Case history checklist

Case history checklist

Sadly, poisoning in animals is not an uncommon occurrence. Whilst many accidental exposures may not result in significant clinical effects or signs of intoxication, some substances pose a significant hazard to pets. Deterioration can be rapid, and speedy responses are therefore crucial. Recording as complete a case history as possible is important to ensure appropriate triage, decontamination, and efficient and optimal further management. The following is a useful checklist of information often needed to help this process for a poisoning case. There may be instances where no incident has actually been observed. In these instances this list can still be helpful.

These data, and the content of this poisons guide, should help you determine your next course of action for common potential intoxications. Treat for the worst likely possible scenario. For specific advice on decontamination procedures see Decontamination.

If the initial communication was by telephone and you later see the owner/animal, it is often useful to re-confirm details taken initially. Histories have a habit of changing!

Keep your notes! Another crucial aspect of unusual or unexpected poisonings is documentation. Where poisonings or adverse reactions relating to veterinary medicines or products occur, it is important that the necessary authorities (e.g. the UK Veterinary Medicines Directorate Suspected Adverse Reaction Surveillance Scheme, www.vmd.defra.gov.uk) and the manufacturers are notified. This should happen even if you feel the reaction or instance is known about or commonplace as such reports can lead to licences, classifications, packaging or package warnings and even manufacturing processes being reassessed or investigated.

Poisons information services like VPIS will usually follow up cases that have been referred to them, particularly where unusual or novel exposures are involved, or new management techniques have been used.

The VPIS Poisons Checklist is available as a download from the VPIS website.

Information needed	Comments
The owner
Name and contact details	Get these at the start, in case you get cut off or lose contact. Calling back may be necessary.
The animal(s)
Name(s)	You may have valuable past data in patient files. Ensures you are talking about the right animal(s) in multi-animal cases/households.
Species/breed	Some poisons act differently in different species and sometimes even in different breeds. Some drugs that might be used in the management of cases could be dangerous in certain species or breeds.
Age	Age or youth can affect metabolic and other physiological processes.
Sex	Sex and also whether neutered or not could affect various physiological processes. Exposures in pregnant or lactating animals may cause poisoning in the unborn or suckling offspring.
Weight	Exact if possible; best estimate if not. This enables calculation of exposure dose per kg bodyweight, which can help determine whether in toxic range, and enables doses of drugs and antidotes to be calculated correctly.
Other medical history	Some disease states may affect responses to poisons. Current medications could interact with poison or drugs used in the treatment.
The ‘poison’
Full name	Record complete name exactly as it appears on product packaging, with ingredients if possible. Similar branding within product ranges by manufacturers can confuse. If a plant, determine common and/or Latin name (if known). Keep packaging, inserts and/or samples if available.
Manufacturer’s name	In some cases this may help gather more information about the product by telephone, internet, poisons information service, etc.
Strength/concentration of active ingredients	Vital for pharmaceutical products and pesticides.
Other composition details	Are there other formulation details, e.g. solvents, excipients? In the case of drugs, is the formulation standard or modified release?
Presentation/packaging details	For example: bottle size, pack weights, tablets, capsules, vials, ampoules, units.
Presentation during the exposure	Concentrated/diluted? Mixed with other products? Which parts of plants/fungi?
The incident
General	Detailed investigation of an incident can often exclude poisoning from a differential diagnosis listing. If no apparent exposure has been observed, ask the owners about medicines and products in the home and garden. Has the animal been outside? Has it been given any medicine or other treatments? Is there any evidence that plants have been eaten in the house or garden? Has it been scavenging in the dustbin, garage or shed? Does the owner live on or near agricultural land? Are any other animals in the house unwell or exposed?
Where?	Knowledge of where the incident occurred can help refine the diagnosis.
When? Duration?	Knowing how much time has elapsed since exposure occurred may affect management options and likelihood or magnitude of exposure.
How and why?	Accidental? Suspicious/malicious? Therapeutic error? Adverse reaction?
Route(s) of exposure	For skin exposures – has the animal groomed itself and ingested poison as well?
Quantity?	Maximum/minimum values can be helpful. How much poison has been consumed or has spilt? How much, if any, is left?
The case
Effects	What effects and/or clinical signs have occurred? Severity? How long after exposure? Are they continuing? If not, how long did they last?
Treatments/investigations	What has been done so far by owners? By you? By others? Have samples been taken? If vomiting has occurred, is there anything in the vomit, e.g. tablets, plant material?