History Taking Flashcards
Information gathered about the patient at every visit
History (Hx)
What is a leading question
Questions that suggest a particular answer is expected
Origin includes
Birthplace and date (Estimate birthdate at time of initial PE if it’s unknown)
Breeder or source
An occasion where there is consumption of an inappropriate, atypical, or excessive amount
Dietary indiscretion
Examples of dietary indiscretion that is the owners fault
Over feeds animal
Inappropriate food
Abrupt changes in animals diet
What to write ab diet/nutrition in history
What? How much? Changes in appetite? Recent changes in diet? Dietary indiscretions
What to write about water consumption in history?
How often fresh water is provided?
How often bowl washed
How much it drinks
Changes in consumption
First 2 most important things for determining a baseline for care
- History
2. Physical exam
Urination and defecation info to write in history
Frequency, volume, color, odor, consistency, pain or discomfort, appropriate (on belongings, etc)
Change in habit
Consistency of defecation examples
Diarrhea, constipation, blood, mucus
examples of routine disease screening and preventatives
Heart worm and Lyme disease testing and preventatives
FIV/ FeLV testing
Fecal flotation or centrifugation and deworming
Fecal flotation or centrifugation tests for
Worms
Past medical history includes
Vaccination Hx Routine screenings and preventatives Reproductive Hx Past med problems Permission to obtain record from previous vet
Information to include for medications taking currently
Name of medication, dosage, frequency of administration, how long
If no drug allergies write
NKDA no known drug allergies
For past medical problems you should note
How it was treated? Who by? Recurrence?
FIV/ FeLV
Feline immunodeficiency virus
Feline leukemia virus
Children in household and their ages or other pets in household would be which section of history
Environmental
At each visit, client should be questioned about _____ in the history since last visit
Changes
Moved furniture within home leading to animal confusion could indicate
Eyesight problems
New people or animals in home
Or
New animals next door or outside could lead to
Feeling competitive, jealous, stress. Urinating in house
History of the present problem (the reason the owner brought the animal in currently)
Chief complaint or Present Problem
Things to list about chief complaints/ presenting problems
Onset, frequency, trigger, duration, progression, relief
