History Taking

Question 1

Why bother to take a history?

Answer 1

To help to establish a diagnosis
or at least a list of diagnostic possibilities
In medicine, approx. 70% of diagnoses can be made on history alone

• Allows a rapport to develop between owners and vets
• Vets need to ascertain what the clients are like and what their expectations are
• Treatment and diagnostic plan that suits the owners

Question 2

Describe the Calgary-Cambridge model approach to taking a consultation

Answer 2

1. Preparation
2. Initiation of consultation
3. Gathering info
4. Physical examination
5. Explanation and planning
6. Closing consultation

Question 3

Calgary-Cambridge model
1. Preparation

Answer 3

• Familiarise with previous history
• Anticipate any conflicts or difficulties relating to client or animal

Question 4

Calgary-Cambridge model
2. Initiating the consult

Answer 4

• Greet the client (and animal)
• Check their names… ‘Ben Dover’
• Introduce yourself
• Attend to client’s and animal’s physical comfort
• Demonstrate interest and concern
– i.e. try not to yawn mid-consult
• Let clients know the plan

Question 5

Calgary-Cambridge model
3. Gathering information

Answer 5

Clarify reason for presentation
Use open and closed questions
-How’s her appetite?
-How often is she being sick?
Listen to answers and try not to interrupt
Avoid jargon
-Does your dog have melaena?

• What is the perceived problem?
• Then ask more closed-targeted questions about each symptom
• Then check list of systematic questions relevant to presenting symptoms
• Then other systematic questions to uncover any other symptoms

Question 6

What kind of closed questions could u ask for eg a dog has been vomiting

Answer 6

– How long has this been going on
– How frequently
– What does it look like
– Is it related to feeding
– Is there blood present
– Are there any missing objects etc….

Question 7

What is each of these?

– Cardiology
– Orthopaedics
– Dermatology
– Endocrinology
– Oncology

Answer 7

1. coughing/difficulty breathing
2. Lameness
3. Itchy/hair loss
4. Increased thirst
5. Weight loss

Question 8

The basic history a)
(A way to remember what to ask)

Answer 8

• Age breed sex
• Vaccinated wormed
• Food in
• Food out
• Water in
• Water out
• Vomiting
• Weight loss

Question 9

The basic history b)

Answer 9

• Age breed sex
• Vaccinated wormed
• Food in
• Food out
• Water in
• Water out
• Vomiting
• Weight loss

Question 10

Calgary-Cambridge model
4. Examine the animal

Answer 10

Examin animal bro

Question 11

Calgary-Cambridge model
5. Explanation and planning

Answer 11

• Listen
• Demonstrate understanding
• Empathy and sensitivity
• Support
• Share thoughts
• Offer choices
• Negotiate acceptable plan

Question 12

Calgary-Cambridge model
6. Closing the consultation

Answer 12

• Summarise plan
• Check client agrees
• Contracts ….. “Sign on the dotted line”
• Ask if they have any questions
• Say goodbye