What’s Your Diagnosis, #8? The Case of the Dishrag Dog, Part 2

Part 1’s history is here - check it out!

Bella is a 7-year-old spayed female Shih-Tzu mix with a chronic history of severe ear infections and allergies.   She is currently very lethargic, has ear and eye infections, and the petsitter is worried she is in pain.

More history for those who asked for it:

The petsitter has not given any additional medications. Bella has not eaten for 3 days.  She has not been defecating for 3 days.  The petsitter reports that Bella has urinary incontinence and urinates in her bed, which the owner had not mentioned to her, but they are not sure if that is a new problem or not.  Bella is not walking at all today, they are concerned that she is painful because she does not want to get up.  Bella is normally on a diet of raw ground beef and beef broth mixed with kibble. 

Physical Exam Findings:

Temperature: 102.1  Pulse: 80 bpm  Respirations: 30/min

Capillary refill time: >3 seconds  Body condition: 3/9

Read More

asker

Anonymous asked: Hi, I recently watched the euthanasia of several animals, one of whom I had known since I was very young. People expect you to break down and cry, but I wasn't even vaguely sad. I felt that this was the wrong reaction, but I couldn't make myself sad, as it were. I'm a much more logical person than emotional, but you'd be amazed how many people gave me funny looks about it. Will this make me less of a vet when I become one, because I don't show my feelings?

beltedgalloways:

I think that the answer to your question really lies in the origins of the word ‘euthanasia’. Forgive me for being a bit of a Classics nerd here, but the word derives from the Greek, εὐθανασία, which means ‘good death’, and in the majority of cases, the meaning really is literal. Most euthanasia solutions are a combination of chemicals whose intent is to effect a termination of nerve transmission and to effect complete muscle relaxation. It is quick and painless and in most cases, it is the right thing to do. To me, what makes you a ‘good’ vet is not how you personally feel, but your ability to empathise. Are you able to be realistic yet sympathetic? Perhaps you don’t feel sad, but can you understand why your client might be upset? Can you explain to them that these feelings are perfectly normal, even though you know that you are atypical?

As you said, some people do break down and cry. Maybe it’s something to do with us as humans projecting our own humanity and mortality onto our pets in their last moments. Maybe there’s a confliction of guilt and confusion - perhaps we feel that it was too late, or too early. Will you be less of a vet because you didn’t have any of these reactions? Absolutely not.

Personally, it’s usually the reaction from the client that has the biggest effect on me. I feel sad for the hole left in the client’s life because their best mate is gone forever. I feel sad that there will be no waggy tail at the door when they get home from work, I feel sad that there’ll be an empty basket in the corner, an empty space at the end of the bed. But do I feel sad, truly sad, for the dog himself? No, I don’t. His suffering has ended, swiftly and peacefully, and on his behalf, I am comforted.

I agree with beltedgalloways’ response - it is all right if you don’t necessarily feel sad (though I admit that not being sad to say goodbye to an animal I had known a long time would be nearly impossible for me), but you need to be able to help your clients accept that their having those emotions is normal.  There are many euthanasias where I do not cry or tear up, but I keep my voice calm and slightly hushed, I move more slowly than in a normal appointment, I try to keep my body language open if the client is close to me (in case they want to hug, for example) or unobtrusive if the client is focused more on their pet.  I try to tailor my response based on what the owner is showing me - if they are gruff and trying to keep it together I stay calm and quiet for them, if they are telling me stories about their pet I will share some of my own pets who have passed on.  Every one is different.  

If you are able to be flexible to the needs of your client it doesn’t matter if you don’t cry or not.  If your demeanor is such that you are calm but sympathetic to your crying client, that would be fine.  However, if you are unable to show empathy with your client, or are uncomfortable acknowledging their grief (i.e. not giving them time to say goodbye to their pet, or not offering them tissues if they cry, or not accepting a hug if they try to give you one in thanks) then that could be more of a problem.  You don’t have to feel all the things they are feeling, but your presence should create a space that says, “Whatever your feelings toward your animal, it is all right to feel them here.  We understand.  You are not weak for missing your pet.”  

As said above, it is extremely rare that I feel sad for the pet in euthanasia.  It is almost always the owner’s emotional response that is the trigger for my own emotions.  If it is not, it is usually because the pet seemed to have been robbed in some way - i.e. a young puppy with a heart condition, a kitten who I could not save.  Then my sadness is an apology for not being able to do more.

What’s Your Diagnosis, #8? The Case of the Dishrag Dog

Hello, it’s been a while since one of these!  I have to confess that this one is a little tricky, because one key aspect of the case was not able to be diagnosed.  However, the main diagnosis is known :)  I will reblog answers to questions after 2-3 days.

—-

Bella is a 7-year-old spayed female Shih-Tzu mix with a chronic history of severe ear infections and allergies.  Previous recommendations had been made for referral to dermatologists and more recently to surgeons for her severe ear infections, which had resulted in proliferation of the tissue of the ear canal to the point that one ear was completely obstructed by cauliflower-like inflammatory overgrowth.  The owner had previously declined all referrals and the majority of workup/diagnostic/treatment options.  Due to limited funds on the part of the owner Bella’s only current treatment is Temaril-P, a steroid/anti-histamine combo, 1/2 to 1 tablet every 24 to 48 hours as needed to control itching.  The owner has previously declined monitoring bloodwork or trials of other allergy medications.

Bella is presented today for severe lethargy.  The owner is out of town and the petsitter feels that something is wrong.  Bella seems a lot thinner than they remember and does not want to eat or move for the past day or so.  Her appetite used to be good, but now it has ceased completely.  She vomited once a few days ago, but has had no diarrhea.  She seemed to be drinking and urinating a lot for the first few days, but is now drinking very little.  She has a lot of ear discharge and the petsitter is worried about an eye infection, since she seems to have a lot of discharge from her eye.

The petsitter is concerned that she is in pain because she does not want to move, and had called your office asking if the dog could get an aspirin.  The petsitter has not given her anything but her normal medication.  Your astute receptionist declined to give her an aspirin dosage and instead recommended an exam.  

You enter the room concerned about Bella’s clinical signs.  She has usually been bright and alert in the past and on the friendly side and you have only seen her for her ears before. 

When you walk into the room, however, you see her laying as limp as a dishrag in the petsitter’s lap, her head flopped over to one side, her eyes barely having energy to blink.  Her hair is matted, especially around her face.  You check her chart and are horrified to see that her previous weight of 14.0 lbs has dropped to 9.7 pounds in 6 months.  She looks extremely thin.

——————-

Exam findings coming up in the next post.  Questions:

- What body systems will you examine most closely?

- Is this likely to be an acute problem or a chronic problem?  Could it be an acute exacerbation of a chronic problem?  Why or why not?

- What additional history would you like?

asker

someone-shot-our-innocence asked: i have a 2 year old king charles spaniel,This morning my dog was left alone for a while(just like every other day) and when i got hom i stroked him on each back and he started whining.i stopped and he still was silently whining for some seconds,Then i stroked him again and he was fine he didnt do anything,After a while i stroked him again on his back and he whined again,he also whines when i try to roll him over.whats wrong?what happened?he was fine this morning and now he is like this

I am sorry but I cannot answer this question, for 3 reasons:

1) A veterinarian is legally unable to diagnose an animal without a valid veterinary client patient relationship (VCPR).  Without an existing relationship between the patient, client, and vet, such as that conferred by examining the animal in person, I would be held liable for any diagnostics and could be in danger of malpractice.  For instance, what if I told you that your dog is probably fine - but really, he had a slipped disk that could cause permanent paralysis?  If you took my advice and did not seek veterinary care, I would be held liable for the fact that your dog got worse because as a professional, I should know better.  You and I and your dog do not have a VCPR.

2) It is impossible to diagnose anything over the Internet.  I can give you a long list of things that could be causing your dog’s issue, ranging from mild to life-threatening.  There is no way to narrow it down without laying hands on your dog.  Dogs can whine due to pain or fear or respiratory distress or an injury or an illness etc. etc.

3) I do not answer questions of this nature on my account for the above two reasons, but even if those reasons did not exist, I would still not diagnose your dog over the Internet.  Veterinary medicine is my livelihood and I cannot provide diagnostics and treatment for free just because.  You wouldn’t ask your lawyer friend to represent you without compensation or your mechanic friend to put in a new transmission for free or your dentist friend to slip you a few new fillings.  In certain cases I will try to work with people with financial limitations to reach a compromise that allows us to provide good care for an animal at reduced cost, but that cannot be done for everybody or a small clinic would go broke.  (Plus, I don’t own my practice and thus I am held liable to my boss for any discounts.) 

I hope your dog is feeling better, and I hope you do not feel like this response was out of spite or anger at you.  I get these questions fairly frequently and sometimes when I do I use them as an opportunity to educate as to why we do not answer these types of questions.  If your dog is acting strangely, I suggest a visit to his veterinarian, and hopefully there is nothing seriously wrong with him.   Good luck.

asker

Anonymous asked: Where in LA do you work? Does your clinic take 4th year externs?

Hi Anon, I try not to post anything that can identify me too closely publicly just to maintain privacy. I work about 35-40 miles north of LA and our clinic is not an approved 4th year site for any veterinary school at this time. We don’t always have the high case load that would be preferred, though sometimes we do get slammed! It could possibly become a 4th year general practice site. Please come off anon if you’d like more info :)

Severe icterus, or jaundice, of the gingiva in a deceased dog.  Icterus may occur with liver failure and inability of the liver to process bilirubin, a waste product; it may also occur with destruction of red blood cells, resulting in excess bilirubin.  The 40 pound dog had a large liver mass the size of a large cantaloupe.  Liver failure was the likely cause of death.

Severe icterus, or jaundice, of the gingiva in a deceased dog. Icterus may occur with liver failure and inability of the liver to process bilirubin, a waste product; it may also occur with destruction of red blood cells, resulting in excess bilirubin. The 40 pound dog had a large liver mass the size of a large cantaloupe. Liver failure was the likely cause of death.

The picture on the left shows a small breed dog’s normal upper canine, lower canine, and third incisor.  The picture on the right shows the same dog’s other side, where the upper canine tooth is completely missing — or is it?  It appears to be present, unerupted, under the gum, despite the fact that the dog is 2 years old.  Teeth should be fully erupted before 6 months of age.  I recommended extraction of the tooth to the owners, given that it is never going to erupt at this stage and may predispose to the formation of dentigerous bone cysts, but the owners have declined for now.

The first photo shows a large splenic tumor in a retriever mix, consistent with a hemangiosarcoma.  The second photo shows metastasis to the liver.  The dog also exhibited hemoabdomen, or profuse bleeding into the abdomen, which is also consistent with a hemangiosarcoma, a tumor of blood vessels.  Impression smears of a cut tumor nodule are photographed below, showing large cells of irregular size and shape, and one cell with two nuclei.  Dividing cells and atypia are two signs of malignancy.  The dog was euthanized after profound anemia occurred, and necropsy discovered the above findings.

A fun picture of yeast (the footprint/peanut shaped purple blobs), cocci (the tiny round purple blobs), and cellular debris seen in a dog’s ear infection.

A fun picture of yeast (the footprint/peanut shaped purple blobs), cocci (the tiny round purple blobs), and cellular debris seen in a dog’s ear infection.

Behind the Medic: “Dr. Cranquis, the electronic prescribing system is down until further notice…”

cranquis:

My nurses just looked at me funny when I started flipping the workstation lightswitch on and off while making glottal techno-beat noises.

Diagnosis: hyperthyroidism-associated cardiomyopathy

Diagnosis: hyperthyroidism-associated cardiomyopathy

(via hallloween)

How can you ensure you get those vital work experience placements and how do you make the most of them?

getmeintovetschool:

I once read a quote from a vet saying ‘if work experience wasn’t so valuable, it wouldn’t be so hard to get’. When I was still at school, I wholeheartedly believed this after applying to endless vet surgeries for placements and often never even getting a reply. Perhaps this is the first hurdle hopeful applicants must pass? Determination is crucial for getting through vet school, so must we prove it before applying?

Many vets are more than happy to take on students once they are at vet school. Often, this is because of insurance policies in place to protect the students and themselves in case of accidents. Often, this is because they have a far more developed knowledge of anatomy, drugs, diseases and treatments. Often, this is because they have proved themselves worthwhile students, keen to learn and willing to get stuck in. This, however, is absolutely no help when still at school or college and is extremely frustrating since every vet school demands at least 2 weeks experience. When vet schools use work experience gained as a way of filtering applicants, these valuable placements become just as important as your grades.

So, what can you do to help get work experience placements and how should you make the most of them?

  1. It’s all about who you know. ANY link to a vet (family, friends, teacher’s friends, your vet, your stable’s vet etc.) is a huge asset in asking for a placement. Don’t be afraid of being shameless in asking favours or name-dropping if it will ensure you gaining that placement!
  2. Be persistent (but not annoying). Send a letter, phone them and if need be, drop in in person. If they say no, accept it and move on. If they are vague or don’t get back to you, try again.
  3. Keep an open mind. Placements don’t have to be purely veterinary based to still be extremely useful. I spent 6 weeks at the University of Liverpool studying molecular biology of plants and learnt loads of laboratory skills. This placement really made me stand out amongst applicants because it was so unusual. I also had to produce a written project report which is really similar to the research project I have to produce in 2nd year. See? Who’d have thought studying plants for a whole summer would land me with the skills I need in vet school?
  4. Be prepared. Read up about the practice, company or type of farm you’ll be going to. It will impress your supervisor if you’re interested in their business and prevents them having to explain the basics to you. Make a list of question you could ask before you go - most of these will be answered within your first few days anyway but you’ll find yourself adding to it during your placement. It’s also a good idea to ring a few days before your placement to confirm the timings, lunch arrangements, clothing required etc.
  5. Network and make contacts. A HUGE part of being a vet is about getting on with other people - colleagues and clients. If you’re shy or nervous, try to be open about it. Placement supervisors won’t push you into doing anything you don’t want to and would rather know if you were feeling uncomfortable. Having said that, make sure you get involved! Chat to as many people as you can and get yourself known. Vets are not experts in every area and are certainly not the only people you can learn from!!
  6. Don’t be disappointed by the bad days, focus on the good days. Everyday is different as a vet so supervisors cannot guarantee you’ll get to see groundbreaking surgery or emergency limb reconstruction. Instead,they’ll take it day by day and do their best to offer you a true taste of veterinary life. You may well spend days addressing envelopes or mucking out stables or sweeping yards. So be it. There’ll be other days where you get to witness something extraordinary, get involved in something exciting or get to meet really interesting people! 
  7. Keep a diary. Sounds silly but you’ll soon forget your experiences or mix up days if you don’t record them properly. It doesn’t have to be long, just a quick summary of your day’s work - you could start a blog like I did! It’s also incredibly useful for adding details into your personal statement or having case studies to talk about at interview.
  8. Leave a good impression; send a thank you card at the very least. At the end of the day, no matter how useful/fun/educational your placement was (or wasn’t), they have done you a huge favour by letting you into their place of work. You never know when you might meet them in the future or need their help/advice for something so make sure they remember you for all the right reasons! In my experience, cakes/biscuits/chocolates always go down well in busy vet practices!

So I think that’s pretty much it…. It’s hard work to achieve, especially while balancing studies, jobs, a social life, hobbies and sleep but in a way it is great preparation for uni! 

Good luck! 

Thank you for everyone who reblogged this post and tried to help spread the word. Merry was taken home this week as a foster, but she was scared and antisocial, and did not seem well-suited to the foster’s home (apartment, with other animals). She behaved poorly and unfortunately will be euthanized tomorrow due to the fact she may never make a good pet. ;_;

This is so sad. I don’t know why they adopted her out to obviously an unsuitable home - multiple other animals are a no no. She should only have gone to an experienced pet owner with a no pet household.

No one would take her. It was not as if there were people lining up for her. One of the staff took her home for a trial period to see if they could collect enough evidence that she could make a good pet to try and convince local rescues/shelters to give her another chance (they have said no every time). No one else has been willing/able to take her even for a trial run. This was basically a last ditch effort, I would not blame the experienced pet-owning person who tried to take her home and isolate her in the home away from the other pets. Even in isolation Merry seemed terrified (not simply cautious as cats usually are in new environments and would wedge herself in behind furniture and places they couldn’t get her out of, and showed not even slight improvement over the course of a week. If you can take her please let me know but otherwise, I would chalk this up to a sad fact of pet overpopulation and lack of spaying/neutering pets, and not blame any particular person. Basically with lack of adopters coming forward for her, the choice is remaining in a cage for the rest of her life, being released in the wild with a health condition to be likely eaten by the coyotes that are common here, or euthanasia. She is unhappy in the cage, and the second option is cruel, leaving the third option as the only reasonable one. :(

(via ofwordsandwaltzes)

thevetsaidwhat:

veterinaryrambles:

Merry is a 9 year old stray female cat, most likely spayed. She is currently living in a veterinary clinic in a cage. A Good Samaritan found her several months ago, with severe injuries to both ears. It took months but the scabs and infection eventually healed, though her ears will always be bald and she will always need to be watched to make sure she doesn’t scratch her ears. She is a little overweight and has dental disease, but otherwise appears to be healthy.

The trouble is, the good Samaritan, while she has been paying for Merry’s care, has been unable to find a home for her. Merry is shy in a cage, and doesn’t always make a great first impression because she stays nervous, even though she’s been in a kennel a long time now. She doesn’t seem to like other animals. No area shelters have wanted to take her because she has been shy, and is not perfectly healthy. Merry is trapped in limbo.

Merry was tested in one of the clinic rooms today with a staff member. To our surprise the shy cat didn’t bolt to hide under the couch, or run away - instead she purred loudly for petting and seemed content sitting on the couch for affection.

Merry could be a great cat in the right home - she just needs someone to reach out, and she will rub your hand for more petting.

Merry lives in the greater Los Angeles area. If you are anywhere near there and could open your home to a lonely kitty, please message me privately for more information. If you can’t take her but know someone or a group who would be interested in helping her find a home, message me. If you can’t help her directly but want to spread the word, please boost the signal. Merry wants a forever home - shy kitties deserve love, too!

Signal boost!

Thank you for everyone who reblogged this post and tried to help spread the word. Merry was taken home this week as a foster, but she was scared and antisocial, and did not seem well-suited to the foster’s home (apartment, with other animals). She behaved poorly and unfortunately will be euthanized tomorrow due to the fact she may never make a good pet. ;_;

(via pandaveganlove)