Clinical decision making

Question 1

How can vets make a diagnosis? 3

Answer 1

• pattern recognition
• minimum database
• logical approach to clinical problem solving

Question 2

Pattern recognition is effective in perhaps 70% diagnoses, when does it work best?

Answer 2

• unique clinical pattern
• only a few possibilities (easily remembered, easily ruled in/out by routine tests)
• vet has extensive experience, is well read and up to date, reviews all diagnoses critically and has extensive memory

Question 3

Pattern recognition - advantages

Answer 3

Quick, cost effective, vet looks good and is happy (all when correct)

Question 4

Pattern recognition - disadvantages -6

Answer 4

-can only be a limited number of diagnostic options, potential to reinforce incorrect diagnoses,, very dependent on experience, knowledge and memory, risk of tunnel vision, risk of confirmation bias, no clear alternate diagnostic approach if wrong

Question 5

Significant pathology can occur in which organs without biochemical or haematological changes? 7

Answer 5

GI, neuromuscular, cardiorespiatory, spleen, brain, liver (esp cats), pancreas (esp cats)

Question 6

What is problem based clinical reasoning based on?

Answer 6

Pathophysiologic principles and understanding

Question 7

What is the process for problem based clinical reasoning?

Answer 7

• Define the problem (always)
• Refine the system and how it may be involved (always)
• Define the location within the system (sometimes)
• Define the lesion (always, always last)

Question 8

What is important when defining the problem?

Answer 8

Is there another clinical sign that this problem could be confused with? (e.g. vomiting and regurgitation)

Question 9

Examples of defining the problem - 6

Answer 9

• vomiting or regurgitation
• diarrhoea or discharge from the genital tract or anal sacs?
• straining to defacecate - constipation or colitis?
• fit - seizures or fainting?
• red uring - blood, haemoglobin or myoglobin
• abdominal pain or back pain?

Question 10

How might diagnostic tests differ for vomiting and regurgitation?

Answer 10

VOMITING: biochemistry, haematology, urinalysis, abdominal imaging, endoscopy, exploratory laparotomy
REGURGITATION: oesophageal imaging (plain rads, contrast, fluoroscopy), endoscopy. As those above for vomiting tell us nothing about an oesophageal lesion. Dangerous. Waste of money.

Question 11

How to refine the system? 2

Answer 11

• Structural (primary - pathology is in that system) vs. functional (secondary - pathology outside of the system is affecting the way the system is workingbut there is no actual pathology in the system and/or the pathology has been caused by another body system)
• Local vs. systemic

Question 12

Define and refine cough

Answer 12

Cardiac or respiratory disease?

Question 13

Define and refine pale mucous membranes

Answer 13

aneamia or poor peripheral perfusion

Question 14

Define and refine jaundice

Answer 14

Haemopoietic (low PCV) or hepatobiliary?

Question 15

How does diagnostic approach between structural and functional problems?

Answer 15

STRUCTURAL: often involves imaging, biopsy and blood work can be completely normal
FUNCTIONAL: often involves blood work as well as other diagnostic tools

Question 16

What would haematology and biochemistry inform you of in a primary GI disease?

Answer 16

clinical status of patient but not cause of vomiting

Question 17

What does DINT stand for? 8

Answer 17

Define the lesion:
Developmental
Degeneration
Infection
Inflammation
Neoplasia
Nutritional
Trauma
Toxic

Question 18

Advantages - clinical problem solving - 7

Answer 18

• provides a structure
• more organised
• reduces need to remember long lists of differentials
• helps prevent getting trapped by a perceived ‘obvious’ diagnosis
• reduces risk of tunnel vision
• provides memory triggers to ensure an appropriate history and thorough PE is taken
• assists communication with owners about appropriate diagnostic procedures or treatment trials required

Question 19

How to approach clinical scenarios

Answer 19

• Create a problem list with the most important problems at the top
• identify specific problems and those which are ‘background noise’
• define and if needed refine the specific problem/s
• for each specific problem identify the body system that must be involved and consider how it may be involved.
• then answer key question related to defining/refining the problem
• follow on with activities provided to develop core knowledge about the topic that week (DDx, diagnostic tools, disease pathophysiology, treatment and prevention)

Question 20

How do you define the problem ‘vomiting and diarrhoea’?

Answer 20

Is vomiting confirmed? Is diarrhoea confirmed?