MED101-LESSON 1

1. Basis for patient care

2. Communication between professionals

3. Legal evidence of care of the patient

What are the purpose of Medical Records?

Basis for Patient Care

Provides documentation of history of the Px, Tx plan, and probable duration of therapy

Documentary Evidence

Clinical course of the patient - test performed an d ther result and care received

Clinical data for education and research

Valuable for the patient data are noted completely

Medical Records

A part of legal evidence including all the radiographs belong to the hospital/cliunics and therefore should not be released

Summary of Information

Regarding the consultation and/or therapy of the px may be given to other veterinarian if they are asking

Release of Medical Records

Information may only be given to a third person with a writtn concnt of the patient owner

Problem-Oriented Medical Records

What is POMR?

POMR - Problem Oriented Medical Record

Encourages the Vets to employ sound logic in the Px education, and it provoded a logical structure for displaying medical data, plans, and outcomes

TRUE

TRUE OR FALSE

Start by grouping diseases into broad categories, then list the specific conditions within each one.

DAMNIT-V

Degenerative

Anomaly

Metabolic

Neoplastic & Nutritional Inflammatory, Infectious, & Immune Mediated

Trauma & Toxicity

Vascular

Enumerate the Major categories of Disease

Data Base: Collect Information

Should contain the information necessary to allow identifications of all problems in the patient

Guaranteed Database

The contents of the database of any particular animal should be specified in advance. This is called the ____

• Chief Complaint

• Patient Profile

• History

• Review of Old Records

• PEX (Physical Examination)

• Laboratory Data

What are the components of Data Base: Collect Information?

History

The first component of database. Clinicians and students are encouraged to takecomplete history and resist temptation to substitute diagnostic tests for a thorough history.

Chronological development

Once the chief complaint is pursued in depth, noting any additional problem in ______ is essential

Physical Examination (PEX)

The second and most important component of database.

15 minutes

HoA complete PEX takes about how many minutes?

History

Each body system is examined with special attentiongiven to those body systems in which dysfunction issuspected from the history

Problem Identification

Second step in CLINICAL PROBLEM SOLVING

Problem

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

Problem

Anything that interferes with the patient’s well-being and requires management or further evaluation

TRUE

TRUE OR FALSE

All problems identified in the history need to bedocumented, since the owner’s observations may be erroneous

MPL - Master Problem List

All problems identified in the history need to bedocumented, since the owner’s observations may be erroneous

FALSE

MPL must be placed in front to serve as table of contents

TRUE or FALSE

MPL must not placed in front of the medical record because it must not serve as the table of contents that direts the care of the patient

• Symptom

• Sign

• Physologic Abnormality

• Physical Finding

• Abnormal Laboratory Findings

• Diganosis

What are the component of MPL?

Plan Formulation

Once the problems are identified and listed on MPL, initial plan is developed and implemented. It is recorded in the medical record

Initial Plan

25-28 hrs

The ____ is a critical step in patient management since it dictates medical action for the first ____

1. Diagnosis Section

2. Treatment Section

3. Client Education Section

What are the 3 Component of Plan Formulation?

Diagnosis Section

• Formulated and written for each problem

• Plan should be organized with the most important or serious problems listed first

Treatment Section

• 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 symptomatictherapy against the alterations that therapy might cause in the laboratory results or progression of signs that may be important to diagnose

Clinical Education Section

Describes the information given to clients about their animal’s problems, diagnostic tests, cost, and prognosis.

Progress Notes: Assessment

● _______ of data collected from the initial plan or

problem specific database

● Results are correlated with the history and

physical findings and compared to the list of

rule-outs for each problem

● Clinician is assessing the hypothesis stated in the

initial plan

● This should be written in the medical record

in the relationship to each problem and should

accurately interpret the result of diagnostic tests or

procedures. It should be explain the logic changes in the MPL.

Progress Notes: Follow up

● This represents actions to be taken on the results of

initial plan or daily poland

● Progress notes contain 3 sections and are written in

POMR manner that is information is grouped

according to the problem it affects

● All problem lists should be written using the SOAP

format. Either in flow chart or Problem Oriented way

• Subjective Data

• Objective Data

• Assessment of the Problem

• Plan

What does SOAP mean?

Subjective Data

History, Owner, Observations, chief complaint, and

services asked by the client

Objective Data

Physical Exam

Assessment of the Problem

Diagnosis, prognosis, and condition statements

Plan

a part of SOAP mnemonics that comprises of diagnosis, treatment, and client education

Diagnosis

Notes the next diagnostic steps and lists

possible conditions being considered

Treatment

explains the planned care and describes the treatment given, including drugs, dosages, duration, and goals

Client Education

records the information shared with the client about the condition and how to manage it

Development of Defined Data Base

What does DDB mean?

1. Minimum DB - for 6-16 weeks of age

2. Maximum DB - for 16 weeks of age to geriatic

3. Comprehensive DB - complicated referrals, extensive physicals, and when searching patients problem longer and more extensive than above

4. Problem-specific - written and used for identified problems. used to standardize the data collection by listing the diagnostic procedures to be taken.

What are the 4 types of DDB (Development of Defined Data Base)? Indicate their function/meaning.

Problem List - Definition of Problem

● Data collected by using any of the DDB are used

to formulate a problem list of animal

● Contains brief summation of the patient’s past and

present health

● May further be classified into major (life-altering)

or minor (temporary)

Development and Utilization of Plans: SOAP Progress Notes

Additional Writing Formats for Client Management

• Narrative Progress

• Discharge Summary

• Flow Charts

Alongside the diagnostic plan, treatment plan,

and client education, the following writing

formats are also established:

Narrative Progress Notes

A chronological documentation in information

Discharge Summary

When discharging

patients with complex management plans, and

Individualized Treatment Plan (ITP) is provided o the owner. This written plan aids in enhancing home care and addressing management issues.

Flow Chart

These are beneficial in any

clinical situation that requires monitoring

multiple laboratory and therapeutic parameters

over an extended period

Pain

unpleasant sensory and emotional experience linked

to actual or possible tissue injury (International

Association for the Study of Pain)

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. (Molony and Kent

1997)

Nociceptors

free nerve endings especially abundant

in the skin, cornea, anus, periosteum, joint capsule,

muscles, tendons, and meninges

1. Extreme Heat

2. Excessive Mechanical Stress

3. Chemical (serotonin, bradykinin, histamin, leukotrienes, and proteolytic enxymes)

What are the 3 types of Nociceptors?

1. Acute/Physiologic Pain

2. Chronic/Clinical Pain

3. Muskulozkeletal Pain

4. Visceral Pain

5. Neurologic Pain

6. Ischemic Pain

7. Referred Pain

Enumerate the Classification/Types of Pain

Acute/Physiologic Pain

● Results came from a minimal tissue damage that

triggers high-threshold sensory nerve fibers

● Pain is typically well-localized, short-lived, and

stimulates reflexive, physiological, and avoidance

response

● This process plays a crucial role in promoting healing

and repairing tissues

Chronic/Clinical Pain

● Results from intense or prolonged stimuli from tissue damage, extended discomfort, and abnormal sensitivity.__________ has no protective value

● 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 response. ______________ can localized or referred

● In most cases, _____________ is caused by tissue damage resulting in chronic inflammation or form peripheral or central nerve injury called neuropathic pain. Some disease cause pain through both mechanisms

Musculoskeletal Pain

● Joint surfaces and periosteum contain abundant

nociceptors, and focal stimulation may cause intense

pain or a waxing and waning pain. Injuries to the

joint capsule, ligaments, and synovium are very

painful

● Degenerative joint disease may episodically painful depending on concurrent inflammatory or mechanical conditions. Lameness is the primary consequence

Visceral Pain

● It has lower density of nociceptors and

more widespread tissue involvement is necessary to

elicit pain. Stimuli include ischemia, distention of

hollow viscus, chemical damage to visceral surfaces,

spasm of smooth muscle, and stretching of ligament

● The parietal peritoneum, pleura and pericardium can

also be sources of ________________. Th parietal surfaces

of the thoracic and abdominal cavities are supplied

by spinal nerves and contain abundant nerve

endings. Stimuli to parietal surfaces causes sharp

pain

● Disease of organs or structures that are located in

the retroperitoneal space (kidneys, ureters) can result in very intense and “stabbing pain” due to the

presence of parietal nerve fibers

Neurologic Pain

● The only nervous structure that has abundant

nociceptors is the meninges.

● Disease affecting the meninges (meningitis) are very

painful and can result in severe neck or back pain

● Compression or inflammation of spinal or peripheral

nerves can also be painful. Lesions affecting the

spinal column can be very painful. Lesions affecting

the spinal column can be very painful if the

meninges, dorsal spinal root, vertebral periosteum,

or disk annulus is affected. Typically, lesions within

the spinal cord or brain are not painful unless they

affect the meninges

Ischemic pain

● Except for the spinal cord and brain, which do not

contain nociceptors, Ischemia of the tissue is a

potent and important cause of pain due to the

production of lactic acid, bradykinin, and proteolytic

enzymes that affect chemical receptors

● Example: Muscle pain associated with early ischemic

myopathy or myositis

Referred Pain

● Pain that is manifested in a site considerable distance

from the primary lesion is called _____________.

● This is common in people whom associated pain

with myocardial infraction and gallbladder disease is

distant from the primary organ

● 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

Quantitating Pain

This had been attempted using various

physiologic parameters but mixed results were

obtained using this approach

Inflammation or Trauma is Resolving

Acute onset of pain followed by recovery within a short period (days or less)

Acute or Chronic Pain that Worsens

Progressive inflammation or tissue degeneration

Diagnostic Plan

It s 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

1. Spinal Column (Cervical & Back Pain)

2. Muscle

3. Joint/Long bones

4. Abdominal Cavity

5. Thoraric Cavity

6. Referred

7. Perianal

Enumerate the most common causes of pain by body region:

1. Intervertebral disk diease

2. Diskospondylitis

3. Fractures/Luxations

4. Meningitis

5. Caudal cervical spondylomyelopathy

6. Lumbosacral stenosis

Enumerate the pain that associated with Spinal Column (cervical and back pain)

1. Polymyositis

2. Ischemic Myoneuropathy

3. exertinal Rhabdomyolysis

Enumerate the pain associated with Muscle

1. Arthritis

2. Fracture

3. Osteomyelitis

4. Neoplasia

Enumerate the pain associated with Joint/Long bones

1. Acute Pancreatitis

2. Pyelonephritis

3. Real and Urinary Calculi

4. Gallbladder Disease

5. Peritonitis

6. Torsion/Volulus (Spleen, Stomach, and Intestine)

Enumerate the pain associated with Abdominal Cavity

1. To the abdomen

   1. Disk disease

   2. Diskospondylitis

   3. Meningitis

2. To the back (referred to the abdominal cavity disease)

   1. Acute Pancreatitis

   2. Pyelonephritis

   3. Renal and Ureteral Calculi

   4. Gallbladder disease

   5. Peritonitis

   6. Torsion/Volvulus (Spleen, Stomach, and Intestine)

Enumerate the pain associated with Referred Pain

1. Fractured Tail

2. Perianal Fistulas

3. Rectal Strictures/Foreign Body

4. Anal Sac Abcess/Impaction

5. Rectal Trauma

Enumerate the pain associated with Perianal Pain

History & Physical Examination

What are the 2 essential components in practicing medicine?

History

It is frequently key in determining

cause of an illness, its significance, treatment

options and even prognosis.

Physical Examination

It is the second and most

important component of the database. A skilled

veterinarian understands that no part of the examination is as important as carefully listening

to the client.

1. Routine Physical Examination

2. Emergency Physical Examination

What are the 2 types of Physical Examination?

1. Obtaining facts

2. Diet and Apetite

3. Drinking, Urination, and Defacation Patterns

4. Geographic History

5. Describe Home Environment

6. The Chronology of the Sequence of Events

7. The initial Abnorm Signs and their Progression

8. Changes in Body Weight

9. Vaccinations and Medications

10. The Animal\s Present Condition

Enumerate the Elements of History

Obtaining the Facts

● You will likely obtain the most information by

reviewing the history with the person who

spends the most time with the patient. Their

familiarity with the animal may provide

valuable insights. It is the care-giver who has

had the best opportunity to have made key

observations regarding a concern or illness, i.e.,

the “ chief concern. ”

● Sometimes the individual who has brought the

pet to the facility is not able to convey the

necessary information because of language,

handicap, or another issue. This will direct you

to attempt identification of the next most

knowledgeable source of information.

● Always verify the patient's signalment as an

easy means of beginning a conversation while

avoiding therapeutic pursuits. It is “best not to

assume anything. ”

Diet and Appetite

● Animals with normal appetites are rarely critically ill.

Changes in appetite, up or down, are easily and often

observed.

● This reality is the reason that appetite is frequently a

cause for concern and may be one of the first

observed signs of illness.

● Changes in appetite often parallel duration of illness.

When possible, determine the current diet, duration

of providing that food, and all other sources of oral

intake.

Drinking, Urination, & Defacation

● These are 3 daily activities typically observed by

owners. As such, they are common areas of concern

and frequently represent an “ owner chief

complaint. ”

● Even if an owner's chief concern appears unrelated

to water intake, urine output, stool quality, or

defecation frequency, having an understanding of the

current status of these physical traits will be of

general value and may help explain a primary

concern.

● Answers to questions about these matters may

provide the clinician with insight regarding the

care-giver's observational skills.

Geographic History

● Knowing the geographic background can provide

important information because certain diseases are

endemic to specific geographic areas.

● Clinical diagnosis can escape the clinician who fails

to understand the importance of where the pet has

traveled or lived.

Describe Home Environment

● Knowing the conditions of the animal's home is

essential.

● A dog or cat that is allowed to be unattended

outdoors might be subjected to various forms of

trauma or be exposed to one of several of nature's

maladies such as venomous snake encounters, toxic

plant ingestion, etc.

● Behavioral problems can sometimes be traced to

changes in the home environment. The addition or

loss of a person or another animal from the home

may be significant.

The Chronology of the Sequence of Events

Knowing when the animal was last normal and

then being able to trace subsequent events in

chronological order may help in understanding

a concern.

● In some cases, this may help categorize the

disorder as being either acute (occurring over

the past hours or days) or chronic (occurring

over a period of two weeks or more).

● The duration of subacute illnesses lies

somewhere in- between.

The Initial Abnormal Signs and their Progression

● This information provides the opportunity for

the clinician to perceive not only how the illness

began, but it furthers the understanding of the

disorder by providing important information for

how the illness progressed and its effects on

the animal.

● As mentioned, it may allow the clinician to

actually get a “feel” for the disease. This can be

illustrated in a dog that is examined for initially

vomiting a clear watery fluid.

● If the vomitus then progressed to being

bilecolored and if the patient then begins to

produce profuse watery brown diarrhea with or

without hematochezia, it may be interpreted as

gastritis that has progressed to involve the

proximal and distal small intestine. The

presence of bile provides evidence that the

pylorus is probably patent.

Changes in Body Weight

Acute disease rarely causes significant weight

loss. When weight loss is present in the acute

setting, it is usually reflected in dehydration

caused by water loss through vomiting and/or

diarrhea.

● Polyuria, if present, will cause dehydration to

develop quickly if the animal is not drinking. It is

possible for an animal to lose as much as 12

percent of its body weight via water lost

through vomiting and diarrhea while retaining

muscle mass.

Vaccinations & Medications

● The owner of every pet should be asked about

current, recent and previous medications given.

Knowing what vaccinations have been given,

when, and where may become valuable.

● Responses by the pet, positive or negative, to

any medications should be noted. This

information is not only important to help

diagnose the disease, but might also help with

its subsequent treatment management.

The Animals Present Condition

● After all of the above information has been

obtained, it is helpful to know if treatment(s)

has helped.

● The basic question is whether the animal is

doing better, remaining the same, or getting

worse.

Routine Physical Examination

The most important practical skill for a clinician

to develop. However, also be one of the most

challenging.

Good Physical Examination

● can detect minor abnormalities before they

become serious problems

● identify major organ dysfunction without

extensive and expensive medical tests.

• Grain Trust

• Restraint

• Awat from the Animal or Back off

• Thorough and Consistent

• Experiences Help

• Records

What does GRATER mnemonics mean?

Gain trust

Socialize yourself with the animal before

abruptly starting the examination.

Restraints

Have an assistant restrainer for a thorough

exam Best restraint is light or moderate

restraint

Away from the animal or back off

Examine the animal from a distance noting

how he or she walks, sits, breathes

Thorough and Consistent

Examine the animal from head to tail, and

be sure to check everything in between.

Develop a consistent method and use it

every time

Experiences help

The more animals you examine, the more

skilled you will become.

○ Consult a supervising veterinarian, if not

sure with the current presenting findings

Record

○ Record ALL results (both positive and

negative) of your examination.

○ Remember to sign the exam record