Vett 118 case
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School
San Juan College *
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Course
118
Subject
Health Science
Date
Apr 3, 2024
Type
docx
Pages
3
Uploaded by AmbassadorQuetzalMaster1069
Page 1
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VETT 118: Medical Record Study Worksheet
Medical Notes: S: A 3-year old F/S
Labrador
is presented
for unilateral
lameness of the right hind limb. Owners have noticed this intermittently, but especially after exercise. No other concerns. O: Auscultation
with a stethoscope normal other than mild tachypnea
. Abdominal palpation
normal. O
toscopic
exam and oral exam WNL
except for missing 104
(previously extracted). Orthopedic evaluation shows muscle atrophy
and decreased ROM
in right hind limb. Abrasion
noted on dorsal
aspect of right hind metatarsals
. A: Lameness
Rule Outs: Infectious / Neoplasia
/ Trauma /
Hip
Dysplasia P:
A CBC
and chemistry panel with a T4
measurement were sent out using a sample obtained via jugular venipuncture. Small hematoma
was noted at site prior to discharge. Sedated V/D
radiograph
taken – acetabulum
shallow, less than 50% coverage of the femoral head estimated. Image sent to radiologist for review.
Will start Adequan at 4.4 mg/kg SQ
q
2 weeks, then decrease to once monthly. Hold on NSAIDs
pending bloodwork results. If these are started will have the client observe the patient for development of diarrhea and/or hematochezia
. Worksheet:
Using the Veterinary Medical Terminology text by Romich, translate the terms / abbreviations from the medical record into words that a client would understand. All abbreviations must also be translated and briefly described. Medical Record Study
Example:
BID
BID = Bis in Die
This is an abbreviation used when giving instructions for how frequently to give a medication. BID means to give the medication twice per day, and this should be spread over an equal period of time, so every 12 hours.
F/S
Unilateral
Auscultation
Tachypnea
Palpation
Medical Record Study Worksheet
VETT 118 Veterinary Medical Terminology
Page 2
of 3
O
toscopic
WNL
104
Atrophy
ROM
Abrasion
Dorsal
Metatarsals
Neoplasia
Hip
Dysplasia CBC
T4
Hematoma
V/D
Radiograph
Acetabulum
SQ
q
NSAIDs
Hematochezia
Bonus Question 1:
Discuss why the veterinarian would want to see the patient’s bloodwork results before starting the patient on an NSAID.
Bonus Question 2:
What is the difference between hematochezia and melena? Be specific. Medical Record Study Worksheet
VETT 118 Veterinary Medical Terminology
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