The Art of Giving a Medical History

You’re in the emergency room with your ill or injured pet.  You’re worried.  Your pet is stressed or in pain.  The staff is bombarding you with questions.  Here are some tips for keeping calm and providing targeted information that will be most useful to the medical diagnostic process, which will enable us to get started treating your pet as quickly and effectively as possible.

Step 1: The Technician

When you enter our waiting room, a veterinary technician will be called to determine whether your pet should be rushed to the treatment area or wait to see the doctor. During this triage process the tech will ask, “What is happening with your pet tonight?” Give simple, concise answers and save the detailed history for the doctor.  For example, “My cat has been open-mouth breathing for the last hour. He is not on any medications. I can’t think of anything that caused this.” Another good example is:  “We were out on a hike and my dog cut his pad on a rock. He is allergic to certain antibiotics and has a heart murmur.”  Both of these answers are perfect: short and to-the-point with relevant information about medications, allergies and chronic diseases.

Step 2: The Doctor

The doctor will ask you that same question: “What happened tonight?” Begin with the issue tonight and then elaborate. Exclude any details that are not relevant to the history. This will help the doctor focus on the most important information and get to the bottom of your pet’s illness more quickly. When you start to elaborate on the events leading up to tonight, try to tell the events in chronological order and in a concise, straightforward manner.

The doctor will ask you about medications. Be sure to list ANYTHING you give your pet: vitamins,   prescription medications, and any human medications or supplements. If possible, bring the bottles of medicine. If you can’t, be familiar with the names and milligram doses of each medication. If you have given your pet a human medicine or another pet’s prescription, let the doctor know.  Sometimes owners feel embarrassed about this, but it’s important information you need to disclose.

You will be asked about coughing, sneezing, vomiting, or diarrhea occurring recently. If your dog vomited once three years ago, it likely isn’t relevant. However, if your dog has a history of chronic vomiting or diarrhea, bring this up! It isn’t necessary to describe each event of vomiting or diarrhea in detail. You can simply say, “Fluffy has a history of intermittent vomiting and diarrhea that seems to happen any time we change her diet.”

You will be asked about past medical history or prior illnesses. This includes prior blood transfusions, chronic illnesses such as a low thyroid level, heart disease, kidney disease, cancer, gastrointestinal problems, Cushing’s disease, and any implants, such as bone plates.

If you think the doctor hasn’t asked you an important question, don’t feel shy about volunteering information!  If you don’t understand a question, ask the doctor.  If you remember information after the exam is over, let the doctor know.

Here is a good example of a conversation that allows the doctor to understand a pet cat’s medical problem most readily:

Doctor: So what brings you here tonight with Muffins?

Pet Owner: Muffins has been vomiting occasionally for the last few days and it seems worse tonight.  She’s missed a few meals and refused to eat tonight, which is not like her at all.  She has vomited about five to six times tonight and seems really weak. I was really worried, so I brought her in. I think she could have eaten some yarn in the last week.

In summary, remember to try and list the symptoms in chronological order, know your pet’s medications, and stick to the relevant details. By following these tips you’ll have a less stressful experience and we’ll have all the information we need to start helping your pet as quickly as possible.

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