Clinical Reasoning in Small Animal Practice E-Book

Jill E. Maddison

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 358

Veröffentlichungsjahr: 2015

Beschreibung

Clinical Reasoning in Small Animal Practice presents a revolutionary approach to solving clinical problems. As a veterinarian, especially as a student or new graduate, a ten minute consultation in a busy small animal practice can be a daunting task. By guiding you to think pathophysiologically, this book will help solve clinical problems as efficiently as possible. The authors set out a structured approach with easy to remember rules which can be applied to most clinical signs small animals present with. This reduces the need to remember long lists of differentials and avoids the potential of getting trapped by a perceived obvious diagnosis. The book will help to unlock your potential to solve clinical problems. It also provides a logical rationale for choosing diagnostic tests or treatments which can be clearly communicated to the owner.

Written by internationally renowned clinicians and educators in clinical reasoning, key features of the book include:

• An easy to remember and logical approach to solving a wide range of clinical problems encountered in small animal medicine and neurology
• An invaluable resource for every level of learner, from student to experienced practitioner
• Flowcharts and key step markers throughout help illustrate the decision making process

Clinical inductive reasoning offers you the ability to solve cases more efficiently, resulting in better treatment and care for pets and happier owners. Clinical Reasoning in Small Animal Practice will help turn a terrifying case into a manageable one!

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Contributors

Author affiliations

Foreword writer affiliations

Contributor affiliations

Foreword

References

Acknowledgement

Chapter 1: Introduction to problem-based inductive clinical reasoning

Why are some cases frustrating instead of fun?

Solving clinical cases

Essential components of problem-based clinical reasoning

The problem-based approach

What do I need to do to define the problem, system, location or lesion?

In conclusion

Chapter 2: Vomiting and regurgitation

Physiology

Assessment of the patient reported to be vomiting

Diagnostic approach to the patient reported to be vomiting

In conclusion

Chapter 3: Diarrhoea

Classification of diarrhoea

Diagnostic approach to the patient with diarrhoea

In conclusion

Chapter 4: Weight loss

Weight loss due to decreased appetite

Weight loss with normal or increased appetite

In conclusion

Chapter 5: Abdominal enlargement

Fluid characterisation

In conclusion

Chapter 6: Weakness

Initial assessment of the weak patient

Diagnostic approach

In conclusion

Chapter 7: Fit, collapse or strange episodes

Introduction

In conclusion

Chapter 8: Sneezing, dyspnoea, coughing and other respiratory signs

Sneezing and nasal discharge

Dyspnoea with minimal coughing

Coughing

Coughing with minimal dyspnoea

Coughing accompanied by dyspnoea

Haemoptysis

Cyanosis

Conclusion

Chapter 9: Anaemia

Assessment of anaemia

Diagnostic approach to acute or regenerative anaemia

Regenerative anaemia

Non-regenerative anaemia

In conclusion

Chapter 10: Jaundice

Physiology

Causes of jaundice

Differentiating causes of jaundice

In conclusion

Chapter 11: Bleeding

Diagnostic approach to the bleeding patient

Local disorders

Systemic bleeding disorders

In conclusion

Chapter 12: Polyuria/polydipsia and/or impaired urine concentration

Pathophysiology

Diagnostic approach to the patient with PU/PD or impaired urine concentration

In conclusion

Chapter 13: Gait abnormalities

Introduction

Differentiating musculoskeletal from neurological gait abnormalities

Conclusion

Chapter 14: Pruritus and scaling

Introduction

Pruritus

Scaling

In conclusion

Index

End User License Agreement

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Guide

cover

Table of Contents

Foreword

Begin Reading

List of Illustrations

Figure 2.1

Figure 7.1

Figure 7.2

Figure 7.3

Figure 7.4

Figure 7.5

Figure 9.1

Figure 9.2

Figure 9.3

Figure 10.1

Figure 11.1

Figure 11.2

Figure 13.1

Figure 13.2

Figure 13.3

Figure 13.4

Figure 14.1

Figure 14.2

List of Tables

Table 2.1

Table 2.2

Table 3.1

Table 3.2

Table 3.3

Table 3.4

Table 6.1

Table 6.2

Table 6.3

Table 7.1

Table 7.2

Table 7.3

Table 7.4

Table 7.5

Table 7.6

Table 9.1

Table 11.1

Table 12.1

Table 12.2

Table 12.3

Table 13.1

Table 13.2

Table 13.3

Clinical Reasoning in Small Animal Practice

Jill E. Maddison

Director of Professional Development, Extra Mural Studies and General Practice Department of Clinical Science and Services The Royal Veterinary College

Holger A. Volk

Professor of Veterinary Neurology & Neurosurgery Department of Clinical Science and Services The Royal Veterinary College

David B. Church

Vice Principal for Learning and the Student Experience The Royal Veterinary College

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Library of Congress Cataloging-in-Publication Data

Maddison, Jill E., author.

Clinical reasoning in small animal practice/Jill E. Maddison, Holger A. Volk, David B. Church.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-74175-7 (pbk.)

1. Veterinary medicine–Diagnosis. I. Volk, Holger A., author. II. Church, David B., author. III. Title.

[DNLM: 1. Animal Diseases–diagnosis. SF 771]

SF772.6.M33 2015

636.0896075–dc23

2014042409

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: [Production Editor to insert]

Cover design by [Production Editor to insert]

Contributors

Author affiliations

Dr. Jill E. Maddison BVSc, DipVetClinStud, PhD, FACVSc, MRCVS

Director of Professional Development, Extra Mural Studies and General Practice

Department of Clinical Science and Services

The Royal Veterinary College

Professor Holger A. Volk DVM, PGCAP, DipECVN, PhD, FHEA, MRCVS

Professor of Veterinary Neurology & Neurosurgery

Department of Clinical Science and Services

The Royal Veterinary College

Professor David B. Church BVSc, PhD, MACVSc, FHEA, MRCVS

Vice Principal for Learning and the Student Experience

The Royal Veterinary College

Foreword writer affiliations

Professor Stephen May MA, VetMB, PhD, DVR, DEO, FRCVS, DipECVS, FHEA

Deputy Principal

The Royal Veterinary College

Contributor affiliations

Mr Elvin R. Kulendra BVetMed, MVetMed, CertVDI, DipECVS, MRCVS

Lecturer in Small Animal Surgery

Department of Clinical Science and Services

The Royal Veterinary College

Dr. Andrea V. Volk Dr.med.vet, MVetMed, DipECVD, MRCVS

Staff Clinician in Veterinary Dermatology

Department of Clinical Science and Services

The Royal Veterinary College

Foreword

Although clinical reasoning and decision making are central to the veterinarian's ( similar to the physician's) role, the process seems to be less well understood and associated with more erroneous statements about it in veterinary educational circles than any other of the skills we expect practitioners to possess. In an era that rightly prides itself on an evidence-based approach to medicine, it is surprising the way that increased repetition of statements such as ‘students should not engage in pattern recognition’, ‘scientific method is used to reach diagnosis’, ‘analytical approaches are more accurate than pattern recognition’ and ‘at least with objective data you do not get biased interpretation’ has led to them being accepted, even by those responsible for the education of the next generation of our profession.

In this book, Dr. Maddison and her colleagues aim to put the record straight through their clear description of their ‘Logical Approach to Clinical Problem Solving’ in the context of small animal practice. Their ideas have evolved from a combination of direct experience of the challenges of their different personal caseloads over many years and their reflections on how best to understand their expertise so that their methods could be explained to students in both the classroom and the clinic. However, with advances in our understanding of the way our brains work, we can increasingly link such insights to the approaches advocated in this book. We know that our processes of reasoning can be grouped into two categories (Evans 2003, 2012): type I (sometimes referred to as pattern recognition) and type II (analytical). Where possible in our lives, we try to use type I in making decisions, as it is rapid and efficient. It relies on our memory of similar problems encountered in the past, and, if we correctly apply such patterns, it is at least as accurate as analytical reasoning. However, our impulse for speed and efficiency, particularly in our busy modern world, can easily trap us into ‘cognitive miserliness’ (Stanovich 2009) where we do not take note of any lack of fit of our repertoire of patterns. In such circumstances, faced with ‘high stakes’ decisions such as the life and well-being of a patient, it is vital we cross-check our initial conclusions with an analytical approach, as this book emphasises (Ark et al. 2007).

Many continue to suggest that the analytical approach to clinical reasoning is ‘scientific’, involving hypothesis testing, but this is misleading. Scientific method involves us creating and testing hypotheses by predicting data and, subsequently, following an experiment, making observations on whether our predictions are correct. This has been called ‘backwards reasoning’. It is extremely robust in the contexts in which it is relevant, but, particularly in primary care settings, where the number of possible diagnoses in an individual patient is large, such an approach quickly leads to cognitive overload. Even if a practitioner can persist in applying a hypothetico-deductive scientific approach, at this point, it is undermined by the very features that are meant to make it robust. The size of the potential data sets generated renders our decision making less accurate, and for novices, it can lead to ‘paralysis by analysis’, with a failure to act even when action is essential (Croskerry et al. 2014).

From observations of clinicians working with real and paper-based cases, clinical reasoning is an inductive process, working forward from data to diagnosis (Patel et al. 2005). This is the systematic approach adopted in this book, and it makes explicit for those starting to work with cases, and those who are more experienced, the intervening steps. In contrast to a backwards approach, which tends to fail to develop pattern recognition, this repeated use of systematic forward reasoning also helps to lay down structured patterns for future use (Sweller 1988). At an early stage, it is important to contain the size of the data set, and this is achieved by clustering signs to clarify the organ system (or systems) involved and how it is affected (Auclair 2007). Only then should we start to think about provisional diagnoses, and then this list will be much shorter than the series of lists, based on consideration of each clinical sign separately, that advocates of a ‘scientific approach’ have promoted in the past.

William Osler wrote that medicine is the ‘practice of an art which consists largely in balancing possibilities (Osler 1910)… It is a science of uncertainty and an art of probability… Absolute diagnoses are unsafe and made at the expense of conscience’ (quoted in Bean 1968). His insight from 100 years ago reminds us that our diagnoses frequently remain provisional, in the sense that they are based on likelihood and may need to be modified as new information comes to light. Our approach is Bayesian, in the sense that these provisional diagnoses provide a prior probability in advance of further tests that we may undertake. Such tests can then be chosen on the basis that their result may increase the probability of our provisional diagnosis being correct. As a result of limitations of sensitivity and specificity, used in ‘screening’ mode, these tests can fail to detect many cases as well as yielding many false positive results. However, following a good clinical work-up and used in ‘diagnostic mode’, well-chosen tests can make us more confident in our diagnosis and plan to manage a case, still recognising that even with all the technology we possess, ‘absolute diagnoses are made at the expense of conscience’.

Donald Schön, in his seminal work ‘The Reflective Practitioner’, uses two memorable images. He talks about specialist (academic) practice as occupying ‘high, hard ground, overlooking a swamp’ where it may be possible to solve problems with scientific approaches, and ‘swampy lowland’ where problems often appear messy and unclear, and where traditional scientific methods cannot apply (Schon 1983, p. 42). This book is meant for, and highly recommended to, all those who practice in the swamps! Another image Schön uses is of the expert pianist who tells a student that they need to modify their playing but cannot immediately say how (Schön 1995). The pianist has to sit at the piano and play the section to recognise the fingering that is required. The difficulty of the expert unpicking the detail of thinking processes that have become automatic, to teach them to others, is well known and can lead to misinterpretation, based on incorrect rationalisations of the processes involved. Therefore, this book is also highly recommended for all experienced practitioners keen to understand how their minds work, in order to support the learning of others in an evidence-based and proven way.

Stephen May

References

Ark, TK., Brooks, LR. and Eva, KW. The benefits of flexibility: the pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies.

Medical Education

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:281–287, 2007.

Auclair, F. Problem formulation by medical students: an observation study.

BMC Medical Education

7

:16, 2007.

Bean WB.

Sir William Osler: aphorisms from his bedside teachings and writings

. 3rd ed Springfield, IL: Charles C Thomas; 1968, p 129.

Croskerry, P., Petrie, DA., Reilly, JB. and Tait, G. Deciding about fast and slow decisions.

Academic Medicine

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:197–200, 2014.

Evans, JStBT. In two minds: dual-process accounts of reasoning.

Trends in Cognitive Sciences

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:454–459, 2003.

Evans, JStBT. Spot the difference: Distinguishing between two kinds of processing.

Mind and Society

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:121–131, 2012.

Osler W. Teacher and Student. In

Aequanimitas, with other addresses to medical students, nurses and practitioners of medicine

. Philadelphia, PA: P Blakiston; 1910, p. 40.

Patel, VL., Aroche, JF. and Zhang, J. Thinking and reasoning in medicine, in K. Holyoak

Cambridge Handbook of Thinking and Reasoning

. Cambridge University Press, 2005. pp. 727–750.

Schon, DA.

The reflective practitioner: how professionals think in action

. San Francisco: Jossey-Bass; 1983.

Schon, DA. Knowing-in-action: the new scholarship requires a new epistemology.

Change: The Magazine of Higher Learning

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(6), 26–34, 1995.

Stanovich, KE. Rational and irrational thought: the thinking that IQ tests miss.

Scientific American Mind

, November/December, pp 34–39, 2009.

Sweller, J. Cognitive load during problem solving: effects on learning.

Cognitive Science

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:257–285, 1988.

Acknowledgement

We would like to thank our students, past and present, undergraduate and postgraduate, as well as practising veterinarians around the world who have worked with us. All have helped shape and inspire our teaching and learning around the concepts of clinical problem solving. We would also like to thank our colleagues Lucy McMahon, Ruth Serlin, Fran Taylor-Brown, Jane Tomlin and Martin Whiting for reviewing and providing insightful advice on early drafts of various chapters. And last, but by no means least, we are indebted to David Watson and Brian Farrow; without their insight, vision and inspiration, the wonderful journey this book represents would not have been possible.