Everyone knows what a consultation is and what it involves…don’t they? It is a process of questions, answers, observation and examination followed by a conclusion. The conclusion should lead to a Plan to achieve definitive diagnosis following which a plan for intervention is established. Alternatively the conclusion may lead to empirical therapy with planned review of response.
In Veterinary Medicine the consultation has been initiated by the observation of a problem in a non verbal family member, perhaps we can take the analogy of a Missing Persons interview for the initial part of the process. The investigator (surgeon) discusses the patient with Family members. The trained investigator is trying to gain information from interested but untrained observers. Orthopaedic disease will often lead to a “missing person” phenomenon as the previously active and mobile dog becomes replaced with a dog of variable disability and comfort. A young pup may become replaced by a dog of much older appearance and behaviour.
The attempt at this stage is to establish enough background information to understand the patient as an individual and then to proceed to gain more information about the impact and nature of the problem. Not asking the right questions here…and just as importantly not listening to the answers, will likely reduce the power of the Gait evaluation and Physical examination phases and most definitely will make evaluation of response to therapy very difficult. Since the magnitude of any intervention should match the magnitude of the problem, any failure at this stage to understand the day to day impact of the Orthopaedic Disease will make a later Risk:Benefit analysis of the proposed intervention difficult and may lead to inappropriate levels of management.
The following is a list of question categories. There is some overlap between the groups but this can permit us to ask the same question in a different way. Repeating questions is an important part of history taking as we may get different answers to the same question depending on how we ask the question.
We should begin by asking the following questions before proceeding to the detailed questions:
In Which Limb or Limbs have you noticed the problem?
Make sure you get the owner to point to the limb if they identify a single limb as some owners will define the left and right sides based on viewing their dog from the front.
Do the owners have more than one dog?
This may be important in terms of aetiology but is of significant importance if you ask the owner to rest the dog for example. Many owners of multi dog households will consider that not taking the lame dog for a walk is resting the dog, despite the fact that continued free play with the other household dog is still permitted. As part of this line of questions you should enquire as to whether they have had a dog before and whether they have had dogs of this breed before. Clearly first time dog owners have less innate knowledge of dogs than owners who have had many dogs of the same breeds. This may influence our view of reliability of responses later on.
Diet and Knowledge of Litter Mates
This is particularly important in relation to Juvenile onset Orthopaedic disease.
Before proceeding down this line of questions, try to make sure that you and the owners share the same definitions of terms that you will use. In particular we often talk about stiffness, lameness and pain and we have specific thoughts in our head regarding the definition of these. It is key therefore that we explain these to our clients otherwise we are not communicating effectively as we are in effect speaking in a different language to our client from the one that they use. This will not be very useful.
Onset and progression of the problem.
This is particularly important when the Orthopaedic problem has been present for two weeks or more. One of the most useful ways to approach this question is to ask the owner to draw a graphic representation of the problem. Draw the axes of a graph and ask them when they became aware of the issue. Mark this point at the intersection of the axes. Indicate to the owner that they should use the Y-Axis to indicate the severity of the problem and then mark another point on the X-Axis representing today. They are asked to draw a line between these points representing their pet’s status over the intervening period. They don’t need to be precise what we want to see is whether the problem “appeared out-of-the-blue”, whether there has been a recent acute deterioration or improvement, whether the problem is up and down and so forth. For some clients it can be useful to draw a graph yourself and indicate to them what this represents. Most owners are pretty good at this, although some may need more coaching than others.
Bear in mind that with many slow onset problems, the owners may not be sufficiently sensitive to the early phases of the disease. This is particularly the case in symmetric joint pathologies as a considerable degree of training is often required to see an absolute lameness or “poverty of action”. Asymmetric pathologies are usually picked up more quickly by owners than symmetric pathologies for this reason.
It is a good idea to file this graph as it can be used later on in the management of the problem to get a feel for the patient’s response to our therapy. If the graph is on a white board, then take a photograph of it with your Smart Phone and either add this to the patient’s medical records or, if you use something like Evernote for example, make a “My Patients” notebook and add the image with a note and title to this notebook.
Intra day Variations (Diurnal Variation).
Here we are trying to understand whether the problem is variable through the course of a day. Clearly the accuracy here will depend on the amount of observed time there is in the pet’s day and whether you are addressing the person who spends most time with the pet.
Often it is best to begin by “framing the day”. Ask how visible the problem is first thing in the morning, after a full night’s sleep. Obviously you want to address this question to the person who first observes the dog. Does the pet take a while to get up from bed? After the pet is up, does he appear stiff for a period? If so how long? Is this the best part of the day? Some owners need the same question asked a number of different ways before you will get a satisfactory response.
The next element in the “frame for the day” is how the pet appears at night time. This is often when many family members will be around to observe and therefore you may get a consensus view. Asking whether they now have to coax the dog out last thing at night for toiletting is useful. Following on from this point, it is certainly worth asking whether the pet sleeps soundly at night and at other prolonged rest periods. If the dog is constantly changing position or cannot get settled, this may indicate discomfort.
We should ask whether there is a point in most days when the pet is at his best or at his worst. If the owners have seen this pattern, ask what they see or do not see that makes them feel that one period of the day is worse than another. Clearly it is likely that it will be the lameness that is being used as the arbiter here but ask whether there are any differences in demeanour noted during these phases.
Inter Day variations.
This line of inquiry is to establish whether there are good days and bad days. If so, it is worth asking the owner whether she feels that there is any pattern to this. In particular we are interested in the effect of a strenuous day’s activity or a day of minimal activity on the subsequent day or days observation of lameness.
Often people will exercise their dog more at a weekend because they have more free time. Asking how the dog appears on a Sunday and Monday therefore is a good way of establishing the role of activity (duration and type) in the severity of the observed problem.
Activities that exacerbate the problem.
This leads on from the previous point but looks at specific activities rather than simply duration of activity. For example if the exercise session includes ball-chasing or interaction with other dogs, will this exacerbate the lameness. If so, will this manifest during the session, on the slow walk home or later in the same day? Asking whether the dog will ever pull up lame or spontaneously abandon the activity are also useful questions here.
Within this group of questions, the effect of walking on a gradient is useful. Is the lameness worse on descent of hills or ascent of hills?
Activities that ameliorate the problem.
Often this is really a question about the effect of reduced activity or stopping the activities that were noted to exacerbate the problem. Within this group of questions however we can include the effect of massage or other contact that seems to give the pet relief.
The ability to perform common domestic activities.
This refers to ascent or descent of steps and stairs, getting into or out of the car, getting on and off furniture and so forth. We should also ask about whether there has been a change in the posture adopted for eating. Some dogs with Elbow and/or Hip pain for example will often lie down to eat rather than stand and eat from a bowl on the floor. Perhaps the owners noted a problem and have begun to raise the bowl. The postures adopted for urination and defecation are also important. In male dogs, suddenly stopping cocking the limb or making efforts to cock a specific leg may give additional information. Dogs that begin defecation in one spot and then move to another to continue defecation may be experiencing discomfort associated with maintaining hip and stifle flexion for example or pain in the elbows that precludes supporting their weight on the forelimbs for an extended period of time.
Tendency to play and behaviour at play with toys in the house.
Dogs with chronic pain will often show a reduced tendency to engage in play. They seem to build an “is it worth it?” equation in their head and this will tend to get stronger over time.
Asking whether the dog will get up and move to a distant toy or “commando-crawl” over to get it may indicate discomfort on rising. If a dog tends to play from the floor this may also indicate difficulty on rising.
Enthusiasm for exercise.
Young dogs in particular may maintain an enthusiasm for exercise sessions despite the fact that they know that they will be more painful after. This is the equivalent of knowing that the fun you are having at the party will give you a hangover, but carrying on anyway! If there has been a reduced enthusiasm for exercise, then again this tells us about the impact of the problem on the patient themselves. A tendency to spontaneously limit activity during the session by lagging behind for example or sitting down frequently may indicate reduced enthusiasm.
Behaviour with other dogs when out for exercise (has this changed).
Dogs with orthopaedic pathology will often feel weak and vulnerable when associating with other dogs in the park for example. Animals have an innate “Fight or Flight” response and if you have orthopaedic problems then both of these mechanisms will be impacted. In some dogs this will lead to a tendency to submissive behaviour whilst in others it may lead to a tendency to pre emptive aggression towards other dogs. The owners may have noticed this change.
By the end of this process the aim is to have as complete a picture as possible of the history, current status and details of the problem.
The next part of this series will be available within the next couple of weeks.