The clinical conundrum has replaced the “What’s your diagnosis?” feature which previously regularly appeared in the association’s journal, the JSAP. With the move to companion the format has been revised with the aim of making this CPD feature more accessible, thought provoking for the reader and to allow more in-depth discussion of the intricacies of the case presented. In particular it is hoped that cases will challenge the reader to consider a dilemma, be it a diagnostic challenge or a treatment/surgical decision and to work through it to a logical conclusion.

Case selection
The aim of the clinical conundrum is to present clinical scenarios which are encountered in small animal practice and discuss briefly any poignant features of the case.  The conundrum can focus on the complete case management or one aspect of the case management in more detail.

Example of how a case may be used in a conundrum

• A problem orientated approach to a challenging diagnosis. In this instance the emphasis would be to challenge the reader to construct a problem list, consider relevant differential diagnoses and ultimately achieve a diagnosis based on the information gained during investigation. In this type of report emphasis should be focused on the rationale for choosing a given test and a logical approach to eliminating all other differential diagnoses.
• Treatment or surgical dilemma. In this type of case the diagnosis may have already been made or be relatively simple to reach. The focus of this type of conundrum would be to challenge the reader to decide how they would gather the information to decide on a treatment plan and to select and justify choice of treatment based on the information obtained. This type of conundrum should not simply be a review of the literature, instead the emphasis should be placed on how the case was assessed and how these particular findings influence treatment choice
• Conundrums that focus on one aspect of a complicated case. Most suitable for a more focused evaluation of a single aspect of an individual cases such as anesthetic considerations and pre-anesthesia stabilization for a clinical presentation or the subtleties of diagnostic imaging interpretation.

An unusual diagnosis although interesting does not necessarily mean that a case will be a suitable to present as a clinical conundrum. In fact the final diagnosis is not the most important part of the conundrum, it may be unusual but is often a relatively common problem. Indeed the cases which make the best conundrums discuss a presentation thoroughly, logically progress through a case and achieve a robust diagnosis or treatment choice. It is the dilemma regarding diagnostic or treatment progression which is important rather than the diagnosis in and of itself. The editorial team are more than happy to advise on the selection of cases for this feature and particularly welcome and encourage submissions from those in general practice.

Style
Case reports should be structured to encourage the reader to consider different aspect of the case or diagnostic procedure as the clinical picture unfolds. This is easiest to achieve by posing questions which outline the author’s thought processes at the time when the actual investigation was taking place and the answers to which dictate the next step in the clinical management of the case. Thus the reader gains an appreciation of the logical progression through the case and, just like in the clinical situation, is not aware of the end diagnosis or final decision at the outset.

Understandably this format is easier to follow for some cases and in some clinical disciplines than others. However the format has been already been successfully adapted to a variety of different scenarios and the editorial board are always willing to assist with the construction of a conundrum around a suitable case.

An example of how a clinical conundrum, in which the focus is achieving a final diagnosis, could be structured is outlined below.  Depending on the type and focus of a conundrum the format will of course vary.

• Initial presentation information
• A brief clinical history to include signalment, presentation and examination findings
• Question - Create a Problem list?
• Answer -A short list summarizing the most important clinical findings
• Question - Consider the differential diagnosis for your problems. Can your differentials be prioritized based on the history and physical examination findings?
• Answer -The author should outline their thought processes as if the case was in front of them. For example “evidence of stranguria and dysuria made the lower urinary tract the most likely source of the haematuria”
• Question -Construct a Diagnostic/treatment plan
• Answer – Should outline which tests and treatments are appropriate in particular why a given test/treatment was been chosen. For example “a biochemistry profile was performed to assess for metabolic causes of seizures such as hypoglycemia and hypocalcaemia”. Any monitoring or ongoing treatments whilst tests are performed should also be outlined
• Results of investigations
• Question –How your interpretation of the test results help you refine your differential diagnosis?
• Answer -The results should be interpreted and the relevance of new findings to case management and diagnosis discussed. The problem list and differential diagnosis list may be reviewed and amended if necessary.
• The process of investigation, interpretation of results and evaluation of patient progression continues until a final diagnosis is reached.

Preparing a Submission
In total authors should aim for a piece of 1000-1200 words in length with a 1-5 illustrative pictures. Given that the emphasis of this feature is problem solving, references are not usually required unless they are integral to the problem solving involved.

Unlike the old “What’s your diagnosis?”, articles in companion are not indexed on Pubmed and are not citable in the traditional sense. Instead the style and remit of this feature has been devised to mirror that required by many of the CPD schemes. We hope that submitting a clinical conundrum will be particularly useful preparation when completing written work required, for example, by the RCVS certificate schemes.

Please email articles for submission to companion@bsava.com providing illustrations as separate graphic files (at highest resolution available) rather embedded within the text of a document.  Following initial review for suitability and style, the editorial board will then forward submissions for peer review. Review time is dependent on reviewer availability but it is intended that submissions be reviewed within 4-5 weeks from submission. An honorarium is payable on final acceptance of the article, provision of all figures/pictures in a suitable format and submission of an invoice.

The editorial team are more than happy to advise on the selection of cases for this feature, the construction of a conundrum around a suitable case and the refining of submitted work. If you have an idea for a conundrum but aren’t sure how to proceed please do contact us at companion@bsava.com