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ASAN001 - Patient Evaluation & Triage > Patient History (ASAN001/1) > Flashcards

Patient History (ASAN001/1) Flashcards

1
Q

Why is taking a thorough & detailed Patient History important? (2)

A

Essential in assisting in the diagnosis & appropriate treatment of a patient.

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2
Q

What is the major role of the consulting / triage nurse? (4)

A
  • Obtain a thorough & detailed patient history.
  • Determine how serious the situation is
  • Seek appropriate assistance
  • Record all data in a clear, concise & legible format.
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3
Q

What Owner details should be recorded (or checked if existing client)? (6)

A
  • Owner name
  • Address (physical not just postal)
  • Home phone number
  • Mobile number
  • Email address
  • Emergency contact number (the best number to contact owner during the patient’s stay)
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4
Q

Why is it important to clarify who the patient’s owner is? (3)

A
  • May not be the person who presents with the patient.
  • Identify who will make decisions regarding treatment.
  • Identify who will be responsible for paying for treatment.
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5
Q

What patient details should be recorded (or checked if existing patient)? (5)

A
  • Name
  • Description
  • Species & Breed
  • Sex & Repro status
  • Age
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6
Q

Why is checking the patient name important? (2)

A
  • Ensure that we have the correct name on file.
  • Determine if the animal has a nick name that the owners use more often than their proper name.
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7
Q

What type of description do we need for the patient? (3)

A
  • Colour
  • Pattern
  • Identifying marks (ie white marks on ventral chest)
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8
Q

Why is a detailed description of the patient important? (2)

A
  • So all staff can easily identify the patients based on their descriptions, not just their names.
  • May be instances where 2 dogs of the same name, breed & colour are in hospital at the same time. Need to be able to tell them apart by identifying marks etc.
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9
Q

What is the benefit of knowing what species & breed the patient is? (3)

A
  • Adds to patient description.
  • Accurate recording of breed or cross breading can help with diagnosis.
    – Some breeds are more prone to certain ailments & diseases.
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10
Q

Why is it important to note patient Sex & Reproductive Status? (3)

A
  • Accurate record of sex & repro status can aid in diagnosis.
    Eg: an entire female dog showing signs of lethargy, inappetence & polydipsia may indicate pyometra, but if dog is desexed we can rule this out.
    Eg: an entire male dog more likely to have prostrate issues then a desexed one.
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11
Q

Why is it important to know a patient’s approximate age? (3)

A

Age of patient can assist in diagnosis:
- Younger & older animals are more prone to certain ailments & diseases.
- Age is important in determining appropriate housing, bedding & nutrition.

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12
Q

How do we establish the reason why the patient has been brought into the clinic? (Presentation) (3)

A
  • Presenting signs
  • Duration of signs (acute, chronic)
  • History (in relation to signs, eg. trauma, change in diet etc)
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13
Q

How do we determine how the patient has been behaving / acting prior to presentation at clinic? (1)

A

Obtain info by asking questions about their general / normal activities.

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14
Q

What is considered general / normal activities? (5)

A
  • Activity
  • Eating
  • Drinking
  • Urination
  • Faeces
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15
Q

Patient’s activity levels? (2)

A
  • Normal
  • Decreased
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16
Q

Patient’s eating habits? (4)

A
  • Normal
  • More
  • Less
  • Not Eating (anorexic / inappetence)
17
Q

Patient’s drinking habits? (3)

A
  • Normal
  • Increased (Polydipsic)
  • Decreased (Oligodipsia)
18
Q

Patient’s urination habits? (4)

A
  • Normal
  • Increased (Polyuria)
  • Decreased (Oligouria)
  • None (Anuria)
19
Q

Patient’s defecation habits? (6)

A
  • Normal
  • Not passing faeces
  • Straining to pass faeces
  • Diarrhoea
  • Consistency of faeces
  • Colour of faeces
20
Q

What Preventative Healthcare for the patient do we need to check? (3)

A
  • Vaccination status
  • Endoparasite control (intestinal worms)
  • Ectoparasite control (fleas & ticks)
21
Q

Why is the patient’s Vaccination Status important? (2)

A
  • Diagnosis – eg. a young pup with only one vx presents with haemorrhagic diarrhoea will most likely have parvo but a 5yr, fully vx dog with same symptoms it would be unlikely to have it.
  • Housing – Vx status important when deciding where to put patient hosptial. eg. An unvaccinated pup may be put in cat ward away from other dogs to prevent cross–contamination.
22
Q

Why is the patient’s Endoparasite Control Status important? (3)

A

Intestinal worming & Heartworm prevention
- Important to know when last treated & with what type of prevention.
- esp in young patients, as heavy worm burden can lead to serious illness
- can help in diagnosis

23
Q

Why is the patient’s Ectoparasite Control Status important? (4)

A

Fleas, ticks & mites
- must determine when last dosed and with what product.
- Esp helpful with patients with skin problems
- Toxicity can occur in cats if given the wrong product – this should always be checked.

24
Q

What Previous / Current Medical Conditions information needs to be obtained or checked? (3)

A
  • Previous Surgical Procedures
  • Previous Medical Conditions
  • Current Conditions
25
Q

Patient’s previous Surgical Conditions information? (5)

A
  • Routine
  • Non–routine
  • Date
  • Any complications from sx?
  • Any complications from anaesthetic?
26
Q

Patient’s previous Medical Conditions information? (4)

A
  • Date of diagnosis
  • Treatment implemented
  • Length of treatment
  • Recovery date / cessation of meds date
27
Q

Patient’s Current Medical Conditions information? (5)

A
  • Date of diagnosis
  • Current medication
  • Dose prescribed
  • Time of last dose administration
  • Previous monitoring (eg. blood tests, ultrasound, urinalysis, blood glucose curve etc)
28
Q

Why is it important to know what medications the patient is currently taking? (2)

A
  • Vet needs to know to avoid dispensing meds that are contraindicated to use with current meds. (eg. cortiosteroids & NSAIDs).
  • May also aid in diagnosis eg if owner has overdosed patient with current meds or not given enough.
29
Q

Patient’s current Medication information? (5)

A
  • Note all medications currently being given, including natural therapies.
  • Name of drug
  • Amount given at last dose (under dosage / overdose)
  • Time last given
  • Length of time medication has been given (eg. 1 day, three weeks etc)
30
Q

Why do we need to obtain information about the patient’s normal Lifestyle & Home Environment? (2)

A
  • Assists in providing suitable housing in hospital (eg. if cat has never seen dog before)
  • Can also identify changes that have occurred that may contribute to presenting problem. eg. cat urinating in house my be due to owner recently moving house.
31
Q

Why do we need to determine what the patient’s current diet is? (5)

A
  • So we can feed the same during hospitalisation if possible.
  • Are they on prescription diet?
  • Do they have favourite foods? Are they fussy?
  • Cats in hospital are usually reluctant to eat.
  • If patient has GI signs, must establish what they were last fed & when, have there been any recent changes to their diet?

ASAN001 - Patient Evaluation & Triage (5 decks)

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