Week Three: History and Physical Examination Flashcards
Who are the SBVM?
Advocate/protect public from veterinarians
Keep track of vets licenses
Discipline vets
State Board of Veterinary Medicine
What is included in a signalment?
- Age
- Breed
- Sex
- Repro. status
Congenital diseases are more likely to be diagnosed in who?
Very young patients than in very old patients
What is SOAP?
Subjective
Objective
Assessment
Plan
What is “subjective”
Information supplied by client (presenting complaint from the client and the pertinent medical history)
Include annotations of vaccination status, repro status, diet, elimination abnormalities, exercise level and any current meds
What is “objective”
Irrefutable information, actual observation, or tests performed
Results of the physical examination, lab tests, or similar “hard data” information
What is “assessment”
What the client is told the problem is
Dx is written if final diagnoses is known
What is tentative? (TDx)
If diagnosis is almost certain, but is waiting for test results
What is differential (DDx)
If there could be several diseases or conditions under consideration, the most likely choice first, the next most likely choice listed next, and so on
What is Dx Open
if the clinician has no diagnosis and needs further study or workup to complete
What is “plan”
Actions the clinician wants to take to resolve the problem or cure the disease
(“put him on steroids”, “trim nails”)
What types of questions do you ask?
Open ended rather than leading questions (let the client fill in the information themselves)
“Has he been drinking more water than usual?” is an example of what kind of question?
Close ended
What is a last normal?
The last time the animal was normal
What goes in the general management spot?
- How long has the pet been owned and from where obtained?
- Amy previous medical problems
- any recent travel
- Where is the pet kept
- diet
What is V/D
Vomitting/diarrhea
What is C/S?
Coughing/sneezing
What is PUPD?
Polyuria and polydypsia
Pyometra occurs most commonly _______ to ______ following a heat cycle
Two weeks to two months
What is pyometra?
Pus in uterus
What is TPR?
Pulse, respiration, temperature
Where is body temperature most accurately measured?
Rectally
Where else can you measure temperature besides rectally?
Axillary or aural
When is an elevated body temperature (hyperthermia) usually occurred?
The presence of infection, inflamation, or neoplasia
