Arnold L Goldman, D.V.M.  
Canton, CT

Specialties: general practice

Interests: critical care, oncology, surgery
Canton Animal Hospital LLC
Canton, CT
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Get the Most From MedHelp, Think & Communicate Like a Doctor: "SOAP" it!

Feb 01, 2010 - 3 comments

Having answered numerous questions from PDOC & MedHelp users I have learned that sometimes veterinarians and pet owners speak very different languages. In some cases a loving pet owner will include so much detail, that the essence of their concern about their pet may be difficult to determine from the totality of what is written.

The good news is that there is no reason anyone can’t learn to think and communicate like a doctor. Doing so will allow you to receive faster and better responses to your questions and allow participating doctors to more easily understand what your concerns are and respond to them.

Veterinarians are trained to use the process of elimination to reach a diagnosis. The attainment of a diagnosis is the first step in the treatment process. You can’t treat something definitively, if you can’t put a name on the condition. Further, there are a limited number of diagnoses and these many “differential diagnoses” can be pared down quite quickly and easily with the logical and step wise process we are trained to use.

True we sometimes treat minor conditions empirically, i.e. without a true diagnosis; anything more serious does require at least a working diagnosis to guide one’s approach. It’s the most efficient and appropriate way to approach a problem or set of problems.

For example, the species, gender, age and neuter status immediately exclude many possible diagnoses that simply don’t apply to a given category of pet. Spayed females do not have heats.  Neutered males do not get testicular cancer. This is the way we start when we begin to think about a problem and taken together, these bits of information are termed the “signalment.” MedHelp makes this part easy because there are specific places to put the signalment information.

Next comes the “complaint” or “complaints.” Simply put, it’s what’s wrong with the pet, described concisely. Vomiting, diarrhea, not eating, itchy skin, lump, cough etc are all complaints characterized in a very few words. In “complaint” we only answer the “what” question. This is not the place to describe how long, what color, what treatments used so far and the response to them, etc. That all comes in the next step, the history.

“History” is where the complaint(s) are expounded upon in detail and the answers to the following questions are sought:

How long has the problem existed?
Is it getting better, worse or the same?
Any treatments given? If so, what was the response?
Any other pets? Are they sick?
Any other problems? Any treatments for those?
Is the problem confined to one area of the body?

…. As well as many other questions that may apply in specific situations.

The next step is the physical examination, and obviously in this setting we cannot perform one, however, you may use your powers of observation to give us information, which may help us, to help you.

If there is a lump, how big is it? Measure with a ruler in 2 or even 3 dimensions.
Is there a swelling or deformity anywhere? Is there pain with manipulation of a limb?
Does the dog or cat limp? Any obvious discharge or odor from the ears? The mouth?
And on and on…

This approach to describing disease and writing about it is called the "SOAP" method.
SOAP stands for "Subjective", Objective", "Assessment" and "Plan", and is an approach taught to veterinary students throughout their training. The "S" and the "O" apply to the above discussion and they are what we need to get to the "A" and the "P."

That in a nutshell, is the standardized approach doctors take to medical problems in pets. Its not difficult to understand nor is it a secret inside language for us alone. You can learn to look at your animal problems the same way we do and describe them to us that way as well.

We MedHelp Docs want to help you in the most efficient, clear manner possible. To the extent you can think and communicate like a doctor, it will be to your advantage. We want to help you!

Here's an example:

Dear MedHelp:
We are worried about our dog. See our case description below.

Signalment: 7 year old, spayed female Lhasa Apso

Complaint: cough

History: Coughs intermittently, but nothing comes up.

Physical exam: There is no nasal discharge and I took her temperature and it was 101.5 (normal). She eats fine and there is no other symptoms of illness.


Lhasa owner

Dear Lhasa owner:

A cough may be a sign of a bronchitis, a heart ailment or other respiratory ailment, either upper or lower respiratory tract. She should have an examination, and perhaps chest xrays or other tests as your doctor may suggest. Please follow through with your own doctor for definitive diagnosis.



We look forward to being of service to all  MedHelp participants!  Help us to help you by organizing your descriptions like a “SOAP”!

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541150 tn?1306033843
by PrettyKitty1, Feb 03, 2010
Nice! Next time any of my cats has a problem I will be more careful how I talk to the vet. It's true we tend to give too many details sometimes that do not help the doctor.  So they key is 'Be precise'. Talk about the facts and not what you feel is going on. Right? I gotta work on that :)

147426 tn?1317265632
by Quixotic1, Feb 08, 2010
This is great!  the most important part about the "S" in SOAP is that we should describe the problem in our own words - for the vets and for our own doctors.  Do not use diagnoses and big medical words unless you are absolutely sure of their meaning.  More than once I had people tell me about their child having "hives" ((which technically is a wheal (welt) with a red flare around the edge) when they actually had chicken pox, or impetigo (scabby infection) or scabies.))

Best to say "they have little blisters that pop and become sores."

Just describe the problem in your own words.  Even doctors are better off doing this type of description sometimes.

Great post!

Quix, MD

931217 tn?1283481335
by Arnold L Goldman, D.V.M.Blank, Feb 09, 2010
Thank you Quix! That is a great point, as it is not helpful to be more specific than the evidence may yet support.
Premature labeling leads to tunnel vision and perhaps blind alleys!

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