History Taking PDF

General Principles of Veterinary Medicine VMed 101 Nneka Mailee de los Reyes, DVM VMed 101 - General Principles of Veterinary Medicine Course Description Principles of diagnosis and treatment Course Outcomes CO1: Identify the clinical manifestations of animal diseases. CO2: Distinguish the basic...

General Principles of Veterinary Medicine VMed 101 Nneka Mailee de los Reyes, DVM VMed 101 - General Principles of Veterinary Medicine Course Description Principles of diagnosis and treatment Course Outcomes CO1: Identify the clinical manifestations of animal diseases. CO2: Distinguish the basic diagnostic procedures used in animals CO3: Describe the different methods of therapy used in animals  Course Information 1. Course Code VMED 101 2. Course Title General Principles of Veterinary Medicine 3. Pre-requisite VMIC 102 (Veterinary Bacteriology and Mycology) VPAT 102 (Veterinary Systemic Pathology) 4. Co-requisite None 5. Credit 2 units 6. Semester Offered First 7. Number of hours 2 hours lecture per week 8. Course Description Principles of diagnosis and treatment. Course Assessment and Evaluation 40% Term exams + 35% Quizzes + 25% Assignments = 100  Announced Not graded 100 points CHEATING The Clinical Examination Veterinary Clinical Examination Knowledge on: Skills: Anatomy Clinical Examination Physiology Clinical Sign Pathology Pathogenesis of the Disease Animal behavior What to do first? History taking One of the most crucial aspects in diagnosing our patient animals -- should be taken from the owners. By far the most important diagnostic tool that veterinarians possess is their ability to obtain a complete history and perform a thorough physical examination -- clues Prevents unnecessary diagnostic testing and needless cost to the owners  General History Objective Data Subjective Data Signalment description of the Primary Environment Complaint Diet historical overview of the Medical History patient's general health. Objective Data Signalment  Environment Where the pet is kept Free roaming or confined to a yard or house. Geographic origin of the pet and any record of recent travels Water source Exposure to toxins (antifreeze, pesticides, or insecticides) Exposure to houseplants or outdoor vegetation. *if the patient's clinical presentation is indicative of intoxication. * access to potential ingested foreign bodies.  Dietary History Appetite and noticeable weight gain or loss Type of diet (e.g., dry, moist, semimoist, or table food) Brand name of food Type of snacks Method of feeding (i.e., free-choice or individual meals) Amount Preventive Health Care Status Prior Medical History Subjective Data Primary Complaint History oriented by Body Systems Eyes Head, Neck, Ears, Nose, and Oral Cavity Cardiopulmonary System Digestive System Urinary System Genital System Integumentary System Musculoskeletal System Nervous System 5 Core Skills (History taking) 1) Open and close-ended questioning 2) Reflective listening – paraphrase parts 3) Pausing 4) Positive nonverbal communication 5) Empathy History taking steps: 1) Start with open-ended questions, then slowly transition to more specific, close-ended questions 2) Identify the chief complaint History taking steps: 3.) Develop the chief complaint through further open- and closed-ended questioning Onset, duration, frequency, severity, location Progression or improvement Factors that increase or decrease Cx signs Any attempted treatment & associated outcomes History taking steps: 4. Obtain a body systems review Encourage the owner to fully describe any abnormalities related to body systems Ex. Vomiting, urinary incontinence, diarrhea, etc. History taking steps: 5. Perform a general overview to identify any risk factors Patient’s lifestyle Humans associated Patient’s environment Vaccination and parasite preventive history Concurrent or previous illnesses, medications administered, or other interventions History taking steps: 6. At the end of the interview, ask the owner to express any other concerns about the patient A complete Physical examination should follow Physical Examination