Taking a history

1 Taking a history

INTRODUCTION

Allowing the client to describe the problem without interruption is the fastest way to take a complete history. Admittedly, the information usually arrives in a disorganized order with extraneous detail or no detail at all. Points made will need clarification. Using a template to collect details aids the memory of the interviewer and assimilates the points of interest in a logical order.

• Never assume the client understands the medical jargon they use.

• Never assume the past diagnosis is correct.

• Many clients describe left and right orientation as they see it, facing the animal. Ask them to point out the side of the problem or ask if it is the same side as that currently visibly affected.

Gentle persistence is required. No one likes to be made to feel stupid, so be tactful when phrasing questions. Allow enough time, but do keep control of the situation. After being encouraged to recount the events, owners sometimes repeat the same story several times at which point it would be appropriate to gently deflect them with a new line of enquiry. Elicit information if it is not volunteered but avoid leading questions which limit observations to those suggested by the examiner. Listen to all parties in the exam room, including children. It is vital to get a description of what the client saw or heard rather than their interpretation.

Example: Dog presented for seizures:

Client: ‘My dog fell down the stairs and hit its head.’

Vet: ‘Did you see that happen?’

Client: ‘No, but I heard a noise and found the dog on the floor thrashing about, hitting the wall with its limbs.’

COMPONENTS OF THE HISTORY

Signalment

The age, sex and breed of an animal. The incidence of many diseases is determined by the signalment.

Presenting complaint

The sign or group of signs which lead to the consultation and the reason for the referral. It may be a historical problem or one that is present at the time of the examination. Generally, the presenting complaint consists of the latest or most catastrophic problem to befall the animal. Chronic clinical disease may go unreported by the owner but must not be ignored by the veterinarian. Concurrent abnormalities affect clinical decisions, overall prognosis, financial outlay, as well as owner compliance.

Last normal

When the presenting complaint began. Clarify by asking if the animal was totally normal prior to that point in time.

History narrative

The description of the animal’s abilities, disabilities, general health and daily routine. Clarify the extent of the animal’s ability with specific questions:

Tags: Saunders Solutions in Veterinary Practice Small Animal Neurology

Sep 3, 2016 | Posted by admin in SMALL ANIMAL | Comments Off

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