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Veterinary Nursing

Acquiring a History

QuestionAnswer
Components of Medical History Chief complaint, History of the chief complaint, Signalment, Environmental, Medications, Diet, General Management, Preventative Medicine, Behavioral, Household history, Allergies, reproductive History, Prior Medical, Problems and/or Surgery
Signalment Age, Species/Breed (dominant breed, mix), Sex Reproductive status (S/N), pregnant, lactating, used for breeding, etc Provides very important clues, as to what may be amiss
Chief complaint Detailed description of problem How long? How bad? Getting worse? How often? What sets it off? Anything make it better? When?
Environmental History Indoor or outdoor, or both, Profession? (show dog, guide dog), roams or confined, Travel history!!!!!, Exercise? Where? Lifestyle
Medication History Name of the medication, Dose, When and how often, Owners perception of: Does it help, Doesn’t help, Has side effect? Vitamins, supplements, homeopathic medications – Aspirin, ibuprofen, Tylenol
Additional possible medications Ear ointment, Eye drops or ointments Skin ointment or sprays Medicated shampoo Heart worm preventatives Flea treatments/preventatives
Dietary History What does the pet eat, How much, When, How long on diet, Why the change Treats: What kind, How much How often, Things to chew on/toys
Should you ask leading questions? No, ask open-ended questions. An unstructured question in which possible answers are not suggested
Systematic Questions always ask about C Coughing S Sneezing V Vomiting D Diarrhea PU/Pd Polyuria/Polydipsia (Increased thirst?) Recent weight change
General Questions Vaccination history, What, when, expiration date or when due, Heartworm preventative, Flea and tick prevention Prior Health Conditions
Closing As you wrap up... Ask if there is anything besides presenting complaints that they wish to discuss with DVM Re-acknowledge owner/pet Assure that DVM will be in shortly (or accurate time)
abdominal pinging “auscultation and percussion” or “pinging” of the abdomen. A pinging noise is heard when there is a gas-filled organ up against the body wall, such as a displaced abomasum.
alopecia the partial or complete absence of hair from areas of the body where it normally grows; baldness
aortic stenosis one of the most common and most serious valve disease problems. It is a narrowing of the aortic valve opening. It restricts the blood flow from the left ventricle to the aorta and may also affect the pressure in the left atrium.
ataxia a neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormality and abnormalities in eye movements.
barbering refers to the abnormal grooming behavior of an animal chewing and tearing the fur and whiskers of either itself or another animal. known to occur in most companion rodent species: guinea pigs, rats, and mice. Results in alopecia in affected areas.
body condition score a number assigned to your pet based on evaluation of fat at a few key locations on their body.
borborygmus a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.
colitis chronic digestive disease characterized by inflammation of the inner lining of the colon.
excoriation disorder is defined as "repetitive and compulsive picking of skin which results in tissue damage". Its most official name had been "dermatillomania" for some time.
fever is a body temperature that is higher than normal
glycosuria a condition characterized by an excess of sugar in the urine, typically associated with diabetes or kidney disease.
halitosis technical term for bad breath.
hyperthermia the condition of having a body temperature greatly above normal.
hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature.
hypovolemia decreased volume of circulating blood in the body.
icterus technical term for jaundice.
mentation animal's level of consciousness can be assessed: it may be alert, obtunded, stuporous, semicomatose, comatose. The animal's quality of consciousness may be appropriate or inappropriate, showing compulsion or dementia
nares the nostrils.
patent ductus arteriosus is a persistent opening between the two major blood vessels leading from the heart. The opening, called the ductus arteriosus, is a normal part of a baby's circulatory system before birth that usually closes shortly after birth
perineal hernia a hernia involving the perineum (pelvic floor). may contain fluid, fat, part of the intestine, rectum, or bladder. often appears as a sudden swelling to one side (sometimes both sides) of the anus.
petechiation the state of being covered with petechiae spotty petechiation of the intestinal mucosa. a small red or purple spot caused by bleeding into the skin.
pleural effusion “water on the lungs,” the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.
pneumothorax is a collapsed lung. occurs when air leaks into the space between your lung and chest wall. This air pushes on the outside of your lung and makes it collapse.
polydipsia abnormally great thirst as a symptom of disease (such as diabetes) or psychological disturbance.
pruritic itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch. It is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases
pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe.
pulse deficit This describes the situation in which there are fewer pulses felt in an artery (like the femoral artery in the rear leg) than are heard through a stethoscope.
pulse pressure Pulse pressure is the difference between systolic and diastolic blood pressure.
pyometra is an infection of the uterus that may occur in dogs and cats making the pet very ill. The uterus is generally filled with pus. Although the disease has been recognized for decades, the true disease process has still not been completely understood.
renomegaly is a condition in which one or both kidneys are abnormally large, confirmed by abdominal palpation, ultrasounds, or X-rays. The cat's respiratory, nervous, hormonal, urinary and digestive systems are all affected by this condition.
shock is the state of not enough blood flow to the tissues of the body as a result of problems with the circulatory system. Initial symptoms may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst.
signalment name, species, breed, age & DOB, sex & reproductive status
stertor is a respiratory sound characterized by heavy snoring or gasping.
stridor is a high-pitched, wheezing sound caused by disrupted airflow. may also be called musical breathing or extrathoracic airway obstruction. Airflow is usually disrupted by a blockage in the larynx (voice box) or trachea (windpipe).
Technician Note Using a consistent, organized system for obtaining historical information about each and every patient is important to ensure that nothing is overlooked.
Technician Note Explain your position and role to clients and tailoring your questions to their level of understanding will allow you to gain the client's trust and obtain more detailed information.
Technician Note The major focus of any medical history is the presenting complaint; however it is equally important to obtain general background information.
Created by: Raevyn1