Medical Records: Primary vs. Secondary

Medical Records: Primary vs. Secondary

• Primary Records are the official medical documentation about a patient's ongoing treatment and health status.
• SOAP Notes are an organized method for documenting a patient's condition.
  • Subjective information comes from the owner or history, such as "The dog is lethargic."
  • Objective information includes observable data and measurements, such as "Temperature 101°F, HR 120 bpm."
  • Assessment is the interpretation of the data, like "Lethargy likely due to infection."
  • Plan includes the treatment or diagnostic plan, such as "Start antibiotics, recheck in 3 days."
• Progress Notes give detailed accounts of the patient's condition changes over time, tracking improvements or deteriorations.
• The Master Problem List is a comprehensive record of all past medical problems and the conditions a patient has had.
• The Working Problem List focuses on current issues that need addressing.
• Secondary Records are supplementary or supporting documents.
• Logs record anesthesia, surgeries, and radiology details.
• Radiographs are X-rays or other imaging reports which document specific conditions.
• Discharge Summaries summarize the care provided, give follow-up instructions, and the details of medication when the patient is sent home.

Problem Lists: Master vs. Working

• The Master Problem List represents a lifetime record of an animal's medical conditions, surgeries, and treatments that does not change over time.
  • Conditions may not be relevant anymore.
  • A dog with hip dysplasia as a puppy would still have it listed even if the condition is not an issue currently.
• The Working Problem List includes active medical concerns.
  • Dynamic list that is updated regularly based on treatment needs.
  • A dog with an ongoing ear infection will have the ear infection added to the working list, but removed once it resolves.

Veterinary Technician Nursing Process

• The Veterinary Technician Nursing Process is a systematic approach to care ensuring comprehensive patient management
• Steps:
  • Assessment: Collect and evaluate the patient's medical history, clinical signs, and diagnostics.
  • Diagnosis: Forming a clinical diagnosis of the condition based on the assessment.
  • Planning: Create a treatment or management plan.
  • Implementation: Carry out the treatment plan, including medications, procedures, and monitoring.
  • Evaluation: Continuously assess patient's progress and determining if the treatment is effective or needs adjustment.

Fluid Therapy Indications

• Dehydration occurs when the body loses more fluids than it takes in, causing symptoms like dry gums or sunken eyes.
• Shock is a life-threatening condition where blood flow is reduced to vital organs, requiring immediate fluid administration to stabilize the patient
• Electrolyte Imbalance involves conditions such as low levels of potassium or sodium in the body, affecting muscle function, heart rhythm, and nerve function.

Medication Administration Techniques

• SQ (Subcutaneous): Administered under the skin, commonly used for fluids, vaccines, or medications needing slow absorption.
• IV (Intravenous): Delivered directly into the bloodstream, providing rapid action, and often for critical conditions.
• IM (Intramuscular): Injected into the muscle, with slower absorption than IV but faster than subcutaneous.
• ID (Intradermal): Given into the skin layer, typically for allergy testing.
• PO (Per Os): Oral administration of medication.
• IP (Intraperitoneal): Administered into the abdominal cavity and often used in emergency situations or with young animals.
• Tracheal: Given directly into the trachea, such as with respiratory medications.
• Intranasal: Given through the nose, and often for vaccines or respiratory treatments.

Feeding Tubes

• Esophagostomy Tube (E-tube): Placed directly into the esophagus through surgery and used for long-term feeding in animals unable to eat by mouth.
• Nasoesophageal Tube (NE-tube): A temporary feeding tube inserted through the nose into the esophagus for short-term feeding.
• Gastrostomy Tube (G-tube): Placed directly into the stomach for long-term feeding.
• Jejunostomy Tube (J-tube): Placed directly into the jejunum, and often used in with severe gastrointestinal problems.

Urine Collection Techniques

• Free Catch is a non-invasive method where urine is collected by allowing the pet to urinate naturally.
  • Not sterile and may result in contamination.
• Catheterization involves inserting a catheter into the urinary tract to collect urine.
  • More invasive but can provide a more sterile sample than free catch.
• Cystocentesis involves inserting a needle directly into the bladder to collect urine.
  • Most sterile method and is preferred for diagnostic testing.

Blood Collection Tubes & Uses

• Red Top tubes have no additive and are used for collecting serum (e.g., for chemistry panels).
• Purple Top tubes contain EDTA, an anticoagulant, used for hematology tests (e.g., complete blood counts).
• Green Top tubes contain heparin and are used for blood chemistry analysis.
• Blue Top tubes contain citrate and are used for coagulation tests (e.g., prothrombin time).

Vaccines in Veterinary Medicine

• Core Vaccines are recommended for all pets:
  • Dogs: Distemper Virus, Adenovirus, Parvovirus, Rabies.
  • Cats: Panleukopenia Virus, Herpesvirus-1, Calicivirus, Rabies.
• Non-Core Vaccines are given based on lifestyle and risk factors:
  • Dogs: Bordetella bronchiseptica, Leptospirosis, Canine Influenza Virus, Lyme Disease.
  • Cats: Feline Leukemia Virus, Feline Immunodeficiency Virus, Chlamydia felis, Bordetella bronchiseptica.

Types of Immunity and Vaccines

• Maternally Derived Antibodies are temporary immunity passed from mother to offspring through the placenta or milk.
  • These antibodies can interfere with vaccine effectiveness; puppies and kittens may need boosters.
• Types of Vaccines
  • Killed (Inactivated): Pathogen is killed, and needs an adjuvant.
    • Rabies, Leptospirosis.
  • Modified-Live (MLV): Weakened pathogen that can replicate without causing disease.
    • Distemper, Parvovirus.
  • Recombinant: Genetically engineered to stimulate immune response without using live virus.
    • Recombinant Rabies.
  • Toxoid: Made from toxins produced by bacteria.
    • Tetanus.

Conditions & Procedures

• Hypothermia: Low body temperature, can occur in a state of shock, anesthesia, or extreme cold conditions managed with warming.
• Hypoglycemia: Low blood sugar often seen in puppies, kittens, or diabetic animals.
• Treat with sugar.
• Bloat & GDV (Gastric Dilatation-Volvulus) is a life-threatening emergency in deep-chested dogs where the stomach twists.
  • Needs Immediate surgery.

Emergency & Critical Conditions

• Hemoabdomen: Blood in the abdominal cavity, often due to trauma or ruptured tumors.
• Uroabdomen: Urine in the abdominal cavity, typically from a ruptured bladder.
• Arterial Catheterization: Insertion of a catheter into an artery to monitored blood gases and pressure in critical patients.

Regulatory Bodies & Drug Classification

• DEA Drug Schedules classify substances based on their potential for abuse:
  • Schedule I: No accepted medical use.
    • Heroin.
  • Schedule II-V: Varying levels of abuse potential, Schedule II being the most tightly controlled.
    • Fentanyl, morphine.
• USDA ensures the safety of biologics, including vaccines and diagnostic tests, for animals.