VETERINARY MEDICINE: Clinical Examination

And Making a Diagnosis Part 1

Introduction
Similar to human medicine, the diagnostic act is actually a process to categorize the animal’s illness. It is an
attempt to recognize the group or class of the animal’s illness so that one can, based on prior individual or
collective experience, determine the likely disease and what further acts or interventions are required to
resolve or mitigate the effects of the illness. Disease can be defined as the “inability to perform physiologic
functions at normal Levels even though nutrition and other environmental requirements are provided at
adequate levels.” Traditionally, a disease was defined by a specific combination of clinical signs and pathologic
and clinic pathologic abnormalities. The definition has been widened to include those animals or herds that
are not clinically ill but do not perform as expected. Epidemiologic information deals with the distribution and
determinants of health and disease in groups, and by extrapolation it provides diagnostically, therapeutically,
and prognostically useful information for individual animals.
Making a Diagnosis
The practice of clinical veterinary medicine consists of two major facets: the making of a diagnosis and the
provision of treatment and control measures. A diagnosis is the identification of the disease affecting the
animal, and to be complete should include three parts:
1. Identification of the clinical manifestation of that abnormality produced by the causative agent
classification of the animal’s illness
2. Abnormality of structure or function produced by the causative agent
3. The above two then usually allow identification of the specific cause of the illness
Diagnostic Methods
At least five distinctly recognizable methods are used and are presented here in order of increasing
complexity. Generally, the experienced clinician uses more of the simpler strategies, and the novice clinician
uses more of the complex ones. This occurs because the simple method omits several steps in the clinical
reasoning process or the appropriate and safe cutting of corners that it is possible to perform with confidence
only after gaining wide experience and after paying a good deal of attention to assessing one’s own personal
competence as a clinician, especially as a diagnostician.
METHOD 1: THE SYNDROME OR PATTERN RECOGNITION
Sometimes referred to as the Aunt Minnie or gestalt diagnostic technique, this method involves the rapid,
almost instantaneous, arrival at a diagnosis. It is gestalt because it involves the recognition of a pattern among
apparently chaotic or confused information and Aunt Minnie because one instantly recognizes a close
acquaintance without the need to thoughtfully identify and assimilate their distinctive attributes. The same
experience can occur while taking the history—in fact most diagnoses in human medicine are made during
collection of the history—in which the description of the clinical situation and signs are pathognomonic or
highly suggestive of a disease. This recognition is based on the comparison of the subject case and previous
cases in the clinician’s memory or training, and one is recognized as a replica of the other. There is no need to
seek further supporting advice, and the definitive diagnosis is made then and there. In the hands of
experienced or well-trained clinicians this method is quick and accurate.
METHOD 2: HYPOTHETICO-DEDUCTIVE REASONING
As soon as the client begins to relate the presenting signs, usually commencing with the key clinical sign, the
clinician begins to draw up a short list of diagnostic possibilities. This is the process of generating multiple
plausible hypotheses from initial cues. The clinician then begins to ask questions and conduct clinical
examinations that test the hypotheses. The clinician then begins to ask questions and conduct clinical
examinations that test the hypotheses. The questions and examinations should be directed at supporting or
discounting the tentative diagnoses but can lead to the addition of more hypotheses and the deletion of some
others. The process of hypothesis and deduction is continued until one diagnosis is preferred over the others.
The original list of hypotheses can be expanded but not usually to more than seven, and in the final stages it is
usually reduced to two or three. These are then arranged in order of preference and become the list of
diagnostic possibilities. One of the important characteristics of this strategy is the dependence on the
selection of a critical or key clinical sign or cue on which to base the original hypotheses. The selection of the
key sign and additional supporting clinical findings is done instinctively by experienced clinicians on the basis
of prior experience in similar situations. For novice clinicians it might be necessary to examine two or more
key signs.
METHOD 3: THE ARBORIZATION OR ALGORITHM METHOD
This is really an extension of Method 2, but the hypothetic-deductive reasoning method is formalized and
performed according to a preplanned program. This reasoning method depends on the clinician remembering
and being aware of an all-inclusive list of diagnostic possibilities in the case under consideration. Because
memory is unreliable and impressionistic, the hypothetic-deductive method is subject to error by omission.
The arborization or algorithmic method similarly approaches a listed series of diagnoses and examines each
one in turn with supporting or disproving questions; if they pass the proving test they stay in, if they fail the
test then they are deleted. This method works well provided the list of possible diagnoses is complete, is
frequently updated as new diagnoses become available, and, just as importantly, new ways of supporting or
discounting each hypothesis are added as soon as they are published. The arborization method is well suited
to the clinician who has not had the necessary experience memorizing long lists of potential diagnoses and the
critical tests that confirm or exclude each of them. Because the algorithms are likely to include all the recorded
diagnoses that have that particular key sign, error by omission is not a risk. Thus they are also valuable to the
specialist, who is less able to afford an omission than the general practitioner and certainly cannot really
afford to miss even the most obscure and unlikely diagnosis.
METHOD 4: THE KEY ABNORMALITY METHOD
This is a more time-consuming method than the previous ones that requires clinicians to rely on their
knowledge of normal structure and function to select the key abnormality or clinical cue.
• Determination of the Abnormality Of Function Present
— Disease is an abnormality of function that is harmful to the animal. The first step is to decide what
abnormality of function is present. In pursuing a diagnosis using this technique one should be aware of
the parsimony principle, sometimes referred to as Occam’s razor, which is the principle that the
simplest of several hypotheses is always the best when accounting for unexplained facts, i.e., always
try first to explain the animal’s clinical signs as being caused by the fewest number of diseases.
Definition of the abnormality is usually in general terms, such as paralysis, diarrhea, bloat, edema, and
so on. These terms are largely clinical, referring to abnormalities of normal physiologic function, and
their use requires a foreknowledge of normal physiology. It is at this point that the preclinical study of
 physiology merges with the clinical study of medicine. The necessary familiarity with the normal,
combined with observation of the case at hand, makes it possible to determine the physiologic
abnormality, e.g., hypoxia. The next step is to determine the body system or body as a whole or organ
involved in the production of the hypoxia.
• Determination of the System or Body as a Whole or Organ Affected
— Having made a careful physical examination and noted any abnormalities, it is then possible to
consider which body system or organ is the cause of the abnormality. In some cases the body as a
whole can be involved. This might not be difficult with some systems; for example, hypoxia can be
caused by failure of the respiratory or circulatory systems, and examination of these is not difficult.
However, special problems arise when attempting to examine the nervous system, the liver, kidney,
endocrine glands, spleen, and hemopoietic systems. As a guiding principle, all functions of the organ
under examination should be observed and any abnormalities noted. For example, if the integrity of
the central nervous system is to be examined, the clinician would look for abnormalities of mental
state, gait, posture, muscle and sphincter tone and involuntary movements, abnormal posture, and
paralysis. Knowing the normal physiologic functions of systems, during examination one looks for
aberrations.
• Determination of the Location of the Lesion Within the System or Organ Affected
— The location of the lesion within the body system involved is not always obvious and might require
special physical and laboratory examination techniques. An exploratory laparotomy with or without
biopsy techniques might be necessary to determine the location of an intestinal lesion thought to be
the cause of chronic diarrhea. Endoscopy is standard practice for the localization of lesions of the
respiratory tract of the horse. Radiography is often necessary to localize lesions of the musculoskeletal
system and diseases of the feet of horses and cattle.
• Determination of the Type of Lesion
— The abnormality observed may be produced by lesions of different types. Generally, lesions can be
divided into anatomic or physical lesions and functional disturbances. the physical lesions can be
further subdivided into inflammatory, degenerative, or space occupying. These classifications are not
mutually exclusive because a lesion may be both inflammatory and space occupying, for example
abscesses in the spinal cord or lung. In these circumstances it is necessary to modify the diagnosis and
say that such and such a lesion is space occupying and may or may not be inflammatory.
• Determination of the Specific Cause Of the Lesion
— If the nature of the abnormality and the type of lesion can be satisfactorily determined, then the
specific causative agent remains to be found. It is at this stage that a careful history taking and
examination of the environment show their real value. It is only by a detailed knowledge of specific
disease entities, the conditions under which they occur, the epidemiology, and the clinical
characteristics of each disease that an informed judgment can be made with any degree of accuracy. If
the diagnostic possibilities can be reduced to a small number, confirmation of the diagnosis by
laboratory methods becomes so much easier because there are fewer examinations to be made and
confirmation by response to treatment is easier to assess. If it is necessary to treat with many drugs
serially or in combination to achieve a cure, the expense is greater and the satisfaction of both the
 client and the veterinarian is diluted in proportion to the range of treatments. Accuracy in diagnosis
means increased efficiency, and this is the final criterion of veterinary practice.
METHOD 5: THE DATABASE METHOD
The basis of this method is to cnduct a complete clinical and clinicopathologic examination of the animal to
acquire a comprehensive animal database. The problems (key signs) in this database are then matched with
the diagnostic database, in which collections of signs or syndromes are labeled with diagnoses, to select the
best fit with the animal’s data. This method also uses the problem-oriented veterinary medical record system,
which is an excellent system for the daily recording of clinical and laboratory data in an orderly, systematic,
and consistent manner that can be easily followed by clinicians and their colleagues. This system is now used
widely by veterinary teaching hospitals. It has four components based on the four phases of veterinary
medical action:
• Database
• Problem list
• Initial plans
• Progress notes
The method is really an expanded version of the hypothetic-deductive method, in which the hypotheses are
made sequentially as further information becomes available. In the database method all the hypotheses are
pursued in parallel because all the possible data have been put into the animal’s data-base. The source of
error in the method is the possibility of undue importance being attached to a chance abnormality in, say, the
clinical biochemistry. If the abnormality cannot be matched to a clinical sign, it should be weighted downward
in value or marked for comment only. The same error can result from inclusion of a sign that is important, e.g.,
diarrhea, but that happens to be present at low intensity.