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Case History versus definitive diagnosis in clinical practice: The risk of being misinformed.

Updated on August 13, 2013

History taking is important in clinical diagnosis as it helps a clinician to arrive at a tentative and possible differential diagnosis which will serve as a guide to confirmatory diagnosis. Therefore, any mistake in the history of a clinical case can pose a serious problem in diagnosis. The common mistake encountered, in Veterinary practice, is that of misinformation by a client. This is usually the case because the patients, unlike in human practice, cannot speak for itself so their owners or keepers speak on their behalf while a Veterinarian doctor has no way of confirming the history expect via his experience, training, skills, and expertise. However, the ethics of the profession is that no matter how knowledgeable a veterinarian may be, he/she should not doubt or argue with his client but should listen carefully and ask questions without disagreement. It is then left for the doctor to determine the truth from what he or she was told in line with the nature of the case and clinical signs, if any, and other laboratory test among others. Yet any mistake in the case history may make the diagnosis difficult especially if the doctor is not experienced enough to know what to do.

It is known that most of the pet owners may not always be with their pets all time so they may not really know when and how a case started but they try as much as they can to narrate what the observed. There are many instances in which there are misinformation in a case history but let us use this case as an example. A client brought a bitch (Bull mastiff) to a clinic with a case of recurrent vaginal prolapse and he wanted a hysterectomy to be done and the prolapsed vagina repaired.

The chief Surgeon suspected that the prolapse may have occurred because the eight months old bitch may have been mounted by a large stud. However, the client’s case history claimed that the bitch was not breed and no male was around and the bitch was kept indoors so it was not possible that the bitch was mounted and insisted on surgery. A hormonal test carried out revealed a hormonal imbalance and in as much as it suggested pregnancy it can as well be false pregnancy since the owner insisted on the bitch not pregnant. The chief surgeon recommended for an ultrasonography to determine if the bitch was pregnant so the surgery could be avoided. The result did not reveal any pregnancy however the bladder was so filled that it well covered the uterus.

Since the result did not reveal any pregnancy, the bitch was prepared for surgery. It was on entry into the abdominal cavity that the chief surgeon saw fetuses and stopped the procedure as it was unethical. The client was called and informed but he doubted that the bitch could not have been pregnant but he later recalled that upon his arrival in the State, in which he brought the bitch for treatment, some weeks earlier he had stopped at a friend’s house and his friend had a large male dog.

The technologist that performed the ultrasonography claimed that since the pregnancy was less than a month, it was not easy to pick it through trans-abdominal ultrasonography coupled with the filled bladder. He said, trans-rectal would have been the best option. The prolapsed vagina was repaired. This case showed why any mistake in case history may make diagnosis and treatment difficult.


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