p.1

APPROACH TO THE PATIENT

CASEY KOHEN DVM DACVECC
MARQUEEN VETERINARY EMERGENCY
AND SPECIALTY GROUP

p.2

OVERVIEW
- BEING A TEAM LEADER
- MENTAL PREPARATION
- SYSTEMATIC APPROACH TO CASES
- DEFINE SUCCINCT PROBLEM LIST
- USE YOUR REFERENCES

p.3

EFFECTIVE TEAM LEADER
- CALM, CALM, CALM
- MOVING AROUND THE ER
- WHY PARAMEDICS DON’T RUN
- VOLUME
- COMMUNICATION
- “CLOSED LOOP”

p.4

MENTAL PREPARATION
- DIFFERENTIAL LISTS AT ALL TIME
- ACKNOWLEDGE THE TWO WAYS OF THINKING ABOUT A CASE
- PATTERN RECOGNITION
- ANALYTICAL PROCESSING
- AVOID COGNITIVE ERRORS

p.5

TWO WAYS TO THINK ABOUT CASES
- PATTERN RECOGNITION
- ANALYTICAL PROCESSING
- TACHYCARDIA
- IRREGULAR
- NO P WAVES

p.6

COGNITIVE BIASES
- DIAGNOSTIC MOMENTUM
- ”THE GI FB TRANSFER IS HERE”
- PREMATURE CLOSURE
- GASTRIC FB IN A SICK DOG
- AVAILABILITY BIAS
- YOUR THIRD PERICARDIAL EFFUSION IN A WEEK, BUT THIS ONE IS DIFFERENT
- PLAY DEVIL’S ADVOCATE
- WHAT ELSE COULD IT BE?

p.7

PETS NEEDING EVALUATION ON ARRIVAL
- ANY PATIENT SUSTAINING TRAUMA THAT IS NOT WALKING
- IE, OWNER IS CARRYING THEM IN
- ANY PATIENT THAT IS PRESENTING FOR RESPIRATORY CONCERNS
- ANY ANIMAL THAT IS UNABLE TO WALK INTO THE HOSPITAL ON THEIR OWN POWER
- NEEDS A STRETCHER OR TO BE CARRIED IN FROM CAR
- KEEP PATIENT WITH OWNER IF POSSIBLE

p.8

PATIENT IS PRESENTED TO YOU
- WHERE DO YOU START?
- HISTORY VS PHYSICAL EXAMINATION
- HOW SICK IS THE PATIENT?
- CAN YOU “DIVIDE AND CONQUER”

p.9

QUICK HISTORY
- WHAT HAPPENED?
- WHEN DID IT HAPPEN?
- PREVIOUS MEDICAL PROBLEMS?
- CURRENT MEDICATIONS?

p.10

COMPREHENSIVE HISTORY
- NOT JUST ALL THE QUESTIONS
- THOROUGH EXPLORATION OF THE PATIENT’S CHIEF COMPLAINT EARLY IN THE CLINICAL ENCOUNTER
- ASKING QUESTIONS ABOUT A DIAGNOSTIC HYPOTHESIS
- DEVELOPING PATTERN RECOGNITION
- ASKING PATIENTS TO PROVIDE FURTHER CLARIFYING INFORMATION
- SUMMARIZING INFORMATION GATHERED DURING THE INTERVIEW
Academic Medicine. 76(10):S14–S17, OCTOBER 2001
PMID: 11597860

p.11

INITIAL EVALUATION OF THE PATIENT
- RAPID ASSESSMENT
- PRIORITIZE LIFE THREATENING ABNORMALITIES FIRST

p.12

DOES THIS ANIMAL NEED CPR?

p.13

PRIMARY EVALUATION
- CPR?
- RAPID RECOGNITION OF CPA IS CRITICAL
- NON-RESPONSIVENESS
- < 10 SECONDS
- EARLY INTERVENTION WITH CPR

p.14

PRIMARY EVALUATION
- CPR?
- NO
- ALTERED
MENTATION/RESPONSIVENESS?
- SHOCK, BG, INTRACRANIAL
- RESPIRATORY DISTRESS?
- OXYGEN
- RAPID DIAGNOSIS
- ANATOMICAL?

p.15

RESPIRATORY EVALUATION
- EVALUATION OF RESPIRATORY RATE AND EFFORT FROM A DISTANCE
- ANY SOUNDS AUDIBLE WITHOUT STETHOSCOPE
- AUSCULTATION
- DECREASED LUNG SOUNDS
- CRACKLES

p.16

PRIMARY EVALUATION
- RESPIRATORY DISTRESS?
- ANY OTHER IMMEDIATE THERAPY?
- SEDATION
- COOLING
- THORACOCENTESIS
- INTUBATION
- VASCULAR ACCESS?

p.17

PRIMARY EVALUATION
- CPR?
- NO
- ALTERED MENTATION/RESPONSIVENESS?
- RESPIRATORY DISTRESS?
- SHOCK?
- PERFUSION PARAMETERS

p.18

SHOCK
- LIFE THREATENING CONDITION OF INADEQUATE CELLULAR ENERGY PRODUCTION TO MAINTAIN HOMEOSTASIS
- MOST COMMONLY DUE TO INADEQUATE PRELOAD
- HYPOVOLEMIA
“Tree of Life”

p.19

SHOCK
- LIFE THREATENING CONDITION OF INADEQUATE CELLULAR ENERGY
PRODUCTION TO MAINTAIN HOMEOSTASIS
- MOST COMMONLY HYPOVOLEMIA
- PERFUSION PARAMETERS – “NOSE TO TOES”
- MENTATION
- MUCOUS MEMBRANE COLOR
- CAPILLARY REFILL TIME
- PULSE QUALITY
- HEART RATE
- EXTREMITY TEMPERATURE
- ALL IN THE VITALS ASSESSMENT

p.20

PERFUSION PARAMETERS- MENTATION
- BAR
- NORMAL
- QAR
- NOT AN OVERLY OUTGOING PATIENT BUT NO CONCERNS
- OBTUNDED
- DECREASED RESPONSE TO ENVIRONMENTAL STIMULI
- CAN HAVE VARIABLE SEVERITY
- STUPOROUS
- ONLY RESPONSIVE TO NOXIOUS STIMULI
- COMATOSE
- NON-RESPONSIVE TO EVEN NOXIOUS STIMULI

p.21

PERFUSION PARAMETERS- MUCOUS MEMBRANES
- MUCOUS MEMBRANES
- COLOR
- PINK
- PALE/PINK
- PALE
- NOT NECESSARILY ANEMIC
- CYANOTIC
- HYPEREMIC
- MOISTURE
- TACKY
- DEHYDRATION, PANTING, KIDNEY DISEASE, ATROPINE
- CAPILLARY REFILL TIME
- NORMAL IS APPROX. 1-2 SECONDS
- DELAYED > 2S
- RAPID < 1S

p.22

PERFUSION PARAMETERS- PULSE QUALITY
- STRONG
- EASY TO PALPATE, CAN ALMOST FEEL “FLOW” UNDER FINGER
- DORSAL METATARSAL(PEDAL) PULSE IS ALSO EASY TO FEEL
- NORMAL ANIMALS, ESPECIALLY LARGE BREEDS
- ADEQUATE
- NOT STRONG BUT QUICKLY PALPABLE
- MOST CAT PULSES
- FAIR
- SOME DEGREE OF PERFUSION DEFICIT
- EASILY COMPRESSIBLE
- VERY DIFFICULT TO PALPATE DP PULSES

p.23

PERFUSION PARAMETERS- PULSE QUALITY
- POOR
- BARELY PALPABLE
- RIGHT BEFORE NON-PALPABLE
- ARE THEY VARIABLE?
- BOUNDING
- HIGH “AMPLITUDE”
- LIKELY DUE TO HIGH STROKE VOLUME
- ANEMIA, EARLY SEPSIS, HYPERTHERMIA
- “THREADY”, “SNAPPY”
- NOT GREAT DEFINITIONS IN LITERATURE
- VARIATIONS OF FAIR OR BOUNDING DEPENDING ON WHO IS COMMENTING

p.24

PERFUSION PARAMETERS- HEART RATE
- PULSE AND HEART RATE MEASUREMENT IS IDEAL
- PULSE IS THE MOST IMPORTANT HOWEVER SO CHECK IT FIRST
- AUSCULTATION CAN BE DIFFICULT:
- BODY CONDITION
- RESPIRATORY SOUNDS
- AMBIENT NOISE

p.25

PERFUSION PARAMETERS- PERIPHERAL TEMPERATURE
- INDICATION OF DISTAL PERFUSION
- COOL EXTREMITIES SUGGEST HYPOPERFUSION, TYPICALLY DUE TO
HYPOVOLEMIA
- IMPORTANT TO COMPARE TO THE RECTAL TEMPERATURE
- HARD TO HAVE WARM EXTREMITIES WHEN RECTAL TEMP IS 93.

p.26

IS THIS ANIMAL IN SHOCK?

p.27

DECISION TIME
- PATIENT IN SHOCK?
- YES!
- THERAPEUTIC INTERVENTION
- OXYGEN
- VASCULAR ACCESS

p.28

DECISION TIME
- PATIENT IN SHOCK?
- YES!
- THERAPEUTIC INTERVENTION
- OXYGEN
- VASCULAR ACCESS
- FIGURE OUT WHY!
- CARDIAC
- ABDOMINAL

p.29

CARDIAC AUSCULTATION
- MUFFLED HEART SOUNDS
- TACHYARRHYTHMIA
- ATRIAL FIBRILLATION
- VENTRICULAR TACHYCARDIA
- MURMUR
- SEVERE BRADYCARDIA

p.30

-ABDOMINAL PALPATION
- ABDOMINAL PALPATION
- FLUID WAVE
- TYMPANIC STOMACH
- LARGE MASS
- LARGE TURGID BLADDER

p.31

COMPLETION OF THE PHYSICAL EXAM
- LYMPHADENOPATHY
- RECTAL EXAMINATION
- ECCHYMOSIS/PETECHIATION
- WATCH THEM WALK AROUND

p.32

COMPLETION OF THE PHYSICAL EXAM
- LYMPHADENOPATHY
- RECTAL EXAMINATION
- ECCHYMOSIS/PETECHIATION
- WATCH THEM WALK AROUND

p.33

POINT-OF-CARE DIAGNOSTICS
- LABWORK
- GLUCOSE
- HYPOGLYCEMIA
- HYPERGLYCEMIA COULD SUGGEST DM OR DKA
- PCV/TP
- HGE/AHDS
- IMHA
- GUIDES FLUID RESUSCITATION

- ELECTROLYTES
- ADDISON’S DISEASE
- URETHRAL OBSTRUCTION
- ACID-BASE
- LACTATE
- “SHOTGUN APPROACH”
- CONSCIOUSLY THINK ABOUT DIAGNOSTICS
- ARE YOU TESTING A HYPOTHESIS OR SCREENING?

p.34

POINT-OF-CARE DIAGNOSTICS
- IMAGING
- RADIOGRAPHS ARE ALMOST NEVER NEEDED IN THE INITIAL ASSESSMENT
- LARGE AMOUNT OF INFORMATION CAN BE OBTAINED WITH ULTRASOUND*
- *IT TAKES PRACTICE

p.35

THE PROBLEM LIST
- PRIORITIZE
- ER VS INTERNAL MEDICINE
- MUST BE TRUE
- LEAVE OUT “SUSPECT""
- COMBINE WHERE IT MAKES SENSE
- AZOTEMIA, HYPERPHOSPHATEMIA, DEHYDRATION, VOMITING
- ACUTE KIDNEY INJURY
- DYNAMIC

p.36

USE YOUR REFERENCES

p.37

Picture