5.2 Obtaining Patient History

5.2 Obtaining Patient History

A thorough and accurate patient history is the first step in clinical evaluation. In veterinary clinics, the veterinary assistant is typically the first person to interact with the client. By conducting an organized interview, the assistant gathers essential subjective information that helps the veterinarian formulate diagnostic and treatment plans.

Interviewing Skills and Communication Techniques

Taking a history is more than just running through a checklist; it requires active communication, empathy, and observation.

Open-Ended vs. Closed-Ended Questions

The way you structure your questions determines the quality of the information you receive.

• Closed-Ended Questions: These are questions that can be answered with a simple "yes" or "no" or a single word. They often lead the client toward a specific answer and limit detail.
  • Example: "Is Daisy scratching her ears?"
  • Problem: The client might say "yes" without explaining how often or if she is also shaking her head.
• Open-Ended Questions: These questions require the client to provide descriptive, narrative answers. They encourage the client to explain what they are observing in their own words.
  • Example: "How would you describe Daisy's behavior with her ears over the past week?"
  • Benefit: The client might respond: "She scratches them constantly, shakes her head every few minutes, and whimpers when I touch her." This provides much more clinical detail.

Active Listening and Clarification

Active listening involves focusing entirely on the client, observing their body language, and clarifying their statements.

• Reflecting and Summarizing: Repeat what you have heard to confirm accuracy.
  • Example: "Just to make sure I have this right, you noticed the vomiting started on Tuesday night after she ate a plastic toy, and she has not been able to keep water down since. Is that correct?"
• Avoid Staring at Screens: While you must document the conversation, maintain regular eye contact and show that you are engaged in the conversation.

Non-Judgmental Communication

Clients may have different standards of pet care, financial limitations, or may have made errors in administering treatments.

• The Danger of Judgement: If a client feels judged (for example, if they admit they forgot to give their pet's insulin or are feeding low-quality food), they will withhold information or lie. This directly compromises patient care.
• How to Frame Questions Neutally:
  • Judgmental: "Are you actually giving the ear drops twice a day like you were told?"
  • Neutral: "How often are you able to administer the ear drops during the week?"

Avoiding Clinical Jargon

Clients do not have veterinary training. Using medical terminology can confuse them or make them feel uncomfortable. Use common terms when speaking with clients, and translate their answers into medical terms for the record.

• Say to client: "Is Max drinking more water than usual?" or "Have you noticed him urinating more frequently?"
• Write in record: "Owner reports polyuria and polydipsia."

Core Components of a Comprehensive Patient History

A complete history covers several specific areas of the patient's life and health.

1. Chief Complaint (CC)

The chief complaint is the primary reason the owner has brought the pet to the clinic. It is crucial to determine exactly what the owner is concerned about and focus the initial history on this issue.

• Example: "Lethargy and loss of appetite."

2. History of the Present Illness (HPI)

Once the chief complaint is identified, ask questions to characterize the symptoms:

• Duration: How long has this problem been occurring? (e.g., "for 4 days").
• Onset: Did the symptoms start suddenly (acute onset, which might suggest a toxin or injury) or gradually (chronic onset, suggesting degenerative disease)?
• Progression: Are the symptoms getting worse, staying the same, or improving?
• Frequency: How often does the symptom occur? (e.g., "vomits 3 times a day, always after drinking water").

3. Current Medications and Preventatives

Every patient history must include a detailed list of all medications the animal is currently receiving.

• Prescription Medications: Document the drug name, concentration (e.g., 50 mg/mL), dose (e.g., 0.5 mL), route (by mouth, in left ear, etc.), and frequency (every 12 hours).
• Compliance Check: Ask if the client has been able to administer the medication successfully.
• Over-the-Counter (OTC) Products: Ask about joint supplements, CBD oils, vitamins, or aspirin.
• Preventatives: Record the brand and the date of the last administration for heartworm, flea, and tick preventatives.

4. Dietary History

Nutrition is considered the "fifth vital sign." An accurate dietary history is essential for diagnosing gastrointestinal, dermatological, and metabolic conditions.

• Food Details: Record the specific brand and formula of the food (e.g., "Purina Pro Plan Sensitive Skin & Stomach Salmon").
• Amount and Frequency: Note how much is fed and how often (e.g., "1/2 cup twice daily").
• Treats and Table Scraps: Ask about everything else the pet eats. A client might say their dog eats 1 cup of kibble, but omit that they also feed the dog a hot dog every afternoon.
• Water Consumption: Note any changes in water intake.

5. Environmental and Lifestyle History

An animal's environment often holds clues to their illness.

• Indoor vs. Outdoor: Does the pet spend time outdoors unsupervised? Do they have access to woods, standing water, or farms?
• Travel History: Has the pet traveled outside their local area recently? (e.g., travel to the Midwest or South exposes pets to different diseases, like fungal infections or heartworms, that may not be common locally).
• Household Changes: Note any new pets, new babies, recent moves, or visitors, as these can cause behavioral changes or stress-induced illnesses (such as feline interstitial cystitis).

Medical Record Entry and the SOAP Format

All collected history must be entered into the patient's medical record. Veterinary clinics use the SOAP format to structure medical entries.

• S - Subjective: This section is dedicated to the patient history, chief complaint, and owner observations. It contains information that cannot be directly measured by the clinical staff.
  • Example entry: "S: Owner reports 3-day history of soft stool, brown in color, containing small amounts of red blood. Pet is eating normally but drinking slightly more water. No vomiting reported. Last flea/tick dose was 3 weeks ago."
• O - Objective: This section contains measurable, clinical data gathered by the veterinary team, including physical exam findings by the veterinarian and vital signs (TPR, weight) taken by the assistant.
• A - Assessment: The veterinarian's evaluation of the case, including diagnoses or differential diagnoses.
• P - Plan: The diagnostic tests, treatments, surgical procedures, prescriptions, and client discharge instructions.

The veterinary assistant is primarily responsible for documenting the Subjective history and parts of the Objective data (vitals).