Intro VT Unit 3

Ethically, information in a patient chart is:

confidential

legal issues, research, and medical business information are all __ medical record purpose

secondary

__ prevent confusion of patient and client identites

medical records

Diagnosis, prognosis, and treatment are all __ purpose of a medical record

primary

by law, controlled drugs must be inventoried how often?

every 2 years

for which procedure is a consent form needed?

euthanasia procedures

for what procedure is a consent form needed

euthanasia procedures

to maintain confidentiality, __ is removed from records before they are used for teaching

patient markers

if you work in a "paperless" office, using an off-site service to store electronic medical records means

this service can act as a third-party agent to verify the absence of tampering

general medical records are typically owned by the:

practice and practice owner

data in a medical record must not be:

erased or scratched out

paper records are required to be stored:

in standard 8 by 10 inch folders

the two most common types of paper folder systems are:

alphabetical and numerical

a separate inventory record must be kept for each schedule __ drug

II

farm animal veterinarians keep __ immunization records on large numbers of animals

combined herd

in a __ oriented veterinary medical record, or SOVMR, recent information is kept together by subject matter

source

in a __ veterinary medical record (POVMR), information in the medical record is grouped by problem, and each problem is assigned a number and addressed separately

problem-oriented

in a SOVMR, clinical observations and progress notes are added in what way

chronologically

the major drawback of SOVMR documentation is that:

individual medical problems may be difficult to monitor

signalment is the term used for

patient identification information recorded in a medical record

the patients history does includes:

preventive medicine programs, known allergies, behavior information

WNL is an acronym for:

within normal limits

in the POVMR, the patient information, physical examination findings, and diagnostic test results are collectively known as the

database

the __ problem list serves as an index to the patients medical history

master

the __ problem list helps the clinician to list clinical signs as they become apparent without offering a specific diagnosis.

working

ongoing management of the veterinary patient is documented in __ notes

progress

the S and O in SOAP stand for __ and __

subjective, objective

the A and P in SOAP stand for __and __

assessment, plan

what form is used for recording the laboratory data collected from an animal

diagnostic flow sheet

the completed authorization form that provides the veterinary practice with legal evidence that the owner has been informed of important information and has agreed to pursue a certain action is the __ form

doctrine of informed consent

what are some logs typically kept in a veterinary office

anesthesia and surgery log, euthanasia and controlled drugs log, ultrasound and laboratory log

what log is helpful for technicians who wish to improve exposure techniques

radiologic procedures log

what categories of controlled drugs is the most addictive

schedule I

the controlled drug log must have pages that:

cannot be easily removed

what acronyms refers to a sheet that offers information on a patients management during hospitalization, including which treatments were delivered, when and by whom

MAOR

a cage card:

is used to identify the patient and the reason for hospitalization

the __ supports the advancement of research in veterinary medicine by allowing studies of national trends in various animal diseases

VMDB

ADR

aint doin right

BAR

bright alert responsive

TPR

temp, pulse, respiration

WNL

within normal limits

QAR

quiet, alert, responsive

MM

mucous membrane

NSF

nothing significant found, no significant findings

BCS

body condition score

CRT

capillary refill time

TX

treatment

SQ

subcutaneous

NPO

nothing orally

RX

prescription

PRN

as needed

R/O

rule out

DX

diagnosis

SX

surgery

IV

intravenous

IM

intramuscular

IP

intraperitoneal

ID

intradermal

TD

transdermal

IC

intracardiac

PO

by mouth

IA

intraarticular

SID

once a day

AD

right ear

EOD

every other day

BID

twice a day

AU

both ears

QID

four times a day

URI

upper respiratory infection

UTI

urinary tract infection

OS

left eye

AS

left ear

OU

both eyes

q_h

every_hour

BP

blood pressure

TID

three times a day

OD

right eye

C/S/V/D

coughing, sneezing, vomiting, diarrhea

wt

weight

kg

kilogram

EAG

express anal glands

NT

nail trim

CBC

complete blood count

ECG

electrocardiogram

OHE

ovariohysterectomy

CV

cardiovascular

GI

gastrointestinal

LN

lymph nodes

SOAP

subjective, objective, assessment, plan

in dogs and cats, the pulse rate is most often evaluated over the:

femoral artery

what body system does observation of the nose for nasal discharge often begin the examination

upper respiratory system

T/F acute moist dermatitis is also known as a "hot spot

true

T/F a thorough physical examination is often the first and most important diagnostic test performed on a patient

true

midabdominal palpation of a normal dog or cat will most likely reveal:

primarily intestines slipping between the palpaters fingers

the condition of having an uneven pupil size is called:

anisocoria

what neurologic test involves tapping the limb to see if there is a reflex of the pets stifle

patellar reflex

T/F the palpebral reflex is where you shine a light in the eye and watch for constriction of the pupil

false. its the pupillary light reflex. palpebral reflex is tapping the medical corner of the eye

a normal capillary refill time (CRT) is

1 to 2 sec

the condition of the lower eyelid rolling inward is called

entropion

what is a characterized by a yellowing of the skin and eyes

icterus

the __ system is the most technically difficult and time consuming to examine completely; therefore a complete examination of this system is usually reserved for the patient with a known or suspected disease of this system

central nervous

mucous membranes are normally __ in color and are often observed __

pink, on the gingivae over the upper canine tooth

the best way to calculate the pulse rate is to

count the number of pulses palpated for 15 sec and multiply by 4

a normal ocular examination generally includes

a white sclera

in dogs and cats, the pulse rate is most often evaluated over the

femoral artery

what are the normal TPR values for a cat

temp: 99.5-102.5
pulse: 110-220
rate: 24-48

the heart rates of small breeds of dog are generally __ those of large breeds of dog s

faster than

difficulty breathing due to stenotic (constricted) nares is most commonly seen in which kinds of dogs

brachycephalic

T/F fleas can cause alopecia in a cat

true

hyperthermia can be caused by

anxiety, neoplasia, infection, inflammation

T/F you can effectively perform a physical examination on a pet starting with different body systems each time

false. you should follow a consistent routine and in the same order each time

during digital rectal palpation of an intact male dog, the normal prostate gland can be palpated as

firm, bilobed, and not painful

the client is usually most concerned with the "chief complaint" which is

the reason the client brought the animal in for evaluation

what is characterized by a yellowing of the skin and eyes

icterus

what body parts or parameters is included in a complete integumentary examination

interdigital areas

the best way to obtain a respiration in a painting dog is

hold their mouth closed

a question about whether a dog is taking heartworm prevention is part of the dogs

medication history

T/F if you are looking for a pulse deficit you are listening to the heart with a stethoscope and feeling over the femoral pulse at the same time

true

what are the 5 peripheral lymph nodes in a dog/cat and indicate where they are located

submandibular-under jaw
prescapular-chest area
axillary-armpits
inguinal-groin area
popliteal-caudal to the stifle

T/F tapetum lucidum is another name for the ear drum

false. tympanic membrane is another name for the ear drum

cyanosis is a

bluish tint that usually indicates extremely low oxygen content in the tissue

T/F the anal sacs are located at the 10 oclock and 2 oclock position

false. 8 and 4

the normal feline heart rate ranges from __ beat/min

140 to 220

a "comedone" is a

blackhead

T/F FORLs are not painful to a cat

false. they are very painful

concerning a complete physical examination, accurate statement

measurement of the vital signs is an important part of the complete physical examination

the term grade refers to the __ of a heart murmur

loudness

T/F nuclear sclerosis is a serious ophthalmic disease in dogs

false. it is a normal change of aging pets

once a new patient is placed in an examination room, the first aspect of his or her visit usually involves the veterinary technician or veterinarian

obtaining a complete medical history and performing a physical examination

what are the normal TPR values for a dog

temp: 99.5-102.5
pulse: 60-180
rate: 10-30

T/F it is ok to leave a retained deciduous tooth alone in a pets mouth without removing it

false

the section of a patients history that addresses the severity, duration, frequency, progression, trigger situations, time of day, and character of the problem is the

history of the present illness

the signalment of the animal includes

age

concerning the veterinary techicians role in the history-taking for a patient, most accurate statement

even the best veterinarian may be unable to solve the problems of a particular patient without an accurate and complete history

T/F it is not important to obtain a pets weight at each visit

false

list the 7 components to obtaining a pets vital signs

temp, pulse, respiratory rate, mucous membranes, capillary refill time, weight, body condition score

PLR (system)

nervous system

MM (system)

cardiovascular system

trachea (system)

respiratory system

conscious proprioception (system)

nervous system

esophagus (system)

gastrointestinal system

uterus (system)

urogenital system

alopecia (system)

integumentary system

crackles (system)

respiratory system

anal gland (system)

gastrointestinal system

muscle (system)

musculoskeletal system

lump (system)

integumentary system

kidneys (system)

urogenital system

what are classic signs of a dog with allergies

licking, chronic ear infections, scratching, discoloration of the hair

when cleaning the ear, be concerned about

rupturing tympanic membrane, injury to ear canal

signs that the anal glands are full

licking at area, scooting

what to prepare for ear cleaning

cotton, bulb syringe, solution, cotton tipped swabs, hemo stat, mild soap, otoscope

what is needed for pedicure

kwik stop/styptic powder, nail clippers

how far to cut a nail

2 mm above base of matrix/quick

complications from nail trims

minor hemorrhage, deformity to nail

equipment for bathing

artificial tears/ mineral oil, cotton balls/gaze, tub

method of expression that is most effective

internal