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
| D = Degenerative |
| A = Anomaly |
| M = Metabolic |
| N = Neoplastic, nutritional |
| I = Inflammatory, infectious, immune mediated |
| T = Trauma, toxicity |
| V = Vascular |
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.
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