1A: Introduction to General Principles of Veterinary Medicine

Medical records including all the results of tests and radiographs

Legal evidence of care of patient: It is belong to the hospital/clinic and therefore should not be released.

Problem Oriented Medical Record

It encourages the vets to employ sound logic in patient evaluation and it provided a logical structure for displaying medical data, plans and outcomes.

Degenerative, Anomaly, Metabolic, Neoplastic - Nutritional, Inflammatory - Infectious , Immune mediated, Trauma-toxicity and Vascular

Major categories of disease

Initial database

Data base: collect information

A database that should contain the information necessary to allow identification of all problems in the patient.

Guaranteed database

Data base: collect information

A database in which the contents of the database for any particular animal should be specified in advanced. It includes:

Chief complaint, Patient profile, History, Review of old records, PEX

and Laboratory data

History

It is the first component of database, it alerts the clinician to the presence of potential problems that need to be explored in depth of PEX

Physical examination

It is the second most important component of database. Problem is not identified in this component of database and are usually also missed when invasive, expensive diagnostic tests are performed.

Master problem list

In problem identification, what problems are numbered consecutively and dated chronologically on a separate form. It is placed in front of the medical record where it serves as a table of contents that directs the care of the patient.

Problem

It is defined as abnormality requiring medical or surgical intervention or one that interferes with the quality of life.

Master Problem List

Problems are numbered consecutively and dated chronologically on a separate form. It is placed in front of the medical record where it serves as a table of contents that directs the care of the patient

Symptoms, Sign, Physiologic abnormality, Physical findings, Abnormal laboratory test and Diagnosis

Contents of Master problem list (enumerate)

Initial plan

It is a critical step in patient management since it dictates medical action for the first 24-48 hours. It is developed and implemented when the problem are identified and listed on Master Problem List.

Diagnostic section

A component of plant formulation, it is Formulated and written for each problem. Plan should be organized with the most important or serious problems listed first.

Therapeutic section

A component of plan formulation where Therapy is coupled with the problem. It is intended to resolve or help. This provides a method to audit the logic of treatment. During formulation of initial plan , a clinician must weigh the possible benefits of symptomatic therapy against the alterations that therapy might cause in the laboratory results or progression of signs that may be important to diagnosis.

Client education section

A component of plan formulation where it Describes the information given to clients about their animal’ s problems , diagnostic tests, cost,

and prognosis

Subjective data, Objective data, Assessment of the problem and Plan

All problem lists should be written using the SOAP format. Either in flow chart or Problem Oriented way. The SOAP stands for?

Subjective data

What component of SOAP does History, Owner, Observations, chief complaint, and services asked by the client are included.

Objective data

What component of SOAP does Physical exam is included?

Assessment of the Problem

What component of SOAP does diagnosis, prognosis, and condition statements is included?

Plan

What component of SOAP does Diagnosis, Treatment and Client Education are included?

Minimum DB for Pediatrics, Minimum DB for Adults, Comprehensive DB, Problem-specific DB

Enumerate the 4 types of Development of Define Data Bases (DDB/DB)

Minimum DB for Pediatrics

DB: 6-16 weeks of age

Minimum DB for Adults

DB: 16 weeks of age

Comprehensive DB

DB: complicated referrals, extensive physicals, and when searching patient’s problem longer and more extensive than above.

Problem-specific DB

DB: Written and used for identified problems. Used to standardized the data collection by listing the diagnostic procedures to be taken

Narrative Progress Notes

A chronological documentation of information

Individualized Treatment Plan (ITP)

When discharging patients with complex management plans, it is provided to the owner. This written plan aids in enhancing home care and addressing management issues.

Flow charts

These are beneficial in any clinical situation that requires monitoring multiple laboratory and therapeutic parameters over an extended period.

Pain

An unpleasant sensory and emotional experience linked to actual or possible tissue injury.

Animal pain

"An aversive sensory and emotional experience representing awareness by the animal of damage or threat to the integrity of its tissues. Producing a change in physiology and behavior directed to reduce or avoid the damage, reduce the likelihood of recurrence, and promote recovery"

Nociceptors

Free nerve endings especially abundant in the skin, cornea, anus, periosteum, joint capsule, muscles, tendons and meninges.

Extreme heat, Excessive mechanical stress and Chemicals

Three types of nociceptors; each is characterized by responsiveness to…

Acute or Physiologic pain, Chronic or clinical pain

Enumerate the classifications of pain

Acute or Physiologic pain

Results stem from minimal tissue damage that triggers high-threshold sensory nerve fibers.

Acute or Physiologic pain

Pain is typically well-localized, short-lived, and stimulates reflexive, physiological, and avoidance responses. This process plays a crucial role in promoting healing and repairing tissues.

Chronic or Clinical Pain

Results from intense or prolonged stimuli from tissue damage, extended discomfort, and abnormal sensitivity. It has no

protective value.

Chronic or Clinical pain

It induces physiologic, metabolic, and immunologic alterations that promote illness and death. Chronic perception of noxious stimuli induces withdrawal, behavioral, autonomic nervous system, neuroendocrine, and suppresses immune system responses. It can be localized or referred.

Neuropathic pain.

In most cases, chronic pain is caused by tissue damage resulting in chronic inflammation or from peripheral or central nerve injury called _____. Some diseases cause pain through both mechanisms.

Joint surfaces and periosteum

In musculosketal pain, what part contain abundant nociceptors, and focal stimulation may cause intense pain or a waxing and waning pain.

Injuries to the joint capsule, ligaments, and synovium

In musculosketal pain, what injuries are very painful?

Degenerative joint disease

In musculosketal pain, it may episodically painful depending on concurrent inflammatory or mechanical conditions.

Lameness

Primary consequence of Degenerative joint disease?

Viscera

Contain a lower density of nociceptors and more widespread tissue

involvement is necessary to elicit pain.

Stimuli

It include ischemia, distention of hollow viscus, chemical damage to visceral surfaces, spasm of smooth muscle, and

stretching of ligaments.

Parietal peritoneum, pleura and pericardium

It can also be sources of visceral pain.

Parietal surfaces of the thoracic and abdominal cavities

Are supplied by spinal nerves and contain abundant nerve endings. Stimuli to parietal surfaces cause a sharp pain

Retroperitoneal space

Disease of organs or structures that are

located in the _____ can result in very intense and "stabbing pain" due to the presence of parietal nerve fibers

Meninges

The only nervous structure that has abundant

nociceptors

Meninges

Diseases affecting the what nervous structure are very

painful and can result in severe neck or back pain.

Brain and Spinal cord

What structure do not contain nociceptors?

Ischemia of tissue

It is a potent and important cause of pain due to the production of lactic acid, bradykinin, and proteolytic enzymes that affect chemical receptors.

Early ischemic myopathy or myositis

Good example of Ischemic pain

Referred pain

Pain that is manifested in a site considerable distance from the primary lesion is called referred pain. This is common in people whom associated pain with myocardial infarction and gallbladder disease is distant from the primary organ.

Referred pain

It is much less common in dogs and cats but can

occur with disease processes that affect viscera in

the abdominal cavity with pain then being referred

to body surfaces.

Diagnostic plan

It is based on localizing pain to a

specific anatomical site or region. Diagnostic imaging

or other selected tests are then used to further

identify potential causes.

Spinal column (cervical and back pain)

1. Intervertebral disk disease

2. Diskospondylitis

3. Fractures/luxations

4. Meningitis

5. Caudal cervical spondylomyelopathy

6. Lumbosacral stenosis

Muscle pain

1. Polymyositis

2. Ischemic myoneuropathy

3. Exertional rhabdomyolysis

Joint/long bones pain

1. Arthritis

2. Fractures

3. Osteomyelitis

4. Neoplasia

Abdominal cavity pain and Referred To the back pain

1. Acute pancreatitis

2. Pyelonephritis

3. Renal and ureteral calculi

4. Gallbladder disease

5. Peritonitis

6. Torsion/volvulus (spleen, stomach, and intestine)

Thoracic cavity pain

1. Pleuritis (numerous causes)

2. Pericarditis

Referred To the abdomen

1. Disk disease

2. Meningitis

3. Diskospondylitis

Perianal pain

1. Fractured tail

2. Perianal fistulas

3. Rectal strictures/foreign bodies

4. Anal sac abscess/impaction

5. Rectal trauma