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Introduction to logical clinical problem- solving 15
communication, damage the trust relationship with clients and on
the whole make veterinary practice less pleasant than it should be.
You also have to know about and remember lots of diagnoses
for this approach to be effective. This is problematical if the
veterinarian does not recognise or remember potential diagnoses
(e.g. for Brutus) or if, as discussed previously, the pattern of clinical
signs doesn’t suggest many feasible differentials (e.g. for Erroll). It
is also less useful for inexperienced veterinarians or veterinarians
returning to practice after a career break or changing their area of
practice.
It is for all of these reasons that we hope this book will enhance
your problem- solving skills as well as build your knowledge base
about key pathophysiological principles. We want to assist you to
develop a framework for a structured approach to clinical problems
that is easy to remember, robust and can be applied in principle to a
wide range of clinical problems. The formal term for this is problem-
based inductive clinical reasoning.
Problem- based inductive clinical reasoning
In problem- based inductive clinical reasoning, each significant
clinicopathological problem is assessed in a structured way before
being related to the other problems that the patient may present
with. Using this approach, the pathophysiological basis and key
questions (see the following sections) for the most specific clinical
signs the patient is exhibiting are considered before a pattern is
sought. This ensures that one’s mind remains more open to other
diagnostic possibilities than what might appear to be initially the
most obvious and thus helps prevent pattern- based tunnel vision.
If there are multiple clinical signs – for example, vomiting,
polydip-sia and a pulse deficit – each problem is considered
separately and then in relation to the other problems to determine if
there is a disor-der (or disorders) that could explain all of the clinical
signs present. In this way, the clinician should be able to easily
assess the potential differentials for each problem and then relate
them rather than trying to remember every disease process that
could cause that pattern of particular signs. It is important that the
signalment of the patient is seen as a risk factor, but this should not
blind the clinician to potential diagnoses beyond what is common for
that age, breed and sex.
16 Clinical Reasoning in Veterinary Practice
Thus, we do look for patterns but not until we have put in place
an intellectual framework that helps prevent tunnel vision too early
in the diagnostic process.
Figure 2.2 shows the steps in the clinical reasoning flow. As
each step is explained you will see the numbered keys to help you
understand where you are in the diagnostic process. We use these
steps, their colours and numbered keys throughout the book to help
‘anchor’ the process for you through the repetition shown in Figure
2.1. Colour bars or shading are also used to identify introductory
concepts (blue), diagnostic approach and steps (brown) and key
introductory and summary points (purple).
Define
Define and and
Define the Define
refine the refine
location the lesion
problem the
system
1 2 3 4
Figure 2.2 Clinical reasoning step- by- step.
Essential components of problem- based clinical reasoning
The problem list
The initial step in logical clinical problem- solving is to clarify and
articulate the clinical problems the patient has presented with. This
is best achieved by constructing a problem list – either in your head
or, in more complex cases, on paper or the computer.
For example, for Erroll the problem list in the order the problems
are reported would be:
1 Vomiting
2 Anorexia
3 Depression
4 Dysuria and haematuria.
Why is constructing a problem list helpful?
• It helps make the clinical signs explicit to our current level of
understanding.
• It transforms the vague to the more specific.
Introduction to logical clinical problem- solving 17
• It helps the clinician determine which are the key clinical problems
(‘hard findings’) and which are the ‘background noise’ (‘soft
findings’) that may inform the assessment of the key problems
but do not require specific assessment.
• And most importantly, it helps prevent overlooking less obvious
but nevertheless crucial clinical signs.
Prioritising the problems
Having identified the presenting problems, you then need to assign
them some sort of priority on the basis of their specific nature.• For
example, anorexia, depression and lethargy are all fairly non-
specific clinical problems that do not suggest involvement of any
particular body system and can be clinical signs associated with a
vast number of disease processes.
• However, clinical signs such as vomiting, polydipsia/polyuria,
seizures, jaundice, diarrhoea, pale mucous membranes,
weakness, bleeding, coughing and dyspnoea are more specific
clinical signs that give the clinician a ‘diagnostic hook’ he/she can
use as a basis for the case assessment.
As the clinician increases understanding of the clinical status of
the patient, the overall aim is to seek information that allows them to
define each problem more specifically (i.e. narrow down the
diagnostic options) until a specific diagnosis is reached.
For example, for Erroll the prioritised problem list would be:
1 Vomiting
2 Dysuria and haematuria
3 Anorexia
4 Depression.
This is because vomiting and dysuria/haematuria are specific
prob-lems, and their assessment will hopefully assist in reaching a
diagnosis – they are our ‘diagnostic hooks’. Anorexia and
depression will be explained by the underlying disorder and are
important to note but are not ‘diag-nostic hooks’ for this case – they
are the ‘background information’.
Specificity is relative!
The relative specificity of a problem will, however, vary depending
on the context.
18 Clinical Reasoning in Veterinary Practice
• For example, for a dog that presents with intermittent vomiting
and lethargy, vomiting is the most specific problem, as in all
likelihood the cause or consequences of the vomiting will also
explain the lethargy.
• In contrast, for the dog that presents with intermittent vomiting and
lethargy and is found to be jaundiced on physical examination,
jaundice is the most specific clinical problem. This is because:
Ꮈ The majority of causes of jaundice can also cause vomiting, but
the reverse is not true, that is, there are many causes of vomit-
ing that do not cause jaundice.
Ꮈ Thus, there is little value in assessing the vomiting as the ‘diag-
nostic hook’, as it will mean that many unlikely diagnoses are
considered, and time and diagnostic resources may be
wasted.• In this case, assessment of jaundice will lead more quickly
to a diagnosis than that of vomiting, as the diagnostic options for
jaundice are more limited than those for vomiting.
In other words, although you identify and consider each problem
to a certain degree, you try to focus your diagnostic or therapeutic
plans on the most specific problem/s (the ‘diagnostic hook/s’) if (and
this is important) you are comfortable that the other clinical signs
are most likely related. If you are not convinced that they are all
related to a single diagnosis, then you need to keep your problems
separate and assess them thoroughly as separate entities, keeping
in mind they may or may not be related.
In emergency cases, the problems at the top of your problem list
are those that would immediately endanger the patient and must be
immediately addressed – remember your ABC of triaging (airway,
breathing, circulation). They may then be followed by the problems
that act as the diagnostic hooks to reach the final diagnosis/man-
agement plan.
Key concept
Create problem list Summarise the clinical problems the
patient has presented
with.
Prioritise the problem list Identify which of the problems are
specific – those that are ‘diagnostic
hooks’
immediately as the +/- those
patient’s life is that must be
at risk.
Introduction to logical clinical problem- solving 19
The reasons that might make one suspect that the clinical signs are related to more
than one problem include the following:
• The chronology of clinical signs is very different, raising the possibility that there
is more than one disorder present. It could be one progressive disorder, but it could
also be two different disorders.
• The problems don’t fit together easily, for example, different body systems appear to
be involved in an unrecognisable pattern, for example, as for Erroll.
• Other clues that may be relevant to the case. For example, some clinical signs
resolved with symptomatic treatment but others did not.
How do I decide what problems are specific?
As indicated previously, specificity is a relative term and will vary with each patient.
There are a few clues that you can look for when trying to decide the most specific
problems the animal has:
Is there a clearly defined diagnostic pathway for the problem with a limited number
of systems or differential diagnoses that could be involved?
For example: vomiting vs. inappetence
• The problem of vomiting has a very clearly defined diagnostic pathway
(discussed in Chapter 3), whereas there is almost an endless set of diagnostic
possibilities for causes of inappetence, and there is no well- defined diagnostic
approach (Chapter 5).
• Hence, vomiting is a more specific and appropriate ‘diagnostic hook’ than
inappetence.
Could one problem be explained by all of the other problems but not vice versa, or
does the differential diagnosis list for one problem include many diagnoses that would
explain the other problems but not vice versa?
For example: vomiting vs. jaundice
• As mentioned earlier, jaundice is the more specific problem because most
causes of jaundice could also conceivably cause vomiting, but there are many
causes of vomiting that do not cause jaundice.
• Hence, the diagnostic pathway for jaundice is more clearly defined (discussed in
Chapter 11), and there are a more limited number of possible diagnoses.
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22 1:
Conics
Completing the square in this equation, we have
3 x′2+ 2√2x′ y′2+ 2√2y′
+7 −1
2 2
3 √2 √2 = 0,
x′+ −6+7 y′+ − 14 − 1 = 0,
and
2 2
so 3 √2 √2
x′+ +7 y′+ = 21
o
2 2
r √2 √2
x′+ y′+
(2
7 + 3 = 1. )
This is the equation of an ellipse.
From equation (2) it follows that the centre of the ellipse is the point
where x′= −√2 and y′= −√2. From the equation x = Px′, it
follows that in terms of the original coordinate system this is the point
√2 1 √√2 −−√√2
x
⎛1 2
y √2 1
=
2⎞⎠
⎝−1
,
=
−2
that is, the point (−2, 0).
It also follows from equation (2) that the major axis of the ellipse has
equation y′= −Finally, since the matrix P is orthogonal we can rewrite the equation√2, and the
minor axis has equation
x= x′=
Px−√2.
′in the form x′= P−1x = PTx, so that
x
or as a pair of equations
x′ y
y′ =⎛⎝1 √1
x −1 2 y,
x′= √2
1
y′=√2 x +1 2 y.
It follows that the equation y′= −√2 of the major axis of the ellipse
can be expressed in terms of the original coordinate system as
1
√
√2x + 1
or 2y = −√2
x + y = −2.
Geometry, 2nd Edition | Solutions for exercises
David A. Brannan, Matthew F. Esplen and Jeremy J. Gray | c⃝ The Open University, 2012
1: Conics 23
Similarly, the equation x′= −√2 of the minor axis
of the ellipse can be expressed in terms of the
original coordinate system
1 as
√
√2 1
or x 2y = −√2,
x − y = −2.
(c) The equation of this conic
x2− 4xy + 4y2− 6x − 8y + 5 = 0
can be written in matrix form as xTAx + JTx +
;
H = 0, where A= 1 −2
that is
−2 4 ,J= −6
1 x x
x y −2 4 +
y −6 −8 y +5=
−2
We start by diagonalizing A. Its characteristic equation is 0.
0 = det (A − λ I) = 1 − λ −2 4−λ −2
= λ2− 5λ + 4 −
4
= λ2− 5λ
= λ (λ − 5) ,
so that the eigenvalues of A are λ = 0 and λ = 5. The eigenvector equations of A are
(1 − λ) x − 2y =
0,
−2x + (4 − λ) y =
0.
When λ = 0, these equations become
x − 2y = 0,
−2x + 4y = 0,
2
,
or x = 2y, so that we may take 1
as a corresponding eigenvector
2/√5
Geometry, 2nd Edition | Solutions for exercises
David A. Brannan, Matthew F. Esplen and Jeremy J. Gray | c⃝ The Open University, 2012
24 1:
Conics
When λ = 5, these equations become
−4x − 2y = 0,
−2x − y = 0,
or y = −2x, so that we may take as a corresponding eigenvector
Now
−2
, which we normalize to have unit length as
2√5 1 √5 ⎛⎝1−2
√
√
5
5⎞⎠.
1√5 −2 √5 = −4 5− 1 5= −1,
so (interchanging the order of the eigenvectors as columns of P) we
(Px′)TA(Px′) + JT(Px′) + H = 0
or
x′T(PTAP)x′+ (JTP)x′+ H = 0.
5 0
Since , this is the equation
0 0
√5 2 √√5
which we can x′ +5 = 0,
1 y′
√5 5⎞⎠
rewrite in the form
x′y′5 0 5y′+ 5 = 0.
Completing the square in this equation, we have
5 − 4√5y′+ 5 = 0,
x′2+ √5x′2
2
5 x′+ 1 − 1 − 4√5y′+ 5 = 0,
√5
2
5 1 − 4√5y′+ 4 = 0,
x′+ √5
2
5 1 − 4√5 1
x′+ √5 y′− √5 = 0,
o
r 1
2 4 1
. (
x′+ √5 = √5 y′− √5
3
This is the equation of a parabola.
Geometry, 2nd Edition | Solutions for exercises
David A. Brannan, Matthew F. Esplen and Jeremy J. Gray | c⃝ The Open University, 2012
1: Conics 25
From equation (3) it follows that the vertex of the parabola is the point
where x′= −1 5and y′ =√5. From the equation x = Px′, it follows
1
that in terms of the original coordinate system this is the point
5⎞
√5 2 √ √
x =
y ⎛⎝1 1−2 √ ⎛⎝−1
√5 1 5⎠
5
√
, 5
= 3 5 5⎞⎠
that is, 5, 3 .
the
It also follows from equation (3) that the major axis of the parabola has
equation x′= −1 5, and the minor axis has equation y′ =√5.
1
x = Px′in the form x′= P−1x = PTx, so that
x
or as a pair of equations ,
y
x′
y′ =⎛⎝1 1 √ 2
x′= √5x − √
2 51
y′= √5x + √
5
It follows that the equation x′= −1 5of the major axis of the parabola
can be expressed in terms of the original coordinate system as
1
√5y = − 1 5,
√5x − 2
or
x − 2y = −1.
1
Similarly, the equation y′=√5of the minor axis of the parabola can be expressed in terms
of the original coordinate system as
2 1 1
√5x √5y =
√
or +
2x + y = 1.
(d) The equation of this conic
21x2− 24xy + 31y2+ 6x + 4y − 25 = 0
can be written in matrix form as xTAx + JTx +
H = 0, where ;
A= 21 −12 −12
Geometry, 2nd Edition | Solutions for exercises
David A. Brannan, Matthew F. Esplen and Jeremy J. Gray | c⃝ The Open University, 2012
26 1: Conics
that is,
x y
−12
21−12
31
x
y
+64
x
y− 25 = 0.
We start by diagonalizing A. Its characteristic equation is
0 = det (A − λ I) = 21 − λ
−12 31 − λ
−12
= λ2− 52λ + 651 − 144
= λ2− 52λ + 507
= (λ − 13) (λ − 39) ,
so that the eigenvalues of A are λ = 13 and λ = 39. The eigenvector equations of A are
(21 − λ) x − 12y = 0,
−12x + (31 − λ) y = 0.
When λ = 13, these equations become
8x − 12y = 0,
−12x + 18y = 0,
3
,
or 2x = 3y, so that we may 2
take as a corresponding
eigenvector
When λ = 39, these equations become
−18x − 12y = 0,
−12x − 8y = 0,
or 2y = −3x, so that we may take as a corresponding eigenvector
Now
−2 3 , which we normalize to
have unit length as
3
2√√
13
13 −2 3 √
√
13 13
(Px′)TA(Px′) + JT(Px′) + H = 0,
Geometry, 2nd Edition | Solutions for exercises
David A. Brannan, Matthew F. Esplen and Jeremy J. Gray | c⃝ The Open University, 2012
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