Topics in Medicine and Surgery Problem Solving in Reptile Practice Paul M. Gibbons, DVM, MS, Dip. ABVP (Avian), and Lisa A. Tell, DVM, Dip. ABVP (Avian), Dip. ACZM Abstract Problem-oriented reptile medicine is an explicit, definable process focused on the identification and resolution of a patient’s problems. This approach includes gathering case information, clearly defining the problems, making plans to address each prob- lem, and following up with the case over time. Case information and published literature serve as evidence to support clinical decisions and pathophysiological ratio- nale. This article describes the problem-solving process used to diagnose and treat a green iguana (Iguana iguana) that presents with ovostasis. © 2009 Published by Elsevier Inc. Key words: evidence-based veterinary medicine; follicular stasis; green iguana; Iguana iguana; preovulatory ovostasis; problem-oriented veterinary medicine roblem-oriented veterinary medicine is a logi- Objective evidence is quantitative and includes vital cal process directed toward the explicit iden- signs and the results of laboratory tests. A case sum- Ptification and resolution of a patient’s prob- mary is limited to information that is pertinent to lems. A complete, problem-oriented, veterinary the problems, but the problem-oriented, veterinary medical record includes evidence about the case, a medical record includes a complete record of all problem list, plans, and progress notes. Each prob- information related to the case. lem is described at the highest possible level of di- For purposes of illustration, the case described in agnostic refinement, and plans are developed to this article involved a 2.2-kg green iguana of unknown address each problem. This process is repeated over age that was determined to be female by observation of time during patient reevaluations until the problem secondary sex characteristics. The current owner had resolves, an etiologic diagnosis is identified, or both. obtained the animal 3 weeks before presentation. The purpose of this article is to illustrate problem Chief complaints included presumed ovostasis for 15 solving in reptile practice by describing the medical weeks, no defecation for 3 weeks, and burn wounds on evaluation and treatment of a green iguana (Iguana the palmar and plantar surfaces of 3 weeks’ duration. iguana) with ovostasis. Information Gathering From the Exotic Species Specialty Service, Animal Emergency Center and Specialty Services, Glendale, WI USA, and the De- Problem-oriented case management begins by col- partment of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA USA. lecting evidence about the case. Many clinicians di- Address correspondence to: Paul M. Gibbons, DVM, MS, Dip. vide case information into subjective and objective ABVP (Avian), Exotic Species Specialty Service, Animal Emer- evidence, although this division is only useful to gency Center and Specialty Services, 2100 W. Silver Spring Dr, acknowledge the level of diagnostic refinement. Sub- Glendale, WI 53201. E-mail: [email protected]. jective evidence is descriptive and includes the pre- © 2009 Published by Elsevier Inc. senting complaint(s), medical history, pertinent hus- 1557-5063/09/1803-$30.00 bandry concerns, and physical examination findings. doi:10.1053/j.jepm.2009.06.013 202 Journal of Exotic Pet Medicine, Vol 18, No 3 ( July), 2009: pp 202-212 Problem Solving in Reptile Practice 203 The iguana had never laid eggs and was not in a Pharmaceuticals, Inc., Bristol, TN USA) applied topi- breeding program. The primary care veterinarian had cally to the affected areas, and bandages. The owner’s presumptively diagnosed ovostasis 15 weeks before pre- description of thermal gradient, light quality, humidity, sentation based on the presence of soft tissue masses in water provision, caging, and diet were appropriate for the reproductive tract that were observed on radio- the species, but information about husbandry before graphic images. The owner reported that the iguana acquisition 3 weeks before presentation was not avail- had become progressively anorectic during the course able. The owner was concerned that the iguana might of illness. For treatment, the owner had provided a require surgery because the eggs did not appear to be litter pan with moist soil as a potential nesting site, but resorbing after more than 3 months, and he had not did not observe nesting behavior. The burns occurred observed the animal defecating over a 3-week period. when the iguana escaped from its cage and was discov- The only notable external physical examination find- ered in direct contact with the heating element on top ings included a mildly distended abdomen and full- of another iguana’s enclosure. These wounds were thickness ulcerations on the palmar and plantar sur- being treated by the primary veterinarian with ceftazi- faces of the distal limbs. dime (20 mg/kg intramuscularly every 72 hours, Fortaz The diagnostic screening protocol included a injectable; GlaxoSmithKline, Research Triangle Park, complete blood count and plasma biochemical NC USA), silver sulfadiazine cream (Thermazine, King panel. The results are presented in Table 1 under Table 1. Assay Result 28 Jan Result 02 Feb Reference Range Unit Uric Acid 4 ND 1.2-2.4 mg/dL Total Calcium 121.2 ND 8.8-14 mg/dL Ionized Calcium 1.51 ND 1.37-1.58 mmol/L Phosphorus 39.6 ND 1.3-3.0 mg/dL Glucose 296 ND 169-288 mg/dL Total Protein 9.2 ND 5.0-7.8 g/dL Albumin 1.6 ND 2.1-2.8 g/dL Globulin 7.6 ND 2.5-4.3 g/dL AST 64 ND 5.0-52 IU/L Creatine Kinase 3342 ND 0-3995 IU/L Lactate Dehydrogenase 145 ND 0-1091 IU/L Cholesterol 704 ND 0-437 mg/dL Blood Urea Nitrogen 2 ND 0-4 mg/dL RBC 1.04 1.06 1.0-1.9 106/ul Hemoglobin 8.1 8.2 6.0-10.0 g/dL PCV 31.5 38 25-38 % MCV 302.9 358.5 165-305 fl MCH 77.9 77.4 48-78 pg MCHC 25.7 21.6 20-38 g/dL RBC Morphology Slight aniso Slight aniso WBC 11000 11000 3,000-10,000 cells/uL Bands 550 0 cells/uL Heterophils 7040 5390 350-5,200 cells/uL Lymphocytes 1980 4730 500-5,500 cells/uL Monocytres 880 440 0-100 cells/uL Eosinophils 110 0 0-300 cells/uL Basophils 440 440 0-500 cells/uL Thrombocytes Adequate Adequate Refractometer plasma protein 10.7 9.5 g/dL Plasma fibrinogen 200 400 mg/dL Icterus index Moderate Slight 204 Gibbons and Tell questions. No single electronic search engine will offer a complete search of all available published literature. Textbooks on herpetological medicine may be borrowed from veterinary school libraries or purchased from the Internet or veterinary booksell- ers. Useful online search engines include PubMed (no fee), ISI Web of Knowledge (subscription re- quired), BioONE (no fee), and Google Scholar (no fee). Figures 3, 4, 5, and 6 demonstrate the different results obtained when searching these databases us- ing the keyword “dystocia” together with either “rep- tiles” or “reptil*”. The PubMed (http://www.ncbi. nlm.nih.gov/pubmed) database includes articles published in many bioscience journals, and, al- though it is available at no charge to the user, it excludes important sources of evidence in herpeto- logical medicine (Fig 3). ISI Web of Knowledge is an umbrella of databases that includes PubMed, CAB Direct, Zoological Record, Web of Science, and BIOSIS previews (Fig 4). It can be accessed at Thomson (ISI) Web of Knowledge (http://www.isiwebofknowledge. com) and allows searching of some additional sources of information that are important to herpe- tological medicine including both the Journal of Her- Figure 1. Dorsoventral radiographic projection of the coelom of an petological Medicine and Surgery and the Proceedings of adult female green iguana (Iguana iguana) with a 15-week history of the Annual Conference of the Association of Reptilian and reduced appetite and lack of defecation for 3 weeks. Note the cluster Amphibian Veterinarians. BioONE (http://www.bioone. of round, soft-tissue-density masses filling the caudal one third of org/search) includes a number of journals not the coelomic cavity (arrows). found in PubMed, including Copeia, Current Herpetol- ogy, Herpetologica, and Journal of Herpetology. It pro- vides access to important background information; the 28 January heading with reference ranges.1-3 in this case, however, it did not identify a source of Reference ranges were selected by reading the information on reptile dystocia (Fig 5). Google primary references to determine how this patient Scholar (http://scholar.google.com) includes a wide best matched the study populations in terms of array of periodicals and textbooks, allows simple or age, sex, and husbandry conditions. Orthogonal advanced use of search terms, and allows cross-ref- radiographic views of the body were taken to eval- erencing of citations (Fig 6). In addition, Veterinary uate the current status of the previously diagnosed Information Network (http://www.vin.com) has a ovostasis and revealed a cluster of round, 1.0 to 1.5 searchable library that offers free abstracts of articles cm, nonmineralized, soft-tissue masses in the cen- from many relevant veterinary journals and full text ter of the caudal third of the coelom (Figs 1 and2). Whenever necessary, published information is used to learn background information about anat- omy, physiology, behavior, and husbandry. Then foreground information is sought to answer ques- tions about diagnostic test interpretation, pathophys- iological rationale, treatment plans, and prognosis. The utility of published information must be ap- praised in terms of veracity and applicability to the case at hand. For example, in this case, text- books,1,4-12 conference proceeding abstracts/manu- Figure 2. Horizontal-beam lateral radiographic projection of the 13-15 16 coelom of the same green iguana in Figure 1.