Comprehensive History Flashcards

1
Q

Patient Demographic Data

A
  • Signalment
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2
Q

Distiguishing features

A
  • Coat color
  • Markings
  • Amputations/ visble scars
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3
Q

Permanent Identificatino

A
  • Tatoo
  • Microchip
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4
Q

Past pertinent history (PPHX) with regards to ownership

A
  • How did the patient come to be owned by the client
  • For how long ha the patent been owned
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5
Q

Past pertinent behavioral history

A
  • Does the patient have any pre-existing behavioral issues
  • has the patient developed any new behavioral issue
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6
Q

Past pertinent patient history with regards to medical and surgical history

A
  • Has the patient been previously diagnosed with one or more medical conditions
    • which conditions and how were they diagnosed
  • Has the patient ever been anesthetized
  • Has the patient been operated on
  • Has the patient ever had any adverse reactions to medical, anesthetic, or surgival therapy
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7
Q

Past pertinent reproductive history

A
  • Has the patient been bred previously
  • Does the client have plans to breed the patient in the future
  • What (if any) experience does the client have with regards to breeding
  • what (if any) problems has the client experienced when breeding this species or this patient
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8
Q

Patient function and client expectations

A
  • Is the patient a companion, show, or performance animal
  • Is the patient a service animal or a working dog, and in what capacity
  • What are the client’s expectations with regards to patient function
  • Are client expectations reasonable
  • Is the client familiar with the breed
  • Is the client familiar with breed predispostions to disease
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9
Q

Patient serological status

A
  • For dogs: Heart Worm/ Lymes/ Ehclichia/ anaplasma
  • For cats: Feline Leukemia/ Feline Immunodeficiency Virus
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10
Q

Patient home life

A
  • Is the patient indoor-only, outdoor-only, or indoo-outdoor
  • Is the patient crated or does the patient have free reign
  • Who does the patient live with (people, conspecifics, other species)
  • Who does the patient live with (in terms of other species)
  • Who is primarily responsible for patient care
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11
Q

Patient actvity level

A
  • What (if any) activities does the patient participate in and how often
  • What (if anything) is the patient expected to do
  • What (if any) problems has the client encountered with regards to exercise
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12
Q

Patient travel history

A
  • How often
  • where
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13
Q

Diet History

A
  • How often is the patient fed
  • what is the patient fed for meals
  • what is the patient fed for snacks
  • what is the patient’s body condition score
  • is the patient of the apprpriate or expected wight for its size and breed
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14
Q

Vaccination history

A
  • What has the patient previously been vaccinated against
  • what is the patient currnly vaccinated against
  • has the patient ever had any vaccine-associated reactions
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15
Q

Pharmacologic history

A
  • Is the patient currently taking any prescription medications
  • Is the patient currentlytaking over-the-counter medications, including vitamins and supplements
  • Is the patient currently taking any prevetatives such as flea, tick, or heartworm medication
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16
Q

Presenting complaint

A
  • What is the patient’s current problem
  • onset of current problem
    • peracute
    • acute
    • chronic
  • Duration of current problem
  • Frequenc;y of current problem
  • Are there any known inciting factors that played a role in the development of the problem
  • how, if at all, has the problem evolved
17
Q

Client perspective

A
  • What has the client observed
  • what does the client think the problem is
  • what concerns the client most and why
  • what past history (if anything) contributes to the client’s perspective and/or concern
18
Q

What if I don’t have time for it all?

A

Prioritize sections based on the circumstances

19
Q

“What kind of food is he/she on?

A
  • Clients tend to treat this question as a closed-ended question, reporting only 1-2 food items that their pet was currently eating 89% of the time
  • Rarely (8% of the time) do clientsdisclose information about treats or human foods
  • Within 75% of the veterinarian did not ask about any additional food items consumed by pet.
  • Instead try “Tell me everything he/she eats throughout a day, starting first thing in the morning through to the end of the day”
20
Q

how to measure food

A
  • Cups can be different to every owner
    • measured cup
    • coffee cup
    • drinking cup
  • Best option is to weigh food
21
Q

How many calories does a pet need?

A
  • Consider Resting Energy Requirement (RER)
    • calcualte using the patient’s Lean (Ideal) body weight
    • Use 70*BW(Kg)^.75
    • or 30*BW(Kg)+70
  • Calculate Maintencance Energy Requirement (MER)
    • Neutered dog we add 60% = RER*1.6
    • Intact dog we add 80% = RER*1.8
    • Puppy RER times 2-3 depending on age
    • Nutered Cat RER*1.2
    • Intact Cat RER*1.4