A job for the robots
| May 28, 2023 | Posted by Melinda under Uncategorized |
On any given ER shift I have large number of dogs that have eaten things they shouldn’t have.
In fact, I’m not sure small animal ER would even exist without the hoover capabilities of Fido.
Aside from making dogs regret their life decisions and vomiting their ill-gotten gains, or going in surgically and playing the game of “just whose underwear is this actually?”, there’s the run of the mill….gastroenteritis cases.
This is where I give a fancy sounding name (gastroenteritis) for a disease that literally means “we don’t have a clue why your dog is vomiting or diarrhea but it isn’t going to matter anyways because it’s going to resolve with supportive out-patient treatment.
I write this same medical record multiple times a night, so I have a little copy and paste template for my record that goes something like *this:
S/O: [Insert history and physical exam templates here]. Usually some form of young to middle aged perfectly normal appearing male dog with or without a history of getting into the trash, on the counter, or one too many treats aka that one time that Fig snuck m&m’s into bed and puked rainbow chocolate all over her sheets when she was three.
*If you aren’t familiar with the SOAP format of medical records, basically the S = subjective and it’s where everything you tell me gets put, the O= objective and that’s the things I see and feel and measure with my own hands, A = is a list of possible diagnosis, and P= the plan.
Assessment:
Problem 1: Acute vomiting and diarrhea. Suspect gastroenteritis. r/o Intestinal parasitism, gastrointestinal foreign-body, dietary indiscretion, salmonellosis, Clostridium spp. infection, pancreatitis, protozoan infestation. Less likely based on history and PE but also consider: rickettsial disease (salmon poisoning disease, ehrlichiosis), viral infections (coronavirus, distemper, parvovirus, etc.), and toxicity.
Plan:
Diagnostics
- CBC/chem
- +/- Snap cpl
- +/- Cortisol
- Abdominal Radiographs – with consult
- Fecal
Medications and treatments
- Cerenia 1 mg/kg SQ
- SQ fluids LRS 30-50 ml/kg
Medications to send home
- Rx Proviable Use as directed
- Rx Low fat bland diet or home bland
Also Consider: (ie depending on the case I might recommend one of these therapies, but rarely, so this part of the section just get deleted most of the time).
- Famotidine 1 mg/kg PO q 12 hours
- Omeprazole
- Odensteron 1 mg/kg PO q 12 hours
- Gabapentin 10 mg/kg PO q 8-12 hours PRN
- Sucralfate 0.5-1 g Slurry with med timing warning
- Metronidazole 15-20 mg/kg PO q 12 hours x 5-7 days OR tylosin
- Cerenia 2 mg/kg PO q24 hours
- Rx Fendendazole 50 mg/kg q 24 hours x 3 days.
TGH instructions
- Bland diet (rx or home)
- Plumbs “Gastroenteritis” client handout.
Client communication:
Discussed the results of the diagnostics (xrays and lab work). Unremarkable, radiologist interpretation is pending. Discussed a gastroenteritis and possible causes. Patient is BAR and stable, discharge with outpatient therapy recommended. Reviewed prognosis (favorable).
Plan
Monitor for further vomiting and worsening diarrhea. Recheck if concerned, progressing, or new symptoms develop. If does not resolve consider abdominal ultrasound, screening for parasites or infectious disease (diarrhea OPG/PCR test), “Texas” GI function panel.
-M. Newton, DVM
*takes a bow*
I mean come on, that’s pretty good right? A doctorate degree, a quarter of a million dollars, and almost a decade of practice has resulted in a pretty damn good record template that works with some modifications for each patient. Let me point out that I get complimented on my records all. the. time. *preening*.
So.
Tonight I had a thought. How would the AI technology fare at my job?
So I asked the AI bot:
“Write a SOAP veterinary medical record about a vomiting and diarrhea young dog that probably has gastroenteritis but could also have a foreign body, parasites, or pancreatitis as main differentials.”
This was the result (feel free to skim to the dividing line where I start chattering away again after the robot is done):
Subjective: Today, a 1-year-old male neutered Labrador Retriever named Max presented to the clinic with a chief complaint of vomiting and diarrhea. Max’s owner reported that these symptoms started approximately 24 hours ago and have persisted since then. The owner mentioned that Max had access to the backyard where he could have potentially ingested foreign objects. Max’s appetite has been decreased, and he has been drinking water but not excessively. No recent changes in diet or exposure to other animals were reported. No recent travel or vaccinations were noted.
Objective: On physical examination, Max, a 1-year-old male neutered Labrador Retriever, appeared alert and responsive. His body temperature was within normal limits (38.5°C). Max’s heart rate was regular and normal, and his respiratory rate was unremarkable. His hydration status appeared fair, with a slightly delayed skin tent. The mucus membranes were pink and moist. Abdominal palpation revealed mild discomfort but no evidence of organomegaly or palpable foreign bodies. No abnormalities were detected on thoracic auscultation.
Assessment: Based on the history and clinical findings, the following differentials are considered for Max’s condition:
- Gastroenteritis: Given the acute onset of vomiting and diarrhea, gastroenteritis is the primary consideration. It could be caused by various factors, including dietary indiscretion, bacterial or viral infection, or parasitic infestation.
- Foreign Body Ingestion: Considering Max’s access to the backyard where he could have encountered foreign objects, ingestion of a foreign body leading to gastrointestinal irritation cannot be ruled out.
- Parasitic Infection: Parasites such as roundworms, hookworms, or Giardia can cause vomiting and diarrhea in dogs. Although Max is not currently on parasite preventives, his regular veterinary care has included previous deworming.
- Pancreatitis: Given Max’s decreased appetite and the possibility of dietary indiscretion, pancreatitis should be considered as it can cause gastrointestinal symptoms including vomiting and diarrhea.
Plan:
- Stabilize Max’s condition: Begin by addressing his fluid balance by administering subcutaneous fluids to correct any dehydration. Monitor Max’s vital signs and hydration status closely during this process.
- Diagnostic workup: a. Fecal examination: Collect a fecal sample for parasitic testing, including a fecal flotation and direct smear. b. Abdominal radiographs: Perform radiographs to evaluate the gastrointestinal tract for signs of obstruction or the presence of any foreign bodies. c. Bloodwork: Conduct a complete blood count (CBC) and serum biochemistry profile to assess Max’s overall health status, identify any electrolyte imbalances, and rule out systemic causes of gastrointestinal symptoms. Include specific pancreatic enzymes such as amylase and lipase to evaluate for pancreatitis.
- Symptomatic treatment: a. Anti-emetics: Administer an anti-emetic medication such as maropitant to alleviate Max’s vomiting. b. Probiotics: Prescribe a probiotic to help restore normal gut flora and promote gastrointestinal health.
- Dietary management: Feed Max small amounts of a bland diet consisting of easily digestible food (e.g., boiled chicken and rice) in frequent meals. Avoid fasting Max and instead provide ongoing nutrition to support his gastrointestinal tract.
- Follow-up: Schedule a follow-up appointment in three days to reassess Max’s condition, review diagnostic results, and adjust the treatment plan accordingly.
Prognosis: The prognosis for Max’s condition is generally favorable, as the primary differentials considered (gastroenteritis, foreign body ingestion, parasitic infection, and pancreatitis) can be effectively managed with appropriate treatment and supportive care. However, the specific diagnosis will rely on the results of the diagnostic workup.
- I provided the appropriate differentials (the top reasons this dog had GI signs) to the bot. Creating a differential list that is likely to have the *real* even if currently unknown reason for a patients clinical signs doesn’t look like much on paper, but it is the key to determining the appropriate plan and therapies.
- The Plan section wasn’t something that could be trusted – a knowledge of disease and disease process and the risk/benefit of any particular therapy is still needed. Initially the bot suggested IV fluids (overkill and expensive), resting the GI tract (stupid and unnecessary), and using antibiotics as an anti-diarrheal (no longer standard of care unless there’s a documented reason for antibiotic use) for this case of an otherwise stable out-patient gastroenteritis case. But I just deleted the antibiotics and then nicely asked the bot to remove the fasting from the plan and replace with frequent small feedings of a bland diet, and substitute SC fluids for IV, and it happily complied with my requests without arguing with me.
- Then of course, there’s the patients that aren’t in the 80% run-of-the-mill cases that will still require me to be able to write a detailed record from scratch. But I’m pretty sure that using AI to speed through that 80% leaves me a lot more time to focus on the 20%.
