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Группа авторов. Clinical Reasoning in Veterinary Practice
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
Clinical Reasoning in Veterinary Practice. Problem Solved!
About the Editors
List of Contributors
Preface
Acknowledgements
CHAPTER 1 Learning to learn and its relevance to logical clinical problem‐solving
The why
Learn more effectively
Let’s get going
How is this learning theory relevant to this book?
Key points – learning more effectively
References
CHAPTER 2 Introduction to logical clinical problem‐solving
The why
Introduction to clinical reasoning
Why are some cases frustrating instead of fun?
Solving clinical cases
Case 1: ‘Sundance’
Case 2: ‘Brutus’
Case 3: ‘Erroll’
Pattern recognition
I’ll do bloods!
Problem‐based inductive clinical reasoning
Essential components of problem‐based clinical reasoning. The problem list
How likely is a diagnosis?
The problem‐based approach
Define and refine the problem
Refine the problem
Why is it so important to define and refine the problem?
Define and refine the system
Why is it so important to define and refine the system?
How to differentiate primary from secondary system involvement?
Define the location
Define the lesion
Putting it all together. What do I need to do to define the problem, system, location or lesion?
Are the steps always in the same order?
But does pattern recognition have a place?
Combinations of clinical signs
Does this make sense?
Think pathophysiologically
It may appear tedious at times!
Ancillary benefits
Time waster or time saver?
Key points
CHAPTER 3 Vomiting, regurgitation and reflux
The why
Pathophysiology
Initiation and the process of vomiting
Vomiting centre
Central stimulation
Vestibular apparatus
Chemoreceptor trigger zone
Peripheral receptors
ASSESSMENT OF THE PATIENT REPORTED TO BE VOMITING. Define the problem
Why is it important to differentiate vomiting from regurgitation, reflux and coughing?
Clues to help differentiation of vomiting, regurgitation and reflux
Haematemesis
Nausea
Define and refine the system. Primary vs. secondary gastrointestinal disorders
Why is it important to differentiate primary from secondary GI disease?
What are the clues that the patient has primary or secondary GI disease causing vomiting?
Exceptions to the ‘rules’
Define the location
Define the lesion. Primary GI diseases causing vomiting
Diseases of the stomach
Intestinal disease
Secondary GI diseases causing vomiting
Haematemesis
Causes of regurgitation
Diagnostic approach to the patient reported to be vomiting
When is clinical pathology useful?
When is a fuller work‐up rather than symptomatic therapy indicated?
In conclusion
Key points
Questions for review
Case example
Define the problem
Define the system
Define the location
Define the lesion
Case outcome
CHAPTER 4 Diarrhoea
The why
Introduction and classification
Pathophysiology
Classification of diarrhoea
Define the problem
Define the location
Define and refine the system
Define the lesion
Diagnostic approach to the patient with diarrhoea. Small bowel diarrhoea. Acute vs. chronic
When to investigate?
Summary
Key points
Questions for review
Case example
Define the problem
Define the location
Define the system
Define the lesion
Case outcome
CHAPTER 5 Weight loss
The why
Define the problem
Refine the problem
WEIGHT LOSS DUE TO DECREASED APPETITE. Refine the problem. Can’t eat or won’t eat?
Can’t eat. Prehension and mastication
Dysphagia
Define the lesion
Assessment of inflammation. Local pathology
Systemic pathology
Define the problem. Won’t eat
Define the lesion
WEIGHT LOSS WITH NORMAL OR INCREASED APPETITE. Define the system
Normal physiology
Pathophysiology
Maldigestion. Define the lesion
Malabsorption. Define and refine the system
Define the lesion. Primary GI diseases causing malabsorption
Secondary GI diseases causing malabsorption
Malutilisation. Define the lesion
Summary
Key points
Questions for review
Case example
Define the problem
Define the system:
Define the lesion
Case outcome
CHAPTER 6 Abdominal enlargement
The why
Define the problem
Fluid characterisation
Define the location
Refine the problem: Ascites – transudate/modified transudate. Ascites
Pure transudate
Modified transudate
Define the lesion: Ascites – transudate/modified transudate
Portal hypertension
Pre‐hepatic hypertension
Intra‐hepatic portal hypertension
Post‐hepatic obstruction
Hypoproteinaemia
Lymphatic obstruction
Refine the problem: Exudates. Characteristics
Define the lesion: Exudates. Causes of non‐septic exudates
Causes of septic exudates
Refine the problem: Eosinophilic effusions
Define the lesion: Eosinophilic effusions. Causes
Refine the problem: Blood
Define the lesion: Blood
Refine the problem: Urine
Refine the problem: Chyle
Characteristics
Define the lesion: Chyle
In conclusion
Key points
Questions for review
Case example
Define the problem
Define the system
Define the lesion
Diagnostics
Case outcome
CHAPTER 7 Weakness
The why
Define and refine the problem
Define and refine the system
Skeletal disorders
Define the location
Common neurological examination findings in neuromuscular disorders
Neuroanatomical localisation within the CNS or neuromuscular system
Hands‐off examination – observation
Hands‐on examination
Hands‐off examination – observation. Mentation and behaviour
Posture and gait
Hands‐on examination. Postural reactions
Cranial nerve examination
Spinal reflexes
Palpation
Sensory evaluation
Define the lesion
Weakness in cats
Episodic weakness
Persistent weakness
Diagnostic approach to the patient presenting with weakness
In conclusion
Key points
Questions for review
Case example
Define the problem
Define the system:
Define the location
Define the lesion
Case outcome
CHAPTER 8 Fits and strange episodes
The why
Define and refine the problem
Syncope
Narcolepsy
Paroxysmal behaviour changes
Vestibular attacks
Paroxysmal movement disorders
Epileptic seizures
Is it an epileptic seizure?
Define and refine the system
Define the location
Vestibular attacks
Narcolepsy, paroxysmal behaviour changes and paroxysmal movement disorders
Seizures
Define the lesion
Vestibular attacks
Narcolepsy
Paroxysmal behaviour changes
Paroxysmal movement disorders
Syncope
Epileptic seizures. Extra‐cranial vs. intra‐cranial
Intra‐cranial causes
Extra‐cranial causes
Diagnostic approach to the patient presenting with fits or strange episodes
Vestibular attacks
Syncope
Narcolepsy
Paroxysmal behaviour changes and paroxysmal movement disorders
Seizures
In conclusion
Key points
Questions for review
Case example
Define the problem
Define the system
Define the location
Define the lesion
Case outcome
CHAPTER 9 Sneezing, coughing and dyspnoea
The why
Introduction
SNEEZING AND NASAL DISCHARGE. Define the location
Define and refine the problem
Define and refine the system
Define the lesion
Diagnostic approach
COUGHING. Define the problem
Refining the problem
Haemoptysis
Coughing with minimal dyspnoea. Define the location (and system)
Define the lesion
Diagnostic approach
DYSPNOEA. Define the problem
Coughing and dyspnoea. Define the location
Normal lung sounds
Abnormal lung sounds
Define the system – coughing –/– dyspnoea
Define the lesion – coughing +/– dyspnoea
Bronchoalveolar disease
Diagnostic procedures
Dyspnoea with minimal coughing. Define the system
Define the location
Key points
Define the lesion – laryngeal disorders
Diagnostic procedures
Appropriate sedation
Define the lesion – space‐occupying disorders of the pleural cavity
Diagnostic approach
Should I remove the fluid?
Define the lesion – constrictive bronchial inflammation
Diagnostic approach
Define the lesion – primary alveolar disease
Define the lesion – secondary disorders
Reduced delivery of normal haemoglobin
Pulmonary thromboembolism
Clinical signs
Diagnosis
Pulmonary oedema. Aetiology
Pathophysiology
Clinical signs
Causes of pulmonary oedema. Cardiac disease
Neurogenic oedema
Adult respiratory distress syndrome
Reduced oncotic pressure due to hypoproteinaemia
Normal delivery of abnormal haemoglobin
Key points
Questions for review
Case example
Define the problem
Define the location
Define the system
Define the lesion
Case outcome
CHAPTER 10 Anaemia
The why/what
Define the problem
Define the system
Assessment of anaemia – refine the system
Regenerative anaemia
Define the location
Haemorrhage vs. haemolysis
Haemorrhage
Haemolysis
Define the lesion. Causes of haemolytic anaemia. Immune‐mediated haemolytic anaemia (IMHA)
Infectious haemolytic anaemia
Drug/toxins
Hereditary haemolytic anaemia
Microangiopathic anaemia
Causes of haemorrhage
Define the location. Non‐regenerative anaemia
Define the lesion. Causes of non‐regenerative anaemia. Anaemia of inflammatory disease
Chronic kidney disease
Bone marrow disorders
Iron deficiency
Key points
Questions for review
Case example
Define the problem
Define the system
Define the location
Define the lesion
Case outcome
CHAPTER 11 Jaundice
The why/what
Define the problem
Physiology
Define the system and location
Pre‐hepatic jaundice
Hepatic jaundice
Post‐hepatic jaundice
Other causes of jaundice
Define the lesion. Pre‐hepatic jaundice
Hepatic jaundice
Post‐hepatic jaundice
Other causes of jaundice
Differentiating causes of jaundice. Pre‐hepatic
Hepatic vs. post‐hepatic
Signalment and history
Clinical signs and physical examination
Clinical pathology
Diagnostic imaging
Cytology, culture and histopathology
Why bother to differentiate?
Summary
Key points
Questions for review
Case example
Define the problem
Define the system
Define the location
Define the lesion
Case outcome
CHAPTER 12 Bleeding
The why
Diagnostic approach to the bleeding patient
Define the problem
Epistaxis
Melaena
Red urine
Other clinical signs of bleeding
Define and refine the system. Is it local or systemic?
Local disorders causing bleeding. Define the lesion: local causes of epistaxis
Clues
Site of bleeding
Character of the nasal discharge
Nasal examination
Local disorders causing epistaxis – diagnostic approach
Define the lesion: melaena due to GI ulceration
Local disorders causing melaena – diagnostic approach
Define the lesion: Local causes of haematuria
Clues
Define the location
Local disorders causing haematuria – diagnostic approach
Systemic bleeding disorders
Physiology
Diagnosis of bleeding disorders
Clinical signs
Platelet count
Activated clotting time (ACT)
Activated partial thromboplastin time (APTT)
Prothrombin time (PT)
Thrombin time (TT)
Thromboelastometry/theromboelastography
Platelet function
Buccal mucosal bleeding time
Clot retraction
Define the lesion: bleeding disorders
Define the lesion: thrombocytopenia
Inadequate production
Excessive destruction
Excessive consumption
Infectious causes
Miscellaneous causes
Define the lesion: platelet function defects (thrombocytopathia) Inherited disorders of platelet function. Von Willebrand disease
Other inherited disorders
Acquired disorders of platelet function
In conclusion
Key points
Questions for review
Case example
The problem list
Define the problems
Define the system
Diagnostic results
Revised problem list
Define the lesion
Further diagnostics and case outcome
CHAPTER 13 Polyuria/polydipsia and urinary incontinence
The why
Polyuria/polydipsia. Define the problem
Confirmation of polydipsia
Determine urine specific gravity (SG)
Pathophysiology. Classifying the mechanisms of polyuria/polydipsia
Primary polydipsia
Primary polyuria
Reduced nephron number and/or function
Absent, deficient or impaired anti‐diuretic hormone function
Altered osmolarity of the glomerular filtrate
Summary
Azotaemia
Diagnostic approach to the patient with PU/PD or impaired urine concentration. Define and refine the system
Define the lesion
Further comments related to Table 13.3
Urinary Incontinence
Define the problem
Define and refine the system and location. Urogenital vs. neurological
Does the animal ever urinate normally, that is, is it incontinent constantly or only intermittently?
If the animal does attempt to urinate, what occurs?
Define the lesion. Intermittent incontinence, normal urination at other times
Constant incontinence, no normal urination initiated
Unsuccessful attempts to urinate
In conclusion
Key points
Questions for review
Case example
The problem list
Define the problem
Define the system
Diagnostic results
Revised problem list and assessment
Define the lesion
Further diagnostics and case outcome
CHAPTER 14 Gait abnormalities
The why
Define the problem
History
General observations
Define and refine the system. Differentiating musculoskeletal from neurological gait abnormalities
Define the location
History
Orthopaedic examination
Distant examination
Gait analysis
Palpation/manipulation
Cranial drawer and tibial thrust
Neurological examination
Define the lesion. Musculoskeletal disorders
Neurological disorders
Painful non‐myelopathic spinal diseases
Myelopathic spinal diseases
Common examples
Diagnostic tools for assessment of gait abnormalities. Lesion localised to the musculoskeletal system
Lesion localised to the nervous system
In conclusion
Key points
Questions for review
CHAPTER 15 Pruritus, scaling and otitis
The why
Pruritis
Pathophysiology
Pruriceptors
Pruritic mediators
Central factors
Define the problem
Define and refine the system
Define the location. Distribution
Define the lesion. Major causes
Primary skin lesions
Secondary skin lesions
Rate of onset
Seasonality
Secondary infections
Self‐trauma
Scaling. Define the problem
Define and refine the system
Important clues
Classification
Define the lesion. Primary scaling disorders. Generalised
Focal
Secondary scaling disorders. Focal or generalized depending on the cause
Diagnostic approach
Skin biopsy
Otitis
Define the problem
Define the system
Define the location
Define the lesion
Canine otitis
Feline otitis
Diagnostic approach to otitis. Visual observation
Palpation
Otoscopy
Sampling
In conclusion
Key points
Questions for review
CHAPTER 16 Problem‐based approach to problems of the eye
The why
Introduction and classification
Classification of eye problems
Define and refine the problem
Red eye
Abnormal‐sized pupil
Opaque eye
Wet eye
Blind eye
Abnormal‐sized eye
Define and refine the system
Define the lesion
Diagnostic approach
The ophthalmic examination
Ancillary tests
Schirmer tear test
Tonometry
Fluorescein staining
Cytology
Culture and sensitivity
Nasolacrimal duct flush
Gonioscopy
Electroretinogram (ERG)
Imaging
Visual testing
Key points
Questions for review
CHAPTER 17 Problem‐based approach to small mammals – rabbits, rodents and ferrets
The why
Introduction and classification
Define and refine the problem
Define the system
Define the location
Define the lesion
Common small mammal clinical scenarios. The rabbit with ‘gut stasis’
Relevant physiology and management. The digestive process
The role of diet
Define and refine the problems
Define the system
Define the location
Define the lesion
When to investigate?
The chinchilla with weight loss
Define and refine the problems
Can’t eat?
Won’t eat?
Define the system. Weight loss with a reduced or absent appetite
Weight loss with a normal or increased appetite
Define the location
Define the lesion
The dyspnoeic rat
Define and refine the problems
Define the system
Define the location
Define the lesion
Chronic respiratory disease (CRD) in rats
The guinea pig with alopecia
Define and refine the problems
Is pruritus present?
Define the system
Define the location
Define the lesion
Diagnostic approach. Primary dermatologic disorders
Secondary dermatologic disorders. Cystic ovarian disease
Hyperthyroidism
Hyperadrenocorticism
The ferret with hindlimb weakness
Define and refine the problems
Define the system
Define the location
Define the lesion
Primary neurological problems
Secondary neurological problems
Musculoskeletal problems
Ferret‐specific diseases causing hindlimb weakness. Insulinoma
Aleutian disease
Disseminated idiopathic myofasciitis
Can this approach be applied in every case?
Summary
Key points
Questions for review
CHAPTER 18 Problem‐based clinical reasoning examples for equine practice
The why
Introduction
Colic (abdominal pain)
Introduction
Define the problem
Define and refine the system
Define the location
Define the lesion
Diagnostic approach to the equine patient with colic
Putting it all together – when to treat and when to refer?
Indications for referral. Pain
Abdominal distension
Absent borborygmi
Gastric reflux
Rectal examination
Abnormal peritoneal fluid
Systemic deterioration
Diarrhoea
Introduction
Define the problem
Define and refine the system
Define the location
Define the lesion
Diagnostic approach to the equine patient with diarrhoea
Coughing. Introduction
Define the problem
Define and refine the system
Define the location
Define the lesion
Diagnostic approach to the equine patient with a cough
Pallor and Anaemia
Introduction
Define the problem
Define and refine the system
Define the location
Define the lesion
Diagnostic approach to the equine patient with anaemia
Other Common Clinical Problems in Equine Practice
Key points
CHAPTER 19 Principles of professional reasoning and decision‐making
The why
Introduction to professional reasoning
Why are professional reasoning skills just as important as clinical reasoning skills?
Define the problem
Analysing the problem according to each stakeholder’s needs
Refining the problem: ongoing communication and collaboration
Solving the problem: identifying, implementing and reviewing the solution
Completing the problem: reflection and analysis
Key points
References
Index
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