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The importance of a complete clinical history

For me as a veterinarian, it is very important to know the clinical history of my patients, whether we meet at the beginning, in the middle or in the last stage of their lives. Questions such as: What does he/she eat? Does he/she have a chronic condition? Has he/she lived in other cities? What treats do you use? and How do you control fleas and ticks? These questions are routine in the form you will receive via email or answer in the reception area of ​​Pet Point when you first visit us.


I know that sometimes filling out this form can be tiresome, but for us doctors this information is gold. From this information, we can more efficiently establish a preventative medicine plan, treatments for chronic diseases, de-worming protocols and even determine which complementary tests are indispensable for diagnosing different diseases. Although medicine is not an exact science, having all the patient's information at hand (including treatments and all types of studies) will allow the veterinarian to not fall into a wormhole, repeating treatments and tests that in the past did not favor the patient's health (and also just increased costs).


Since patients in veterinary medicine are not able to express their symptoms, as clinicians we start our treatment protocols from simple to complicated (unless the patient's symptoms are acute). This means that initially with symptoms of vomiting and diarrhea, i would think about parasitosis, an abrupt change in food regimen, or the theft of some human food, rather than in more serious issues such as parvovirus, pancreatic insufficiency or some type of cancer. The patient and the evolution of their status are what will guide me at all times to make decisions in their treatment and lead me to make the decision to do more advanced complementary tests.


In other words, if a puppy comes to my office for the first round of vaccines and the owners know their clinical history and even the mother's diet, then I will decide to start the vaccination schedule that day. On the other hand, a puppy that may have the same age, but that was acquired in the market a couple of days ago and now looks healthy, would not receive the same treatment. This is because the second puppy is very likely to have been exposed to infections that could put their life at risk. For this patient, I will surely leave them under observation and with the indication that I should be notified at the smallest sign of illness and laboratory tests will be done so that treatment can be given immediately. If no symptoms present themselves, then we will start vaccines. Otherwise, we must wait until the puppy is healthy again.


Now in a more complex case, if my patient presents with a digestive condition that was treated with certain medicines without success at another clinic, it is very likely that I will decide to do complementary studies such as an ultrasound and blood tests, since there are other possible reasons for which the patient in question did not improve despite receiving first-hand treatment. This does not mean that the initial veterinarian did something wrong. In fact they just took the necessary steps for treating any patient with vomiting and diarrhea, and we in Pet point now have to continue their work. Since we have asked for the clinical history, our patients do not have to go through an already tried treatment that would be destined for failure, because another colleague had already treated the symptoms adequately, but without success.


Having all the information of my patients, even before meeting face-to-face, and having them scheduled by appointment, allows me to be more and better prepared, thus allowing me to provide them with the best possible medical assistance.

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