VMED 101 — General Principles of Veterinary Medicine & POVMR

Vocabulary flashcards covering core definitions, POVMR structure, diagnostic types, and medical record formats from VMED 101 Topic 1.

Disease

The inability to perform physiological functions at normal levels even though nutrition and other environmental requirements are provided at adequate levels.

Disorder

A disturbance of function, structures, or both resulting from genetic or embryologic failure or from exogenous factors such as trauma, poison, etc.

Diagnosis

Identifying disease in the patient by its characteristic signs, symptoms, and test findings, including laboratory, imaging, and electrodiagnostic tests.

Problem-Oriented Veterinary Medical Record (POVMR)

A method of recording data about the health status of a patient in a problem-solving system that emphasizes accurate and complete medical records.

Initial Problem List

A compilation of problems identified from the patient history, clinical examination, and results of preliminary laboratory screening tests.

Master Problem List

A numbered, usually condensed list of every active or resolved problem, placed at the front of the patient's record preferably in chronological order.

IPPA

A mnemonic representing the four physical diagnosis techniques: Inspection, Palpation, Percussion, and Auscultation.

Symptomatic Diagnosis

A diagnosis based on prominent clinical signs where the site and course of the primary abnormality remain unknown (e.g., colic, coughing, lacrimation).

Tentative Diagnosis

A diagnosis used when a disease is not recognizable with certainty; it is based on currently available information and is subject to change.

Direct or Definitive Diagnosis

A diagnosis made when a disease is clearly recognized by directly observing structural lesions or pathognomonic lesions during physical examination.

Confirmatory Diagnosis

A diagnosis that denotes the actual disease condition of an animal, established through clinical, clinical-pathological, and immunological investigations.

Snapshot Diagnosis

A diagnosis declared at a glance upon the very approach to a patient, relying on clinician experience and distinct clinical signs, though prone to bias and error.

Test Therapy Diagnosis

A diagnosis determined by an animal's clinical response to a specific drug or medication (e.g., response to IV thiamin hydrochloride for polioencephalomalacia).

Exclusion Diagnosis

A method of determining a disease by systematically ruling out all other possible differential conditions.

Laboratory Diagnosis

A diagnosis determined through clinical pathology based on the examination of specimens such as stool, urine, blood, or milk.

Herd Diagnosis

A diagnosis utilized when a condition affects an entire group or herd, resulting in production loss, decreased work efficiency, weight stagnation, or death.

SOAP Format

A structured progress-note framework consisting of Subjective data, Objective data, Assessment, and Plan.

DAP Format

A condensed progress-note format consisting of Data, Assessment, and Plan.

Discharge Summary

A document prepared at the end of case management for the owner and referring veterinarian, detailing diagnosis, therapy, response, prognosis, and management advice.

Subjective Data (S)

Information in progress notes obtained from owner history and observational assessments, such as changes in mental attitude, activity, and appetite.

Objective Data (O)

Measurable and observable clinical information, including physical examination findings, normal baseline parameters, laboratory values, and diagnostic imaging results.