The consultation Flashcards
Outline the contents of the planning and explanation section of the consultation using the Calgary-Cambridge guide
- Usually merge into one
- Explanation of findings from physical exam, test results, outcome of surgery etc.
- Planning based on this
- Explanations along the way as decisions made are not always clear to the client
What should be included in the planning stage of the consultation?
- Options for treatment, diagnostic tests required, prognosis
- Utilise shared decision making
- Return to client’s agenda and check concerns have been addressed
What is meant by compliance?
Thee owner following the recommendations you have given
What is concordance?
Making and following through shared decisions
What is chunking and checking?
Giving small pieces of information and checking after each that it has been explained clearly
What is signposting?
Signalling what has just been discussed and what will be discussed next
What is safety netting?
Give options before they are needed, meaning decisions are less of a shock to owner, and owner is aware of how to respond to different situations
What are the benefits of using shared decision making?
- Improves compliance
- Improves owner understanding
- Less likely to encounter resistance if things go wrong
- True informed consent
What is meant by relationship centred care?
- Balance between paternalism and client autonomy
- Characterised by joint venture between vet and client to provide optimal care to the animal
What are the characteristics of relationship centred care?
- Respect for client’s interests and perspectives
- Elicits clients opinion
- Recognition of client’s expertise
- Acknowledgement of animal’s role in environment/family
- Lifestyle and social aspects all considered i.e. farmer vs child’s pet
What techniques can be used in breaking bad news?
- Relationship building
- Warning shots
- Pauses
- Hope and reality balancing
- Shared-decision making
What is meant by a warning shot?
- Give some indication that bad news is about to be delivered
- Allows client to prepare self
What diagnostic methods are commonly used in farm animal practice to improve reproductive performance?
- Internal examination (rectal and vaginal)
- Ultrasound
What structures can be felt in rectal palpation of the reproductive tract of the cow?
- Cervix
- Uterus
- Uterine horns
- Ovaries
What can rectal palpation in a reproductive exam of the cow be used for?
- Assessment of uterine tone to give idea of stage of cycle
- Presence/absence of follicles/CLs on ovaries
What structures can be examine by ultrasound in the reproductive exam of the cow?
- Uterus
- uterine horns
- Ovaries
What information can be gained from ultrasound in the reproductive exam of the cow?
- Presence of fluid in the uterus
- Presence of a foetus
- Follicles or CLs on ovaries and their size
- Assess preganncy status
- Uterine pathology (infection, trauma)
- Ovarian pathology (e.g. cysts, rarely may find neoplasia)
- Stage of oestrus cycle as an educated guess
Describe the tone of the bovine uterus in oestrus?
High one
What is assessed in the vaginal exam of the cow?
- Vaginal mucus quantity
- Mucus consistency
- Presence of blood
What features of the history are of particular interest in a reproductive exam of the cow?
- Calving dates
- Oestrus dates
- Treatments received
What are the limitations of the common diagnostic methods in large animal reproductive examination?
- Easy to miss information
- Farmer may not give full history
- Ultrasound is only a short snapshot of a 21 day period
At what point in the cycle can the stage of oestrus be accurately determined in the cow and how?
- 1-2 days after ovulation
- Lots of clear mucus +/- small amounts of fresh blood
- Increased uterine tone
- No CLs or folllicles on ultrasound of the ovaries
- Looks like anoestrus but with vaginal exam, know that cow has ovulated 1-2 days ago
Briefly describe the hormonal changes in the oestrus cycle of the cow
- After ovulation, CL forms
- Present for 15 days, progesterone high
- Minimal greyish vaginal mucus
- Low uterine tone
- At end of luteal phase becomes prostaglandin sensitive
- Luteolysis due to natural prostaglandin release
- Now into oestrus, oestrogen rises and falls
- Uterine tone rises and falls
- At beginning mucus is increasing, at ovulation have copious clear mucus
- High GnRH leads to LH surge, leading to ovulation
- After ovulation CL begins to form
- Mucus decreases and is often blood stained, no large follicles found
What drugs are mainly used in the management of reproductive performance of cows?
- Prostaglandin
- Gonadotrophin Releasing Hormone
- Progesterone Releasing Intravaginal Device (PRID) or Controlled internal Drug Release (CIDR)
Outline the importance of considering the cow as part of the herd
- Individual cow may act as indicator of wider problems/health
- E.g. more cows thinner than usual suggests herd wide nutritional problem
- Easy for farmer to miss if was a gradual herd wide change as cows wouldn’t stand out
Outline the role of prostaglandin (e.g. Estrumate) in reproductive management of the cow
- Causes luteolysis
- Progesterone production turned off
- Enters oestrus 3-4 days after administeration (80% of cows enter within 2-7 days)
- Decreases P4
Outline the role of GnRH (e.g. Receptal) in reproductive management of the cow
- Causes large release of LH
- Much larger than physioogical dose, little effect on FSH
- If follicle near ovulation then will ovulate, if not then will not ovulate but will luteinise and form CL
- New luteal tissue formed
- Progesterone productin increases
- i.e. Role is to increase P4
Outline the role of PRIDs or CIDRs in the reproductive management of the cow
- Slow release of progesterone over 7-11 days
- Effectively acts as temporary removable CL
- Removal mimics luteolysis
- If no other luteal tissue is present, removal results in cow coming into oestrus 2-4 days later
- Role is to decrease P4
Describe the basic information needed o assess reproductive performance in an individual cow
- Health assessment
- Locomotion score
- BCS
- Conformation (body, udder)
- Vaginal discharge
- Bulling signs
Describe the type of history that is likely to be given by a farmer with regards to a cow presented for reproductive examination
- Exception reporting i.e. will only give unusual information
- Gives reason for presentation e.g. not seen bulling
What can be inferred from a history of “not seen bulling”?
- Normal cow
- No calving problems
- No retained foetal membrane
- No vaginal discharge
- More than VWP days have passed
- Oestrus not observed
- Cow has not been served
- Cow is not run with a bull
- i.e. this cow is normal, should have been observed in oestrus but has not
What is the main purpose of pregnancy diagnosis in cows?
Identification of cows that are not pregnant when they would be expected to be
What history can be inferred from a cow presented for pregnancy diagnosis?
- Cow is normal, healthy and milking ok
- Cow has been inseminated
- Falls into PD window for this farm
- Has not been seen bulling since service
- No vaginal discharges seen
Where uterine infection is suspected, what information is required?
- Days since calving
- Nature of discharge
- General state of cow i.e. is she ill?
- CL present?
Describe metritis
- Whole uterus inflamed and infected
- Occurs straight after calving
- Cow sick
- Serious medical condition
- Risk of death
Describe endometritis
- aka whites
- Only lining affected
- Some vaginal discharge ranging from almost normal to normal with some yellow spots to completely yellow to worst case scenario of bad smell and blood present
Describe pyometra in the cow
- No discharge found on vaginal examination
- Scanning of uterus indicates it is full of pus
- Closed cervix i.e. closed pyometra
What is indicated by a persistent CL?
- No PG production from the endometrium
- If endometrium is damaged, then PG will not be produced and luteal phase will continue
What is the significance of a persistent CL for uterine infection?
- High progesterone, low uterine tone
- Uterus not cleaning itself so infection will not be removed
- Infection is likely to clear when cow comes into oestrus, especially if it is an endometritis
Why is oestrus beneficial for the clearing of infection?
- Cervix open
- Uterine tone increased and pushing out material
- Mucus production high which flushes the uterus
What actions can be taken following a PD exam in the cow?
- PD+ve: no action or abort if inappropriate pregnancy
- PD-ve: reassess as not seen bulling cow
How can uterine infections be treated in the cow?
- In sick cows: use parenteral antibiotics
- In cows with white and no CL: intrauterine antibiotics
- In cows with whites and a CL present: prostaglandin to bring into oestrus
Describe the OvSynch protocol
- GnRH at day 0
- PG at day 7 of protocol
- GnRH at day 9 of protocol
- AI 12-16 hours later
Describe the PG synchronisation protocol used in cows
- PG at day 0
- PG at day 11-14
- AI 2-4 days after second PG
How soon after treatment with GnRH is ovulation induced?
Within 24 hours
When should GnRH be administered in relation to AI/servicing of a cow?
Either at time of AI or service, or 6-8hours before
What are some important factors when considering a dog as a new pet?
- Select breed to suit lifestyle
- Space available and activity levels
- Potential allergies
- Inevitable additional costs (insurance, food, worming etc)
- Experience of teh owner
- Other animals, young children
What are some important factors when considering a cat as a new pet?
- Home location (busy road?)
- Other animals in the home
- Risk of zoonoses, particularly to pregnant women
- Allergy
- Children
- Obligate carnivores
What are some important factors when considering a rabbit as a new pet?
- Should be kept in pairs
- Need sufficient space
- Nutritional requirements important
- More complicated and time consuming than may appear
- Presence of wildlife and predators
- Inappropriate pets for children
What are some important factors when considering a horse/pony as a new pet?
- Land
- Finances
- Time, experience of owner
- Support
- Purpose (e.g. competition or teaching)
What are some important factors when considering a guinea pig as a new pet?
- Good for children
- Need regular handling
- Nutritional needs need careful consideration
- Need to secure against wildlife and predators
What are some important factors when considering chickens as new pets?
- Regular careful handling
- Protection from wildlife
- Space available
- Risk of zoonoses
- May have restrictions re cockerels in urban areas
What are some important factors when considering snakes/other reptiles as new pets?
- High risk of zoonoses e.g. Salmonella
- Feeding of mice may not be comfortable with some
- Strict environmental and nutritional needs
- Expensive
What are some important factors when considering hamsters as new pets?
- Breed depending may need to be alone or in a pair
- Prone to biting
- Nocturnal
- Nutritional needs
- Careful handling
Describe the role of physiotherapists
- Help individuals affected by injury, illness or disability through movement and exercise, manual therapy, education and advice
- Manage pain and prevent disease
- Encourage development and facilitate recovery
What are the regulations surrounding physiotherapists?
- No regulatory body
- Can become Chartered Physiotherapists
- Do not diagnose conditions, should always seek permission from animal’s vet before starting a treatment
- Report to vet after treatment
Describe the role and regulations for osteopaths
- Title protected by law
- Use touch, physical manipulation, stretching and massage to increase mobility of joints, relieve muscle tension, enhance blood and nerve supply to tissues and help body’s own healing mechanisms
- May aid recovery and prevent symptoms recurring
Describe the role of chiropracters
- Treat, manage and prevent disorders of MSK system and effects these can have on nervous system and general health
- Mainly spine and neck
- reduce pain, improve function, increase mobility using hands-on manipulation of the spine or other areas of the body that are not moving properly
- May use ice, heat, ultrasound, exercises, acupuncture
What are the regulations with regards to farriers?
- Must be registered in accordance with Farriers (Registratio) Acts 1975 and 1977 (Farriers Registration Council)
- Not exempt from restrictions in Veterinary Surgeons Act 1966
- Must not normally penetrate sensitive structures, cause unnatural stress to the animal, make a diagnosis or administer drugs
What does farriery consist of?
- Trimming and balancing equine hoof prior to and for the fitting of conventional or surgical shoes
- Where vet requires particular work from a farrier this should be specified in personal contact between them
Describe the Farriers registration Council
- Corporate body established under Farriers (Registration) act 1975
- Aim is prevention and avoidance of suffering by equines through ensuring equine owners are able to access equine hoof-care that best meets their needs in a timely and assured manner
- Delivered only by those capable and qualified to do so
Who is legally allowed to carry out hoof trimming, balancing and fitting of conventional or surgical shoes to a horse?
- Vets
- Vet students under supervision
- Registered farriers-
- Farriery apprentices under supervision
What are equine dental technicians allowed to do?
- Remove deciduous caps
- give advice about oral health
- Rasp sharp enamel points
- Extract digitally loose teeth
- Seat the bit
- remove non-displaced erupted wolf teeth
What are equine dental technicians not allowed to do?
- Extract teeth with vial periodontal attachments
- Remove non-erupted, displaced or molarised wolf teeth
- Incise or elevate gingiva, mucosa or any viable animal tissue
- Perform surgical procedures within the oral cavity
- Sedate horses
What are the regulations around homeopathy in veterinary practice?
- Can nly be administered by veterinary surgeons
- Illegal in terms of Veterinary Surgeons ACt 1966 for lay practitioners, even if qualified in human field, to treat animals
- Vets need to be trained in its application
- Heavily regulated by the RCVS
What are the regulations regarding faith healers for veterinary purposes?
Must not treat animals without prior permission of a veterinary surgeon
Who should clients be referred to for training and behaviour support in dogs?
- Those that are members of recognised organisations
- e.g. Association of Pet Behaviour Counsellors (APBC)
- Association of Pet Dog Trainers (APDT)
- The Canine Behaviour and Training Society
- Puppy School
- Professional Association of Canine Trainers (PACT)
- International Association of Animal Behaviour Consultants (IAABC)
- Karen Pryor Academy
- Dog Knows
Outline some of the requirements when referring a client to a behaviour specialist
- Referral slip from vet
- Referral may be for diagnosis, procedure and/or possible treatment, after which the case is returned to the vet
- Are not required to provide clinical records to the APBC member
- Diet should not be manipulated before communication with the referring vet
When might referral to a canine behaviour specialist be indicated?
- Prevention better than cure
- Some behaviours require expert attention e.g. aggression, house soiling, multi-pet households, fears and phobias, geriatric pets with cognitive dysfunction, separation related problems
Describe the roles and regulations around AI technicians
- Work with farmer to ensure best quality semen used for insemination at the correct time
- Is not an act of veterinary surgery but must be certified by DEFRA
Describe the roles and regulations around sheep scanners
- Scan entire flock to identify numbers of each lambs in each eye and improve management
- Is not an act of veterinary surgery and not regulated by the RCVS
Describe the roles and regulations around Foot trimmers
- Improve foot health of sheep and cattle
- Not considered an act of surgery as long as there is no diagnosis and horn is simply removed
- There is a National Association of Cattle Foot Trimmers who exist to help encourage registration and regulation, but hold no jurisdiction over non-members
Who owns clinical records and radiographs?
- Clinical records owned by veterinary surgeon
- Radiographs on film are property of the practice
- Can make copies when requested by the client
Who can access the clinical records for a patient?
- Owner, vet and vet nurses
- However does not include records which relate to the same animal but a different client
What information must be included in the clinical records?
- Details of examination
- Treatment administered
- Procedures undertaken
- Medication prescribed/supplied
- Results of tests
- Provisional/confirmed diagnoses
- Advice to owner
- Plans for future treatment/investigations, follow-up care
- Notes of telephone conversations
- Fee estimates/quotations
- Consent given/withheld
- Contact details
- Recommendations/discussion about referral or re-direction
- Factual, no personal observations or assumptions
- Identity of peron recording
What are the guidelines for adding to clinical records at a later time?
Can add corrections or additional thoughts, but note these alongside the relevant entry and give date and person adding/correcting
What is the SOAP format of clinical records?
- Subjective observations e.g. bright, responsive, alert
- Objective observations: e.g. defecation/urination normal, presence of pea-sized lump attached to abdomen, drinking/eating normally, resp rate 40 etc
- Assessment e.g. patient clinically normal with small mass requiring removal, may require histopathology of mass
- Plan: e.g. discussed options and owner elected to remove mass, GA booked for tomorrow
What are the regulations for giving consent for a procedure?
- Under 18 generally considered to lack capacity to make binding contracts, should not be made liable for veterinary or associated fees
- Under 16 should not be asked to sign consent form
- Where person seeking veterinary services is 16/17, vet should depending on extent of treatment, costs, welfare of animal, consider whether consent should be sought from parent or guardian before work is undertake
Explain what is meant by informed consent
- Can only be given by client who has had the opportunity to consider the options for treatment, and had the significance and risks explained to them
- Includes discussion of cost
- Must be notified if procedure if procedure may be carried out by a veterinary student, listed veterinary nurse or other member of support staff
What are the regulations regarding veterinary nurses and the induction of anaesthesia?
- Can administer medication under vet’s direction
- In induction, only permitted where is by a set dose prescribed by vet, rather than dosing to effect as this requires a decision to be made while inducing the anaesthesia
- VNs may undertake Schedule 3 procedures, depending on vet’s assessment of competency, risks and difficulty of the procedure
Describe what can be felt in the bovine gravid uterus at 4-6 weeks
- Embryonic vesicle grape sized
- No enlargement of horn
- “membrane slip” from ~5 weeks
- Presence of mature CL but not always on same side as pregnancy, may also be present in non-pregnant animals
- Diagnosis only possible by experienced clinicians at this stage
When can pregnancy be diagnosed on rectal palpation in the cow?
- 5 weeks if experienced
- 6 weeks as standard
- 8 weeks or less at graduation
What is “membrane slip” in cows?
- If non-pregnant horn gently pinched between thumb and forefinger, wall simply squeezes away between them
- If pregnant horn gently pinched, then chorioallantoic membrane “slips” away just before the wall
- Risk of damage to foetus and causing abortion
Describe what can be felt in the gravid uterus of a cow at 6 weeks
- First signs of uterine horn enlargement on side of pregnancy
- Embryonic vesicle grape sized
- Slight turgid/fluid feel to the uterine horn on gravid side
- Membrane slip
- Mature CL
Describe what can be felt in the gravid uterus of a cow at 8 weeks
- Obvious increase in size of pregnant horn (thickness of a cucumber)
- First signs of increase in size of non-pregnant horn
- Embryonic vesicle plum sized (7 weeks), tennis ball at 8 weeks
- Turgid/fluid feeling to uterine horns
Describe what can be felt in the gravid uterus of a cow at 10 weeks
- Obvious increase in size of pregnant horn (thickness of marrow)
- Obvious increase in size in non-pregnant horn
- Embryonic vesicle tennis ball sized
- Turgid/fluid feel to uterine horns
Describe what can be felt in the gravid uterus of a cow at 12 weeks
- Both horns grossly distended, turgid, fluid filled
- Embryonic vesicle no longer palpable due to the degree of distension
- May be possible to ballot foetus
- Placentomes palpable
- Uterus may have fallen over pelvic brim
Describe what can be felt in the gravid uterus of the cow from 14weeks to 3.5 months
- Definitive diagnosis difficult, little to feel
- Uterus over pelvic brim and difficult to reach, too heavy to draw back into pelvis
- Placentomes may be papable
- Sometimes possible to ballot foetus
Describe what additional features can be felt in the gravid uterus of the cow at 5 months
- Fremitus, middle uterine artery
- Located laterally at the level of the pelvic brim
- Artery increases in size due to supply to pelvis and has unique vibrating quality
Describe what additional feature can be felt in the gravid uterus of the cow at 6 months
- Bilateral fremitus
- Uterus begins to expand back towards and into pelvis making placentomes easier to identify
- Accurate staging of pregnancy difficult
Describe what can be felt in the gravid uterus of the cow at 7 months
- Bilateral fremitus obvious
- Uterus continues to expand back towards and into pelvis, making placentomes and foetus easier to identify
- Can be palpated to judge size
- Accurate staging of pregnancy difficult
Outline some factors that may cause problems for the diagnosis of pregnancy on palpation
- Failure to identify positive signs of pregnancy
- Delayed involution causing disparity in horn size
- Pyometra
- Mucometra
- Subsequent prenatal death
- Incorrect service date
What are the advantages of ultrasonography in the pregnancy diagnosis of cows?
- Increased accuracy of PD
- Earlier definitive diagnosis
- Identification of whether or not foetus is alive
- More accurate determination of stage of pregnancy
- Better identification of ovarian structures
- Client can see conceptus
What are the disadvantages of ultrasonography in the pregnancy diagnosis of cows?
- Expensive equipment
- Need power and suitable viewing conditions
- Increased risk of rectal damage with probe head
- Takes practice to master
What is the purpose of vaginal examination of the cow?
- Post natal check
- Check for endoemtritis
- Check for vaginal/cervical trauma
Outline the preparation for vaginal examination on the cow
- Use clean glove for every examination
- Apply lubricant to examination hand and distribute
- Grasp tail with non-examining hand, place on examination arm
- Clean vulva with paper towel
Outline the procedure for the vaginal examination on the cow
- Visually appraise vulva for signs of injury or disease
- Apply lubricant, cone fingers, tuck thumb
- Face palm laterally, introduce hand, rotate palm down just after knuckle
- Palpate wall for signs of injury
- Assess degree of dilation of external os of cervix using tip of first finger
- Scoop fluid in front of cervix
- Gently rotate hand as exit the vagina so retain any fluid in the palm of your hand
- Examine fluid in palm and glove and assess volume, colour, consistency, smell
Describe the procedure for rectal examination of the cow
- Lubricate hand, raise tail with other hand to one side, stand sideways to cow
- Wipe lubricant from hand onto anus
- Cone fingers and tuck thumb into cone
- Reach hand into anus using body weight
- Open hand once anus around wrist, feel pelvic floor with fingers
- Run forward until identify pelvic brim
- Run hand along pelvic floor/pelvic brim until identify cervix
- Grasp cervix, move to midline of pelvis
- Move forward to body of uterus then to individual horn
- Use index finger and thumb to palpate forward entire length of horn,first over ventral curve then laterally to its tip
- Assess dimensions and quality
- Find ovary, fallopian tube normally difficult to palpate, may need to flip ovary out of bursa
- Assess structures on ovary
- Reverse to cervix
- Repeat on opposite side, may need to turn hand over or flick end of horn forward to reach end
Describe how to conduct a basic ultrasonic examination of the reproductive tract of the cow
- Commoly from 28 days
- Use real time B-mode with linear array transuducer probe, 5-7MHz
- Perform manual palpation then tuck probe into palm of hand at centre of cone
- Turn hand through 90degrees and scan uterus in cross section
Outline the first feature that can be used to diagnose pregnancy in the cow on ultrasound
- Yolk sac
- Appears anechoic on ultrasound
- Detection of fluid anywhere in uterus may be indicative of pregnancy but there are other causes of free uterine fluid (in pregnancy, fluid contained within allantochorion)
What are the positive signs of pregnancy at rectal palpation from day 30 to day 60 in the cow?
- Membrane slip
- Amniotic vesicle
What are the positive signs of pregnancy on rectal palpation at day 75 in the cow?
- Membrane slip
- Amniotic vesicle
- Placentomes
What are the positive signs of pregnancy on rectal palpation at day 90 in the cow?
- Membrane slip
- Foetus
- Placentomes
What are the positive signs of pregnancy on rectal palpation at day 105 to 4 months in the cow?
- Foetus
- Placentomes
- Ipsilateral fremitus of middle uterine artery
What are the positive signs of pregnancy on rectal palpation at 5 months in the cow?
- Foetus
- Placentomes
- Bilateral fremitus of middle uterine artery
What are the positive signs of pregnancy on rectal palpation at 6 months in the cow?
- Placentomes
- Bilateral fremitus of middle uterine artery
What are the positive signs of pregnancy on rectal palpation at 7 months in the cow?
- Foetus
- Placentomes
- Bilateral fremitus of middle uterine artery
When can the chorion be detected on ultrasonographic examination of the cow?
After identification of the yolk sac, approx 25 days after ovulation
What can be identified using ultrasonography in the pregnant cow between 4-6 weeks?
Yolk sac with small conceptus
- Can identify embryonic heart beat confirming that pregnancy is currently viable
