Purveyors of the recently published data on the declining perceived value of our services would like us to know that the economic sky is falling.
Purveyors of the recently published data on the declining perceived value of our services would like us to know that the economic sky is falling. But you can stem the tide by incorporating the acronyms MENSCHRUG and NITSCOMP-DH—remember them from last month's column?—in your daily practice. Just watch the perceived value of your examinations, assessments and treatments rise.
The comprehensive and thorough physical assessment and the offering of a thoughtful differential that comes with covering all your bases is noticed and appreciated by the concerned client. Take note and talk about your Musculoskeletal, External Systems, Neurological, Sensory, Cardiovascular, Hemolymphatic, Respiratory, Urogenital and Gastrointestinal findings during an exam. With each diagnosis, cover Neoplasia, Infections, Toxicities, Structural, Congenital, Other, Metabolic Parasitic, Diet and Husbandry.
As a nascent practitioner I made all sorts of mental mistakes with examinations and when creating a differential. Help was needed.
I could have blamed my dyslexia or the nuns beating my left-handedness out of me, but to survive in school when straight memorization didn't work, I had to develop systems to help me. No matter how strong, smart, rich, fast or talented you are, your given talents run out sometime somewhere and further development will require blood, sweat and tears.
Another of many events that troubles us clinicians is that bad habit of—after the fact—remembering the body part we didn't examine. I'll never forget an annual examination of a patient when I forgot to assess the lymph nodes. A week later, problems sprouted up in—you guessed it—the offending lymph nodes.
Every veterinary instructor at every level told us to examine all patients the same, but no one ever explained to me exactly what "same" meant.
Compounding the confusion are specialty assessments by ophthalmologists, neurologists, cardiologists and surgeons who all examine patients differently.
So to ensure consistent examinations, I've used the acronym MENSCHRUG for years. I've seen many other versions of examination guides for practitioners, but some important element always seems to be missing.
One of many events that can flatten a clinician is remembering—after the fact—a forgotten differential that turns out to be the final diagnosis.
I will never forget the seizing pup—which I remembered in the middle of the night—that might have been afflicted with lead poisoning. It was.
In 1974 and 1975, I learned at the knee of a human radiologist, Dr. David Russell, the DAMNIT system. It worked to a degree for a differential, but it missed important things for a veterinarian.
The assessment that is the differential can be entered into the record when taken with the NITSCOMP-DH acronym. The differential acronym NITSCOMP-DH is road-tested. It was used for a decade before first being published in DVM Newsmagazine. I've used it for three decades, and I can verify that it gets a clinician in the "right neighborhood" of diagnosing and client communication.
A major issue in medicine is the necessity to make decisions without a definitive diagnosis. Much of clinical medicine, if not most, is in-the-moment with the patient right now. These acronyms aid this process.
Clients see only an itchy ear and fail to understand the differential: tumors, infections (including yeast), foreign bodies, anatomical issues, and such.
My personal rule is: Every sick pet should receive a differential with at least five items for consideration on the rule-out list.
In the medical record, computer or hard copy, a clear listing of physical assessment findings and the assessment with differential are to be present and easy to read and for review next week, next month or years down the road.
Do these things, and your clients will develop greater appreciation, respect and value for your services.
Dr. Riegger, dipl. ABVP, is chief medical officer at Northwest Animal Clinic Hospital and Specialty Practice. Contact him at (505) 898-0407, Riegger@aol.com, or northwestanimalclinic.com. Find him on AVMA's NOAH as the practice management moderator. Order his books Management for Results and More Management for Results by calling (505) 898-1491.
For a complete list of articles by Dr. Riegger, visit dvm360.com/riegger
History. Is the patient limping or having difficulty getting up or lying down? How many calories are consumed daily to achieve this body weight?
Examination. Include muscle tone assessment, a pass over the joints (including patellas and umbilical region), flexing the joints and making a judgment about relative obesity, weight loss or gain.
2. External Systems
History. Has the patient been scratching? If so, where on the body? Has the owner noticed any lumps or bumps?
Examination. Check texture of hair, relative thickness of dermis and epidermis and a look at interdigital tissues and nails.
History. Is patient depressed or listless? Any changes in appetite or attitude? Behavior issues? Locomotion changes? Any seizures?
Examination. Overview of cranial nerves, long motor tracts and cerebellar function. Are parasympathetic and sympathetic balance within normal limits? Check temperature and assess level of pain.
History. Subjective questions, including client's perception of the pet's hearing and sight.
Examination. Ophthalmic structures and adnexa and a look at the cornea, lens and retina with ophthalmoscope. Feel pinna and view vertical and horizontal canals and tympanic structures with otoscope.
History. Tires easily? Has the client noticed any fainting, weakness or exercise intolerance?
Examination. Listen to heart valves with both sides of stethoscope. Feel the femoral pulse and assess warm or cold sensation of distal extremities. Check tissue perfusion.
History. Any noticeable membrane color changes?
Examination. Look at mucous membranes, assess capillary refill and feel lymph nodes.
History. Any coughing, sneezing or distress noted?
Examination. View upper respiratory airways, assess inspiratory and expiratory patterns and note wheezing, crackle or pharynx rattle.
History. Any polydipsia, polyuria, incontinence or micturition problems? Record date of last estrus, any breeding patterns and data on ovariohysterectomy or orchiectomy.
Examination. External genitalia notations. Palpation of bladder, external organs including male prepuce, testes and female vulva and mammary tissues.
History. Regurgitation? Diarrhea? Stool size, color and shape? Bad breath?
Examination. Lips, teeth, oral cavity, salivary gland and thyroid palpation, abdominal palpation, anus examination along with anal sac questions (scooting?). Note dental score on whatever scale you use.