The Patient
Unit 4: Preoperative Assessment & Management
Topic 1: History
In taking a history it is important to be thorough and to listen carefully to the owners observations. It has been observed that the history may reveal up to 70% of the useful diagnostic information in a case.
History-taking: The individual animal
Initial Data
Usually collected at reception rather than in the consultation, but will provide valuable initial information.
a) Client data: For record-keeping and accounting purposes.
b) Patient data: For animal identification and as a starting point of history:
- Animal name, number
- Species and Breed
- Colour/description
- Age
- Sex and if neutered
- Vaccination
- Current or routine medications
- Previous problems: related and unrelated
It is useful to develop a system, aimed at defining the animal's problem/problems. Be prepared to rephrase questions to ensure that you are understood.
Presenting Complaint
Get to this promptly, it is the main reason for the visit.
Establishing the time sequence of clinically relavent events is very important.
The nature of the presenting problem usually directs the type of further questioning, to gain maximum understanding of the problem.
Complete the general data on the patient:
- Diet, appetite, thirst
- Urination, defaecation
- Demeanour, Exercise tolerance
- Environmental factors
- Previous illnesses and their outcome
When history-taking is completed, summarize back to the client your understanding of the problem. You need to be sure that you are dealing with the client's concern!
Record the history
It is important to identify the salient details!
Be thorough but keep it concise!
See topic 4 for details of recording systems.
Some useful hints
Establish who is giving the history.
If not the immediate owner or custodian of the animal, the history may be incomplete.
Make an assessment of the owner's powers of observation.
Avoid confusing or intimidating owners with technical jargon.
Learn to communicate in terms they will understand. E.g.:
- trachea = windpipe
- respiration = breathing
- arrhythmia = abnormal heart beats
- ovariohysterectomy = spey, desexing
Be prepared to rephrase questions to clarify the response.
The chronology of events is particularly important. E.g.:
- "When did you first notice that"?
- "And what happened next"?
A veterinary visit is a stressful and often intimidating event for most clients: they are concerned about
- the animal's suffering
- potential expense
- unfamiliar surroundings and terms
You must gain their confidence, in order to get an accurate history, and to ensure that clients trust your clinical judgement and follow your advice.
History-taking: group problems
If animal is part of a herd or flock, you need to establish if this is an individual animal problem, or if the presenting animal represents a problem affecting other members of the group.
If it is a true group problem, data is needed on the group size, feeding and management practices, topography, pasture type and condition, stocking rates, frequency of group observation etc. For many problems, you may need to look at farm records and overall management in order to properly understand the problem. This information will also help to assess the level of management and husbandry skills of the property.
You will receive further details of this in specific species lectures.