Step-by-Step Guide to Taking Better Patient Histories

The importance of the pet owner interview as a diagnostic tool should not be overlooked. In a human medicine study, the top differential diagnosis generated by internists after only taking the history matched the eventual diagnosis in 76% of cases.¹ The quality of information gained from the interview can be enhanced through several communication techniques.^2-4

Obtaining an effective history requires 5 core skills:

• Open- and closed-ended questioning. Start with open-ended questions to obtain details on the presenting complaint in the owner’s own words, then progress to more focused closed-ended questions to clarify details (eg, duration, frequency [see Table below]). 

• Reflective listening. Paraphrase parts of the owner’s story while allowing the owner to add further information, clarify points, and correct misconceptions. Reflective listening confirms the veterinarian’s desire to understand what the owner is saying. Reflective listening can also provide opportunities for the veterinarian to voice his or her interpretation of the owner’s feelings.

• Pausing. Avoid interrupting the owner’s story.

• Positive nonverbal communication. Use gestures such as eye contact, head nodding, and open body posture to encourage the owner to tell his or her story.

• Empathy. Use empathic statements (eg, “It sounds like you did all that you could for Leo.”) to build trust and rapport and show the owner that he or she is being understood and heard. Empathic statements can help obtain better diagnostic information and encourage adherence to treatment, resulting in a more positive outcome. 

Good organizational skills are essential to ensuring the patient’s history is obtained clearly and efficiently. Use of an interview template can ensure no questions are missed and facilitate capturing the information in the medical record (See Medical Record Form).

Step-by-Step: History-Taking

WHAT YOU WILL NEED

• Owner interview template (See Medical Record Form)

• Patient medical records

Step 1

Begin the interview by asking  the owner open-ended questions. Encourage the owner to actively participate in the interview process. As the interview progresses, gradually transition to more specific, closed-ended questions to help elicit more detailed information (Table).^2,4

Table: Sample Open- & Closed Ended Questions

Note: Avoid questions that begin with “why” during the owner interview. Such questions may cause the owner to feel defensive or that his or her actions need to be justified.³

By starting with open-ended questions, the veterinarian is more likely to learn the range of owner concerns at the beginning of the consultation. This information can be helpful in setting the agenda  for the current visit and can help ensure that the owner does not wait to disclose a major concern or problem until the end of the visit.⁵

Step 2

Identify the chief complaint (ie, the reason the owner is presenting the patient to the clinic) by asking open-ended questions.

Step 3

Develop the chief complaint through further open- and closed-ended questioning to encourage the owner to elaborate on the initial details. Questions should inquire about:

• Onset, duration, frequency, severity, and location of the problem. Because specific dates can be difficult to remember, owners can be encouraged to remember landmark events (eg, holidays).  

• Progression or improvement of the problem 

• Factors that increase or decrease clinical signs

• Any attempted treatment (eg, over-the-counter or prescription medications, supplements, other nonfood items) and associated outcomes

Step 4

Obtain a body systems review to help identify localizing or nonlocalizing clinical signs, which may be related to the chief complaint or to other concerns. This review is particularly important, as clinical signs related to the primary complaint or other pathology can be documented. Check for:

• Attitude, activity, and behavior 

• Appetite and body condition 

• Water intake and urination 

• Presence of abnormalities (eg, seizures, dyspnea, vomiting, diarrhea, coughing, sneezing)

• Skin, hair coat, and mass(es)

• Discharge from the eyes, nose, vulva, and/or prepuce

• Change in gait or lameness, including weakness or collapse

• Duration of the chief complaint

Encourage the owner to fully describe any abnormalities related to body systems. For example, a description of vomiting can help distinguish episodes from regurgitation⁶; urinary accidents may be better classified as urinary incontinence, pollakiuria, polyuria, or other episodes, depending on the details⁷; and, with the appropriate details, diarrhea may be classified as originating from the small or large bowel.⁸

Step 5

Perform a general overview to identify any risk factors. Questions pertaining to the patient’s lifestyle can help identify any risk factors related to the patient, the humans associated with the patient, or the patient’s environment. Using open-ended questions can help gather complete information. For example, veterinarians who pose “telling” prompts (eg, “Tell me about Molly’s eating habits over the past few days.”) can invite the owner to give more complete answers to questions^9,10; in contrast, “what” questions (eg, “What food are you giving?”) often lead to more limited responses and the potential for under-reporting of the patient’s nutritional information.⁹ 

Check for other potential risk factors, including:

• Environment. Investigate the pet’s type of abode and home environment. In addition, ask about exposure to other animals (eg, via kennels, dog parks, recent pet acquisition, presence of sick animals in the household), which can increase infection potential. Outdoor cats have a greater chance of being exposed to trauma and/or infections. Travel outside of the local region can place a pet at risk for acquiring certain infectious diseases (eg, clinical signs of leishmaniasis may manifest up to 7 years after infection).¹¹ Also check for exposure to human drugs (oral or topical).

• Vaccination and parasite preventive history for each pet in the household. The likelihood  of acquiring transmissible diseases depends on the patient’s preventive history. Vaccination history can help the veterinarian more accurately interpret laboratory tests for certain infectious diseases.¹² 

• Concurrent or previous illnesses, medications administered, or other interventions. Awareness of a patient’s past and current diagnoses and any treatments provided can help identify potentially related issues (eg, gastric ulceration secondary to treatment with NSAIDs).

STEP 6

At the end of the owner interview, ask the owner to express any other concerns about the patient. This helps ensure that all issues have been heard and that all relevant information has been gathered. A complete physical examination should follow.¹³

Conclusion

Human medicine studies have demonstrated the importance of a thorough medical history in making accurate diagnoses. Encouraging an owner to tell his or her pet’s story increases the amount and quality of information obtained by the veterinarian during the owner interview. A detailed patient history is an important source of data in the problem-based medical approach.

Editor’s note: This article was originally published in February 2018 as “History-Taking.”