A master problem list is a complete list of medical concerns, including dates of inception and resolution (when relevant), in a patient’s medical record. This list should be easily accessible, simple, and concise in order to facilitate updates by current and future clinicians. All clinicians managing the patient can use the list to understand comorbid conditions and therapeutic responses to past and current diagnoses. Maintaining an accurate and up-to-date master problem list can aid the diagnostic process and successful transfer of the case to colleagues and/or specialists when needed.
Being an excellent veterinary diagnostician depends on a solid foundation in the basics. In this General Practice Skills series, we’ll tackle a different skill critical to daily practice: history-taking, making a master problem list, compiling differentials, and utilizing heuristics/patterns.
Back to Basics: Making a Problem List
In addition to maintaining a master problem list for a patient’s full medical history, generating a more specific, updated list when a patient is presented with a new concern can help focus the diagnostic process, particularly in patients with complex medical histories, comorbidities, or atypical clinical presentations.
For the following cases, generate an initial problem list based only on patient history and physical examination results.
The Case: Lethargy & Anxiety in a Dog
Bentley, an 8-year-old 57-lb (26-kg) neutered male crossbreed dog, is presented for lethargy, panting, and anxious behavior of 2-days’ duration. His owner reports he was previously healthy.
History
Bentley is fed a commercial diet. Vaccinations are current, but his owner reports administration of flea, tick, and heartworm preventives is inconsistent and often forgotten for 1 to 2 months at a time.
Bentley has no travel history, lives in Florida, and is an active dog that swims in the family pool and goes on nightly walks. Two nights prior to presentation, he resisted going on his regular walk. On the next night, he was again reluctant to go on a walk and woke his owners up several times by whining and pacing. He was taken outside multiple times during the night and urinated normally each time.
Physical Examination
On physical examination, Bentley’s temperature is 99.7°F (37.6°C). Respiratory rate is 36 breaths per minute at rest, heart rate is 180 bpm, and capillary refill time is 3.5 seconds. BCS is 8/10.
Auscultation of the heart is difficult because of Bentley’s constant panting, but no murmurs or arrhythmias are identified. Lung sounds are normal over all lung fields. Pulses are weak and synchronous with the heartbeat. There is a palpable fluid wave in the abdomen and a positive hepatojugular reflux. All extremities feel warm to the touch. The remainder of the physical examination is normal.
There is no evidence of trauma, and Bentley gets up a couple of times to reposition himself in the examination room. He does not seem anxious but appears uncomfortable when lying down, similar to the behavior that prompted presentation to the clinic.
In the box below, generate an initial problem list based only on patient history and physical examination results as described above.
Continue to explore this case, including treatment and outcome: Lethargy & Anxiety in a Dog
The Case: Rare Autoimmune Disease in a Dog
Spike, a 6-year-old neutered male crossbreed dog, is presented for a 2-day history of lethargy.
History
The owner reports Spike was previously healthy, is up to date on core vaccines, was given his last vaccines 1 month before presentation, and receives monthly heartworm and flea preventives. The owner notes some of Spike’s stools have recently seemed darker in appearance, and there has been no possible exposure to rodenticides.
Physical Examination
Spike is quiet, alert, and responsive on presentation. Thoracic auscultation reveals tachycardia (heart rate, 150 bpm) with a grade II/VI left systolic heart murmur and bounding femoral pulses. Oral mucous membranes are pale pink and have numerous petechiae. Ecchymoses are noted on the abdomen. Rectal temperature is elevated (103.2°F [39.56°C]). Melena is noted on rectal examination.
Continue to explore this case, including treatment and outcome: Rare Autoimmune Disease in a Dog
The Case: Acute Pelvic Limb Paresis & Respiratory Effort in a Cat
Watson, a 9-year-old neutered male domestic shorthair cat, is presented for acute onset of pelvic limb paresis, increased vocalization, and progressive apparent breathing difficulties.
History
Watson’s owners returned home from work and found him dragging his pelvic limbs, vocalizing excessively, and breathing with an open mouth. He had acted normally that morning. During routine wellness evaluation 6 months before presentation, a grade II/VI systolic parasternal murmur had been noted. Results of thyroid tests were within reference intervals.
Physical Examination
On presentation 2 hours after he was found by his owners, Watson continues vocalizing and breathing through an open mouth. Rectal temperature is 99.6°F (37.6°C), and heart rate is 220 bpm. A grade II/VI parasternal murmur and gallop rhythm are heard on thoracic auscultation. Heart sounds are mildly muffled ventrally, and increased bronchovesicular sounds are noted bilaterally.
Swelling of the gastrocnemius muscles of the pelvic limbs is noted bilaterally. On palpation, the pelvic limbs are firm and paws are cold to the touch. The digital and metatarsal pads are markedly dark and cyanotic. Voluntary motor function of the pelvic limbs is absent below the hips. Deep-pain testing is negative in both pelvic limbs.
Continue to explore this case, including treatment and outcome: Acute Pelvic Limb Paresis & Respiratory Effort in a Cat
The Case: Gastric Foreign Body Versus Myasthenia Gravis
A 4-year-old spayed Labrador retriever crossbreed is presented for vomiting and excessive drooling of 2-days’ duration.
History
GI surgery to remove a rock foreign body was performed ≈1 year prior to current presentation. The surgery was uneventful, and the patient had a complete recovery. There is no known history of toxin exposure.
Physical Examination
On physical examination, temperature is 101.7°F (38.7°C), heart rate is 110 bpm, respiratory rate is 30 breaths per minute, BCS is 6/9, mucous membranes are pink, and capillary refill time is <2 seconds. Ptyalism and apparent abdominal pain are noted, but no foreign body or mass is palpated.
Continue to explore this case, including treatment and outcome: The Case: Gastric Foreign Body Versus Myasthenia Gravis
Up Next: Compiling Differentials
Up next in our General Practice Skills series, we’ll discuss the ins and outs of compiling a differential list. Stay tuned!