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
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
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
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
http://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