What is a History and Why is it Important?

  

Photo taken by Dr. Haus

History

The history is the second step of assessing a patient where you are gathering the owner's/patient's medical concerns, medical history, and any other pertinent information about the patient.  A signalment consists of the patient's... 

 

Presenting Complaint (why they are here today)

Medical History

Description of last time patient was normal (if applicable)

 

Description of  the signs of illness

 

Changes and concerns

 

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History Examples:

Rosa is presenting today because her owners feel she is acting more tired than usual.  Rosa had her last menstrual cycle a few weeks ago.  Over the past few days, Rosa has been more lethargic, is not eating very well, is drinking and urinating more than usual, and seems to be licking at her vulvar region excessively.  Rosa vomited bile twice last night.  Today Rosa can barely get up and is looking very ill.  Rosa’s owner also thinks she has been gaining weight because her belly looks bigger.​

Rosa has a dog sister named Ruth and a cat brother named Randy.  No other animals are showing any signs of illness.  Rosa has never had puppies.​

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Marty the mule was born to his horse mother Madeline one day ago.  Marty’s father is a donkey named Mark.  Marty’s birth was completely normal without any complications for mother or baby.  Marty was up and nursing within two hours of delivery and did not show any signs of illness or abnormalities.  Tonight, Marty is acting lethargic, is unwilling to nurse, and has started to breathe heavily.​

Madeline birthed a healthy foal four years ago and a healthy mule by a different jack two years ago.

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Why is the history important?

A patient's history gives us the background information to start narrowing down the list of potential causes of the patient's disease.  This history helps to give us the necessary information to start to piece together the puzzle of what is ailing the patient and how to work up the patient's case.

*Aside, clinical signs is the technical way to refer to a symptom in an animal because animals cannot self-report their ailments.  Symptoms need to be self-reported and expressed by the patient to another person.  

 

We interpret and describe an animal's behavior, thus they are not self-reporting how they feel.  Any animal (or human who cannot express themselves) have clinical signs and not symptoms by definition.