The importance of a medical history!
VETgirl loves the quote, “It is widely taught that diagnosis is revealed in the patient’s history. ”Listen to your patient; they are telling you the diagnosis.'”1
When veterinary students are taught how to take an appropriate medical history, they are often taught to include:
- Presenting complaint
- Last normal regarding the signs of illness and presenting complaint
- Past (pertinent) medical history (Previous diseases/illnesses, previous surgery, etc.)
- Medication history
- The three “T’s” (e.g., trauma, ticks, toxins)
- Systems review:
- Cardiovascular system
- Respiratory system
- Gastrointestinal system
- Nervous system
- Musculoskeletal system
- Genitourinary system
In this online veterinary continuing education blog, VETgirl wanted to highlight the “medication history” aspect of the medical history. One of the biggest mistakes we see is the veterinary team member asking the simple question, “Is your pet on any medication?”
The simple and easy answer from the owner is often, “No.”
Bluntly, owners at times are confused at the definition of medication.
- Does that include drugs prescribed for that pet only?
- Does that include over the counter (OTC) medications?
- Does that include homeopathic or nutraceutical medications?
Ultimately, as a veterinary professionals, we need to adapt with the changing times. The simple question of, “What medications is your pet on?” may no longer suffice. You may be saying…”if it ain’t broke, don’t fix it.” Unfortunately this will be a regrettable decision the first time you put a patient on a NSAID or corticosteroid where the owner didn’t disclose that their pet was already on aspirin prior to evaluation.
Maybe a better question moving forward is, “Are you giving any medication by mouth or otherwise to your pet? Prescription, over the counter, or homeopathic?”
When in doubt, better safe than sorry. Keep in mind that pet owners don’t always understand the same “lingo” that we use, and it’s important – for the pet’s sake – to make sure you are appropriately communicating to them!
1) Smith R. Thoughts for new medical students at a new medical school. British Med J. 2003;20;327:1430-1433.