water consumption?
Water consumption questions should try to determine if the animal is normal and consistent in its consumption habits.
What questions should be asked about urinary habits?
Questions about urinary habits should regard frequency, quantity, color, odor, and difficulty of elimination.
What assessments should be made during the physical examination?
The physical examination should include the following assessments: posture, gait, attitude, body condition, vital signs, mucous membrane color, and capillary refill time.
What observations should be made about the posture of an animal during a physical examination?
To evaluate the posture of an animal, observation of status such as natural, unnatural, and dominance need to be made.
What indications should be looked for in assessing gait?
To assess gait, veterinary personnel should be observing for possible lameness, weakness, dizziness, or signs of disorientation.
How is attitude assessed during a physical examination?
Attitude is assessed by the observer trying to determine how they perceive the animal seems to feel.
Name five descriptions used in assessing attitude.
Five descriptions used in assessing attitude are: BAR, QAR, dull, lethargic, and unresponsive.
What does the term BAR refer to when assessing attitude?
An animal described as BAR is bright, alert, and responsive.
What does the term QAR mean in assessing attitude?
The term QAR is used to describe animals that are quiet, alert, and responsive.
What does it mean when an animal is described as dull during an attitude assessment?
An animal described as dull is uninterested in its surroundings.
What does it mean when an animal is described as lethargic during an attitude assessment?
An animal described as lethargic is showing no energy and listlessness.
What does it mean when an animal is described as unresponsive during an attitude assessment?
An unresponsive animal shows no response to stimuli.
Why is taking body temperature so important?
Body temperature is one of the best indicators of disease.
What is one of the more critical reasons that body weight must be measured accurately?
Body weight must be measured accurately to correctly calculate drug dosages.
What are the four vital signs that are checked during a physical examination?
The four vital signs that are taken during a physical examination are: body weight, body temperature, pulse, and respiratory.
Describe a dog whose body condition is considered excellent.
An excellent body condition would be well muscled, ribs can be palpated but not visible.
Describe a dog whose body condition is considered good.
A dog in good body condition will be muscled with ribs that can be palpated.
Describe a dog whose body condition is considered fair.
A dog with fair body condition is muscled with ribs visible.
Describe a dog whose body condition is considered poor.
A dog who has poor body condtion is thin, lacks muscle structure, and ribs are highly visible.
Describe a dog whose body condition is considered obese.
An obese dog has ribs that cannot be palpated and is extremely overweight.
What is a normal condition causing elevated temperature?
Temperature can be elevated if animal is excited.
What are the features of a normal pulse?
A normal pulse will be strong and regular, not thready or weak.
What does it indicate when mucous membranes are pale in color?
Pale gums indicate anemia, which is a lack of iron.
What does it indicate when mucous membranes are blue in color?
Blue gums indicate the animal is cyanotic, or lacking in oxygen.
What does it indicate when mucous membranes are muddy in color?
Grey or muddy-colored gums are indicative in shock.
What does it indicate when mucous membranes are yellow in color?
Yellow gums are indicative of ictrus or liver problems.
How is capillary refill time measured?
Capillary refill time is measured by pushing on mucous membranes and counting to see how long it takes to return to normal color.
What causes capillary refill time to slow down?
Capillary refill time slows down with dehydration or shock.
What are the standards to determine ideal, normal, and abnormal capillary refill time?
Ideal CRT is no more than 1 second, normal CRT is 1 to 2 seconds, and abnormal CRT is over 2 seconds.
What is the meaning of the term assessment?
Assessment is the term used to describe the evaluation of a condition.
What information is included in a signalment?
A signalment is a description of the animal and includes information about species, breed, age, and sexual status.
What are two terms used to describe fever, or elevated body temperature?
Febrile and pyrexia are medical terms for fever.
What term is used to describe a decrease in body temperature?
A decrease in body temperature is known as hypothermia.
How is a pulse rate taken?
A pulse rate is taken by palpation of an artery.
What is auscultation?
Auscultation is listening to body sounds, usually involving a stethoscope.
What methods of examination use touching to assess conditions?
Palpation and percussion are used to assess conditions by touching.
What is a differential diagnosis?
Differential diagnosis is a list of possible diagnoses based on the history and clinical signs observed that the clinician will attempt to rule in or out using specific diagnostic tests.
What is one of the requirements of a complete systems review?
A complete systems review requires that one or two questions be asked about each body system.
Which bodily system is the most difficult and time consuming to examine completely?
The nervous system is the most difficult and time consuming to examine completely.
Which kinds of dogs are mostly commonly afflicted with difficult breathing due to constricted nares?
Brachycephalic dogs are most commonly afflicted withe difficult breathing due to constricted nares.
How do heart rates compare between small breed and large breed dogs?
Small breed dogs generally have faster heart rates than large breeds.
Where is pulse rate most often assessed in dogs and cats?
Pulse rate is most often evaluated over the femoral artery.
What is usually revealed during abdominal palpation of a normal dog or cat?
Abdomination palpation of a normal dog or cat will most likely reveal primarily intestines slipping between the palpater's fingers.
What is the normal size for a kidney in a cat?
In a normal cat, kidneys should be 2.5 to 3.5 cm in length.
Which parameters are used to assess the brain during a nervous system examination?
Cranial nerves and mental status parameters are used to assess the brain during a nervous system examination.
How are spinal reflexes measured?
Spinal reflexes are measured by a firm but gentle tap on a tendon and observation of degree of contraction of corresponding muscle.
What is the normal response to a firm toe pinch?
The normal response to a firm toe pinch is some acknowledgement of pain and withdrawal of the leg.
Name three pairs of peripheral lymph nodes palpable in the normal animal.
Peripheral lymph nodes palpable in the normal animal are submandibular, prescapular, and popliteal.
Name the two pairs of peripheral lymph nodes not generally palpable in the normal animal.
Peripheral lymph nodes not generally palpable in the normal animal are axillary and inguinal.
What is a comedone?
A comedone is a blackhead.
Describe the grading of reflex responses.
Reflex responses are graded as follows: 0 for no response, 1 for hyporeflexia (less than normal response), 2 for normal response, 3 for hyperflexia (greater than normal response), and 4 for clonus (repetitive response).
What is the normal RR and HR for cats?
Normal RR is 16-30 and HR is 160-240 in cats.
What is the normal RR and HR in cows?
Normal RR is 20-30 and HR is 50-70 in cows.
What is the normal RR and HR in dogs?
Normal RR is 16-24 and HR is 70-180 in dogs, while puppies can have HR up to 220.
What is the normal RR and HR in horses?
Normal RR 8-12 and HR is 35-50 in horses.
What is the acronym SOAP used to describe?
SOAP stands for subjective, objective, assessment, and plan in a problem oriented medical record.
What is a master problem list?
A master problem liste is a list of actual diagnoses for that patient, notated on a separate summary sheet.
What is the PPH?
PPH is an acronym for past pertinent hbistory, which is medcial history which may impact current problem.
Where would past pertinent history be notated for a new patient in the problem oriented medical record?
Past pertinent history would be recorded in the subjective portion for a new patient.
Where would the chief complaint be listed in the problem oriented medical record?
The chief complaint would be listed in the subjective portion of the problem oriented medical record.
Describe the subjective part of the problem oriented medical record.
The subjective part of the problem oriented medical record deals with our impressions of the animal, is subject to change, includes comments from client, and lists specific history questions.
Describe the objective part of the problem oriented medical record.
The objective part of the problem oriented medical record includes actual physical data compiled on patient such as vitals as well as lab data.
Which two sections of the problem oriented medical record are not completed by veterinary assistants?
Veterinarians complete the assessment and plan sections of the problem oriented medical record.
What is included in the assessment section of the problem oriented medical record?
The assessment section is a list of possible diagnoses.
What is in the plan section of the problem oriented medical record?
The plan section summarizes the diagnostic and therapeutic plan for the patient.
What are the eight parts of a problem oriented medical record?
The eight parts of a problem oriented medical record include: signalment, master problem list, past pertinent history, chief complaint, subjective, objective, assessment, and plan.