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Every dermatologic case should start with a complete evaluation of the patient’s history, which can often take longer to complete than the actual physical examination. The first part of this process should include a review of all previous medical records. Dermatologic patients frequently have extensive medical histories and often have been managed by multiple veterinarians/clinics, sometimes even at the same time. Obtaining and reviewing medical records prior to evaluating the patient are vital, but often overlooked. People’s memories are frequently incomplete or skewed, and records can provide firm information. For instance, owners may feel that their dog’s pruritus is not seasonal, but medical records may demonstrate that the patient has only required glucocorticoids during the spring and summer months for the previous three years. Medical records can also provide information about treatment successes and failures, disease progression, and previous clinical signs.

The next part of the history is gathering the client’s perception of the problem. Veterinarians only see patients for a short window of time at the appointment. Clients, however, are typically in the patient’s presence daily and will have a more complete picture of what the pet is experiencing. Begin gathering the client history prior to the appointment by providing a standard form that can be filled out and returned in advance (example in Figure 2.1). Review of this form and the medical record prior to the appointment maximizes the time in the clinic with the client and patient. The form can have a combination of closed questions (yes or no answer) and open questions where the client can formulate a response. Both question types can help to develop the complete history. The history should also be discussed with the client, as repetition can provide more detail and allow for clarification and confirmation of previous responses.

Given a complete history including both client and record information, a reasonable differential list can often be formed prior to evaluating the patient. However, the clinician should keep an open mind and not rush the physical exam. The following elements of a patient’s history should be considered, using information collected from a completed history form, discussion with the client, and the previous medical records.

Figure 2.1 Example of a dermatology history form for a client.