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patient eval/medical records

Terms

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copy deck
temp decrease
hypothermia, physiological, shock
brown/muddy
tylenol toxicity (cats cant break down)
temp increase
fear, pain, infection, exercise, hot weather, circadian rhythum
edema
spongy/swollen/puffy pitting edema=pitting imprint
pale/white
anemia, blood loss, shock
what to look for povmr
o info, animal info, master problem list
bright red/hyperemic
toxins, sepsis
blue
cardiovascular problem
goal
meet standards of practice, improved medical care, improved communtication, decreased liability
pulse deficit
every beat does not have pulse
crt (clinical)
heart, vascular perfusion, cardiovascular/blood flow
yellow/jaundice
liver, blood disorder
soap
subjective, objective, assesment, plan
subjective
what o reports, hx, bar, qar, adr
skin
doughy=(6-8%) tenting/remains in position=(10-12%)
chronological order
dated entries, most recent on top, dated visits, phone convo, soap
patient evaluation
tpr
hydration
normal-75-80: dehydration-life threatening
repiration
breath per min., small animal chest, large animal nostril, feel air on hand
gray/muddy
toxins, sepsis, heart failure
master problem list
hx of problems or diagnostics, proceedure hx, vax hx
mm clinical
pink=oxygenated hemoglobin, oxygenated of tissues
site for cow/goat
facial artery
other lesions
clotting disorder, injury, toxin
pulse
pulsation blood through an artery, same as heart rate
consistency pulse
description of strength- weak/thready force/bounding
respiration/clinical
panting, tntc, excitement, fear, exercise, pulmonary disease, metabolic acidosis
respiration character
tachypnea, dyspnea, hyperdysnea (deeper), Euphnea=normal
assesment
eval of medical status, diagnosis, risk factors
cover sheet
basic info
progress notes
hospitalized stays, boarding stays, formulating follow up plans
emaciation
lost skin elasticity/will tent with normal hydration
under anesthesia
palmar/pedal, tounge/most common
plan
directions for tx, futher work up for diagnostics
other forms
anesthesia records, release forms, lab forms, health certificates
pulse (clinical)
reflects heart function, bp, peripheral blood flow
types of medical records
osha logs, drug log, financial accounting/billing
aspects of medical record
original,legal, neat, blue or black ink
plan
initial plan, diagnostics and tx
crt
1-2 seconds
mucous membranes
conjuntival,genetalia, anus
objective
measured, pe, physical findings, lab results
site for horse
sub mandibular artery, digital pulse/ distal seasmoid
hydration asses
horse/lateral neck, eyes/sunken(12%) mm-sticky or tachy
ulcers
renal failure, infections, toxins
povmr
database, id. owner and animal, signalment,history, vaccinations

Deck Info

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