The Importance of Case History Taking
By Eleanor Andrews & Angela Lemanis
Osteopaths or those training with AOI will regularly hear about the importance of Case History Taking, but what is its significance?
Case history taking is such an important component of your consultation. It is the first part of your osteopathic consultation sieve and will help you form differentials and direct your assessment, treatment, and management plan, highlighting any case considerations, clinical flags and/or contraindications.
Consider what types of questions you want to ask an owner to help paint a picture about the animal, and then think about why these are important.
Why might you want to ask if the animal is drinking more (or less)? Why ask if there have been any recent changes (to exercise, to routine, to environment, to tack/harnesses, etc)? Is there anything you may ask that is going to inform the way you will handle the animal, such as any sensitivities, areas the animal doesn’t like to be touched, etc.? Why is it important to know the previous medical history or if the animal is currently on any medication
The more information you can receive from the owner at this initial stage of your consultation, the easier you can generate, filter, and rank your differentials, and the better you can direct your assessment and testing to rule in and out considerations as well as highlight any emerging clinical flags or referrals required.
At this stage, you are trying to form the best picture of what may be occurring with this individual patient and whether it is safe to continue with your consultation or whether referral, for example, to the animal’s veterinarian, is required.
When undertaking a case history, another important consideration is that owners will often provide information that they think is important based on their own knowledge and experience, and therefore, the information they give will be offered or discounted through this lens. If the owner doesn’t consider it important, they may not tell you something which is important. Therefore, it can help to have some prompts.
For example, with the question, ‘Have you noticed any changes since the onset of injury/illness?’ you may need to have some additional prompts such as: ‘Has your animal’s breathing changed? Is your animal generally stiffer and slower to get moving/warm up? Have his/her eating, drinking or toilet habits changed since the illness/injury? Is he/she standing away from the herd recently or avoiding others in the household? Has he/she started laying down less or more?’ to get them to consider if they have noticed any changes in behaviour (no matter how small).
A top tip is to ask questions which may lead the owner to describe their animal’s personality or behaviour – as this can tell you a lot.
Another consideration is the format of your case history document and whether this is a document you want to email to owners to have them fill in and return prior to your initial consultation or whether it is something you will go through at the appointment. Potentially try out both. For some, you may find that having information prior to the appointment means that the animal isn’t standing around so long while you are asking the owner questions; it may also mean you can research the condition, breed type norms, medications or have a greater understanding of the presentation through which to initiate vet consent or veterinary communications as appropriate. For some, the process of going through the form’s questions with the owner face to face-may yield more information. Others may find a combination works best, with owners giving key information, which is then supplemented by additional (but reduced) questioning face to face. Finding the format that works best for you and how you are capturing and recording this information may take some trial and tweaking but is fundamental to building strong foundations within your initial consultation. Too onerous, and you lose your owner, too brief, and you miss out on key information.
The more you use your case history document, the more you will refine it to be exactly what you need, and the more you will gain from this process. The key is to then utilise this information to inform and direct your initial consultation, treatment and management moving forward, rather than parking the information and not effectively utilising it.
Remember you should always have a rationale for asking the questions you do, or for carrying out assessment or testing, and this reason should never be, because I do, or because I was told to. Remember, every time, ask yourself what it is you are trying to learn, what you will rule in or rule out, and how this question or assessment helps to inform and direct your approach to the patient.
This is why AOI places emphasis on this part of the initial consultation process and supports their students in the creation of their own effective patient and clinical documents to ensure professional robustness, clinical safety, and a truly osteopathic analysis.
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