exam 1 Flashcards
Clinical Diagnosis: pattern recognition
-A constant “unconscious” interplay of exam and patterns
-Tends to prioritize the most likely differentials automatically
* Have to have enough of a repertoire to know when pattern doesn’t fit
* Can be efficient but also wrong at times (not enough reflection). Type 1 thinking (fast).
Clinical Diagnosis: Deductive Reasoning
- Also common to experts, need to be expert to know which clues are most important
- Novice can’t see the forest for the trees
- Establish a hypothesis from initial clues
- Use physical exam or other information to
prove or disprove theory - Type 2 thinking (slow)
Clinical Diagnosis: Algorithms
- Often generated by experts
- Have formalized the diagnostic approach
used by that expert or group of experts - Can be very helpful for complicated cases,
common to clinical pathology
types of thinking in critical thinking
- Usually are in Type 1 (95%) intuitive
- Type 2 is work (analytic)\
-two types work together
-why not always type 2? it is not reactive enough, can be draining due to increase brain energy leading to fatigue. can be effected by stress, tired, feelings, ect.
Framing bias
(Huckleberry Finn, lean vs. fat meat)
Availability bias
easiest to recall)
Anchoring bias
reliance on first piece of information given “tunnel vision”
Outcome bias
(FIC cats, metronidazole and diarrhea)
Confirmation bias:
everything supports your theory
Clinical Diagnosis: Problem
Oriented Approach
- What is used at the WCVM
Type 2 thinking (if you give it a chance). - Basis for the Problem Based
Medical Record (POMR) - A well written POMR should
allow any doctor to come in
and understand what has
happened and what is planned for a patient.
Problem Based
Medical Record (POMR)
- Lists all problems identified
- Once all problems listed then can go on to
establish plan and possibly diagnosis - Provides documentation of all the diagnostics,
treatments, and communication, including
plans, established diagnoses, and ongoing patient assessments - Serves as a legal record of diagnoses considered,
treatments provided , communications with clients,
and your reasoning for any action or lack of action
taken.
POMR steps in diagnostics in problem orientated approach
1.) Data base collection (initial problem list)
– History and Physical Exam
2.) Problem Identification
– Integrating the History and Physical Examination
– Propose a relevant list of Differential Diagnoses for each problem
3.) Plan Formulation
– Diagnostic, Treatment, Client- education plan
4.) MR documentation Assessment and Follow-up
Clinical Diagnosis: Problem
Oriented Approach to organize problems
-get POMR interpret
-place problems in groups or categories such as look at later and prioritize problems,
-make differential list
-try to localize system: ex primary GI (parasites), secondary GI (renal disease)
* Can use the DAMNITV
crutch
* Refining problem list, problems change as start treating the patient.
– Inactivate some problems (no longer dehydrated)
– Establish diagnosis in others
– Generate new plan
Problem Oriented Approach three types of diagnostic plans
- There are 3 types of plans that need to be
accounted for in this initial summary and in the subsequent progress report ( or SOAP)
– Diagnostic plan(s),
– Therapeutic plan(s)
– Client education plan(s)
Client Communication Plan
and Documentation
– Update on the animal’s status
– Update on complications that have occurred
– Prognosis update
– Financial update
– Make sure everything is documented in a
timely fashion, especially if things are declined.
parts of physical exam
-distance exam
-posture and gate
-behavioral assessment
-vital peramitors
-body weight (BCS, MCS)
-head and neck
-oral exam
-thoracic exam
-palpate abdomin
-hair and skin
-musculoskeletal
-genitals
posture and gait in physical exam
■ Is the patient able to stand?
– If not, then is there an abnormal posture?
■ In lateral, or sternal recumbency
■ Head posture – opisthotonus, head tilt
■ Limb rigidity – flaccid, rigid in extension
■ Tremors, convulsions
– If able to rise, then is there a generalized weakness, a lameness or a gait abnormality
Normal temperature ranges dog and cat
– 37.5 to 39.2 oC in dogs
→ 38.3 to 39.2 according to the AKC
– 38.1 to 39.2 for cats
Heart rate
■ Normal heart rates (ranges can vary
Canine :
■ Small dogs (< 10 kg): 110-160 bpm
■ Medium dogs (10-25 kg): 80-120 bpm
■ Large dogs (> 25 kg): 60-100 bpm
– Feline :
■ 160-220 bpm
Respiratory Rate
■ Normal
– Canine: 15-30 bpm
– Feline: 12-36 bpm
Capillary refill time (CRT)
■ Normal is < 2 seconds
■ Prolonged CRT is associated with shock syndromes, vasoconstriction (can be secondary to medications or hypothermia), cardiac disease
■ Anemia makes it hard to assess
dehydration versus hypovolemia!
(dehydration)
■ MM
– Tachy or dry
■ Skin tent
– Over thorax/scapulae
– Overweight animals hard to get
a skin tent when dehydrated
– Underweight or older animals
can have a skin tent when not
dehydrated
-sunked eyes
(hypovolemia)
■ CRT
– >2.5 seconds
■ Heart rate
– elevated
■ Blood pressure
– low
■ Pulses
– Weak
■ Extremities
– cool
Muscle condition score (MCS)
■ Visualize and palpate the spine, scapulae, skull, and wings of the ilia.
■ Muscle loss usually occurs in the epaxial muscles on each side of the spine, while
muscle loss at other sites can be more variable
■ Muscle condition score is graded as normal, mild loss, moderate loss, or severe loss
Performing thoracic examination
■ Palpate over the thorax for conformation, symmetry and masses
■ Auscult the thorax
– Both right and left
– Dorsal and ventral
– Move the stethoscope in a “checkboard” manner over the lungs and heart
Cardiac system : normal heart sounds
■ LUB DUB with short gap between
– S1 = closure of the AV valves
– S2 = closure of the semilunar valves
– Occasionally split S1 or S2 if the corresponding valves close at slightly different times
basic musculo + neuro exam
During a general physical examination, you should do a minimum of:
– Watch the patient walk
– Palpate each limb
■ Feel for heat, swelling, masses, pain, joint swelling
– Evaluate paws, pads, and nails
■ Depending upon presenting complaint or observed findings above:
– Put each limb through range of motion
– Perform more specific orthopedic and/or neurological examination
problem orientated approach
▪ Exhaustive, and systematic collection
of information through history and
physical examination followed by
integration and analysis of this
database
▪ Pros - minimize errors, train new
professionals, solve complex cases,
communicate effectively and
document appropriately
▪ Cons – inefficient in terms of time,
possibly not ideal for general practice
or first opinion car
pattern recognition
▪ Immediate integration of information
to identify the most probabilistic
diagnosis(s) used by experienced
clinicians
▪ Pros – catches the majority of common
problems; efficient
▪ Cons – common problems can present
in unusual ways or uncommon
problems can present like common
problems; miss out on the complete
history and lead to misdiagnosis; jump
to conclusions
database = history and physical exam
▪ A systematic approach to collecting information (the database) is critical to solving
clinical problems
▪ The database consists of two parts:
▪ History
▪ Physical examination
▪ Dynamic, yet consistent communication is paramount to assembling the first part of the
database which is history
▪ The database is the first step that then allows clinicians to identify problems for which
we make differential diagnoses to guide diagnostic and treatment plans
ESTABLISH THE TIME FRAME
▪ Understanding both the time frame over which the clinical signs developed and the
progression, improvement or static nature of these clinical signs is important
▪ The time – clinical sign curve can help you prioritize differential diagnoses when
using the problem oriented approach to veterinary medicine
▪ Peracute, seconds to minutes to hours →blood clot, trauma, IVDD(if spinal), hemorrhage
▪ Acute, hours to days → a lot of things!
▪ Subacute, days to weeks → inflammatory versus infectious disorders
▪ Chronic, >2 months → neoplasia, degenerative disorders
PAST MEDICAL HISTORY
▪ Past vaccination history – types and dates
▪ Deworming
▪ flea/tick and heartworm preventatives
▪ Major medical or surgical problems in the past or current
▪ Nutrition: type of diet, frequency of feedings, how they feed, recent changes
▪ Supplements
▪ Medications and dosages
▪ Husbandry
animal welfare 5 freedoms
1.) Freedom from hunger and thirst
2.) Freedom from discomfort
3.) Freedom from pain, injury or disease:
4.) Freedom to express normal behavior
5.) Freedom from fear and distress.
making a medical record
- Complete but concise
- Legible and written in blue or black ink
- Written or typed in a timely fashion
- Need to include only pertinent information
- Be written in professional language
- Clearly identify the patient (name and hospital ID#) and the owner of the animal on
all forms - Each entry must be signed and dated
purpose of medical records
- It is a comprehensive record of the patient’s medical care
- serves as a legal record of diagnoses considered, treatments provided , communications with
clients, and your reasoning for any action or lack of action taken
MANAGING THE MR
- Medical records are the property of the practice and the practice owner but the owner is
entitled to a copy if requested - The original record must be retained by the practice for the period specified by the licensing
body (5 years according to the SVMA) - Ethically, the information within all veterinary medical records is considered privileged and confidential
4 COMPONENTS OF THE POVMR
1.) Data base collection
* History and Physical Examination, presenting complaint
2.) Problem Identification list
* Integrating the History and Physical Examination
* Propose a list of Differential Diagnoses for each problem
3.) Plan Formulation
* Diagnostic, Treatment, Client-education plan
4.) MR documentation Assessment and Follow-up (initial assessment, SOAPs, discharge notes)
PROBLEM LIST:
SPLITTING VERSUS LUMPING?
S P L I T T I N G
* When is it more appropriate to keep problems separate ?
– Different systems
– Different time of onset and clinical course
– Uncertain or not known to be
secondary to the primary problem
L U M P I N G
* When is it appropriate to lump
problems ?
– same system
– same time of onset and clinical
course
– apparently secondary to the primary problem
diagnostic plan
- Encompasses formulation of a list of Dx tests to help rule in or rule out the DDx that
you have identified for each problem - Examples :
– The intent to perform blood work or diagnostic imaging
– Taking additional more specific history
– Plan to recheck and monitor physical examination findings, blood work, repeat exams.
treatment plan
-Should be written as accurately and specifically as possible
* Specific drug name (s)
* Specific dose, route of administration, frequency of administration, and the timing
* Don’t forget to account for the patient’s dietary and fluid needs in your therapeutic plan
– Ideally use a formula to calculate nutritional requirements.
4 types of treatments and what they do
- Specific treatments:
– eliminates or modifies the primary cause of the disease process - Supportive treatment:
– corrects or modifies abnormalities that occur secondary to the primary disease process - Symptomatic treatment:
– eliminates or suppresses clinical signs without affecting or knowing the underlying cause - Palliative treatment:
– treatment prescribed for an untreatable disease in order to make the patient more comfortable
CLIENT COMMUNICATION PLAN
-Includes plans to update the client by telephone, email, text or in writing
* Discharge notes!
* A synopsis of all client communications needs to be documented in the MR with date, time and signature
- Client Communication should include:
– Update on the animal’s status
– Update on complications that have occurred
– Prognosis update
– Financial update
A S S E S S M E N T A N D
F O L L OW U P
1 INITIAL ASSESSMENT:
* A summary of the initial data base
* Problem list & a prioritized list of DDx for each major problem
* Plans
– what diagnostic tests or initial treatments were provided
– initial client communication
* Diagnostic test findings
– includes an interpretation of these results
* Refined Problem List
– if appropriate
2 ONGOING ASSESSMENTS: SOAP (subjective objective assessment plan)
3 DISCHARGE NOTES: Prepared to go home with the owner and to remain an important summary of the current visit in the medical record, must be in terms client can understand. summary of what is wrong with the pet and provide
instructions for their pets homecare
* Make sure you have written down when medications are next due
SOAPS (subjective objective assessment plan)
-written for each major problem, numbered and titled to master problem list, usually written once a day or more.
S- subjective data: new history from client, non-quantitative observations such as changes in mental attitude, appetite ect.
O= objective data: numbered, exam findings, data, ABNORMAL lab values should be mentioned and trends listed. dont need to list normal values.
A-assessment: analyze sub and ob data. most important part of daily SOAP. if you have diagnosis state here, or list DDx. and what evidence supports DDX.
P=plan: * Actions you want to take to manage the problem/disease
* Updated diagnostic and therapeutic plans should be formulated
history components LA
- What type of animal /signalment?
- Current presenting complaint
- Previous illness/problems
- General management
- Preventative healthcare
history component 1 signalment/ type of animal
▪ Species
▪ Breed
▪ Age
▪ Sex
▪ Weight/BCS (has there been a change)
▪ Reproductive status
▪ Production stage
▪ Current/intended use
history component 2 CURRENT PRESENTING COMPLAINT
▪ Clinical signs
▪ Duration
-Treatment & outcome
▪ Owner
▪ Veterinarian
-previous illness/ problems: similar to presenting complaint? when? previous treatments and outcomes
history component management
- Housing
▪ Contact with wildlife
▪ Feeding
▪ Water source
▪ Any recent changes
-work routine
-travel: shows or new purchases
-other animals
HISTORY COMPONENT – PREVENTIVE
HEALTHCARE
▪ Vaccination (herd/individual)
▪ Deworming
▪ Dental care (horses)
▪ Foot care
▪ Colostrum (neonate)
▪ Vitamin E/Se
▪ Magnet (cattle)
why perform a physical examination
▪ Establish a clinical diagnosis
▪ Maybe arrive at final diagnosis
▪ Establish a problem list
▪ Establish DDX
▪ Direct additional diagnostics
▪ Interpret with diagnostic results
other cases for physical exams and history not injury or sickness
Prepurchase examination
▪ Breeding soundness
▪ Foal health check
▪ Health certificates
▪ Export papers
▪ Insurance examinations
→ You may need to confirm normal
→ You may be liable
PHYSICAL EXAM BASICS
-Distant exam
▪ Close exam
▪ General exam
▪ Specialized exam (body system)
▪ Examination of the environment/herd
complete physical exam:
▪ Rectal examination
▪ Neurologic examination
▪ Lameness examination
▪ Reproductive examination
▪ Ophthalmologic examination
LA distance exam
- Attitude
- Behaviour (prey animals)
- Physical condition (BCS)
- General body shape/contour
- Respiratory rate, effort
- Posture & conformation
- Hair coat
- Defecation/urination
- Trailer
- Perineum
- Environment
Head exam
- Facial expression, symmetry:
- Ears → position, movement
- Eyes, nose → discharge, icterus
- Eyes cow: skin tent for hydration
- Mouth:
- Tongue tone
- Teeth
- Oral mucous membranes
- Ulcerations
- CRT
- Female cattle – vulva
- Male cattle - eye
- Ability to eat:
- Prehension
- Mastication
- Swallowing
Pulse:
▪ Facial artery
▪ Quality, rate
▪ Sinus percussion
▪ Cranial nerves
▪ Edema (bottle jaw)
head/ upper neck exam LA
- Lymph Nodes:
- Submandibular
- Retropharyngeal
- Viborg’s triangle
- Guttural pouch
- Parotid gland (horse) grey horse melanoma
- Thyroid glands
neck exam LA
- Trachea:
- Auscultation
- Palpation
- Inducible cough
- Jugular veins:
- Patency
- Distension
- Jugular pulsation
- Brisket (cattle)
- Skin tent (horse; neonate)
- Hydration
- Esophagus
- Choke
- Lacerations
- Injection sites
- IM
- IV
- SQ
thorax exam large animal
- Cardiac auscultation
- Rate
- Rhythm
- Murmurs
- Peripheral edema
- Withers
- Girth/saddle area
limbs exam LA
-Swellings, wounds, joint effusion (neonate!)
▪ Temperature
▪ Digital pulses (horse laminitis would have pounding digital pulses)
▪ Hooves
▪ Lameness examination
