History and Physical Exam Flashcards

A set of vocabulary flashcards covering the role of the veterinary technician and the essential components of obtaining a patient medical history.

Role of the Veterinary Technician

Responsibilities include freeing up the veterinarian to do other work, obtaining complete and accurate information, and gaining the trust of the client.

Patient History Methods

Includes introducing yourself, developing rapport, knowing the names of the client and pet, and asking questions in an effective manner.

Questioning Etiquette

Avoiding complex medical terminology without belittling the client, asking open-ended questions, and remaining non-judgmental of pet care.

Medical Documentation

Utilizing standardized history forms as part of the permanent medical record, writing legibly or typing, and using appropriate medical terminology.

Signalment

A listing of important identifying information including age, breed (or dominant breed if mixed), sex, reproductive status, and color.

General Management Background

Identifying how long the pet has been owned, where/when it was obtained, previous medical problems, and the pet’s normal routine.

Diet History

Information regarding the type of food eaten, amount, frequency, recent diet changes, or if the animal ingested something unusual before illness.

Preventative Medicine

Records concerning vaccination history, heartworm prevention, and flea and tick prevention.

Behavioral Information

Ascertaining the pet's normal behavior and noting any changes in behavior relative to the current illness.

Household Information

Information about the health status of other pets and any transmittable or infectious illnesses among humans in the family.

Allergy History

Notes on known allergies, adverse reactions to medications or food, blood transfusion history, blood type, and poor anesthetic recovery.

Reproductive History

The record of when a patient was neutered or spayed, prior reproductive history, and the last known heat cycle for intact females.

Presenting Complaint

The most important information addressed in the medical history; the reason the owner brought the animal into the clinic.

Last Normal

A technique to help the client recall a time when the pet was acting normally to construct a chronological timeline and find a diagnosis.

Progression

Determining the order and duration of problems and ascertaining if they are getting better, worse, or staying the same.

Systems Review

A series of questions covering basic body systems, including appetite, energy level, weight changes, and the presence of V/D/C/S or PU/PD.

V/D/C/S

Acronym used during systems review for Vomiting, Diarrhea, Coughing, and Sneezing.

PU/PD

Acronym used during systems review for Polyuria (excessive urination) and Polydipsia (excessive thirst).

Current Medications

Documentation of the type, dose, frequency, duration, and reason for all medications, including vitamins, supplements, topicals, and shampoos.

WNL

Within Normal Limits

NDW

Not Doing Well

BAR

Bright Alert Responsive

Pulse Deficit

Femoral and Heart beats are not synchronous

Purulent

PUSSY

NSR

Normal Sinus Rhythm

Deep Pain Test

Pinch toes with hemostat (pull back, have deep pain)

Borborygmus

Gut motility sounds

Main Lymph Nodes On A Horse

Carotid and Submandibular lymph nodes