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DIAGNOSTIC MEDICINE > 2 – History > Flashcards

2 – History Flashcards

1
Q

What are the 2 approaches to organizing clinical information?

A
  1. Problem oriented approach
  2. Pattern Recognition
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2
Q

Problem oriented approach general

A
  • Exhaustive and systematic collection of info through history and physical exam followed by integration and analysis of database
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3
Q

What are the 4 steps to a problem orient approach?

A
  1. Start with database assembly
  2. Leads to problem ID with DDx proposed for each problem
  3. Plan to rule in/out proposed differentials and initiate treatment based on your working diagnosis
  4. Assessment and re-evaluation: during hospitalization or follow-up appointments
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4
Q

Problem oriented approach pros

A
  • Minimize errors
  • Train new professionals
  • Solve complex cases
  • Communicate effectively
  • Document appropriately
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5
Q

Problem oriented approach cons

A
  • Inefficient in terms of time
    o Maybe not ideal for general practice or first opinion care
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6
Q

Pattern recognition general

A
  • Immediate integration of into to ID most probabilistic diagnosis used by experienced clinicians
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7
Q

Pattern recognition pros

A
  • Catches majority of common problems
  • Efficient
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8
Q

Pattern recognition cons

A
  • Common problems can present in unusual ways
  • Uncommon problems can present like common problems
  • Miss out on complete history and lead to miss diagnosis
  • Jump to conclusions
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9
Q

What is our data base? What does it consist of?

A
  • Systematic approach to collect info=critical to solve clinical problems
    1. History
    1. Physical examination
  • Dynamic, yet consistent=paramount to assemble history
  • *allows clinicians to ID problems and make DDx
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10
Q

Getting history when you have a problem visit

A
    1. Presenting complaint: need to understand owner’s expectations and address it
    1. Get thorough history: open-ended questions and body systems review (2.5-3mins), the closed end to ‘funnel’
    1. General or background history
      o General health, past medical problems and conditions in which the animal lives
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11
Q

Getting history when you have a preventative medicine visit

A
  • Get general or background history
  • Problem specific inquiry
    o Presenting complaint: may not have a specific one
    o Thorough history: open end to then closed end to ‘funnel’, body systems review
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12
Q

What are some history taking tips?

A
  • Always discus with the person who is MOST familiar with the day to day care of pet
  • Ask if they caught their concerns in video or pictures
  • Adopt a consistent method for taking a history
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13
Q

What are some communication tips?

A
  • Beginning: open ended inquiry (describe Max’s coughing), AVOID closed ended inquiry (Is max coughing?)
  • Summarizing back to them
  • Avoid leading questions (was the vomit bloody?)
  • Get them to describe what they have seen, rather than their interpretation (vomiting vs. regurgitation)
  • Follow up with closed ended questions if needed
    o Details that were missing and an opportunity to speak first and feel heard
  • For specific systems can ask closed ended questions for specifics
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14
Q

Establishing the time frame

A
  • Clinical curve can help you prioritize DDx when using problem orient approach to vet med
    o Traditionally associated with neurological DDx
    o Peracute: blood clot
    o Acute: lots
    o Subacute: inflammatory or infectious
    o Chronic: neoplasia or degenerative disorders
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15
Q

Body system review: another approach

A
  • Go through each body system
  • Memory and use physical exam form in medical record as a checklist or guide
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16
Q

What are some important aspects of a past medical history?

A
  • Vaccination: type and dates
  • Deworming
  • Flea/tick and heartworm prevention
  • Major medical or surgical problems
  • Nutrition
  • Supplements
  • Medications and dosages
  • Husbandry
17
Q

What are the 5 animal welfare freedoms?

A
  1. Freedom from hunger and thirst
  2. Freedom from discomfort
  3. Freedom from pain, injury or disease
  4. Freedom to express normal behaviour
  5. Freedom from fear and distress
18
Q

Front desk and waiting room: things to consider

A
  • First few minutes meeting a vet will shape the nature of their future contact
  • Want to make a good first impression
    o Staff, ID by name and pronoun, ask for clarification
    o Visual presentation
    o Minimize wait times and acknowledge wait time
    o Entertainment: WiFi magazines, coffee/tea
19
Q

Appointment: things to consider

A
  • Call by name and know sex
  • Accept what they saw about their pet or the breed without question
  • Dedicate time to pet and client (10-15min history)
  • Nonverbal communication=90% of communication
20
Q

Client connection

A
  • Connect on a personal level before you connect on a professional level
  • If you know specific info about the pet, then use it
  • Set a professional tone
    o Appearance and demeanor
    o Clean workspace
    o Remain still and appropriate eye contact
    o Take away barriers
  • Develop an understanding of the client’s relationship to the animal (owner, trainer, etc.)
21
Q

Patient connection

A
  • Fear free principles
    o Notes on behaviour
    o Sedation or muzzles
    o Gabapentin or trazadone
22
Q

What are 2 things that help keep the client in the loop?

A
  1. Reflective listening
  2. Summarizing
  3. Sign posting: review and outline next steps
    *then tell the owner what you recommend in order to investigate the possible underlying cause
    -don’t prejudge clients financial means
    -negotiate if recommendations are not acceptable
23
Q

How can I get all the info when dealing with a chatty person?

A
  • Polite interruptions
    o “thank you for all the important info. I was hoping you could tell me more about….”
24
Q

Ending the appointment

A
  • Summarize
  • Establish when next point of contact will be
  • Shake owners hand to conclude visit and walk them up to reception area
  • Don’t leave client in a room or wandering up front with UNCLEAR instructions as to what happens next

DIAGNOSTIC MEDICINE (3 decks)

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