D ouble Issue O ctober 2 0 0 7 - M arch 2 0 0 8 Vol. 23, No. 1 health to C linical D ecision M aking C l in ic a l D e c is io n M a k in g Page 1 Professors Richard Malik,1,2 DVSc, DipVetAn, PhD, FACVSc, FASM, and Paul J. Canfield,2 DVSC, PhD, FACVSc, Grad Cert Higher Ed FRCPathi R e fr a c t o r y U lcer s o n t h e N asa l B r id g e ‘Post Graduate Foundation in Veterinary Science and “Faculty of Veterinary Science, University of o f a Y o u n g C a t : A n Sydney, Australia E x e r c is e in D ia g n o s t ic R e a s o n in g ! 8 &Rlo2d4nifts)j An j which patients pres­ Page 6 Introduction and Conceptual Framework ent with signs that appear referable to N ontuberculous mandibular salivary gland disease, but Reasoning is a term used to refer to M ycobacterial generally respond completely to anticon­ S y n d r o m e s in C ats mental activity through which we vulsant drugs such as phenobarbitone. It Page 15 transform available information in order is therefore vital that we learn through to reach conclusions (in our case the our working life how to draw on the * Adapted with diagnosis of disease). It requires decision experience of junior colleagues (fresh out permission from the making (choosing between alternatives) of veterinary school), senior colleagues proceedings of the 19th j and problem solving (finding paths to annual Fred Scott (with vast experience, and special “local” desired goals - in our case determining Feline Symposium knowledge), textbooks, local and inter­ held at Cornell on July | plans to prove or disprove diagnostic national experts, and medical and veteri­ 27-29, 2007. possibilities or therapeutic approaches). nary electronic databases, and resources such as the Veterinary Information As veterinarians in small animal Network (VIN). practice, not a day goes by that we do not make critical decisions about the In relation to diagnosis, there are investigation and treatment of cases at least three important conceptual under our care. Interestingly, most of us approaches: have received very little specific training in clinical decision making as part of our 1. Pattern recognition — the recogni­ undergraduate curriculum, and most tion of characteristic combination of continuing education forums emphasize clues or signs (e.g., cutaneous reaction the acquisition of new knowledge, rather patterns, radiologic patterns, histologi­ than philosophical approaches to diag­ cal patterns, hematological patterns). nostic and therapeutic decision making. 2. Problem-based medicine In small animal medicine, we are 3. Diagnosis based on clinical prob­ frequently confronted with disease ability — i.e., that certain diseases conditions we have never encountered occur much more commonly than before. This makes life challenging and interesting, but it can also make life very others. stressful. We try our best to use common The best diagnosticians can use all sense, deductive reasoning, and to work of these approaches interchangeably, things out first from principles using a combining great analytic skill, a systematic pathophysiologic approach. Unfortu­ approach, but utilizing, also, good clinical nately, some things are counter-intuitive. intuition, which can make the diagnostic For example, the disease necrotizing process faster and less expensive. — ► continued on page 2 In this new century, veterinar­ 3. Skepticism — non-acceptance tongue was elevated by application ians more than ever should try to of findings until verified. In of pressure to the intermandibular consider a scientific approach to our case, don’t accept evidence space. The abdomen was palpated clinical decision making. The scien­ unless it has been well proven gently; however, no pain, discon tific approach or method is founded through testing. fort or abnormal structures were evident. on several key values or standards, 4. Accuracy — gathering and eval­ which are linked: uating information for accuracy. Questions for Consideration: In our case, it is evidence-based 1. Objectivity — evaluating the medicine. Rather than continue What is your Clinical Assessment? evidence free from bias as much to write abstractly about these (This is easy.) as is humanly possible; bias disparate concepts, I will attempt 1. The cat may or may not have develops from our past experi­ to illustrate them by working swallowed a sewing needle. ences. through what would seem to be 2. The needle may or may not have 2. Open-mindedness — a commit­ a “very straight forward” case. had attached thread. ment to changing one’s views in I will then challenge readers in 3. If so, there may be as a conse­ the face of evidence that these relation to HOW and WHY they quence a variety of clinical views are inaccurate. make clinical decisions. problems. Case Presentation What are the potential problems? Signalment 1. Penetration of the pharynx. ^£U N E hea£ ^ The ultimate Magic is a two-year-old desexed purpose of the 2. Penetration of the esophagus. female Australian mist cat. This Cornell Feline 3. Migration of the needle from u| Health Center is an Australian breed, based on the stomach to other sites. ■ M is to improve initial crosses between Burmese (50 a. W hich sites? the health of percent), Abyssinian (25 percent) cats everywhere and Australian domestic crossbred b. W hy these sites? by developing methods to prevent cats. or cure feline diseases, and by 4. Complications related to three providing continuing education to — i.e., intestinal plication. Presenting Complaint veterinarians and cat owners. All a. When does plication occur? The cat may have ingested a contributions are tax-deductible. sewing needle. What would you do next? Interim Director: (This is a bit harder.) Fred W. Scott DVM, PhD History 1. Radiology Veterinary Consultants: The owner observed the cat play­ 2. CT Christine Bellezza, DVM ing with a sewing needle. The needle Marnie FitzMaurice, DVM allegedly had no thread attached. The 3. MRI Paul Maza, DVM owner tried to intervene and stop 4. Endoscopy Carolyn McDaniel, VMD the cat from playing with the needle; Administrator: 5. Hematology, biochemistry and however, when the owner caught the urinalysis, plus FIV and FeLV Michael Lenetsky cat, there was no needle to be found. Administrative Assistants: tests To complicate matters further, the Kathleen Mospan cat then ate 100 grams (6.25 oz.) of Radiology Donald Personius 1. Chest? Pamela Sackett commercial tinned cat food. Sheryl Thomas 2. Abdomen? Physical Findings Phone: (607) 253-3414 No abnormalities were detected 3. Whole cat, in one go? Consultation: 1-800-KITTYDR on physical examination. Coughing Web: www.vet.cornell.edu/FHC 4. How many views? was not noted, nor was vomiting ©2008 by Cornell University on or regurgitation during the dura­ behalf of the Cornell Feline Health Center, College of Veterinary Medi­ tion of the physical examination. cine, Ithaca, NY 14853. No foreign bodies or lesions were All rights reserved. Permission to reprint se­ detected within the oral cavity. A lected portions must he obtained in writing. thread was not evident in the vicin­ Cornell University os am equal opportunity, affirmative action educator and employer. ity of the lingual frenulum when the \ ______________________________ s -2- Questions: (1) Where is the needle? (2) Do we need a 2nd radiograph? CRITICAL QUESTIONS • How should we manage this case? • On what basis should we make decisions regarding clinical management? Lateral radiograph of Magic How do we manage this patient? Is endoscopic removal a viable the United Kingdom (U.K.). He (This may be controversial.) possibility? had seen them migrate to the 1. Conservative - do nothing. 1. In general, yes - although liver or thoracic cavity. needles are hard to catch and 2. Conservative - use drugs, other 2. Veterinary Information Network hard to safely retrieve. techniques. (VIN) — A U.K. surgeon recom ­ 2. You need good equipment and mended surgery to be sure 3. Endoscopic removal. great expertise. the cat would be okay. He said 4. Surgical removal. the needle might pass without 3. In this case, the ingestion of surgery, but he couldn’t be sure On what basis should we make deci­ food immediately prior to this would happen. sions regarding clinical manage­ presentation would have made ment? endoscopic removal very prob­ Veterinary textbooks 1. Look up in textbooks. lematic. Furthermore, anesthe­ A wide variety of textbooks were . Ask colleagues. sia would be contraindicated in consulted, but they did not prove this setting. helpful in this case. 3. Ask local experts/specialists. 4. Consult veterinary and medi­ What about surgery? Evidence-Based Medicine using cal databases - CAB, Medline, Advantages Electronic Databases PubMed. 1. It likely will resolve the problem. 1. Look at veterinary databases, which are most reliable. 5. Post a question on VIN. 2. It has a high success rate. 2. Also, look at medical databases. But before we do that, what are 3. There should be minimum These are less reliable, but more the unique considerations of the morbidity involved. inform ation is available for present case? 4. It makes more money for the certain topics, such as those 1. The cat has been presented early. clinic. pertaining to this case. 2. We cannot be sure whether or 5. It takes away all the possible 3. Case series are much more help­ not there is thread attached to complications associated with a ful than individual case reports the needle. penetrating object and thread. when looking for overall recom­ 3. The cat has just eaten a large Disadvantages mendations. meal. 1. It is invasive. 4. Look at: (i) year of the report, 4. It is a young, healthy patient that 2.