History taking
Routine HealthCare Examination: Medical and surgical history
Medical and surgical history
Collecting and reviewing information on the medical and surgical history of the cat is a part of the routine healthcare examination.
Many of these issues will be obvious and will be a part of the medical record if the cat is a long-standing patient at the clinic. Nevertheless, some owners take their cat to more than one veterinary clinic, so it is important not to overlook other relevant problems the cat may have suffered.
The Cat Care for Life clinical history form can be used to make collecting a full standard history easier.
Even when an accurate history is known, it is still important to consider:
- Any current medications
- Any non-prescription medications the owner may be using (e.g., nutritional supplements, parasiticides, alternative medications, etc.)
Reviewing the history during the clinical examination is an ideal opportunity to allow the cat time to come out of the carrier and explore the room. This helps acclimatise the cat to the clinic environment and helps reduce stress during the subsequent examination.
History-taking should always include the use of open-ended questions such as:
- ‘How has Fluffy been doing since the last visit?’
- ‘Have you noticed any change in his appetite recently’, and
- ‘Has there been any change in Fluffy’s stool consistency’
- These are always better than leading questions such as:
- ‘Have you seen any diarrhoea’, or
- ‘Has he been eating more recently’
The emphasis and importance of different aspects of the history will vary according to life stages.