Back to Basics: A Case for Problem-oriented Medical Records
Holly Ahlgrim, DVM
Flash back to that lecture during the first year of vet school… Undoubtedly, most of us were in a state of sleep deprivation and caffeine-induced hysteria, surrounded by the lingering smells of anatomy lab. The lecture on problem-oriented medical records was not likely at the forefront of what we were all focusing our study groups on that semester/quarter. Once the clinical year of vet school rolled around, forming problem lists and endless SOAP writing became a large portion of our typical day on most rotations. Still, the importance of those lists does not fully sink in until the safety net of an overseeing clinician is gone, and you are the sole clinician responsible for a patient’s care. Record keeping in any branch of healthcare is essential—both for legal purposes and continuity of care. Problem-oriented medical records can also be a helpful tool in helping clinicians work through a case, direct your diagnostic and therapeutic approach, and ultimately achieve a diagnosis. I can recall several clinicians telling us in rounds in vet school, “If it isn’t on your differential list, you’re likely going to miss it”. Organizing our thoughts about a case can also make speaking with clients about what may be wrong with their pet much easier. Most clients are more agreeable to diagnostics when they understand what we are looking for.
Case Series
The following is a series of fictitious cases, all of which have the primary problem of anemia. For the sake of brevity, initial presentation and diagnostic work up are the primary focus of these case discussions.
Case One
Exam Findings and Diagnostic Test Results
Problem List
Additional Diagnostics
What are the common or recurring themes through your differentials? Can you narrow down your list?
Intravascular or extravascular hemolysis would explain anemia and hyperbilirubinemia and bilirubinuria. Inflammation secondary to hemolysis could explain the leukocytosis and fever.
Spherocytosis and increased nRBC count should move IMHA higher on the list. Splenomegaly is a common finding in patients with IMHA either due to EMH or neoplasia or underlying infectious disease.
How do these results change the differential list?
Significant blood loss is ruled out by the imaging that was performed, normal UA and the absence of melena or hematochezia. Abdominal survey radiographs are primarily performed in cases where hemolysis is suspected to rule out metallic foreign material (zinc), abdominal ultrasound is always more sensitive for screening for neoplasia and other abdominal abnormalities. Normal clotting function along with normal platelet count makes the chance of spontaneous hemorrhage unlikely. There are also no chemistry findings that would support blood loss in general (low total protein and/or low albumin) or GI bleeding (elevated BUN or phosphorous). Positive saline agglutination and spherocytosis is supportive of IMHA (primary or secondary). In the absence of any other significant findings on imaging or infectious disease screening and no known toxin exposure, primary/idiopathic IMHA is most likely.
Outcome
Bailey was treated in hospital with blood products, started on prednisone for immune suppression and clopidogrel for platelet inhibition. She was discharged home on prednisone and clopidogrel and managed long term through the internal medicine department.
Case Two
Exam Findings and Diagnostic Test Results
Problem List
Additional Diagnostics
What are the common or recurring themes through your differentials? Can you narrow down your list?
Low serum proteins along with anemia should raise the concern for some type of blood loss as the source of the anemia. Elevated BUN and phosphorous, along with melena make GI blood loss most likely. The character of the anemia (microcytic, hypochromic +/- evidence of regeneration) is common in animals that have had chronic GI bleeding. Chronic GI hemorrhage often leads to non-regenerative anemia due to iron deficiency or sequestration. The abdominal mass should be expected to be associated with the intestinal tract and the likely cause of GI bleeding.
How do these results change the differential list?
Abdominal ultrasound confirms presence of intestinal mass and source of anemia is GI blood loss.
What is your diagnosis?
Small intestinal mass causing GI blood loss.
Outcome
Louie was stabilized with a blood transfusion and taken to surgery for intestinal resection and anastomosis. He recovered and was discharged home after several days in hospital. Intestinal mass histopathology returned as lymphoma.
Conclusion
While generating problem and differential lists can seem tedious and sometimes daunting, there is something to learn from nearly every case. During busy shifts, it can feel like you do not have time to properly think through cases. As with anything else, repetition will eventually improve your efficiency. Paying attention to the commonalities between differential lists can often help narrow down which tests to prioritize and help you determine which therapies to initiate while you await test results. While some of the diagnostics discussed here would not necessarily commonly be performed in the day practice setting, clients are often appreciative and more prepared for what may happen at a referral center when they understand the major concerns.