The medical history: Are you asking questions right?


From a client's viewpoint, timely differentiation of potentially reversible disease from irreversible disease is an important expectation related to clinical assessment of illness.

From a client's viewpoint, timely differentiation of potentially reversibledisease from irreversible disease is an important expectation related toclinical assessment of illness.

After describing their concerns to us, clients often ask, "Can youhelp him/her, Doctor?"

They are concerned about the probability of recovery of their animalsfrom illnesses with or without therapy, the nature and cost of therapy,and whether recovery is likely to be partial or incomplete. Assessment ofthe medical history usually plays a key role in formulating meaningful answersto these questions. Most would agree that obtaining a reliable medical historyis not only a "science" (i.e. asking the right questions), itis an "art" (i.e. asking the questions right).

To achieve this balance, considerable skill is required to efficientlydirect the flow of information without stifling the client's conversationor putting words in his/her mouth. In this context, considering the designof questions is often beneficial.

Requesting rather than suggesting answers

In order to minimize bias associated with preconceived ideas, the conceptof avoiding use of leading questions is important. Answers to questionsshould be requested rather than suggested since clients will sometimes respondby giving an implied answer, even if it is erroneous, in order to pleaseyou or to hide their perceived ignorance.

For example, if a question related to detection of polydipsia is phrased,"Has your dog been drinking a lot of water?", a client whose dog'swater consumption was normal might answer affirmatively because (s)he perceivesthat drinking a lot of water is normal. By providing several alternativeanswers to such questions, this problem may be minimized.

Thus, the question related to polydipsia could be phrased as, "Doyou know if the quantity of water your dog has been drinking during thepast few days has increased, decreased or remained the same compared toher water consumption two months ago (or other appropriate intervals)?"

One of the most important alternatives that should routinely be includedas a potential answer, and yet one that is frequently omitted is, "Idon't know." Why? Because if owners provide incorrect responses toquestions about which they do not have accurate information, the doctormay formulate an erroneous or even contraindicated plan of management onthe basis of misinformation. Won't you agree that it is better to have noinformation and be open-minded than to formulate erroneous conclusions basedon inaccurate information?

Incorporating alternative answers

Consider the following examples of questions incorporating alternativeanswers: "Is the volume of urine voided during micturition more, lessor the same as compared with a month ago? Do you know?" "Is thefrequency of voiding urine more, less or the same as compared with a monthago? Do you know?" Clients may be able to accurately assess the frequencyof urination of the patient, but unless the dog has been urinating in thehouse they often are unable to accurately assess the volume of urine voided.

Keep in mind that it is important to ask these questions in such a waythat the client will recognize that the alternative of not knowing the answeris acceptable.

Once a historical problem (such as vomiting) has been identified, subsequentquestions about its history may incorporate the following:

1. When was the vomiting first observed and by whom?

2. Is there any relationship between the onset of this problem (vomiting)and other problems or events: yes, no or don't you know?

3. What was the sequence (or chronological order) of the onset of thisproblem in relation to other problems? (For example, vomiting followed bypolydipsia might suggest a primary gastrointestinal disorder, while vomitingpreceded by several weeks of polydipsia and polyuria suggests a secondarygastrointestinal disorder.)

4. What has been the duration of the problem: acute, chronic or don'tyou know?

5. During the past week (or other appropriate interval) has the severityof the problem increased, decreased, remained constant, or don't you know?

6. Have you provided any form of treatment? If yes, what type of therapywas given, and who (you and/or others) gave it? Do you know if the severityof the problem improved, remained the same or increased in association withthe treatment?

Additional points

1. Strive to conduct the interview about the medical history as a conversationrather than an interrogation.

2. Try to determine if the source(s) of the information about the patient'smedical history is directly from the client being interviewed of whetherit is "second-hand" information.

3. Strive to discern the difference between observations (facts) andinterpretations of observations (inferences). We frequently interview clientswho confuse observations and interpretations when describing the illnessof their animals to us.

A classic example is the client's tendency to misinterpret the observationof tenesmus in a male cat with urethral outflow obstruction as constipation.Although either observations or interpretations may be erroneous, in myexperience misinterpretation of a correct observation is the most commonpattern of error by clients. Why is this point worthy of emphasis? Because,a misinterpreted problem is the worst of all problems. If misinterpretationsare unknowingly accepted as facts, misdiagnosis followed by misprognosisand formulation of ineffective or contraindicated therapy may result. Thisis indeed ironic since the patient may then be in a worse condition as aresult of having visited the doctor.

4. At the conclusion of the interview, summarize the important findingsfor the client to ensure that you have identified his/her concerns and placedthem in proper perspective.

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