Establishing a patient’s medical history (ie, anamnesis) is the crucial first step on the path to diagnosis. In veterinary medicine, this information cannot be directly obtained from patients, and pet owners must instead be relied on as the intermediary. Pet owners do not always know which details are important to share. The responsibility of identifying critical information needed to point the case in the right direction thus lies with the clinician.
Being an excellent veterinary diagnostician depends on a solid foundation in the basics. In this General Practice Skills series, we’ll tackle a different skill critical to daily practice: history-taking, making a master problem list, compiling differentials, and utilizing heuristics/patterns.
Back to Basics: History-Taking
Obtaining a thorough medical history that includes past and present concerns is as important as the physical examination. Information may be collected at multiple points starting before examination and throughout case management. It is important to remember that the owner is the expert on their own pet—behavior normal for some pets may not be normal for others. When details are key but consultation times are limited, learning how to efficiently elicit the right details will bring your history-taking skills to the next level and streamline the diagnostic process.
Below, explore a variety of common history questions you might ask in 4 separate cases. Select the questions that might be most important to ask for each case. Note that the correct options aren’t the only questions you should ask. These examples highlight the type of information that can help you efficiently and accurately compile a master problem list for your patient.
The Case: Seizures in a Young Portuguese Water Dog
Poncho, a 3-month-old intact male Portuguese water dog, is presented for lethargy, anorexia, and onset of seizures.
Explore the history-taking questions that were crucial to solving this case: Seizures in a Young Portuguese Water Dog
The Case: Chronic Dermatitis in a German Shorthaired Pointer
A 48.5-lb (22-kg), 6-year-old spayed German shorthaired pointer adopted from a shelter 1 year prior is presented for chronic dermatitis.
Explore the history-taking questions that were crucial to solving this case: Chronic Dermatitis in a German Shorthaired Pointer
The Case: Splenic Masses
An 8-year-old neutered male German shepherd dog is presented for lethargy.
Explore the history-taking questions that were crucial to solving this case: The Case: Splenic Mass(es)
The Case: Intermittent Vomiting & Diarrhea in a Dog
Millie, a 5-year-old 55-lb (25-kg) spayed Labrador retriever, is presented for a 3-week history of intermittent vomiting and diarrhea.
Explore the history-taking questions that were crucial to solving this case: Whipworm in a Dog: Could It Be More?
Up Next: Making a Master Problem List
Up next in our General Practice Skills series, we’ll discuss the ins and outs of making a master problem list. Stay tuned!