Tuesday, 2 February 2016

Common presentations

So part of every veterinarian's daily appointment schedule is a line describing the reason for the visit, or the "presenting complaint". You know, like coughing, limping, vaccines etc. This gives us a guide for when to book, how long to block off, what to expect, all sorts of useful info. The problem is that we rely on what the owner tells us since, because of the nature of a linear timeline, these are all scheduled before we have assessed the pet. This can lead to some errors regarding the TRUE problem. After a while, vets get used to seeing certain presentations but interpreting them differently based off experience. So here's a list of the common presentations as described by owners vs what is usually the case.

Complaint: Choking
Problem: Coughing, vomiting, or oral irritation causing gagging
The thing about choking is that if they survive for more than a few minutes after onset, it very likely isn't actual choking. I can't even count the number of times we get a "choking" dog in that has been showing symptoms for days/weeks (and end up being in heart failure). It's also sometimes surprising to a lot of us how few people know what coughing actually sounds like in dogs and cats, most people don't recognize it for what it is. 

Complaint: Tick that won't come off
Problem: Nipple
This has happened quite a few times, which is a few times too many for me. People come in frustrated that they can't pull this tick off their dog, and the dog appears quite painful. So on exam, I find a swollen, sore nipple, with a long-suffering dog staring sadly at me. So I explain the the owners, who are good people who thought they were helping the dog, that they have been trying to amputate the dog's nipple for the past 3 hours. I also get the complaint of a suddenly-noticed skin lump with the same diagnosis. These are often male dogs brought in by male owners, who are (more often than I would wish), confused as to why their male dogs have nipples. Cue awkward conversation. 

Complaint: Sore toe
Problem: Probably a joint or ligament injury
A lot of people tend to assume whenever their dog is limping or sore on one leg that it's because he hurt his toe. I don't know why that's the first thing people assume when a dog is limping, but it's very common. Often times, they have never checked to see if the toenails are okay, or have and found nothing but continue to believe it. Have I seen dogs with actually injured toes? Yes (often from broken/bleeding toenails). But it always seems weird to me that it's the very first thing people assume, when in reality I diagnose knee ligament injuries way more often. 

Complaint: Constipated cat
Problem: Constipated, or urethral obstruction
So most people can't tell when their cat is posturing to go pee or poo. They look very similar, and if the cat is hunched up in pain, you often can't tell which act they were going for. This is very unfortunate because most constipated cats can survive a day or two of waiting, but most blocked cats are true emergencies (can't pee = bad kidneys = can't live). Again, people tend to assume certain things, and for some reason can't poo seems more believable than can't pee. I treat any "constipation" complaint as if it might be urethral obstruction and recommend immediate appointments for this reason. This is more confusing in French, because often people will use "blockage" to mean urethral obstruction, constipation, or intestinal foreign body, so I never know what to expect!

Complaint: Cat peeing around the house (often owners think cat is being spiteful/rude)
Problem: Depends on cat's age
Old cat with weight loss: Crap. Your cat probably has kidney disease, diabetes, hyperthyroidism, or some combination of the 3. This is why you should take your cat to the vet more than once every 15 years. By the time I see these cats, often they are so far gone in disease there's not much to do. I dread these appointments. Sometimes I make a little bet with myself which disease(s) it turns out to be on the blood tests, occasionally I'm surprised. 
Young cat: bladder inflammation (often due to stress, crystals/stones, infection, or just because "cat"). Though once again, obstruction is on my list so you can be damn sure I'm making you come in soon. I actually love these because I have a good success rate with treatment and prevention, though people with pee-soaked furniture rarely agree with my enthusiasm. 

Complaint: Itchy skin, rash, bumps on skin (often in late summer)
Problem: Allergies
Specifically, environmental allergies or "atopy". One of the most frustrating diseases to treat, as basically everything boils down to "your dog will consistently try to tear his skin out and get frequent infections every year for the rest of his life, and nothing we do will cure him". Sure, there are treatments that can help, sometimes even help a lot, but by year 5 of living with an atopic dog, you're going to forget that and assume I'm just terrible at treating it. You'll switch to another vet who will use a slightly different approach (but usually very similar), and repeat the process every few years. I hate diagnosing diseases like this because it looks to people like some scheme to withhold the "cure" to get more money, when really I'm on their side and hoping for better therapies myself.

Complaint: Bleeding from the bum
Problem: Vaginal discharge, or anal glands
A lot of people have problems telling the difference between anal and vulvar discharges in female dog. I don't know if they just feel too uncomfortable to really look, or just see smears on the floor and assume, or what. Now bloody vagina could be a normal heat, or a life-threatening infection. So it is pretty important to find out what exactly is going on back there. Again, this is why I often recommend ASAP appointments for what seems like a relatively benign problem at times. 
Alternatively this may be an anal gland rupture, which is just as gross as it sounds. Again, it's not bleeding from the anus, just from around it. For how awful these looks, they're actually not the end of the world. Just very, very unpleasant. 

Complaint: Penis infection
Problem: Smegma
This is usually a call that comes in from a worried owner of a male puppy. The dog will be otherwise completely normal, not having any urination issues or bothering at his penis at all. They'll describe it like pus and have horrible visions in their head of nasty infections. In reality, he's just a messy boy who hasn't cleaned himself up. Smegma is very common in male dogs, and while intact ones show it more, neutered dogs get it too. It's a white-green discharge from the tip of the prepuce (made up of normal secretions and white blood cells), which gets all over your arms when picking the puppy off the ground. Often when dogs are sick, they don't take care of themselves and you'll see more if it then. I put a lot of otherwise clean lab coats in the washer after picking up boy dogs. Nothing like feeling that smear across your bare arm when you're trying to take x-rays. Ick. 

Complaint: "OMG what is wrong with my kitten, she's going crazy, she must have a broken back". (Often seen as an emergency)
Problem: Cat is in heat
Due to the fact that a lot of cats are adopted from animal shelters already vaccinated and sterilized, I think a lot of people have never seen a female animal in heat (ovulating). And let me tell you, cats in heat can be very alarming. They typically have their first heat around 6-10 months of age, but Siamese in particular can be early bloomers. The screaming, flailing, rolling around can be annoying and scary to the uninitiated. Luckily, this is pretty simple to "treat", and we get to have a good talk about when and why to spay the next cat. 

Deciphering presenting complaints is part of my job, so I never really assume anything until I get into the exam room and see for myself. But this is why a lot of vets do not give advice over the phone except "if you are concerned, please make an appointment". Because honestly, we can't trust someone untrained to know the subtle differences that could drastically alter treatment plans.

Dr. Interpreter