By A. Rijnberk and F.J. van Sluijs (Eds.)
ISBN-10: 0702029688
ISBN-13: 9780702029684
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Example text
O costal Beside each component of the physical examination a number of possible findings are given. These can be checked off on the form. The following is an example from the form for the ‘General examination’. O abdominal O pendulating Supplements on the DVD In other cases, such as in the following example from the form ‘Behavior’, there is a place for the addition of a not yet specified possibility or finding. Anxiety - for sounds O thunder O fireworks O traffic noise O . . . . . .. Fig.
Curves representing variables plotted against time, such as pulse rate, temperature, respiration, or blood urea, are familiar examples of this. 7 Mucosae pale pale pink pink pink <1 <1 <1 Pulse Respiration CRT ? 4 Fig. 1 Example of notation on a progress sheet. the clinical status of the patient and prevents relevant information from being overlooked. The composition of such a ‘problem list’ will be described in more detail later in this chapter. It constitutes an essential component of the problem-oriented medical record, but it can also be valuable in the source-oriented or chronological record.
At the first examination the observations are recorded in the data base and the assessment consists * In the original design of Weed, a distinction was made between subjective and objective observations. Subjective observations are made by the patient, objective observations by the physician and nurses. In veterinary medicine one can only guess at what the patient experiences in its illness, so a comparable distinction is not applicable. 30) = 11 mmol/l A Diabetes still inadequately regulated. P d Repeat blood glucose on 29 Feb 02 t Increase insulin from 13 to 15 units.
Medical History and Physical Examination in Companion Animals by A. Rijnberk and F.J. van Sluijs (Eds.)
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