Wednesday, July 16, 2008

Jumping To Conclusions

So, I have been out in practice for over a year already (amazing!) and have seen a lot of things from the mundane to the unique to the ridiculous. Some of those things I have posted about on here, and some I haven't. One case I saw about 2 weeks ago is still haunting me a bit.

I was on call on the weekend a few weeks back and got the fateful and strangely typical Sunday evening call: "my dog Cooper has not been eating and has been vomiting for the last week or so." It is amazing how few of these calls you need to get before you start to get a little tired of them. Honestly, you need to wonder sometimes...if it didn't bother you for the last 7 days, why are you worried about it now, on a weekend evening when it will be infinitely more difficult to do a work-up on it than it would be during the week? Relatively simple procedures like blood collection, IV placement, and radiographs suddenly become next to impossible, because I have learned the hard lesson that -- essentially without exception -- people cannot restrain their animals for most medical procedures. It's not a demeaning is just fact! People think it would be easy to restrain little Fluffy for a blooddraw, but if you aren't trained or experienced in it, forget it!

But before I digress on that subject, lets return to Cooper. After discussing the myriad of issues that could lead to inappetance and vomiting in a 2 yr old Golden Retriever (they are many) and clarifying the clinical signs (will eat treats but not food, sometimes vomits them up, not lethargic, normal drinking/urination, no diarrhea), the owners decided that , yes, they would like to bring him in that evening.

When Cooper came in, I was certainly relieved to see that, yes, he seemed to be a happy, active Golden. Wagging his tail while I examined him from stem to stern and finding nothing particularly alarming, he certainly seemed a happy healthy dog. Given his age and breed, the next step was radiographs to see if there were any obvious signs of a foreign object in his stomach or intestines that could be blocking things up. There really wasn't anything remarkable that I could see.

The next step was bloodwork just to make sure that there was nothing to blame there. I also wanted the firmly establish his hydration status. One would expect a vomiting dog to be at least a little dehydrated, but Cooper didn't seem dehydrated at all on physical exam. However, I wanted to see the bloodwork to confirm that subjective observation. The bloodwork confirmed that he was not dehydrated and didn't have changes in his white blood cells that would indicate any type of specific problem.

Then I looked at his chemistry values......and my heart nearly stopped. The kidney values were higher than my machine could even read. I ran the blood twice to make sure there wasn't something wrong with the machine, though I had run bloodwork on it on a different emergency earlier in the day and had gotten numbers that made sense.

A very long story made very short, Cooper was in acute renal failure, the cause of which we'll likely never know. He may have had access to some antifreeze, but the owners weren't certain. Though his kidney values stayed hugely elevated and his kidneys actually stopped working altogether despite aggressive treatment (he became almost anuric -- he didn't produce nearly the amount of urine he should have, given the liters of fluids I was giving to his through an IV) and he continued to refuse to eat, he still would walk with a wag in his tail and would greet everyone at the clinic with a happy Golden grin. On ultrasound, his kidneys were vaguely the shape they should be, but the architecture was completely destroyed. I sent his blood to another laboratory to make sure that I was getting accurate numbers. What little urine he did have even before fluids was like water, not concentrated at all. Ultimately, he was euthanized, though until the end he didn't look anywhere near as sick as he really was.

Things are not always what they appear to be. Oh how I wish he had swallowed a toy.

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