We do it every day with practically every patient and client. It's the foundation for a thorough medical examination. What
is it? Of course we're talking about obtaining a medical history. But that's – BORING! Right? Not so fast. Obtaining at thorough
medical history in a structured and succinct fashion is as much art as science. The ultimate goal is to get the most amount
of pertinent information in the least amount of time. By obtaining an accurate medical history, we help the doctors arrive
at a diagnosis much faster and benefit the client and patient.
Where Do We Start?
Every appointment involves a basic transaction: the client comes to us to give them a solution for a problem or provide some
benefit for their pet. In order for us to give the client and patient what they need, we must communicate with them. Sounds
really basic – and it is. But ask yourself a simple question: How many times a day does a doctor ask you something about a
case that you didn't know? It was some information that you should've asked the client while getting the medical history.
For example, a dog presents with diarrhea and you forgot to ask them what they normally feed the pet. Or an itching pet and
you forgot to find out what flea and tick preventive they used and when it was last applied.
Let's face it, these things occur every day. While we'll never be perfect, we can reduce these omissions to a minimum. This
will save us valuable time, allow our doctors to get to the work of diagnosing and treating sooner and demonstrate to our
clients the attentiveness and thoroughness of our team.
So how do we improve our ability to obtain an accurate medical history in a timely manner? The first step is to determine
what information is vital to acquire. I recommend that you have the doctors write down a list of the information they feel
is most important to them. Start with the basics:
Pet and Client's Name – sounds silly, but you need to verify this information. People get married or divorced or your doctors forget.
Date – for the record and for future reference
Chief Complaint and Duration – critical – make sure to identify the leg the pet is limping on, how long the cat has been urinating outside of the litter
box, when the last dose of medication as administered, etc.
Weight and Temperature – basic physical information that is key to a thorough physical examination
Diet – Main food fed, brand and amount and treats, including table or people foods. Also, be sure to ask about vitamins, supplements,
etc. that the client will often forget to mention.
Medications – Any and all medications administered, including heartworm and flea preventives.
Previous Medical Conditions – Has the pet had anything like this before? If so, what was the diagnosis, treatment and how did it resolve?
Vaccination and Test Status – Are they current on needed vaccines, heartworm antigen tests, Feline Leukemia Virus (FeLV) and Feline Immunodeficiency
Virus (FIV) tests, senior blood and urine tests?
Exposure to Other Pets, Travel, or Stressful Events – Ask about other household pets. Remember, most dog owners have about two dogs. Is the other pet healthy? Have they traveled
recently? Has there been any stressful event such as moving, visitors, a new pet, fireworks, etc.? Has the pet been recently
bathed or groomed?