Canine Internal Medicine: What’s Your Diagnosis 1st is an ideal guide to how internal medicine cases are handled in the clinical setting
What’s your diagnosis? How did you reach it? Through logical deductive reasoning or through ‘clinical shortcuts’? Which methods work best? Internal Medicine (IM) is a subject that relies on problem solving so test your problem-solving skills by perusing these cases and see…
Canine Internal Medicine is neither intended to be an Internal Medicine textbook, nor to include examples of every disease situation encountered in an Internal Medical caseload. What I have intended to do, by use of examples from my clinical practice, is to provide a wide ‘spread’ of clinical problems in which the case itself becomes ‘the teacher’. Canine Internal Medicine is intended for anyone with an interest in Internal Medicine, whether at undergraduate or post-graduate level, General Practice or Speciality Practice. Inevitably there will be some, relatively common, case presentations that there has not been room to include or where the clinical skills challenged by them are replicated in another case example.
It is a frequent, and in many ways valid, criticism of undergraduate teaching, that by situating it mostly in referral hospitals (where the caseload is by nature highly selected and clients generally motivated and financially secure to expedite diagnosis and therapy) the cases may not offer a ‘realistic substrate’ for learning the art as well as the science of small animal medicine. However, I would counter this by stating that, in my experience, these hospitals are usually staff ed by very talented
clinicians who are both well-adept at drawing attention to specific case details that are important ‘learning points’ but also at focusing on those basic skills of history taking and physical examination that are the cornerstones of medical diagnosis. This is a point that is often missed – critics may remember that such cases are unusual and may not be representative of the vast majority of their own caseload, but usually forget the basic (and transferable) steps that led to diagnosis of the unusual problem in the first place. Furthermore, none of these cases miraculously ‘appear out of the ether’ in the reception area of a referral hospital – all have walked (or been carried) through the door of a general veterinary practice and the presenting complaint will be one encountered every day in a practice somewhere. You might be the vet who encounters it; are you ready?
Similarly, post-graduate education has become much more widely available and there are a plethora of excellent CPD courses, post-graduate qualifications, modular programs, etc., for the interested and committed individual. However, what none of these can do is replicate a busy Internal Medicine caseload and it is all too easy to fall into the trap of being well-informed, but never having the chance to experience the practical caseload that a busy IM department sees and thus not generating the ‘right sort’ of case experience. These cases are all taken from our Internal Medicine caseload at Dick White Referrals. We are a very busy department with 10 full-time Internal Medicine Clinicians and a tremendous and varied caseload. Our Residents have the luxury of being totally immersed in large numbers of these cases every day and I hope to share some of these with you. Where there are ‘take-home’ messages (which have become popular to refer to as ‘pearls’, and who am I to argue?), which I believe are pertinent to each case, I have tried to highlight these. I’ve also tried to include some useful additional information in the form of common diff erential diagnoses and case approaches, which, whilst not intended to be as complete as a textbook, will hopefully be easier to remember when attached to an interesting case. I always learn better with the immediacy and constant cue of a patient with which I am dealing and I hope the reader also fi nds refreshing their memory in the context of a clinical case that much more engaging than an abstract text.
I am a busy Specialist clinician having spent the last nineteen years exclusively in small animal Internal Medicine (canine and feline – I am not a particular advocate of a ‘species-ist’ restriction of one’s caseload) referral practice at four major UK referral centres and being continuously ‘on clinics’ during that time. During this time I have also examined many veterinary surgeons in their pursuit of post-graduate qualifications at both Certificate and Diploma level. Partly the choice of which case subjects to include in Canine Internal Medicine is informed by this experience of those clinical problems that often seem to cause the most diagnostic difficulty and conversely in the exclusion of some common scenarios that really do not present much of a diagnostic ‘challenge’.