I frequently give out "brownie points" to my technicians (and sometimes my fellow doctors) at work. These aren't anything that I keep track of, much less remember from day to day who I've even given them too.
Sometimes it comes in the form of, "brownie points to whoever can tell me where I left this chart", or "brownie points if you come up with a good treatment plan for this patient".
Other times I give them out more as recognition that someone took the initiative to do something less than pleasant. Someone was going to have to do it anyways, but it's nice when someone does it cheerfully and quickly. For example, "you gave him a bath after he danced in diarrhea?!?! glad it wasn't me, you get brownie points!!"
Yesterday I made a big batch of oatmeal chocolate chip cookies, and today I brought them into work to share. I told everyone that if they needed an excuse to eat cookies (as many of us generally do), they could tell themselves that they were redeeming their brownie points!
Maybe next time I'll make real brownies - I even have a recipe bookmarked for one that includes ingredients I have in the house!
Tuesday, December 16, 2008
Monday, December 15, 2008
My First CCL
First time for everything - and today it was an cranial cruciate ligament tear in a 90-pound 5-year-old yellow Labrador Retriever.
She was the perfect candidate for the tear, and I had diagnosed her after seeing her for a mere 5 or 10 seconds in the lobby. She bounced towards me, completely non-weight bearing on her left hind leg. I asked her to sit for me like a good girl, and when she did she flipped that knee right out, refusing to put it where it belonged. Classic. I informed her that her daddy and I had a very expensive discussion to have, and invited him into the exam room.
She had all the right history, she was out hunting (her collar read "forever pheasants") on Friday, and she came up lame all of the sudden. She wanted to keep hunting. Dad kept her quiet for the weekend, but she just didn't spring back by this morning. Her knee was lax and swollen, but everything else about her looked great.
We took x-rays, I checked with my boss (the TPLO guy), and went in to deliver the damage to the poor owner. $200 for today's visit. ~$2000 to do the surgery here. ~$2800-3100 to do it at the U. He's gonna call me back to let me know where he wants to do the surgery - all he wants is for her to be able to hunt again.
I think they would both be devastated if she couldn't.
She was the perfect candidate for the tear, and I had diagnosed her after seeing her for a mere 5 or 10 seconds in the lobby. She bounced towards me, completely non-weight bearing on her left hind leg. I asked her to sit for me like a good girl, and when she did she flipped that knee right out, refusing to put it where it belonged. Classic. I informed her that her daddy and I had a very expensive discussion to have, and invited him into the exam room.
She had all the right history, she was out hunting (her collar read "forever pheasants") on Friday, and she came up lame all of the sudden. She wanted to keep hunting. Dad kept her quiet for the weekend, but she just didn't spring back by this morning. Her knee was lax and swollen, but everything else about her looked great.
We took x-rays, I checked with my boss (the TPLO guy), and went in to deliver the damage to the poor owner. $200 for today's visit. ~$2000 to do the surgery here. ~$2800-3100 to do it at the U. He's gonna call me back to let me know where he wants to do the surgery - all he wants is for her to be able to hunt again.
I think they would both be devastated if she couldn't.
Saturday, December 13, 2008
The pyo that took a month
I first saw her, S, for drinking more water. She was a 9 year old Chow crossbreed dog. She had never been spayed, but otherwise was kept well by a young man without too much money to spare. After careful interrogation, I determined that there was really nothing at all wrong with her other than she had quadrupled her water intake in the past week or so.
As any good new grad would, I looked in my brain for the most obvious things. An older intact female who was at the very least PD (polydypsic) - obviously it was a pyometra, or an infected pus-filled uterus. Other options for polydypsia included kidney disease, urinary tract infection and kidney disease. X-rays at our clinic are $150, a CBC and chemistry profile is $110, and a urinalysis plus culture is about $120. Due to the financial constraints of this situation, I had to go with the most likely causes of disease. She was acting totally normally, and her temperature was normal. She had no pain in her abdomen, no vaginal discharge and I had no reason other than instinct to order abdominal radiographs.
Her urinalysis was normal, although her specific gravity was a little lower than I would have hoped. Her urine culture was negative. I did manage to convince her owner to run bloodwork when she was just not acting well a couple of days later. Because I was still curious about pyometra, I did a vaginal swab (negative) and an abdominal tap (negative). The bloodwork came back with a mild mature neutrophilia, a mild non-regenerative anemia (anemia of chronic disease), and a completely normal profile.
I didn't treat S with anything at that time. I explained the symptoms of pyometra as a surgical emergency, gave him directions to the e-clinic and sent him on his way. I didn't hear back from him for almost a month.
She appeared back on my schedule about a month later, unexpectedly. The appointment book said that she was not eating and that she had lost some weight. When she came in, I immediately noticed a couple of things. First, she had obviously lost a significant amount of weight, about 10 pounds. Second, she smelled awful! I lifted her tail to take her temperature, and asked if she had been having any diarrhea. Her hind end was coated in fetid material. Her owner denied any abnormal stools.
I pretty much didn't give the owner a choice at this point, we were going to do some x-rays (the last thing on my original 'want list'). We took her in the back and gave her a butt bath, and clipped some of the matted fur. X-rays were pretty clear - a grossly distended uterus. I again did an abdominal tap - this time easily acquiring 3cc of bloody purulent fluid. It then clicked on what the "diarrhea" was - it was pus, resulting from an open pyometra.
An open pyo was definately preferred, as it was about 5pm and the last thing I wanted was emergency surgery. I gave him the estimate and prepped her by giving a shot of antibiotics and a liter of fluids subcutaneously. He was scheduled the next morning to drop her off for surgery.
Surgery, like almost nothing else in this case, went textbook perfect. I had a vet student with me, and she had fun scrubbing in and helping me out. She was bright, alert and eating the next morning. More than she'd eaten in a long time. She went home that afternoon on antibiotics.
A week later her owner was pleased to report that she was bright, alert and eating normally again. Success! Score one for intuition. :)
As any good new grad would, I looked in my brain for the most obvious things. An older intact female who was at the very least PD (polydypsic) - obviously it was a pyometra, or an infected pus-filled uterus. Other options for polydypsia included kidney disease, urinary tract infection and kidney disease. X-rays at our clinic are $150, a CBC and chemistry profile is $110, and a urinalysis plus culture is about $120. Due to the financial constraints of this situation, I had to go with the most likely causes of disease. She was acting totally normally, and her temperature was normal. She had no pain in her abdomen, no vaginal discharge and I had no reason other than instinct to order abdominal radiographs.
Her urinalysis was normal, although her specific gravity was a little lower than I would have hoped. Her urine culture was negative. I did manage to convince her owner to run bloodwork when she was just not acting well a couple of days later. Because I was still curious about pyometra, I did a vaginal swab (negative) and an abdominal tap (negative). The bloodwork came back with a mild mature neutrophilia, a mild non-regenerative anemia (anemia of chronic disease), and a completely normal profile.
I didn't treat S with anything at that time. I explained the symptoms of pyometra as a surgical emergency, gave him directions to the e-clinic and sent him on his way. I didn't hear back from him for almost a month.
She appeared back on my schedule about a month later, unexpectedly. The appointment book said that she was not eating and that she had lost some weight. When she came in, I immediately noticed a couple of things. First, she had obviously lost a significant amount of weight, about 10 pounds. Second, she smelled awful! I lifted her tail to take her temperature, and asked if she had been having any diarrhea. Her hind end was coated in fetid material. Her owner denied any abnormal stools.
I pretty much didn't give the owner a choice at this point, we were going to do some x-rays (the last thing on my original 'want list'). We took her in the back and gave her a butt bath, and clipped some of the matted fur. X-rays were pretty clear - a grossly distended uterus. I again did an abdominal tap - this time easily acquiring 3cc of bloody purulent fluid. It then clicked on what the "diarrhea" was - it was pus, resulting from an open pyometra.
An open pyo was definately preferred, as it was about 5pm and the last thing I wanted was emergency surgery. I gave him the estimate and prepped her by giving a shot of antibiotics and a liter of fluids subcutaneously. He was scheduled the next morning to drop her off for surgery.
Surgery, like almost nothing else in this case, went textbook perfect. I had a vet student with me, and she had fun scrubbing in and helping me out. She was bright, alert and eating the next morning. More than she'd eaten in a long time. She went home that afternoon on antibiotics.
A week later her owner was pleased to report that she was bright, alert and eating normally again. Success! Score one for intuition. :)
Friday, December 12, 2008
New Directions
This blog needs to change direction I guess. I graduated from vet school this past spring and am now working at a 3.5 doctor practice in a moderately affluent neighborhood.
To sum up: I received my masters in public health in september of 2007 and my doctors of veterinary medicine in may of 2008. I took 3 weeks off and started full time at this small animal practice. Another new grad started with me at the same time, and the last full-time doctor has been practicing for about 15 years. The clinic owner has been in practice for about 10 years, and splits his time pretty evenly between the two practices that he owns.
Once the first 8 or 10 weeks had passed, I started seeing very few new things. I quickly became proficient at the everyday things: vaccinations, ear infections, acute and chronic vomiting and diarrhea, kidney disease, food allergies, etc. Even the things that I have come to think of as routine can be unique and interesting depending on the client and patient. Seeing these things frequently means that I have become more adept at diagnosing them and have perfected my "speil" that I give while explaining the diagnosis and treatment process it has also enabled me to better explain to clients the specific challences and difficulties that they may face while following through with the course of treatment.
But, as usual, it's the new and different things that keeps things fun and interesting for me. Last week I did two surgeries that I had never done before, both reproductive. The first was a pyometra (infected uterus) which has a story that almost deserves its own post. The second was a cryptorchid (retained testicle) cat. Both went off without a hitch, and I'm very proud of myself.
In the meantime, I'll try to keep my eye out for fun and interesting cases and post about them more often. Also, some housekeeping around the website to update some of the blogs that I follow.
To sum up: I received my masters in public health in september of 2007 and my doctors of veterinary medicine in may of 2008. I took 3 weeks off and started full time at this small animal practice. Another new grad started with me at the same time, and the last full-time doctor has been practicing for about 15 years. The clinic owner has been in practice for about 10 years, and splits his time pretty evenly between the two practices that he owns.
Once the first 8 or 10 weeks had passed, I started seeing very few new things. I quickly became proficient at the everyday things: vaccinations, ear infections, acute and chronic vomiting and diarrhea, kidney disease, food allergies, etc. Even the things that I have come to think of as routine can be unique and interesting depending on the client and patient. Seeing these things frequently means that I have become more adept at diagnosing them and have perfected my "speil" that I give while explaining the diagnosis and treatment process it has also enabled me to better explain to clients the specific challences and difficulties that they may face while following through with the course of treatment.
But, as usual, it's the new and different things that keeps things fun and interesting for me. Last week I did two surgeries that I had never done before, both reproductive. The first was a pyometra (infected uterus) which has a story that almost deserves its own post. The second was a cryptorchid (retained testicle) cat. Both went off without a hitch, and I'm very proud of myself.
In the meantime, I'll try to keep my eye out for fun and interesting cases and post about them more often. Also, some housekeeping around the website to update some of the blogs that I follow.
Wednesday, April 02, 2008
It's almost over now
And so another year has passed, and I have continued to be incapable of updating this blog on even a monthly basis. I can't decide if it's because no one actually reads it or because I'm not invested in it. I'm not sure it actually matters. Vet school will be over in 4 weeks, so this blog naturally must come to an end.
I defended my MPH in September and received my degree. My thesis was on MRSA and resident animals in a long-term care facility. I'm proud of myself for finishing it while being in vet school. It has been fun to sometimes put "MPH" at the end of my name when writing discharge letters :) I'll be able to put on the DVM in a month, so that's even more exciting.
I'm currently on Cardiology. I have radiology and emergency remaining prior to graduation. I'll try to find a fun case to write up for people to think about. But in the meantime, this is all the update I appear to be able to provide. And you wonder why I don't bother blogging - nothing interesting to write!
I defended my MPH in September and received my degree. My thesis was on MRSA and resident animals in a long-term care facility. I'm proud of myself for finishing it while being in vet school. It has been fun to sometimes put "MPH" at the end of my name when writing discharge letters :) I'll be able to put on the DVM in a month, so that's even more exciting.
I'm currently on Cardiology. I have radiology and emergency remaining prior to graduation. I'll try to find a fun case to write up for people to think about. But in the meantime, this is all the update I appear to be able to provide. And you wonder why I don't bother blogging - nothing interesting to write!
Monday, September 24, 2007
E.J.
His name was E.J. I never asked what it stood for... only now does it occur to me to wonder. He was a middle aged cat. A gray tabby with longer fur. He started off beautiful, but days of hospitalization, eventually with an e-collar, caused his coat to become grungy and gross.
He had bladder stones that he couldn't pass. And when he tried, they got stuck in his urethra, and he became blocked. A week ago, he presented to the emergency clinic for this problem. It was the first time it had happened to him. His owners weren't properly educated on what this meant in terms of lifestyle changes, diet changes, and survival time. Bladder stones are managable, they can be influenced by diet and water intake. They can be removed with surgery. They can be an incidental finding that will never affect the health of the animal.
But E.J. had problems from his. And each time the stones reentered his urethra, he had to be anesthetized again. He blocked 4 times in the last week. Yesterday, we did a cystotomy. That's the surgery where we go into the bladder through the abdomen and scoop out all the stones. It was like picking grains of sand out of a beach blanket. The stones were tiny, most of them. Many he could likely pass on his own. But two were larger, round stones that were small enough to enter his urethra from the bladder, and large enough to not be able to pass all the way through. We took out 30+ stones. Carefully flushing and flushing and flushing until we were convinced that the larger stones were all gone, and anything too small for us to remove would probably be able to be passed on his own.
We closed the abdomen. We took a radiograph that showed a nice bubble of air in his bladder, but no remaining stones big enough to be spotted. We placed an indwelling urinary catheter, because his urethra has been traumatized so many times in the last week that we wanted to relax it while the inflammation died down. Amy went to make some phone calls. The technicians were placing a new IV catheter, because his current one (though working well throughout surgery) had been in for 4 days and was at increased risk for infection.
They walked away for 10 seconds. Both new catheters were in, he was still on the table on anesthesia. The pulse-ox slipped off his tongue and the alarm went off. Gail went to replace it, and noticed he was very pale. Then she noticed he wasn't breathing. We located doctors, three of them.
We did CPR for almost 10 minutes. We used epi, atropine. We ventilated him at 40 times per minute, we pumped his heart as fast as we could (you try making a heart beat 150 times/minute). We watched the ekg each time we paused. He didn't make it.
A week ago, before first going to the emergency clinic because he couldn't pee, he was a healthy cat. Whatever stones may have been present were not affecting his life at all. Yesterday, he died. The owners elected a group cremation, with no ashes returned.
But E.J. had problems from his. And each time the stones reentered his urethra, he had to be anesthetized again. He blocked 4 times in the last week. Yesterday, we did a cystotomy. That's the surgery where we go into the bladder through the abdomen and scoop out all the stones. It was like picking grains of sand out of a beach blanket. The stones were tiny, most of them. Many he could likely pass on his own. But two were larger, round stones that were small enough to enter his urethra from the bladder, and large enough to not be able to pass all the way through. We took out 30+ stones. Carefully flushing and flushing and flushing until we were convinced that the larger stones were all gone, and anything too small for us to remove would probably be able to be passed on his own.
We closed the abdomen. We took a radiograph that showed a nice bubble of air in his bladder, but no remaining stones big enough to be spotted. We placed an indwelling urinary catheter, because his urethra has been traumatized so many times in the last week that we wanted to relax it while the inflammation died down. Amy went to make some phone calls. The technicians were placing a new IV catheter, because his current one (though working well throughout surgery) had been in for 4 days and was at increased risk for infection.
They walked away for 10 seconds. Both new catheters were in, he was still on the table on anesthesia. The pulse-ox slipped off his tongue and the alarm went off. Gail went to replace it, and noticed he was very pale. Then she noticed he wasn't breathing. We located doctors, three of them.
We did CPR for almost 10 minutes. We used epi, atropine. We ventilated him at 40 times per minute, we pumped his heart as fast as we could (you try making a heart beat 150 times/minute). We watched the ekg each time we paused. He didn't make it.
A week ago, before first going to the emergency clinic because he couldn't pee, he was a healthy cat. Whatever stones may have been present were not affecting his life at all. Yesterday, he died. The owners elected a group cremation, with no ashes returned.
Ethical Dilemma
S is a 11 month old Doberman Pinscher. She is not spayed. She is purebred with papers. She has a class III malocclusion, an anterior crossbite (example in picture below), and "rostral flare" of her lower incisors.
A class I malocclusion is just when the front teeth (between the canines) don't quite meet the way they're supposed to. It is presumed to be some combination of factors including environment, congenital, genetic, and dumb luck.
A class III malocclusion is when the mandible is just a little bit too long, and rather than the top teeth fitting nicely and prettily over the bottom, instead they either meet straight on (try it, you can see how it would hurt after a while) or have the "bulldog look". Class III's are considered to be a genetic skeletal deformity, where the pre-molars and molars are involved to some degree as well as the more obvious incisors.
(For reference, a class II is when the maxilla is waaay to long, and a class IV is severe skeletal deformities like where the teeth don't even meet in the front, or one side of the mandible is longer than the other.)
Dogs that are shown are typically in the highest demand for breeding and continuing the lines of the breed. As a result, they need to be the best genetics available, and breeding dogs with cranial skeletal deformities is not in anyone's best interest.
S's owner came to the dentistry clinic when she was about 6 months old. In hand, he had an article written by the AKC for judges about how to spot (and disqualify) dogs who have had orthodontic work to correct malocclusions. The article had a picture of a dog with an expansion device, which many people I know had as children in conjunction with their braces. The expansion devices angle the teeth outward appropriately so that the skeletal abnormalities are disguised and the dog has a normal bite.
He pointed to the device in the picture and said "I want that for my dog."
After many hours of ethical discussions amongst themselves and with the owners, my clinicians ultimately decided to use the expansion device to correct S's malocclusion and crossbite. The owner desires to show this dog, and insists that "no other dogs in the line have any teeth problems".
I have several major ethical issues with treating this dog and working with this owner, which I will briefly highlight, along with some pertinent facts.
1) The dog is in no pain and has no quality of life issues with her current bite.
2) The dog is an intact female that may be bred in the future, potentially to relatives.
3) The dog is intended as a show dog, and judges are clearly *taught* to look for these changes.
4) There is no real way for us to "report" this owner to the AKC.
5) In order to become board certified in veterinary dentistry, a resident must perform and document two orthodontic device fitting and placements.
Personally, I have decided to not treat an animal when placed in this situation. While I would be happy to place the device, I would do it on contingency of spaying the dog. As a student, I abide by the choices of my attending clinicians.
A class I malocclusion is just when the front teeth (between the canines) don't quite meet the way they're supposed to. It is presumed to be some combination of factors including environment, congenital, genetic, and dumb luck.
A class III malocclusion is when the mandible is just a little bit too long, and rather than the top teeth fitting nicely and prettily over the bottom, instead they either meet straight on (try it, you can see how it would hurt after a while) or have the "bulldog look". Class III's are considered to be a genetic skeletal deformity, where the pre-molars and molars are involved to some degree as well as the more obvious incisors.
(For reference, a class II is when the maxilla is waaay to long, and a class IV is severe skeletal deformities like where the teeth don't even meet in the front, or one side of the mandible is longer than the other.)
Dogs that are shown are typically in the highest demand for breeding and continuing the lines of the breed. As a result, they need to be the best genetics available, and breeding dogs with cranial skeletal deformities is not in anyone's best interest.
S's owner came to the dentistry clinic when she was about 6 months old. In hand, he had an article written by the AKC for judges about how to spot (and disqualify) dogs who have had orthodontic work to correct malocclusions. The article had a picture of a dog with an expansion device, which many people I know had as children in conjunction with their braces. The expansion devices angle the teeth outward appropriately so that the skeletal abnormalities are disguised and the dog has a normal bite.
He pointed to the device in the picture and said "I want that for my dog."
After many hours of ethical discussions amongst themselves and with the owners, my clinicians ultimately decided to use the expansion device to correct S's malocclusion and crossbite. The owner desires to show this dog, and insists that "no other dogs in the line have any teeth problems".
I have several major ethical issues with treating this dog and working with this owner, which I will briefly highlight, along with some pertinent facts.
1) The dog is in no pain and has no quality of life issues with her current bite.
2) The dog is an intact female that may be bred in the future, potentially to relatives.
3) The dog is intended as a show dog, and judges are clearly *taught* to look for these changes.
4) There is no real way for us to "report" this owner to the AKC.
5) In order to become board certified in veterinary dentistry, a resident must perform and document two orthodontic device fitting and placements.
Personally, I have decided to not treat an animal when placed in this situation. While I would be happy to place the device, I would do it on contingency of spaying the dog. As a student, I abide by the choices of my attending clinicians.
Wednesday, April 18, 2007
Lazy me
Monday:
The first case I had in the morning was a dog with progressive vision loss and cloudy eyes for the last month. She's a 5 year old Papillon (the most ADORABLE dogs ever, I love them). Her history is actually of stomach problems, which is more unusual in smaller breed dogs - so that threw us for a loop. She'd never really had any issues before with her eyes. When I looked in here eyes, mostly what I noticed was that she had complete cataracts in both eyes. This means that we can't see in and she can't see out. She can probably tell where shadows are, but not much else. What surprised me was that the owner hadn't reported any changes in the dog's drinking or peeing habits, and what I was seeing was incredibly consistent with diabetic cataracts. I asked the owner twice, Dr P asked again when we got in the room. Apparently any acute onset cataracts can cause separation of the Y-sutures, but the top 5 differentials in dogs are Diabetes. We talked to the owner about surgery, but warned them that because of the dogs ongoing digestive issues that we were a little hesitant about taking her to surgery. We did run bloodwork to check for diabetes and to see if she would even be a tiny bit of a candidate for surgery. She doesn't have diabetes (good), but she does appear to be in kidney failure (bad). This, of course, is my non-clinical-pathologist diagnosis based on anemia, low serum albumin, azotemia and no urine sample.... We called to let the owners know that the dog isn't a candidate for surgery, but that it's pretty important that she get a medical work-up by either her regular DVM or by the internal medicine service here. Also, she had fleas. Ew.
The next case I saw was a 7 year old basset hound that had primary glaucoma. This is an acute onset painful condition in dogs,unlike in humans where the eye pressures rise slowly over time and is generally first noticed when vision begins to be lost. They'd been treating the dog for about 6 weeks, and they had brought the eye pressures down to a nice low good level. It was a pretty straightforward case with good owners :) Unfortunately, eventually this type of glaucoma will become refractory to treatment and the eye will become blind and painful, and probably have to be removed. Double-badness is that this is a developmental eye issue, and the other eye is incredibly likely to also develop primary glaucoma, and eventually the poor dog will probably be blind in both eyes.
The last case that I saw for the day was a recheck from a dog that I'd had the opportunity to see last week! It was the dog with blood in her eye, glaucoma, an ulcer and KCS. We were only treating for the glaucoma and the ulcer over the last week, and while the glaucoma is now under control, the ulcer is still tiny but present. As soon as the ulcer resolves, we can start the dog on topical steroids in addition to the oral steroids to help drop the inflammation and resolve the blood inside the eye and start the dog on optimmune (cyclosporin A) ointment to help to decrease the corneal pigmentation and thickening from the poor tear production. I wish I was on this service longer so that I could continue to follow her treatment - but you do what you can do.
The first case I had in the morning was a dog with progressive vision loss and cloudy eyes for the last month. She's a 5 year old Papillon (the most ADORABLE dogs ever, I love them). Her history is actually of stomach problems, which is more unusual in smaller breed dogs - so that threw us for a loop. She'd never really had any issues before with her eyes. When I looked in here eyes, mostly what I noticed was that she had complete cataracts in both eyes. This means that we can't see in and she can't see out. She can probably tell where shadows are, but not much else. What surprised me was that the owner hadn't reported any changes in the dog's drinking or peeing habits, and what I was seeing was incredibly consistent with diabetic cataracts. I asked the owner twice, Dr P asked again when we got in the room. Apparently any acute onset cataracts can cause separation of the Y-sutures, but the top 5 differentials in dogs are Diabetes. We talked to the owner about surgery, but warned them that because of the dogs ongoing digestive issues that we were a little hesitant about taking her to surgery. We did run bloodwork to check for diabetes and to see if she would even be a tiny bit of a candidate for surgery. She doesn't have diabetes (good), but she does appear to be in kidney failure (bad). This, of course, is my non-clinical-pathologist diagnosis based on anemia, low serum albumin, azotemia and no urine sample.... We called to let the owners know that the dog isn't a candidate for surgery, but that it's pretty important that she get a medical work-up by either her regular DVM or by the internal medicine service here. Also, she had fleas. Ew.
The next case I saw was a 7 year old basset hound that had primary glaucoma. This is an acute onset painful condition in dogs,unlike in humans where the eye pressures rise slowly over time and is generally first noticed when vision begins to be lost. They'd been treating the dog for about 6 weeks, and they had brought the eye pressures down to a nice low good level. It was a pretty straightforward case with good owners :) Unfortunately, eventually this type of glaucoma will become refractory to treatment and the eye will become blind and painful, and probably have to be removed. Double-badness is that this is a developmental eye issue, and the other eye is incredibly likely to also develop primary glaucoma, and eventually the poor dog will probably be blind in both eyes.
The last case that I saw for the day was a recheck from a dog that I'd had the opportunity to see last week! It was the dog with blood in her eye, glaucoma, an ulcer and KCS. We were only treating for the glaucoma and the ulcer over the last week, and while the glaucoma is now under control, the ulcer is still tiny but present. As soon as the ulcer resolves, we can start the dog on topical steroids in addition to the oral steroids to help drop the inflammation and resolve the blood inside the eye and start the dog on optimmune (cyclosporin A) ointment to help to decrease the corneal pigmentation and thickening from the poor tear production. I wish I was on this service longer so that I could continue to follow her treatment - but you do what you can do.
Tuesday:
Yesterday we had just three cases. We started off the morning with a Jack Russell who had excessive tearing in one of his eyes. He was in to have his teeth cleaned, and as long as he was anesthetized we went ahead and evaluated the drainage through his nasolacrimal duct. (Un?)Fortunately, it was normal. So, we have no idea what's up with him. Oh well.
Next we played with J's cat Velvet, a hypothyroid Rex cat (go ahead and google Rex, I'll wait). She was incredibly patient with us and we got to play with both the super duper expensive slit lamp and the headset with the light on it. WOW do those things have a learning curve. I'm glad that I mostly use the handset that I've had years of practice with, as well as that's what most practices that I'm going to be working in have - and it's nice to become comfortable diagnosing with less sophisticated equipment if that's all that will later be available to you.
Then we went to 2 lectures, one on proptosis (don't google this one ~.o) which is when the eye pops out of the socket, and one on exotics. Both were lectures that I went to last year, and not too much had changed. I spent most of the lectures texting Sam and drinking Diet Coke (read: crack).
In the afternoon we had a horse come in who had a history of cloudy eyes. I ended up taking the case. In horses, their eyelids are so strong that you actually have to do a local anesthetic block in order for them to let you completely examine their eye. Dr P did most of the exam, I did most of the writing up and talking to the (young) owner afterwards. First of all, the owner was a senior in high school, and I'm pretty sure not old enough to legally enter into a binding contract.... The woman who drove her and the trailer in was a friend's mom, and had no say. So this teenager was making costly decisions for the horse and spending her mom's money... talk about a weird conversation to have. Anyways, we diagnosed the horse with equine recurring uveitis (moon blindness), but really what the horse had was a secondary uncontrolled glaucoma. We upped the anti-glaucoma drug that the horse was on and added in another drug. The horse had asteroid hylosis (it looks like the starry night screen saver only in the back of the eye), baby cataracts, a pale optic nerve head, and something called Haab's Striae (I'm going to recheck spelling on this). The Striae is when Decemet's membrane (the basement membrane on the inside of the cornea) cracks and it gets all cloudy with edema. It's related to increase pressure inside the eye at some point in time. The other eye was fine, but will probably ultimately also be affected. They don't know how/why it happens, except that it seems to happen to Appaloosa's more often, which this horse was.
Then we had the opportunity to see a cria, a baby alpaca, with lots of developmental defects. I missed most of the explanation, but I do know that the membrane between the nose and the throat never dissolved during development, so she can't eat and breathe at the same time. As a result, she never got colostrum after birth (2d old now) and has a blood infection. Also, she's completely blind, has an eye full of blood, and this kinda neat spiderweb of vessels in the back of the eye. Also, she's kinda neurologic, isn't walking well and has a head tilt. I'm pretty sure they put her down this morning, which is the right thing to do in an animal with so many congenital defects.
We spent the remaining time in the afternoon harassing R's dogs, Samoyeds, that she brought in for our amusement. It was kinda entertaining :) We got to use the toys again, and he had some cool tapetums, very grainy. He probably has early progressive retinal atrophy, because when we set up a maze in the room for him in the very very dim light he ran into a trash can. R's choice about the workup for him, he's a 10ish year old dog :)
Saturday, April 14, 2007
TGIF
I gave my self a break last night from posting, because the week just completely drained me. It's rough to go from a 20 hour a week "desk job" to a 50 hour a week running around like craziness!
Yesterday was kinda fun, though absolutely insane. I was about 3 minutes late due to an important trip to pick up bagels and cream cheese before school. I remain convinced that the bagels maintained everyone's blood sugar at a reasonable level throughout the day and prevent the uber cranky that we've been seeing around noon when no one has gotten to eat since 6 or 7 am.
I had agreed on Thursday night to take the 8am diagnostic appointment, just so that we didn't have to choose first thing in the morning. Fortunately, my owner was a little late, so I had some time to settle in. This poor owner was absolutely hysterical on the phone on Thursday night, including kinda verbally abusing our (amazing) technician. We knew that she was pretty stressed, so I had really prepared myself for coping with the morning.
Her poor puppy had detached retinas due to high blood pressure and uncontrolled hyperadrenocorticism back in February. With blood pressure medicine her referring vet managed to get the left retina to reattach on it's own, but seemed to have limited success in the right eye. Based on the lab results that came with the record from her vet, her cushings has NEVER been controlled, and they haven't really changed the dose either (weird). It also looks like her hypertension is back in full form. Her right eye is completely filled with blood, and we presume that the retina is detached behind it. She is completely blind in that eye (if we can't see in, she can't see out), but the eye is not painful at all. So we prescribed some topical steroids to help resolve the blood, and referred her to the internal medicine service to get her cushings and hypertension under control. At last check she had an abdominal ultrasound that did not reveal anything diagnostic (big liver, spleen, lymph nodes, cystic pancreas, sludgy gallbladder, tubular mineralization in the kidneys... no tumors). I hope they can get her under control, because if they can do it by next week, there's a chance that we can actually resolve what's going on in her right eye and get her partly visual again.
I missed the 9am trip to the raptor center because of that first appointment, but R and J went with all the doctors, and got to see a snake. Apparently there were no birds, and one of the raptor center people had a snake with a retained spectacle (for whatever reason when the snake shed, the "lens" of skin over the eye didn't shed with it). They were unsuccessful in helping it to shed, so they prescribed some warm compresses and misting it with water to keep it moist and bringing the snake back next week.
The rest of the morning was just a series of rechecks that seemed to go on forever. I know that I rechecked a dog with dry-eye (KCS) who was slightly improved. We didn't have the records from the previous visit (grrrr), so I told Dr P that I thought I saw "slight flare" in the affected eye, and she agreed with me! I didn't know it was going to be there weee go me! I saw a dog with bilateral uveitis (inflammation in the front of the eye), that was also doing amazingly better. I helped hold for a couple of appointments that other students had, but I can't really think of what their cases were - I mostly just know the ones that I wrote up.
I finally grabbed a brief lunch break around 1:15 and got to eat my pizza, yummy! Because of the upcoming AVMA accreditation visit (starting today, actually), a group of gullible sophomores were under the Larry's supervision cleaning out refrigerators and microwaves that were REALLY NASTY. I've taken to eating my food at room temperature because if you put them in the fridge they pick up this really ... rancid kinda taste. SO gross. Oddly, reminds me of Boy's dorm room fridge in college at one point :) I totally ruined our leftovers one day.
The students after lunch kinda took the opportunity to regroup and talk amongst ourselves about cases and questions that we had. By the time the doctors found us (we were hiding in an exam room), we had the eye model, a laptop, an ophtho textbook, a set of Ross notes and a set of class notes out, trying to figure out the answers to our questions. Dr K stole R and J to hold the super insane lab that was getting a CERF exam (like OFA for eyes), so P and I just hung out for a little bit. Then Dr P came in and we held rounds for about 2 1/2 hours on eye emergencies. We got through glaucoma and the acutely blind eye. I have soo many pages of notes in my little notebook! It was really interesting, and while pretty similar to the lectures given in class 2 years ago - this time around it made sense! While Dr P was giving a powerpoint presentation, because there were only 5 of us in a very small room, it really played out like more of a discussion.
Yesterday was kinda fun, though absolutely insane. I was about 3 minutes late due to an important trip to pick up bagels and cream cheese before school. I remain convinced that the bagels maintained everyone's blood sugar at a reasonable level throughout the day and prevent the uber cranky that we've been seeing around noon when no one has gotten to eat since 6 or 7 am.
I had agreed on Thursday night to take the 8am diagnostic appointment, just so that we didn't have to choose first thing in the morning. Fortunately, my owner was a little late, so I had some time to settle in. This poor owner was absolutely hysterical on the phone on Thursday night, including kinda verbally abusing our (amazing) technician. We knew that she was pretty stressed, so I had really prepared myself for coping with the morning.
Her poor puppy had detached retinas due to high blood pressure and uncontrolled hyperadrenocorticism back in February. With blood pressure medicine her referring vet managed to get the left retina to reattach on it's own, but seemed to have limited success in the right eye. Based on the lab results that came with the record from her vet, her cushings has NEVER been controlled, and they haven't really changed the dose either (weird). It also looks like her hypertension is back in full form. Her right eye is completely filled with blood, and we presume that the retina is detached behind it. She is completely blind in that eye (if we can't see in, she can't see out), but the eye is not painful at all. So we prescribed some topical steroids to help resolve the blood, and referred her to the internal medicine service to get her cushings and hypertension under control. At last check she had an abdominal ultrasound that did not reveal anything diagnostic (big liver, spleen, lymph nodes, cystic pancreas, sludgy gallbladder, tubular mineralization in the kidneys... no tumors). I hope they can get her under control, because if they can do it by next week, there's a chance that we can actually resolve what's going on in her right eye and get her partly visual again.
I missed the 9am trip to the raptor center because of that first appointment, but R and J went with all the doctors, and got to see a snake. Apparently there were no birds, and one of the raptor center people had a snake with a retained spectacle (for whatever reason when the snake shed, the "lens" of skin over the eye didn't shed with it). They were unsuccessful in helping it to shed, so they prescribed some warm compresses and misting it with water to keep it moist and bringing the snake back next week.
The rest of the morning was just a series of rechecks that seemed to go on forever. I know that I rechecked a dog with dry-eye (KCS) who was slightly improved. We didn't have the records from the previous visit (grrrr), so I told Dr P that I thought I saw "slight flare" in the affected eye, and she agreed with me! I didn't know it was going to be there weee go me! I saw a dog with bilateral uveitis (inflammation in the front of the eye), that was also doing amazingly better. I helped hold for a couple of appointments that other students had, but I can't really think of what their cases were - I mostly just know the ones that I wrote up.
I finally grabbed a brief lunch break around 1:15 and got to eat my pizza, yummy! Because of the upcoming AVMA accreditation visit (starting today, actually), a group of gullible sophomores were under the Larry's supervision cleaning out refrigerators and microwaves that were REALLY NASTY. I've taken to eating my food at room temperature because if you put them in the fridge they pick up this really ... rancid kinda taste. SO gross. Oddly, reminds me of Boy's dorm room fridge in college at one point :) I totally ruined our leftovers one day.
The students after lunch kinda took the opportunity to regroup and talk amongst ourselves about cases and questions that we had. By the time the doctors found us (we were hiding in an exam room), we had the eye model, a laptop, an ophtho textbook, a set of Ross notes and a set of class notes out, trying to figure out the answers to our questions. Dr K stole R and J to hold the super insane lab that was getting a CERF exam (like OFA for eyes), so P and I just hung out for a little bit. Then Dr P came in and we held rounds for about 2 1/2 hours on eye emergencies. We got through glaucoma and the acutely blind eye. I have soo many pages of notes in my little notebook! It was really interesting, and while pretty similar to the lectures given in class 2 years ago - this time around it made sense! While Dr P was giving a powerpoint presentation, because there were only 5 of us in a very small room, it really played out like more of a discussion.
Thursday, April 12, 2007
Paper towel tube doo doo doo
Today was relatively low key, which was much welcomed after a first week that gave me a ton of blisters! I got in at 8 this morning, we talked about what was going on today, and went to watch Dr P give Grand Rounds. Her talk was about aldose reductase inhibitors for the prevention of diabetic cataracts in dogs. It looks cool, but because results for peripheral neuropathies in humans have been disappointing (side effects for the lose), there isn't anything available on the market. 90% of dogs have cataracts 18 months after being diagnosed with diabetes. Scary numbers.
(There's odd thumping from the other room, I hope Oberon doesn't get squished!)
Then I took the 9am recheck appointment, a cat who had massively severe uveitis in one eye two weeks ago and was here today for a recheck. The eye is about 95% better! Woooot. I kinda blew my exam though... I forgot to use the slit lamp to actually EVALUATE the uveitis - though I did a pretty reasonable exam other than that. We put the cat on antibiotics for another couple of weeks just in case it was toxoplasmosis and the antibiotics were the reason that it got better (could have been the steroids...). I managed to correctly diagnose a pupil that did not respond to light as an eye that had atropine put in it daily for the last two weeks, go me! (We gave it atropine to keep it's pupil as wide open as possible so all the inflammation wouldn't make the iris stick to the lens of the eye.)
(Update, it was a wrapping paper tube that he was wrestling to it's death)
Then I went and watched the eye be removed from the cat that I saw yesterday. He was doing well this morning, and did great in surgery. Next Dr D and R removed the eye of a little mini poodle. She was a GIANT sweetheart, and we cuddled for about an hour tonight while waiting for her mom and brother (a little black mini poodle) to come pick her up. R actually got to do some of the cutting of the conjunctiva during the surgery! It was awesome!!
I grabbed myself a quick lunch of leftover pizza from last night (did I mention that I was so exhausted last night that I ordered pizza and drank wine and put myself to bed early?), and relaxed for a couple of minutes. We had lab with the sophomores from 1-5, and I think I did a much better job this week. We had about a half hour break between labs, during which I grabbed a Coke Zero and chatted with A who had a concurrent break from her surgery rotation. It was nice to get to see her.
I hung out until we managed to do a quick rounds, and then waited with R to do the discharge of the poodle so that she could give me a ride home afterwards.
(There's odd thumping from the other room, I hope Oberon doesn't get squished!)
Then I took the 9am recheck appointment, a cat who had massively severe uveitis in one eye two weeks ago and was here today for a recheck. The eye is about 95% better! Woooot. I kinda blew my exam though... I forgot to use the slit lamp to actually EVALUATE the uveitis - though I did a pretty reasonable exam other than that. We put the cat on antibiotics for another couple of weeks just in case it was toxoplasmosis and the antibiotics were the reason that it got better (could have been the steroids...). I managed to correctly diagnose a pupil that did not respond to light as an eye that had atropine put in it daily for the last two weeks, go me! (We gave it atropine to keep it's pupil as wide open as possible so all the inflammation wouldn't make the iris stick to the lens of the eye.)
(Update, it was a wrapping paper tube that he was wrestling to it's death)
Then I went and watched the eye be removed from the cat that I saw yesterday. He was doing well this morning, and did great in surgery. Next Dr D and R removed the eye of a little mini poodle. She was a GIANT sweetheart, and we cuddled for about an hour tonight while waiting for her mom and brother (a little black mini poodle) to come pick her up. R actually got to do some of the cutting of the conjunctiva during the surgery! It was awesome!!
I grabbed myself a quick lunch of leftover pizza from last night (did I mention that I was so exhausted last night that I ordered pizza and drank wine and put myself to bed early?), and relaxed for a couple of minutes. We had lab with the sophomores from 1-5, and I think I did a much better job this week. We had about a half hour break between labs, during which I grabbed a Coke Zero and chatted with A who had a concurrent break from her surgery rotation. It was nice to get to see her.
I hung out until we managed to do a quick rounds, and then waited with R to do the discharge of the poodle so that she could give me a ride home afterwards.
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