Small Animal Medical Diagnosis E-Book

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

Seitenzahl: 772

Veröffentlichungsjahr: 2013

Beschreibung

Small Animal Medical Diagnosis, Third Edition takes a problem-oriented approach to clinical diagnosis and outlines core information necessary to effectively evaluate the major medical problems in dogs and cats. The text starts by defining problems caused by disease and proceeds to integrate the history, physical examination, and diagnostic modalities into a logical approach designed to assist with the medical management of patients. The new edition continues to serve as a vital tool in accurate and appropriate diagnosis for small animal veterinarians, emergency and critical care veterinarians, and veterinary students.

Leseprobe

CONTENTS

CONTRIBUTORS

PREFACE

CHAPTER ONE The Problem-Oriented Approach

Step 1: Database Collection

Step 2: Problem Identification

Step 3: Plan Formulation

Step 4: Assessment and Follow-up

Summary

Suggested Readings

PART ONE General (Polysystemic) Problems

CHAPTER TWO Pyrexia (Fever)

Clinical Vignette

Problem Definition and Recognition

Regulation of Body Temperature

Pathophysiology of Fever

Function of Fever

Diagnostic Plan

Clinical Vignette—Case Summary

References

CHAPTER THREE Disturbances of Food Intake: Anorexia And Polyphagia

Clinical Vignette

Problem Definition and Recognition

Regulation of Food Intake

Anorexia

Polyphagia.

Clinical Vignette—Summary

CHAPTER FOUR Episodic Weakness

Clinical Vignette

Problem Definition and Recognition.

Pathophysiology

Diagnostic Plan

Clinical Vignette—Summary

CHAPTER FIVE Polyuria and Polydipsia

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Minimum Database

Extended Database

Clinical Vignette

Suggested Readings

PART TWO Behavioral Problems

CHAPTER SIX Aggression

Clinical Case

Problem Definition and Recognition

Pathogenesis

Causes

Diagnostic Plan

Suggested Readings

CHAPTER SEVEN Fear, Anxiety, and Compulsive Behavior

Clinical Case

Problem Definition and Recognition

Pathogenesis

Diagnosis

Suggested Readings

PART THREE Conformational Problems

CHAPTER EIGHT Ascites, Peripheral Edema, and Abdominal Distention

Clinical Vignette

Definition and Problem Recognition

Pathophysiology

Diagnostic Plan

Edema

Clinical Vignette—Conclusion

References

CHAPTER NINE Retarded Growth

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Clinical Vignette—Summary

References

CHAPTER TEN Changes in Body Weight: Weight Loss and Obesity

Normal Physiologic Control of Metabolic Rate

Weight Loss

Obesity

Causes of Obesity

Diagnostic Plan—Weight Gain and Obesity

PART FOUR Dermatologic Problems

CHAPTER ELEVEN Pruritus

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette—Summary

CHAPTER TWELVE Primary and Secondary Skin Lesions

Clinical Vignette

Problem Definition and Recognition

Primary Skin Lesions

Secondary Skin Lesions

Clinical Vignette—Case Summary

CHAPTER THIRTEEN Alopecia

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Classification

Diagnostic Plan

Prognosis

Clinical Vignette-Summary

CHAPTER FOURTEEN Disorders of Pigmentation

Clinical Vignette

Problem Definition and Recognition

Normal Skin and Hair Pigmentation

Increased Skin Pigmentation

Decreased Skin Pigmentation

Clinical Vignette—Summary

PART FIVE Hematolymphatic Problems

CHAPTER FIFTEEN Bleeding Disorders

Clinical Vignette

Problem Definition and Recognition

Normal Hemostasis

Pathophysiology

Diagnostic Plan

Clinical Vignette

CHAPTER SIXTEEN Lymphadenopathy

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette—Case Summary

PART SIX Cardiovascular Problems

CHAPTER SEVENTEEN Disturbances of Heart Rate, Rhythm, and Pulse

Normal Anatomy and Physiology

Pathophysiology

Classification

Arterial Pulse Abnormalities

Jugular Veins

Clinical Vignette

References

CHAPTER EIGHTEEN Murmurs and Abnormal Heart Sounds

Clinical Vignette

Problem Definition

Normal Physiology

Pathophysiology

Clinical Associations

Initial Diagnostic Plan

Advanced Cardiovascular Diagnostics

Clinical Vignette—Summary

References

CHAPTER NINETEEN Abnormal Mucous Membranes

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Initial Diagnostic Plan

Extended Diagnostic Plans

Clinical Vignette—Diagnostic Plan and Follow-Up

Suggested Readings

PART SEVEN Respiratory Problems

CHAPTER TWENTY Coughing and Hemoptysis

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Minimum Database

Extended Database

Clinical Vignette

Suggested Reading

CHAPTER TWENTY-ONE Respiratory Distress and Cyanosis

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnosis

Clinical Vignette—Conclusion

Suggested Readings

CHAPTER TWENTY-TWO Syncope

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Minimum Database

Laboratory Evaluation

Extended Database

Clinical Vignette

Suggested Readings

CHAPTER TWENTY-THREE Abnormal Lung Sounds

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Minimum Database

Clinical Vignette

Suggested Reading

CHAPTER TWENTY-FOUR Sneezing and Nasal Discharge

Clinical Vignette

Problem Definition and Recognition

Normal Nasal Structure and Function

Pathophysiology of Nasal Discharge

Diagnostic Plan

Symptomatic Therapy

Clinical Vignette–Case Summary for Rex

Reference

PART EIGHT Digestive Problems

CHAPTER TWENTY-FIVE Ptyalism

Problem Definition and Recognition

Normal Physiology of Saliva Production

Pathophysiology

Initial Diagnostic Plan

Reference

CHAPTER TWENTY-SIX Dysphagia

Clinical Vignette

Problem Definition and Recognition

Physiology of Swallowing

Pathophysiology

Diagnosis

Clinical Vignette

Suggested Readings

CHAPTER TWENTY-SEVEN Regurgitation and Vomiting

Clinical Vignette

Definition

Physiology

Pathophysiology

History and Physical Examination

Diagnostic Plan

Clinical Vignette

Suggested Readings

CHAPTER TWENTY-EIGHT Diarrhea

Clinical Vignette

Definition

Physiology

Pathophysiology

Diagnostic Plan

Clinical Vignette

Suggested Readings

CHAPTER TWENTY-NINE Constipation and Flatulence

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette—Case Summary

CHAPTER THIRTY Abdominal Pain

Problem Definition and Recognition

Pathophysiology

Diagnosis

Suggested Readings

CHAPTER THIRTY-ONE Icterus

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette—Conclusion

References

PART NINE Urologic Problems

CHAPTER THIRTY-TWO Abnormal Micturition: Dysuria, Pollakiuria, and Stranguria

Problem Definition and Recognition

Pathophysiology

Causes

Diagnostic Plan

CHAPTER THIRTY-THREE Discolored Urine

Problem Definition and Recognition

Red Urine

Brown Urine

Miscellaneous Urine Colors

Reference

CHAPTER THIRTY-FOUR Urinary Incontinence

Problem Definition and Recognition

Pathophysiology

Causes

Diagnostic Plan

Nonneurogenic Urinary Incontinence

Neurogenic Urinary Incontinence

REFERENCES

PART TEN Reproductive Problems

CHAPTER THIRTY-FIVE Vaginal and Preputial Discharge

Clinical Vignette

Problem Definition and Recognition

Diagnosis

Preputial Discharge

Clinical Vignette—Summary

Suggested Readings

CHAPTER THIRTY-SIX Abnormalities of the External Genitalia

Problem Definition and Recognition

Abnormalities of the Female External Genitalia

Abnormalities of the Male External Genitalia

Suggested Readings

CHAPTER THIRTY-SEVEN Abortion, Abnormal Estrous Cycle, and Infertility

Abortion

Abnormal Estrous Cycles and Infertility in the Bitch

Abnormal Estrous Cycles and Infertility in the Queen

Infertility in the Male Dog

Infertility in the Tom

Suggested Readings

PART ELEVEN Musculoskeletal Problems

CHAPTER THIRTY-EIGHT Lameness

Clinical Vignette

Problem Recognition and Definition

Pathophysiology

Classification

Diagnosis

Clinical Vignette–Conclusion

CHAPTER THIRTY-NINE Bone, Joint, and Periskeletal Swelling

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnosis

Clinical Vignette—Conclusion

Suggested Readings

CHAPTER FORTY Nociception (“Pain”)

Clinical Vignette

Problem Definition and Recognition

The Neuroanatomy of Pain

Pathophysiology of Pain

Diagnostic Plan

Clinical Vignette—Case Summary

Reference

PART TWELVE Neurologic Problems

CHAPTER FORTY-ONE Paresis or Paralysis

Clinical Vignette

Problem Definitions and Recognition

Pathophysiology

Diagnostic Plan

Prognosis

Conclusion to Clinical Vignette

References

CHAPTER FORTY-TWO Ataxia

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Prognosis

Conclusion to Clinical Vignette

References

CHAPTER FORTY-THREE Head Tilt

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Prognosis

Clinical Vignette—Conclusion

Reference

Suggested Readings

CHAPTER FORTY-FOUR Collapse (Seizures, Syncope, Cataplexy, and Narcolepsy)

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette Answers and Conclusion

References

CHAPTER FORTY-FIVE Stupor and Coma

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Prognosis

Clinical Vignette—Conclusion

References

PART THIRTEEN Special Sensation Problems

CHAPTER FORTY-SIX Blindness

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnosis

Clinical Vignette—Case Summary

CHAPTER FORTY-SEVEN Anisocoria

Clinical Vignette 1—Initial Presentation

Clinical Vignette 2—Initial Presentation

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette 1—Diagnosis and Treatment

Clinical Vignette 2—Diagnosis and Treatment

CHAPTER FORTY-EIGHT Nystagmus and Strabismus

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnosis

Clinical Vignette—Case Summary

Reference

CHAPTER FORTY-NINE Loss of Corneal Transparency

Clinical Vignette—Initial Presentation

Problem Definition

Pathophysiology

Corneal Disease

Clinical Vignette—Diagnosis and Treatment

CHAPTER FIFTY Abnormal Anterior Chamber

Clinical Vignette 1—Initial Presentation

Clinical Vignette 2—Initial Presentation

Problem Definition

Pathophysiology

Anterior Chamber Abnormalities

Clinical Vignette 1—Diagnosis and Treatment

Clinical Vignette 2—Diagnosis and Treatment

CHAPTER FIFTY-ONE Abnormal Lens

Clinical Vignette 1—Initial Presentation

Clinical Vignette 2—Initial Presentation

Problem Definition and Recognition

Pathophysiology

Lens Disease

Clinical Vignette 1—Diagnosis and Treatment

Clinical Vignette 2—Diagnosis and Treatment

Reference

CHAPTER FIFTY-TWO Anosmia—Loss of Olfaction

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette

CHAPTER FIFTY-THREE Deafness

Clinical Vignette

Problem Definition and Recognition

Pathophysiology

Diagnostic Plan

Clinical Vignette

PART FOURTEEN Laboratory-Defined Problems

CHAPTER FIFTY-FOUR Hematologic Problems

Anemia

Erythrocytosis (Polycythemia)

Leukocyte Concentration Abnormalities

Platelet Concentration Abnormalities

CHAPTER FIFTY-FIVE Abnormalities of the Standard Biochemical Profile

Increased Blood Urea Nitrogen

Decreased Blood Urea Nitrogen

Increased Creatinine

Decreased Serum Creatinine

Hyperalbuminemia

Hypoalbuminemia

Hyperglobulinemia

Hypoglobulinemia

Increased Serum Alanine Aminotransferase

Decreased Serum Alanine Aminotransferase

Increased Serum Alkaline Phosphatase

Decreased Serum Alkaline Phosphatase

Increased Serum Aspartate Aminotransferase

Decreased Serum Aspartate Aminotransferase

Increased Serum Creatine Kinase

Decreased Serum Creatine Kinase

Increased Serum Gamma Glutamyltransferase

Decreased Serum Gamma Glutamyltransferase

Increased Serum Total Bilirubin

Decreased Serum Total Bilirubin

Increased Serum Glucose

Decreased Serum Glucose

Increased Serum Amylase

Decreased Serum Amylase

Increased Serum Lipase

Decreased Serum Lipase

Hypernatremia

Hyponatremia

Abnormality Hyperchloremia

Hypochloremia

Hyperkalemia

Pathophysiology

Hypokalemia

Hypercalcemia

Hypocalcemia

CHAPTER FIFTY-SIX Problems Identified on Urinalysis

Physicochemical Abnormalities

Urine Sediment Abnormalities

CHAPTER FIFTY-SEVEN Abnormal Blood pH, Anion Gap, and Blood Gases

Acid–Base Disturbances

Index

Edition first published 2009

© 2009 Blackwell Publishing

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell.

Editorial Office

2121 State Avenue, Ames, Iowa 50014-8300, USA

For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book, please see our website at www.wiley.com/wiley-blackwell.

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting Service are ISBN-13: 978-0-8138-1338-7/2009.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Disclaimer

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Small animal medical diagnosis / [edited by] Michael D. Lorenz, Mark Neer, Paul L. Demars. – 3rd ed.p.

Includes bibliographical references and index.

ISBN 978-0-8138-1338-7 (pbk. : alk. paper) 1. Dogs–Diseases–Diagnosis. 2. Cats–Diseases–Diagnosis.

3. Veterinary medicine–Diagnosis. I. Lorenz, Michael D. II. Neer, Mark. III. Demars, Paul L.

[DNLM: 1. Dog Diseases–diagnosis. 2. Cat Diseases–diagnosis. SF 985 S635 2009]

SF991.S592 2009

636.089′6075–dc22

2009014915

A catalog record for this book is available from the U.S. Library of Congress.

1 2009

This book is dedicated to Dr. Larry Weed and our many colleagueswho have championed the problem-oriented method of medical diagnosisand to those students and practitionerswho have faithfully applied the process in their daily practiceof veterinary medicine

CONTRIBUTORS

Robin W. Allison, A.A.S., D.V.M., Ph.D. Diplomate, American College of Veterinary Pathologists; Assistant Professor, Department of Veterinary Pathobiology, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Jude Bordelon, B.S., D.V.M. Resident—Small Animal Surgery, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Mary H. Bowles, D.V.M. Diplomate, American College of Veterinary Internal Medicine—SA Internal Medicine; Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Charles C. Broaddus, D.V.M., PhD. Diplomate, American College of Veterinary Theriogenologists; Resident—Theriogenology, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Kristy Broaddus, D.V.M. Diplomate, American College of Veterinary Surgeons; Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Jill D. Brunker, D.V.M. Diplomate, American College of Veterinary Internal Medicine—SA Internal Medicine; Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Paul L. DeMars, B.S., D.V.M. Diplomate, American Board of Veterinary Practitioners—Canine/Feline; Clinical Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Margi A. Gilmour, B.S., D.V.M. Diplomate, American College of Veterinary Ophthalmologists; Associate Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Marjorie E. Gross, B.S., M.S., D.V.M. Diplomate, American College of Veterinary Anesthesiologists; Clinical Associate Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

G. Reed Holyoak, B.S., M.S., D.V.M. Diplomate, American College of Veterinary Theriogenologists; Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

John P. Hoover, D.V.M. Diplomate, American College of Veterinary Internal Medicine—SA Internal Medicine; Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Michael D. Lorenz, B.S., D.V.M. Diplomate, American College of Veterinary Internal Medicine—SA Internal Medicine; Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Chelsea Makloski, D.V.M. Resident—Theriogenology, Oklahoma State University, Stillwater, Oklahoma

Emily L. Medici, D.V.M. Resident—Small Animal Internal Medicine, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

James H. Meinkoth, D.V.M., M.S., PhD. Diplomate, American College of Veterinary Pathologists; Professor, Department of Veterinary Pathobiology, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Gregor L. Morgan, M.V.S., B.V.Sc., PhD. Diplomate, American College of Veterinary Theriogenologists; Associate Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

T. Mark Neer, D.V.M. Diplomate, American College of Veterinary Internal Medicine—SA Internal Medicine; Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Jennifer L. Peters, D.V.M. Diplomate, American Board of Veterinary Practitioners—Canine/Feline; Clinical Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Nicole Ponzio, B.S., M.S., D.V.M. Diplomate, American College of Veterinary Internal Medicine—Cardiology; Clinical Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Theresa E. Rizzi, D.V.M. Diplomate, American College of Veterinary Pathologists; Clinical Assistant Professor, Department of Veterinary Pathobiology, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

Chris Schreiber, D.V.M. Resident—Theriogenology, Oklahoma State University, Stillwater, Oklahoma

Justin D. Thomason, D.V.M. Diplomate, American College of Veterinary Internal Medicine—SA Internal Medicine; Assistant Professor, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma

PREFACE

The problem-oriented process and corresponding medical record was introduced to veterinary medical education in the early 1970s. The problem-oriented process was the inspiration for Small Animal Medical Diagnosis. The first edition was introduced in 1987 and the second edition was published in 1993. The third edition continues the format of the first and second editions. Information has been updated and diagnostic plans have been refined or revised on the basis of new information or development of new diagnostic techniques and tests. Clinical case vignettes have been added to most chapters to demonstrate the process in action on clinical cases.

Small Animal Medical Diagnosis is organized and written in a problem-oriented format similar to the instructional philosophy of the problem-oriented veterinary medical record. The book contains the core information necessary to effectively evaluate the major medical problems in dogs and cats. It relates clinical signs to the pathophysiological mechanisms of disease and describes the appropriate diagnostic plans for clinical problems.

Small Animal Medical Diagnosis is an excellent textbook for veterinary students and practitioners who need assistance in formulating diagnostic plans for their cases. The book is not an encyclopedia of diseases. This is a book that first defines problems that are caused by disease and then proceeds to integrate the history, physical examination, and the diagnostic modalities into a logical approach to medical management of patients.

The editors are indebted to our colleagues at Oklahoma State University for their contributions to this book. We extend our appreciation to the staff of John Wiley & Sons for their assistance in the development of the third edition.

Michael D. Lorenz, B.S., D.V.M.

T. Mark Neer, D.V.M.

Paul L. DeMars, B.S., D.V.M.

CHAPTER ONE

The Problem-Oriented Approach

Michael D. Lorenz

During the 1960s, the problem-oriented medical record (POMR) was introduced in medical practice by Dr. Larry Weed. Dr. Weed developed a system of clinical problem solving that linked components of the medical record to the patient via “problems” or clinical signs. The POMR encouraged the physician to employ sound logic in patient evaluation and it provided a logical structure for displaying medical data, plans, and outcomes. In the early 1970s, the POA (problem-oriented approach) and POMR were adopted by the faculty at the University of Georgia for use in the veterinary teaching hospital. Since then, the POA and the POMR have been adopted by most veterinary colleges in North America. It has largely replaced the differential diagnosis approach, but elements of differential diagnosis are employed in the POA.

The basic tenet of the POA is that disease alters anatomy and function to cause clinical signs, which are called “problems” in the POA system. Emphasis is placed on accurate problem identification and a clear understanding of the pathophysiology that create each problem. When the underlying pathophysiology is understood, specific diseases that cause the problem are more quickly recalled. It is useful to first identify categories of disease for each problem and then list specific diseases for a category. The major categories of disease can be recalled by using the acronym DAMNIT-V, where each letter stands for a specific category of disease. The acronym is presented in Table 1-1. In the POA, specific etiologies or diseases are called “rule-outs.” The most appropriate diagnostic procedures needed to rule in or rule out each suspected cause are coupled with each rule-out.

The clinical reasoning process utilized in the POA is based on four steps: (1) database collection, (2) problem identification, (3) plan formulation, and (4) assessment and follow-up.

Step 1: Database Collection

The initial database should contain the information necessary to allow identification of all problems in the patient. The contents of the database for any particular animal should be specified in advance. This is called the “guaranteed” database, and it is collected on each and every animal. The content of the guaranteed data is often debated, but there is agreement that the minimum guaranteed database must always include a complete history and complete physical examination. In older animals, a strong argument can be made to include a complete blood count, biochemical profile, and urinalysis. These diagnostic procedures can be viewed as an extension of the physical examination since they broadly screen several body systems.

TABLE 1-1. Diagnostic acronym—the DAMNIT-V scheme

In this book, the problems discussed are largely identified from the history and physical examination. A problem-specific database is the information necessary (from diagnostic tests and procedures) to properly evaluate the rule-outs for a specific problem. In each of the following chapters, a specific problem is presented and the rule-outs and diagnostic procedures for that problem are discussed.

History

The history is the first component of the database. Clinicians and students are encouraged to take a complete history and to resist the temptation to substitute diagnostic tests for a thorough history. The history alerts the clinician to the presence of potential problems that need to be explored in depth on the physical examination. First, the chief compliant is determined. This complaint is pursued in depth, noting any additional problems and their chronological development. All medications are listed since treatment often alters the normal progression of signs that would indicate organ or system dysfunction. See Figure 1-1 for an example of a form used to record the history.

Physical Examination

The physical examination is the second and most important component of the database. Problems not identified in the physical examination are usually also missed when invasive or expensive diagnostic tests are performed. The assessment of laboratory tests involves correlation with the history and physical examination findings. A complete physical examination takes about 15 minutes. Each body system is examined with special attention given to those body systems in which dysfunction is suspected from the history. Ocular and neurologic examinations take more time and frequently are slighted during the physical examination. A physical examination form should be followed that stresses a complete review of body systems (see Figure 1-2). Abnormalities are recorded for each system. Special examination forms for the integumentary system, eye, and nervous system are very helpful and reduce writing time.

Step 2: Problem Identification

The second step in clinical problem solving is problem identification. A problem is defined as any abnormality requiring medical or surgical intervention or one that interferes with the quality of life. Problems should be stated at their current level of understanding. An overstated problem may cause expensive, invasive, or needless diagnostic tests to be performed.

FIGURE 1-1. History form—an example of a form for recording the medical history in a problem-oriented medical record.

Problems identified in the history need to be documented, since the owner’s observations may be erroneous. Problems are numbered consecutively and dated chronologically on a separate form called the master problem list (MPL; see Figure 1-3). As additional problems are identified, they are dated and assigned the next number.

The POMR couples all notations in the medical record to numbered problems listed on the MPL. The MPL is placed in the front of the medical record where it serves as a table of contents that directs the care of the patient. Problems can be redefined to a higher level of understanding, or they may be combined with other problems. Clinical problem solving has problem resolution as the primary goal. Problems may be resolved, updated, or combined with other problems to a specific diagnosis or only resolved therapeutically. Problems can be inactivated when no further diagnostic or therapeutic action is warranted but resolution has not occurred.

FIGURE 1-2. Physical examination form—an example of a form used to systematically record physical examination findings.

FIGURE 1-3. Master problem list—a form used to list the problems identified in the patient. Note that each new problem is numbered and dated. Space is provided to record health maintenance. The master problem list serves as the table of contents for the medical record.

Step 3: Plan Formulation

Once the problems are identified and listed on the MPL, an initial plan is developed and implemented. It is recorded in the medical record. The initial plan is a critical step in patient management since it dictates medical action for the first 24–48 hours. The plan has three components: (1) a diagnostic section, (2) a therapeutic section, and (3) a client/owner education section. Each section is described in subsequent sections.

The Diagnostic Plan

A diagnostic plan is formulated and written for each problem (see Figure 1-4). The plan should be organized with the most important or serious problems listed first. Potential causes (called rule-outs in the POMR) are listed for each problem with priority given to the most likely causes. Diagnostic procedures for each rule-out are listed. In this manner, clinical reasoning is displayed and can be audited. The clinician has stated his or her thought process: that is, “Here are the problems I have identified,” “These are the most likely causes (rule-outs) in my opinion,” and “I will perform these diagnostic procedures to test my hypothesis.” When displayed in the POMR, the clinical reasoning process can be quickly audited.

FIGURE 1-4. Initial plan form—a form used to record the initial plan in a problem-oriented format.

Developing a well-founded diagnostic plan is the subject for each chapter of this book. The POA emphasizes the management of problems through knowledge of their mechanisms and causes. By listing the problems, interrelationships can be more easily elucidated. A rule-out that appears in the diagnostic plan for more than one problem should be highly suspected as the primary diagnosis and diagnostic tests should be directed at that condition.

The management of certain problems involves the collection of data beyond that contained in the initial database. This collection of data is called a problem-specific database. It includes tests or procedures that help establish the cause and the metabolic or biochemical consequences of the problem(s). Clinical algorithms are sequential steps in clinical reasoning on the basis of the results of the problem-specific database. Clinical algorithms are used in this book to display the logical progression of problem management. “Perfect” algorithms do not exist. Therefore, understanding the reasons for each decision is important. Algorithms are very useful in medical management, since it is impossible to remember all the causes of specific problems.

Therapeutic Plan

Therapy is coupled with the problem it is intended to resolve or help. This provides a method to audit the logic of treatment. During the formulation of the initial plan, a clinician must weigh the possible benefits of symptomatic therapy against the alterations that therapy might cause in laboratory test results or progression of signs that may be important to diagnosis. Serum should be saved prior to therapy for future biochemical or immunologic tests.

Client/Owner Education

This section of the initial plan describes the information given to clients about their animal’s problems, diagnostic tests, cost, and prognosis.

Step 4: Assessment and Follow-up

Step 4 is the assessment of data collected from the initial plan (or the problem-specific database). The results are correlated with the history and physical findings and compared to the list of rule-outs for each problem. In this manner, the clinician is assessing the hypothesis stated in the initial plan. The assessment should be written in the medical record in relationship to each problem and should accurately interpret the results of diagnostic tests or procedures. The assessment should explain the logic for changes in the MPL.

Follow-up represents actions to be taken on the results of the initial plan or daily plans. In the POMR, follow-up is maintained in daily progress notes (see Figure 1-5). Progress notes contain three sections and are written in a problem-oriented manner; that is, information is grouped according to the problem it affects. Section 1 is for new or additional data, section 2 is the assessment, and section 3 is for follow-up plans. Plans always have three components: a diagnostic section, a therapeutic section, and a client/owner education. When information is properly organized according to the MPL, auditing the medical record for appropriate decisions and medical action is enhanced.

FIGURE 1-5. Progress notes—a form used to assess and follow-up care of a patient that is either hospitalized or for one that is returning for continuing care on a regular basis.

Summary

The POA to medical management is based on logical concepts. Disease creates clinical signs or problems. When problems are logically managed, the underlying cause(s) can be identified. The POA is not a new system; it follows the same logic that astute clinicians have used for many years in developing a differential diagnosis. In the differential diagnosis method, problem solving is done mentally. The POMR provides a structured format for the display of an old system of medical management. It is no panacea for sloppy medical records or poor clinical reasoning. It will not correct the problems created by superficial histories or incomplete physical examinations. It is a system that functions well when all steps are meticulously followed.

This is a book about problems: how they are identified, why they occur, what diseases are ultimately responsible, and they are logically pursued. It is not a book about specific diseases, which are amply covered in other textbooks. When the knowledge of disease is coupled with the knowledge of problems, the clinical reasoning process operates at its highest level.

The POA is a logical way to think about diagnosis and patient management. A POMR is not necessary for a clinician to think in terms of “problem solving.” However, when the POMR is used, it forces one to use a logical problem-solving approach. The POA is especially beneficial in the clinical training of students.

Suggested Readings

Weed, L.L. 1964. Medical records, patient care, and medical education. Ir J Med Surg 6:271–282.

Weed, L.L. 1968. Medical records that guide and teach. N Engl J Med 278:593–600.

PART ONE

General (Polysystemic) Problems

CHAPTER TWO

Pyrexia (Fever)

Emily L. Medici and Michael D. Lorenz Clinical Vignette

Clinical Vignette

History

BoBo is a 5-year-old neutered, short-haired domestic male cat. During the past 3–4 weeks, he has a very poor appetite and has lost 2–3 lb. There is no vomiting, diarrhea, sneezing, or coughing. BoBo is mostly inside and has received vaccinations every year for panleukopenia, upper respiratory viruses, and feline leukemia. He is occasionally boarded with another veterinarian. There is one other cat in the household that is not affected.

Physical Examination

The temperature was 104.2°F; the heart rate was 140 bpm; the respiratory rate was 45 rpm; the mucous membranes were pink; and the capillary refill time was less than 3 seconds. BoBo is thin and depressed. No other abnormalities were detected.

Using the problem-oriented format, identify the problems in BoBo and write an initial plan for each.

Problem Definition and Recognition

Pyrexia or fever is a pathologic increase in body temperature above the normal range occurring in a wide variety of pathogenic conditions. Hyperpyrexia is a fever greater than 105°F. An intermittent fever is one in which the temperature becomes normal but then rises again each day. A remittent fever is characterized by marked variation in temperature level each day with the lowest temperature level still remaining above normal. A relapsing fever has periods of increased temperature distributed among periods of one or more days of normal temperature. A septic fever has large daily oscillations in body temperature (Lorenz 2006).