Friday, August 17, 2012

fuzzy thinking

Few things frustrate me more than lack of a proper diagnosis.  Certainly, there are some cases where a diagnosis isn't attainable for financial, logistical, or medical reasons, but a lot of times, it's a failure on the part of the doctor.

A 10 year old great dane presented to me for a 5 week history of dribbling urine, which had progressed to not really being able to pee a full stream.  He wasn't straining, the urine was clear (not bloody) and he was otherwise acting normally.  His regular veterinarian had prescribed antibiotics 5 weeks ago, without any testing, and when those didn't help, prescribed a second antibiotic. The first error in logic is in this decision. Dribbling urine is not a common symptom of a urinary tract infection.  Antibiotics only help if a UTI is present and won't help a long list of other problems.  Signs of a urinary tract infection include frequent small urination, bloody urine, or straining to urinate.  Furthermore, male dogs are very unlikely to get a urinary tract infection without a mitigating factor, primarily due to the length of their urethra.  If a male dog indeed does have a UTI (confirmed with a urinalysis or culture), a search is indicated to look for the underlying cause (such as bladder stones, diabetes, etc.)

Medical training teaches the new doctor to start with a history (to gather a list of symptoms) and physical exam (to look for abnormalities), and then create a list of medical problems, followed by a list of most likely causes (differential diagnoses in medical terminology), which should each be ruled in or ruled out with testing.  This dog's problem list consists of dribbling urine, which could be a result of urinary incontinence, inability to empty his bladder (due to obstruction, bladder stones, mass, or spinal cord problems), or a long list of other possibilities.  The job of the clinician is to determine the cause of the symptoms, and most of the time, that requires testing.  I can't (nor can any human) be 100% sure if there's bladder stones, or bacteria, or a mass in the bladder without imaging (such as ultrasound). The treatment for each of these is very different, and so a diagnosis must be achieved to select the proper course of therapy.

Unfortunately, the regular vet did not recommend nor offer any testing, such as a urinalysis or imaging to the clients.  When their dog didn't improve after the antibiotics, the vet added pain medications to "relax" the dog's muscles, which also didn't provide any relief or ability to urinate.  When the patient still didn't get better, referral was not offered or any sort of diagnosis as to the cause of his symptoms.  The clients didn't know to ask for any other testing (as most laypeople have no way of guessing at the proper tests, and trust their doctor implicitly to do the right thing). When the clients felt their dog was simply too uncomfortable, they showed up at the ER for evaluation.

Immediately upon hearing the history I knew that this dog never had a urinary tract infection.  As I mentioned above, UTIs are rare in male dogs.  More likely, the cause of an adult/geriatric male dog to be dribbling urine is a bladder mass or bladder stones. I recommended an ultrasound, which was immediately authorized, and found the large mass with ease.

Breaking the sad news to the clients was beyond devastating.  I am frustrated at the poor diagnostic process and lack of options the clients were given; perhaps 5 weeks ago, the tumor would have been operable.


  1. Wow, that's awful. Those poor people and that poor dog! I have a very strong fear of missing a diagnosis because I missed a differential and therefore failed to recommend the proper diagnostics. This is nightmare material, right here!

  2. It's not nightmare material because it's easily avoided. You just need to remember to create a problem list, create a differential list and ALWAYS recommend the best diagnostic plan to determine the cause. If the clients choose not to do testing, you can treat for the most likely diagnoses, but never assume they don't want to test. Pay attention in school, do a high quality internship and you'll do great!

  3. So sad and all too common. It's hard to be proud of this profession sometimes, when stuff like this goes on.

  4. It happens in human medicine, too - trust me. The patient and their family should be an advocate for their health!

  5. Yes things like this happen all too often.. As a member of a dreaded online support group for owners of dogs with Addison's I sadly see dogs who are diagnosed with Primary Typical Addison's and given Percorten when in fact they had perfectly normal electrolytes and never needed percorten. They have Atypical and only need prednisone. Often these Vets when questioned on the need for percorten with normal lytes often say they are giving it "just in case"..

    Often when owners try to be advocates they are told to stay off Dr. Google.. Now I totally understand the garbage that is out there and what vets are presented with at times but you must be an advocate for your pets health and for your own..

  6. Elizabeth -
    While I am 100% in support of being an advocate of your own health care and that of your family (including pets), I MUST caution everyone against using Dr. Google as a know-all resource. While there are reputible websites with pertinent information (, AAHA, ASPCA, etc), there is just as much mis-information. The majority of the time, your doctor DOES know what he/she is doing and is working long hours to care for you/your pet. I'm not suggesting that we should be skeptical or untrusting of our medical community, I'm just reminding everyone that doctors are human and make mistakes. If clients come in to me with a chip on their shoulder, untrusting and suspicious, it makes the task of determining what is wrong with the pet a million times harder. Medicine is as much an art as it is a science. My goal with this blog is to educate, not to increase the chasm between patients and their doctors. Be aware, be educated, ask lots of questions - but don't be a difficult patient/client. It's a fine line.

  7. Lastly, attempting to self-diagnose yourself or your pet with Dr. Google is a very dangerous endeavor. Medical school is 8+ years of specialized training, and anyone who thinks they can get the information they need to replace their doctor with a web search is obviously mistaken. Once your doctor has reached a diagnosis, the web is a great place to read about the condition that has been diagnosed - but it's not a place to find out what's wrong with your dog. Thanks for reading and thanks for your comments!

    1. I totally 100% agree with you. My first stop is always my Vet. I never stop to see if I can find out what is wrong online. Even if I were to stop and find out what it might be, what the heck am I going to do about it.. I use the info my Vet provides to then further educate myself online. But I am very careful where I go. I see people all the time posting questions asking what to do because their dog has bloody diarrhea, can't walk, vomiting, not eating for three days or has collapsed.. go to the Vet people. Waiting usually makes things much worse... and much more expensive in the long run..

  8. I just started clinic rounds in our teaching hospital...and i feel embarrassed to say that this is the state in the medicine ward in our hospital...maybe not for all the cases but for many..