Comprehensive History Flashcards
(21 cards)
1
Q
Patient Demographic Data
A
- Signalment
2
Q
Distiguishing features
A
- Coat color
- Markings
- Amputations/ visble scars
3
Q
Permanent Identificatino
A
- Tatoo
- Microchip
4
Q
Past pertinent history (PPHX) with regards to ownership
A
- How did the patient come to be owned by the client
- For how long ha the patent been owned
5
Q
Past pertinent behavioral history
A
- Does the patient have any pre-existing behavioral issues
- has the patient developed any new behavioral issue
6
Q
Past pertinent patient history with regards to medical and surgical history
A
- Has the patient been previously diagnosed with one or more medical conditions
- which conditions and how were they diagnosed
- Has the patient ever been anesthetized
- Has the patient been operated on
- Has the patient ever had any adverse reactions to medical, anesthetic, or surgival therapy
7
Q
Past pertinent reproductive history
A
- Has the patient been bred previously
- Does the client have plans to breed the patient in the future
- What (if any) experience does the client have with regards to breeding
- what (if any) problems has the client experienced when breeding this species or this patient
8
Q
Patient function and client expectations
A
- Is the patient a companion, show, or performance animal
- Is the patient a service animal or a working dog, and in what capacity
- What are the client’s expectations with regards to patient function
- Are client expectations reasonable
- Is the client familiar with the breed
- Is the client familiar with breed predispostions to disease
9
Q
Patient serological status
A
- For dogs: Heart Worm/ Lymes/ Ehclichia/ anaplasma
- For cats: Feline Leukemia/ Feline Immunodeficiency Virus
10
Q
Patient home life
A
- Is the patient indoor-only, outdoor-only, or indoo-outdoor
- Is the patient crated or does the patient have free reign
- Who does the patient live with (people, conspecifics, other species)
- Who does the patient live with (in terms of other species)
- Who is primarily responsible for patient care
11
Q
Patient actvity level
A
- What (if any) activities does the patient participate in and how often
- What (if anything) is the patient expected to do
- What (if any) problems has the client encountered with regards to exercise
12
Q
Patient travel history
A
- How often
- where
13
Q
Diet History
A
- How often is the patient fed
- what is the patient fed for meals
- what is the patient fed for snacks
- what is the patient’s body condition score
- is the patient of the apprpriate or expected wight for its size and breed
14
Q
Vaccination history
A
- What has the patient previously been vaccinated against
- what is the patient currnly vaccinated against
- has the patient ever had any vaccine-associated reactions
15
Q
Pharmacologic history
A
- Is the patient currently taking any prescription medications
- Is the patient currentlytaking over-the-counter medications, including vitamins and supplements
- Is the patient currently taking any prevetatives such as flea, tick, or heartworm medication
16
Q
Presenting complaint
A
- What is the patient’s current problem
- onset of current problem
- peracute
- acute
- chronic
- Duration of current problem
- Frequenc;y of current problem
- Are there any known inciting factors that played a role in the development of the problem
- how, if at all, has the problem evolved
17
Q
Client perspective
A
- What has the client observed
- what does the client think the problem is
- what concerns the client most and why
- what past history (if anything) contributes to the client’s perspective and/or concern
18
Q
What if I don’t have time for it all?
A
Prioritize sections based on the circumstances
19
Q
“What kind of food is he/she on?
A
- Clients tend to treat this question as a closed-ended question, reporting only 1-2 food items that their pet was currently eating 89% of the time
- Rarely (8% of the time) do clientsdisclose information about treats or human foods
- Within 75% of the veterinarian did not ask about any additional food items consumed by pet.
- Instead try “Tell me everything he/she eats throughout a day, starting first thing in the morning through to the end of the day”
20
Q
how to measure food
A
- Cups can be different to every owner
- measured cup
- coffee cup
- drinking cup
- Best option is to weigh food
21
Q
How many calories does a pet need?
A
- Consider Resting Energy Requirement (RER)
- calcualte using the patient’s Lean (Ideal) body weight
- Use 70*BW(Kg)^.75
- or 30*BW(Kg)+70
- Calculate Maintencance Energy Requirement (MER)
- Neutered dog we add 60% = RER*1.6
- Intact dog we add 80% = RER*1.8
- Puppy RER times 2-3 depending on age
- Nutered Cat RER*1.2
- Intact Cat RER*1.4
