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10 axioms to aid your diagnostic skills


2. A reproducible (objective) diagnostic finding (e.g., mild proteinuria; urine/protein creatinine ratio of 4:7; palpable splenic mass; a hematocrit of 15 associated with marked polychromasia; serum potassium concentration of 2.4 mEq/l). If the problem is mild and transient, treatment may not be warranted. However, if it is severe, persistent or progressive, further information usually is warranted to identify its source/cause, and to formulate a prognosis and treatment plan. In addition, it may be useful to repeat appropriate diagnostic procedures to determine if the abnormality is getting better, worse or remaining the same, and to determine the rate of change of the abnormality.

3. A pathophysiologic syndrome (e.g., renal failure, congestive heart failure, hepatic encephalopathy, nephrotic syndrome, or malabsorption syndrome). Problem refinement of this degree requires integration of signs induced by the disease (e.g., polyuria) and the body's compensatory responses to the effects of disease (e.g., polydipsia). Pathophysiologic syndromes are frequently recognized without knowledge of their underlying cause(s). Patients with various pathphysiologic syndromes of unknown cause often benefit from supportive and symptomatic therapy (e.g., in patients with renal failure, correction of deficits and excesses in fluid, electrolyte, nutrient, acid-base, and endocrine balance).

4. A specific diagnostic entity (e.g., immune complex protein-losing glomerulonephropathy and nephrotic syndrome caused by Borrelia bergdorferi; splenic hemangiosarcoma with metastases to the peritoneum, omentum, lungs and heart; congenital intahepatic portovascular shunt with hyperammonemic encephalopathy and ammonium urate urocystoliths). The goal of determining the specific cause(s) of disease is of more than academic interest. Knowledge of the specific cause of an illness is most likely to permit: 1) a more accurate prognosis of the biological behavior of the illness; 2) assessment of the ability of the body to functionally compensate for irreversible damage to various biologic functions; 3) assessment of the availability of specific therapy (in contrast to supportive and symptomatic therapy) to eliminate, halt, or control progression of the underlying cause(s) of the disease (s); and 4) assessment of the need for supportive and/or symptomatic therapy of associated dysfunctions.

Although a specific diagnosis represents the highest level of refinement of the patient's status, it is not always necessary or even desirable to expend the resources or expose the patient to unnecessary risks associated with invasive diagnostic techniques to determine the specific cause of all illnesses.

Examples include self-limiting non-communicable infectious diseases, transient gastrointestinal signs associated with dietary indiscretion, and end-stage organ (hepatic, renal, etc.) failure that has advanced beyond recovery even if the underlying cause is eliminated.

Diagnoses should not be overstated by guessing their underlying causes based on insufficient or faulty evidence. They should be stated at the level of refinement that can be reasonably justified on the basis of current knowledge about the patient. Why? Because if the diagnosis is overstated, misdiagnosis, misprognosis and formulation of ineffective or contraindicated therapy may result. No patient should be worse for having seen the doctor.

What is the meaning of the word iatrogenic? The term iatrogenic contains Greek root word "iatros," which is translated as physician, and the Greek root word "gennan." which means " to create or produce." Dorland's medical dictionary defines iatrogenic as any adverse condition or complication in a patient occurring as a result of treatment by a physician. Because there is no comparable English word for adverse events in patients resulting from treatment by veterinarians, the word iatrogenic has been adopted by our profession. The fact that iatrogenic is considered as a pathophysiologic mechanism of disease emphasizes that there are some patients we cannot help, but there are none we cannot harm.

As is the situation with the research scientist, consistent success of practicing veterinarians in defining and solving patients' problems is dependent on reproducibly collecting, recording, organizing and interpreting clinical data. The problem oriented medical system provides a "blueprint" which all of us in veterinary practice can follow in our efforts to provide proper, timely, and cost-efficient care for our patients.

The problem-oriented veterinary medical record is the focal point of the problem-oriented veterinary medical system, in that relevant information is linked visibly to specific problems (i.e., it is problem-oriented).

It is the antithesis of the chaotic veterinary medical record. The problem-oriented system is a practical clinical method that can be relied upon to guide us toward the correct diagnosis.

by Carl A. Osborne DVM, PhD, Dipl. ACVIM

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.


Source: DVM360 MAGAZINE,
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