|A PROBLEM is anything that has required, does require, or may require health care management.|
|Verify -- Localize -- Disease Process -- Specific Disease|
If you remember these four steps in the approach to all patient's problems it will serve you well. In creating a set of hypotheses about what may be causing a problem (i.e. formulating a differential diagnosis) it is tempting to skip forward to disease process (DAMNIT). Resist this temptation until you consider localization of the problem. In the handout from Dr. Squires it mentions definition of a body system. This is not the only way to localize problems. Many problems, in fact, are localized mechanistically.
|decreased production||**||prerenal||**||prehepatic (hemolysis)|
|compensatory||**||post renal||**||post hepatic|
Chapter 3 of Ettinger is great for this.
Understanding disease processes is critically important for clinicians, but localizing problems is much more helpful in pointing diagnosticians along the right diagnostic path.
And something for all you dog aficionados....
"Not only is life a bitch, it has puppies." - Adrienne E. Gusoff
Case Signalment: K9 5 yo, f/s, Miniature Schnauzer "Tessa"
Hx/PE: Tessa ate a pork chop 2 days ago. Approximately 8 hours ago, he became depressed and started vomiting. She has vomited a clear, yellow fluid 6 to 8 times. She is completely anorexic now. She has no previous medical illness or surgery except for spay after one litter at 3 years of age. She has had no known adverse drug reactions nor is there any history of trauma or toxin exposure. She is an indoor dog and current on vaccinations and heartworm preventative. She eats Kibbles and Bits free choice and some people food. No C/S/D/PUPD.
PE: 10 kg. QAR, 7%deH2O, T=102.0, P=140, R=40, mm-pink, 1-2 sec
2cm SC soft mass on the right flank
tense abdomen, resentful of palpation
no other abnormal findings
1. Vomiting (ch by anorexia, deH2O, abdominal pain, depression)
2. Subcutaneous mass (right flank)
(this is what you do after you've seen the patient in the exam room)
|1. vomiting||primary GI (eg. obstruction, inflammation, toxic)|
vs. secondary GI (pancreatic, renal, adrenal, hepatic)
|abdominal rads, pretx CBC, UA, chem panel w/ lipase||NPO, IV LRS (700 cc replace, 600 cc maint., 100 cc ong. loss)||need supportive care, minimal dx risk|
|2. subcutaneous mass||inflammation; benign or malignant neoplasia, trauma||FNA w/ cytology||none||pending results|
|S||Tessa has not changed appreciably in since this morning attitude. She is depressed, but responsive and resting comfortably in her cage. She vomited small amount of fluid only once today.|
|O||TPR - normal|
Abnormal Labs: ALB 4.5, ALP 298, ALT 310, AMY 6900 U/L, T.BILI 3.2, LIPASE 7400 U/L, TP 9.9, Na 139, Cl 99
WBC 19,500/Bands 2,950 (mild toxic change), Hct 58.6
UA shows moderate bacteruria, USG=1.058, 2+ bili
RADS: fluid and gas-filled stomach, poor contrast R upper quadrant
|A||The laboratory data are consistent with secondary GI, specifically acute pancreatitis. The amylase, lipase and radiographic findings are supportive. The elevated ALT, ALP, Tbili suggest either inflammation to the liver or probably post-hepatic jaundice associated with inflammatory swelling impeding bile flow through the bile duct. The hyponatremia and hypochloremia can be explained by vomiting and the drinking of electrolyte-free water (hypotonic dehydration). The high Hct and TP reflect hemoconcentration assoc. w/ deH2O. Bacteruria is unlikely to be related and has been made a separate problem (#3). Problem 1 may be redefined as acute pancreatitis with biliary stasis.|
|P|| Monitor for complications of pancreatitis including ARF (body weight, approx. ins and outs), DIC (ACT, check venipuncture sites), and cardiorespiratory complications (TPR and character)
Monitor for resolution of acute pancreatitis and biliary disease. Repeat lipase, amylase, Tbili, ALT, ALP and lytes tomorrow _______.
Assess resolution of deH2O with body weight and PCV/TP tomorrow _____.
Rx: specific--keep NPO until no vomiting and lipase is WNL
2. Subcutaneous mass
|S||see problem 1|
|O||FNA shows only fat|
|A||As no cells were seen on FNA the mass is constant with lipoma and the problem will be inactivated.|
|P||No dx or rx plans. Advise the client that the mass is benign and can be left alone unless it gets significantly larger and bothers the dog.|
|S||Tessa has urinated several times and no dysuria or pollakiuria was noted.|
|O||UA showed moderate bacteruria, 0 -2 WBC|
|A||Need to verify bacteruria, especially since no significant pyuria nor signs of lower urinary tract disease have been seen.|
|P||Aerobic culture with sensitivity if grows. Advise the client of the possibility of UTI but need to confirm the problem.|
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