DAMN-IT' acronym offers practical diagnostic aid

Mar 1, 2005
By: Carl A. Osborne, DVM, PhD, DACVIM
DVM360 MAGAZINE





Most would agree that a correct diagnosis is an essential prerequisite to providing safe and effective treatment for
various illnesses.
Diagnosis of specific causes of various clinical disorders is of importance because it facilitates: 1) accurate forecasts
(e.g. prognosis) of the biological behavior of the disorder, and, 2) selection of specific (rather than symptomatic or
supportive) therapy for the disorder. However, diagnoses are often a matter of opinion rather than matter of fact.
In fact, isn't it true that most diagnoses often require us to make decisions in the absence of certainty?
Our diagnoses are based on probability. This being the case, we must use caution not to fall into the trap of making
diagnoses on the basis of faulty logic or insufficient information. It is one thing to make a diagnosis and another to
be able to substantiate it. Though we name the things we know, we do not necessarily know them because we
name them.
Shortcuts in diagnostic reasoning tend to become increasingly prevalent when veterinarians are subjected to the pressures of a
high caseload in a busy hospital.
In this context, short cuts are often defended on the basis of "practicality". Although practicality is a virtue, we must
use caution not to use the concept of practicality as an excuse for ignorance. A misdiagnosis can be more
detrimental to the patient than the illness. A wise sage penned this thought: "Heaven defend me from a busy
doctor."
Recall that the problem-oriented veterinary medical system is a simple, structured and reproducible set rules and
directions that efficiently and effectively guide our care of patients. It is based on four related phases of medical
action: 1) initial collection of information (so-called database); 2) identification of problems (so-called problem list;
3) devising plans to further refine the causes of problems, and also devising plans to treat the problems (so-called
initial plans); and, 4) interpretation and recording of additional information generated by initial plans in order to
determine whether additional diagnostic and/or therapeutic plans are necessary (so-called follow-up plans; also
called progress notes).
A frequent error in diagnostic reasoning, made even by veterinarians with years of experience, is prematurely
guessing the specific cause of an illness, first, without verifying the presence of the problems (especially problems
identified by owners), second, localizing problems to various organs or body systems, or third, considering basic
pathophysiologic disease mechanisms that might be involved. Making a practice of bypassing the fundamental
priorities of diagnostic planning often results in over dependence on past experiences or textbook descriptions to
identify the underlying causes of various diseases. As a result, our ability to recognize specific causes of diseases
that we have not encountered previously is hindered. Likewise, memorization of textbook descriptions of
characteristic clinical findings of specific diseases is not consistently effective. Why not? In different patients, the
same disease typically induces a variety of manifestations of different degrees of severity. Most textbook
descriptions are compilations of prototypical manifestations of diseases, all of which do not coexist in the same
patient. Just as no two individuals are exactly alike in health, so neither are any two alike in disease.
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DAMN-IT' acronym offers practical diagnostic aid
Mar 1, 2005
By: Carl A. Osborne, DVM, PhD, DACVIM
DVM360 MAGAZINE





Based on the premise that a well-defined problem is half solved, the primary objective of this Diagnote is to review
application of the DAMN-IT acronym as an aid in formulation of diagnostic plans (a component of the third phase of
medical action of the problem oriented system).
Priority plans To enhance our ability to detect the underlying cause of various types of illness, we
chronologically follow a prioritized sequence of diagnostic steps (Table 1, Osborne: Veterinary Clinics
of North America, Vol. 13, Nov. 1983). To summarize, after initial identification of the patient's
problems (Phase 1- Database) and appropriate refinement of these problems (Phase 2-Problem List),
further diagnostic plans are formulated to confirm and identify the underlying causes of these problems
(Phase 3-Initial problem list). When formulating diagnostic plans, we routinely follow the following
sequence of steps: 1) verify or confirm the presence of problems, especially those defined by clients, 2)
localize problems to an organ or body system, 3) consider the most probable pathophysiologic
mechanism(s) associated with the identified problems (DAMN-IT acronym; Table 2), and 4) based on
the probable (in contrast to the possible) pathophysiologic mechanisms present in the patient, formulate
specific diagnostic rule-outs (tentative diagnoses) that would explain the underlying cause of the
problems, and implement diagnostic tests to confirm them. By using the DAMN-IT acronym when
considering diagnostic rule-outs, numerous diagnostic possibilities can be logically reduced to a few
diagnosticprobabilities.
The acronym The DAMN-IT acronym encompasses familiar pathophysiologic disease processes.
Therefore, with routine use, it rapidly becomes part of our memory. When routinely used in
conjunction with the history, physical examination and other diagnostic data, the acronym facilitates
rapid and reproducible formulation of probable rule outs (or tentative diagnoses) for each of the
patient's undiagnosed problems. Since I developed the DAMN-IT acronym as an aid to taking
examinations when I was a sophomore veterinary student in 1962, I have added some additional
pathophysiologic mechanisms (Table 2). As an iterative memory aid, some of the pathophysiologic
mechanisms listed with different letters in the DAMN-IT acronym overlap (i.e. autoimmune and
immune; and developmental, anomalous, and inherited).
What is next?
After developing a list of pathophysiologic mechanisms likely to be causing the clinical
problems, the most probable cause(s) of these problem(s) should be ruled-in or ruled-out by
implementing appropriate diagnostic plans. The specific diagnostic tests and procedures
chosen to evaluate each problem, and the rate and frequency with which these tests are implemented, are
dependent on several factors, especially the status of the patient.
If rapidly changing problems are likely to result in irreversible dysfunction or if the problems are an immediate
threat to the patient's life, then diagnostic plans for several rule-outs should be implemented simultaneously (that
is, in parallel).
For example, if a critically-ill patient is admitted because of rapidly progressing vomiting, dehydration, impaired
urine concentrating capacity and extreme depression, it is advisable to simultaneously implement diagnostic plans to
rule-out renal failure, diabetic ketoacidosis, hypoadrenocorticism, pyometra and hepatic dysfunction. If an individual

Table 1: Four phases
of medical action

Table 2: DAMN-IT
acronym of
pathophysiologic causes
of disease
priority list of these rule-outs is established and plans are implemented to rule-out only one cause at a time (that is,
in series), then the patient might die before a specific diagnosis is established.
Concluding caveats Diagnoses should not be overstated by guessing their underlying cause based on
insufficient evidence. They should be stated at the level of refinement that can be reasonably justified on the basis
of current knowledge about the patient. Why? Because if the diagnosis is overstated, then misdiagnosis,
misprognosis and formulation of ineffective or contraindicated therapy can result. No patient should be worse for
having seen the doctor.
DAMN-IT' acronym offers practical diagnostic aid
Mar 1, 2005
By: Carl A. Osborne, DVM, PhD, DACVIM
DVM360 MAGAZINE





The Greek term " iatros" means physician and is derived from the word "iasthai", which means to heal or cure. In
the context of pathophysiologic mechanisms of disease, what is the significance of the term iatrogenic (Table 2)?
The term iatrogenic means "physician induced". The fact that the term iatrogenic is listed as a pathophysiologic
mechanism of disease emphasizes that there are some patients we cannot help, but there are none we cannot
harm.
Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the
Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.