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History matters

May 16, 2021 at 4:00 a.m.
Dr. Jessica Rhodes

When your pet is sick or injured, your focus is on getting help. You make an appointment, drive to your vet's office, and are greeted by the staff. Someone asks you why your pet is being seen today, and you answer, "coughing," or "not eating," or whatever symptom you feel is the most prominent. Then, one of the most important parts of your pet's evaluation happens. Someone takes a "history." History in a veterinary setting refers not only to a description of the obvious problem, but also to aspects of the animal's health and lifestyle that help to create a list of possible causes for their illness or injury.

Let's look at an example case. Rufus is a 5-year-old, neutered male Golden Retriever mix. As Rufus' Dad checks him in with a receptionist, he is asked what Rufus is being seen for today. Dad answers, "he's coughing." The receptionist escorts Rufus and Dad to an exam room. Next, a veterinary assistant (VA) enters the room and says, "So, Rufus is coughing?" Dad nods. Now comes the history:

VA: How long has Rufus been coughing?

Dad: Oh, about three days, I guess.

VA: Has the cough gotten better or worse over the past few days?

Dad: It's been about the same the whole time.

VA: Does Rufus spit up with his cough?

Dad: Yeah, a little sometimes, but it's just clear.

VA: Has Rufus visited a boarding or grooming facility, day care, or dog park within the past two weeks?

Dad: Yes, we go to the dog park every Wednesday.

VA: Do you have Rufus' vaccine record with you?

Dad: Yes, he's a month behind on vaccines, but I take him in every year.

VA: OK, Rufus, I'm going to take your temperature now and then we'll get the Doctor in to see you.

Doctor: Hi, Rufus and Dad. My assistant tells me that Rufus has been coughing for a few days and sometimes spits up when he coughs. Is there anything else you would like for me to know?

Dad: Well, I did give him a rawhide chew the other day. You don't think he could have gotten it stuck in his throat, do you?

Doctor: We'll see if we find any signs of that on his exam.

Dad: I also just gave his heartworm prevention. One of my friends gave their dog the same medicine and he had a problem with it, too. Do you think that's it?

Doctor: Coughing isn't something I would expect to see in that situation.

Doctor: OK, I've done my exam. Rufus' heart and lungs sound normal, he's not running a fever. His color looks good and he seems well hydrated. Rufus is breathing easily and has a normal respiratory rate. With the symptoms we are seeing, my exam findings, and the history of visiting the dog park, the most likely diagnosis is "Tracheitis," which is sometimes called, "kennel cough."

We can see here how Rufus' history and exam findings together helped the Doctor determine the most likely cause of his symptoms. There were details in the history that didn't exactly lead to the answer, but they did not hinder it either.

Can you tell your vet too much history? It's true that there are parts of the history that may not pertain to the symptoms we are evaluating, but collecting extra information is better than not having enough information. Don't be shy about telling us what you've observed at home. We can ask questions to direct you toward the important stuff.

It's easy when giving your pet's history to try and draw conclusions for your vet about why your pet is sick. That's a fine line, and we understand that. It's best to stick to the facts. It's best not to assume that your pet must be sick as a result of the last thing they ate or did, or the last medication you gave, etc. It's best not to allow any online searches, message boards, or social media friends to convince you of a cause for illness. Doing so slants your perspective and makes it more difficult for you to hear and understand the objective information your veterinarian will be giving you.

A couple of tips: It is helpful for the person who knows the most about the pet to accompany them to their doctor's appointment. If that person is unable to attend, perhaps he/she might arrange to be available by phone during the appointment time.

When a pet is sick or hurt, it can be difficult to sort through the past several days or weeks of activity in the moment. It is often easier if clients jot down a few notes at home before coming. We are better able to answer all of your questions and concerns, and to collect better information about your pet.

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