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Rechecking with your veterinarian

Dr Lee
August 19th, 2007, 01:10 PM
I just wanted to post a small story about a patient of mine and why it is important not to switch vets the moment things get rough...

There was a gentlement Mr. B who brought in Coco, a 14 year old lab mix who is his best friend. Coco just wasn't feeling well. Physical examination showed the normal old dog problems - nuclear sclerosis (haziness in the eyes), bad teeth, dry hair coat, low muscle condition but was otherwise fine. We ran X-rays of the chest and abdomen which were normal - no masses seen or other problems. We also ran blood tests which showed a positive Ehrlichia titer (tick fever) which isn't uncommon in Arizona. We treated her with doxycycline for one month and Coco was feeling great! No problems.

Almost three months later Coco comes back because most all the hair has been lost off of her and she is highly itchy. Also she has been drinking more water lately and not feeling great. Physical examination was the same other that the fact that she had huge bald spots all over and was itchy and depressed. We ran skin tests - negative, repeated blood work, tried to get urine but she had just peed, and placed her on a trial of antibioitics and anti-mite medication.

Blood work now showed a high ehrlichia titer along with increased antibodies and kidney enzymes being raised. Discussing this with an internal medicine specialist, she was concerned that Coco had a tenacious infection of tick fever with secondary kidney damage and stated that she may need doxycycline life long. The specialist was also concerned about pemphigous for the skin and with the other skin tests negative, she recommended biopsy - which I had discussed with the owners but we were reluctant due to her advanced age.

So we recheck her for urine testing, blood pressure and to recheck the blood levels. Her skin had slightly improved. This time on physical examination she had a swollen lymph nodes and a mass effect of her right mammary (breast) area. When I brought this up to the owners, they said that the mammary mass had been there before but comes up and then goes away completely. We took fine needle aspirate samples of the mammary mass and lymph nodes which when evaluated by the pathologists was positive for adenocarcinoma (breast cancer) of the mammary mass and metastatic (spread) adenocarcinoma of the lymph nodes. :cry: The owners are now thinking of pursuing chemotherapy.

There reason I tell this long story is that I commonly hear from my clients and sometimes on this forum that, "I went to the vet, the imbecile didn't know what was going on, so now I am finding a new vet!"

In hindsight, I am convinced that the pet probably was suffering from adenocarcinoma from the first day I saw her and that the tick fever was a secondary issue. (if it was truly present, titers are don't differentiate between infection and exposure many of the time). However with no masses on radiographs (x-rays), no cancer signs on the blood work and no palpable masses or enlarged lymph nodes until the last visit - there was no possibility of diagnosis.

I perform a complete physical exam every time I see a sick patient. I felt that dogs mammary region and lymph nodes everytime that pet had come in my door! There was no way for us to have known that. If the owners had gone to new vets each time, then on the last time they would have not found a vet that wasn't an imbecile but a vet that was lucky enough to have a pet with palpable lymph node enlargement and a clinically evident mammary mass.

I see a lot of second opinions in my practice and when the owner tells me what an idiot there last vet was when I give them a diagnosis - I always try to explain that what was here today may not have been there at the last visit. In this case, I had consulted with an internal medicine specialist twice before the last visit to help see any other possibilities - cancer never came up in the conversation with the specialist as a possibility.

Medicine and the study of biologic life is inherently difficult and doctors (human or veterinary) often face cases that cannot be diagnosed at the first few visits because of the nature of the information that is available. Usually as time goes by and diagnostic tests and therapeutic trials occur, we can usually figure most of it out. So next time your vet runs tests, can tell you all the possibilities that you have ruled out but doesn't have a diagnosis - have some patience. The investigation may not be solvable in one or two visits.

Is your veterinarian compassionate? dedicated to helping you and your pets? seemingly of good intelligence? utilizing specialists and other avenues of information? These are in my opinion the most important questions.

Sorry for the length, but I feel that if you have a compassionate, dedicated, intelligent, open minded veterinarian treating your pet - switching when they don't have the answer can in many cases not be in the interest of your pet. You just get a new vet starting from scratch rather than a good one who has some patient history to help draw her or his conclusions. :pawprint:

Jim Hall
August 19th, 2007, 01:20 PM
Thank you very much for your always lucid and very compaasionate posts. It is obvious you give a good deal of time and thought to your insights into a Veternarian's world.

August 19th, 2007, 01:22 PM
Thank you for sharing that Dr. Lee, and I agree with you 100%.

August 19th, 2007, 02:37 PM
Great post indeed.
but, what would you recommend for someone such as myself who actually did switch vets because of me and them not seeing eye to eye on other things?
My dogs were in great health at the time, however, they did NOT support and were not even willing to accept my choice of raw feeding for one.
Secondly, kept trying to convince me that titers were not necessary and it would just be cheaper to get the vaccinations and be sure.
And finally, on the vaccincation note again, would not humor me as to why one of my dogs only needed rabies vaccine once every 3 years and the other one needed them every year!:shrug: The 2 of those dogs always went in together for vaccines, and had the same rounds.
They vet had no actual reasoning behind the 2 different vaccination protocols for my dogs.
I did get them to forward all our records to the new vet though, and said I was switching due to conflict in hours. The new vet is opened on Saturdays and until 8 pm on thursdays as well.
Was I wrong to switch them? Honestly I feel I had valid reasons.

Dr Lee
August 19th, 2007, 02:49 PM
Great post indeed.
but, what would you recommend for someone such as myself who actually did switch vets because of me and them not seeing eye to eye on other things?
Was I wrong to switch them? Honestly I feel I had valid reasons.

From what you are describing, it sounds like you had some valid reasons. Not every vet is good for everyone and some vets are actually good for almost no one! My point here is not to stay with your vet no matter what, but that if a diagnosis is not immediately forthcoming that the reasons may be other than your vet not doing her or his job. Sometimes second opinions are very important and I am a veterinarian who refers clients to specialists on a regular basis when the pet would benefit from their expertise (as in this example, I have recommended them to an oncologist for further work up). Does that help explain my point? I think you need to find a vet that is open to your needs and is a person that you trust with your family! Sometimes that takes a few tries. I hope your new vet works out!:pawprint:

August 19th, 2007, 02:51 PM
Its true though, alot of us especially are always saying "you need a second opinion" however true it may be sometimes, I dont think people should just run and abandon their vet completely.
I get what you are saying.

August 19th, 2007, 04:25 PM
Dr. Lee, thank you so much for that advice, and you're right, not all vets work for everyone. I've been so blessed that my regular vet, the internal specialist, and the 3 emergency vets that I've worked with for both Peaches and Simon have been TOP notch, and have all complimented each other. When my regular vet couldn't figure out what was going on in Peaches' nose, he referred us immediately to the specialist. When she ingested the towel, the emergency vet and surgical team shares the office with our specialist vet, and they collaborated. After all that, they've faxed AND briefed my regular vet for her followup care. But one other point that's crucial, is that ALL pet owner's have a right to ask and receive copies of their pet's medical records, which can and should be taken to any vet appt. It's a team effort, and benefits our pets most of all if we, as owners, come prepared. :pawprint: