Saturday, October 4, 2008

The Importance of a Complete History

I walked in a room the other day to be greeted by not only the real-life representation of Cujo but also of Cletus the Slack-jawed Yokel of Simpson's fame. While digesting the irony of being faced with two caricatures in the same room, I had the more immediate problem of what to do with this case.

The presenting complaint was that "he gots the puppy mange." While essentially all I could see of Cujo was his hugely dilated eyes as he stared me down with all of his 100 lbs of 1 year old St. Bernard, I could also see the spots of hairloss on the dog's side that had Cletus concerned. We eventually coaxed the beast onto an elevator table in the clinic; one that allows us to raise large dogs to our level without having to lift them. This contraption has the secondary effect of often disorienting aggressive or nervous dogs enough for a short period that we can work on them with relative safety if we work before they get their bearings.

So, with Cujo at eye-level and Cletus soothing him up by his head, I quickly went to work gathering the skin scrapings and impression smears I hopped would diagnose the cause of this dog's hairloss. In an ideal world, we would have been able to get a muzzle on him...but it was not to be. I decided to proceed anyway, hopeing I could get my samples before Cujo knew what was going on.

However, it wasn't long until Cujo's patience waned. With amazing speed, he spun his head, and with what I can only describe as survival reflexes, I jumped back. I felt the side of one of Cujo's teeth brush my forearm as I did so, knowing that what samples I had gotten by then were all I was going to get.

"Oh, 'e won't bite 'che," Cletus commented with a laugh, clearly amused by my jump back from his "puppy" which likely wasn't as graceful as the jungle cat moves I was hoping for. I lowered the elevator table and quickly excused myself to the lab and the relative safety of the microscope.

Unfortunately but unsurprisingly, I didn't see anything of interest in the hasty samples I had obtained. I was mostly looking for mites as the cause of the hairloss. "The puppy mange," as Cletus called it, is caused by the demodectic mite and is not uncommon in young puppies. If an older dog has it, it can be the sign of very serious disease elsewhere. Demodectic mites are often somewhat easy to find on a skin scraping, but can be frustratingly hard to treat at times, requiring very odiferous mite dips and the like over the period of several weeks.

The other main type of mange mite we worry about is the sarcoptic mite which causes "scabies" as many people know it. Sarcoptic mange is highly contagious and of human health interest as well since people can catch it from their pets and visa versa. Sarcoptic mites, as opposed to the demodectic ones, can sometimes be hard to find on the microscope, but are relatively easy to treat. In some cases, if we suspect sarcoptic mange, but can't demonstrate the mites via skin scrapings, we'll treat for it anyway to be on the safe side.

As I was explaining these things to Cletus, he perked up when I mentioned that sarcoptic mange was transmissible to people. Suddenly suspicious, I asked him if anyone in the family had been itchy.

"You mean like a rash?"

"Um, yeah...."

"Oh yeah, me an' the boys all gots rashes. The doctor said it could be mites."

I knew I was in dangerous territory. From experience, I know that people have surprising lack of modesty when talking about their own medical conditions with their vet, thinking that we are interested in and/or knowledgable about human health problems because we are doctors. I'm sure all vets can tell you stories about clients showing them their own rashes, lumps, scars and injuries with surprising speed and unembarrasment.

Hoping fervently that Cletus would not show me his own rash, I told him of my plan to empirically treat Cujo for sarcoptic mites and monitor for response to treatment. Cletus informed me that his doctor told him that mites weren't transmissible to pets, so he hadn't thought to mention that. I knew I should have asked initially when faced with a dog with mange, but I hadn't. Being faced with Cujo and Cletus in the same room, who can think of anything except a Simpson's Halloween special?

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