Medical Records: Primary vs. Secondary

Medical Records: Primary vs. Secondary

• Primary records are the official medical documents detailing a patient's ongoing treatment and health.
• SOAP notes are an organized method for documenting a patient's condition.
  • Subjective information includes what the owner provides about the animal.
  • Objective information refers to measurable data.
  • Assessment is the interpretation of the data.
  • Plan refers to the prescribed treatment or diagnostic steps.
• Progress notes offer detailed accounts of a patient's condition over time, documenting any improvements or declines.
• The master problem list is a comprehensive record of all past medical issues a patient has experienced, regardless of their current status.
• The working problem list focuses on current issues requiring treatment.
• Secondary records supplement primary records and provide supporting documentation.
• Logs provide a record of anesthesia, surgeries, and radiology procedures.
• Radiographs document specific conditions using X-rays or other imaging.
• Discharge summaries recap the provided care and list follow-up instructions and medications to administer at home.

Master Problem List vs. Working Problem List

• The master problem list is a lifetime record that includes medical conditions, surgeries, and treatments.
  • It doesn't change and can include resolved or irrelevant conditions.
  • Hip dysplasia in a puppy is an example of something that stays on this list.
• The working problem list includes active medical issues.
  • It is dynamic and regularly updated based on treatment needs.
  • An ongoing ear infection would be added to the working list until it resolves.

Veterinary Technician Nursing Process

• The Veterinary Technician Nursing Process ensures comprehensive patient management.
• Steps include:
  • Assessment: Collect and evaluate the patient's medical history, clinical signs, and diagnostics.
  • Diagnosis: Form a clinical diagnosis based on the assessment.
  • Planning: Develop a plan for treatment or management.
  • Implementation: Carry out the plan, including medications, monitoring, and procedures.
  • Evaluation: Continuously assess the patient’s progress and adjust the treatment as needed.

Fluid Therapy Indications

• Dehydration happens when the body loses more fluids than it takes in, causing symptoms such as dry gums or sunken eyes.
• Shock happens when blood flow to vital organs is reduced. Immediate fluids are required.
• Electrolyte imbalance includes conditions like low potassium or sodium levels, affecting muscle function, heart rhythm, and nerve function.

Medication Administration Techniques

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

Feeding Tubes

• Esophagostomy Tube (E-tube): Placed into the esophagus for long-term feeding.
• Nasoesophageal Tube (NE-tube): Temporary tube inserted through the nose into the esophagus for short-term feeding.
• Gastrostomy Tube (G-tube): Placed into the stomach for long-term feeding.
• Jejunostomy Tube (J-tube): Placed into the jejunum, common in patients with severe gastrointestinal issues.

Urine Collection Techniques

• Free Catch: Non-invasive collection by allowing the pet to urinate naturally, which is not sterile and may lead to contamination.
• Catheterization: Insertion of a catheter into the urinary tract to collect urine. More invasive, but can provide a more sterile sample than free catch.
• Cystocentesis: Insertion of a needle directly into the bladder. It is the most sterile method, and preferred for diagnostic testing.

Blood Collection Tubes & Uses

• Red Top tubes have no additive and are used for chemistry panels.
• Purple Top tubes contain EDTA, an anticoagulant, and are used for hematology tests.
• Green Top tubes contain heparin for blood chemistry analysis.
• Blue Top tubes contain citrate, used for coagulation tests.

Vaccines in Veterinary Medicine

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

Types of Immunity and Vaccines

• Maternally Derived Antibodies: Temporary immunity passed from mother to offspring that can interfere with vaccine effectiveness.
• Types of Vaccines:
  • Killed (Inactivated): The pathogen is killed, and often requires an adjuvant (Rabies, Leptospirosis).
  • Modified-Live (MLV): Weakened pathogen replicates without causing disease (Distemper, Parvovirus).
  • Recombinant: Genetically engineered to stimulate immunity without using live virus (Recombinant Rabies).
  • Toxoid: Made from toxins produced by bacteria (Tetanus).

Common Conditions & Procedures

• Hypothermia: Low body temperature can happen in shock, anesthesia or extreme cold; treat by warming the animal.
• Hypoglycemia: Low blood sugar, often in puppies, kittens, or diabetic animals; administer sugar or glucose.
• Bloat & GDV (Gastric Dilatation-Volvulus): A life-threatening emergency in deep-chested dogs involving stomach twisting, which requires 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 caused by a ruptured bladder.
• Arterial Catheterization: Insertion of a catheter into an artery to monitor blood gases and pressure in critical patients.

Regulatory Bodies & Drug Classification

• DEA Drug Schedules classify substances based on abuse potential.
  • Schedule I has no accepted medical use (heroin).
  • Schedule II-V have varying abuse levels with Schedule II being most controlled (fentanyl, morphine).
• USDA ensures the safety of biologics for animals, like vaccines and diagnostic tests.