patient history Flashcards
what general information should you recive
- genral back ground information
- patient diet
- behavior
-current medication
what is in the patient signlaments
-age
-reproductive status
-sex
-breed
species
when talking to patient owner what should you avoid
you should avoid asking yes or not questions
what is background info
how long has the patient been owned
there normal routine
where they got the patient from
what does it mean by diet
- the food they consume
- how much they consum
-any recent changes
-did they get into anything that they were not suppose to
what is preventative medication
-vaccine history
-heartworm preventation
-flea/ tick prevention
current medication
-how much is given
at what frequency
- why is it giving
-for how long
- if its for eye , mouth medication
what is behavior
- asking how the patient is
-has there behavior change over time due to illnes
-transmittible dieses
patient medical past historyu
prior medical problems
-any surgeries or hospitliziation recently
-previous history problems
what is presenting complaint
- why the patient is here for
-most important getting there background info
what do u do incase of emergencies f\for patient present complaint
get information as quickly as possible for the current complaint before getting the patient history
Systems Review
Ask a series of questions that reviews each of the pet’s basic body systems
+Questions asked about each system may provide information that would
otherwise be overlooked by the owner
+All clients should be asked about presence of coughing, sneezing, vomiting,
diarrhea, polyuria, and polydipsia
+Question current appetite and energy level
+Note any perceived weight loss or weight gain
+If some questions have already been answered when discussing the
presenting complaint, do not repeat the questions
poregession
ask if the animal condition has been improving or staying the same or has gotten worse since there last visit
