When We Don't Get An Answer

One of the most frustrating things in veterinary medicine is not getting a diagnosis or a definitive answer on why something is going on with a pet. Sometimes, it's simply because we are limited in the tests we can run due to an owner's finances. In other cases, the answers are not found in the most common tests we do run.  The MOST important "diagnostic" is the physical exam. A thorough exam is more important than any technology we have. And many times, we can either find an answer or at a least a clue to point us down the road we need to take. I had two cases this week though that illustrate how elusive a diagnosis can be. 


1. An 11 yr old cat that hadn't been to a vet in a LONG time. He went outdoors and was NOT up to date on vaccines. His presenting problem was weight loss and anorexia of 5 days duration.  His exam was normal. He had a mild fever. He was a little thin and surprisingly not icteric (yellow): when a cat doesn't eat for that many days, they often end up with a condition called fatty liver syndrome and the get a yellow tone to their skin, eyes and gums.  We started with the most basic of "sick" kitty tests - the Feline Leukemia/Feline AIDS test - negative. Basic in house blood work - a complete blood count and a diagnostic panel, looking at organ function (kidney, liver, pancreas, etc). ALL normal.  Next test: x-ray - esp because you can have tumors in the chest and all else seems normal..we can't "hear" these by listening. Guess what? The lateral cat-o-gram (we can fit the entire kitty on an x-ray because of their size): NORMAL. Great. Now what?


Well, the owner couldn't go the next step: abdominal ultrasound. So we did some supportive care: fluids, antibiotics and an appetite stimulant, stressing the importance of getting this cat to eat. We have NOT ruled out cancer. Believe it or not, all these tests can be normal and sometimes, it's not until you do an exploratory and/or get some biopsies that you find this to be the case. I have seen it many times.


Hopefully, kitty will respond.  


2. A middle aged German Shepherd mix comes in for being lethargic and lame on one leg.She is not eating well. She has a fever. She also has not been to a vet in a few years and is not up to date on vaccines.  Oh and she is difficult to examine without sedation. Her exam, though somewhat limited by her temperament, was pretty normal, EXCEPT for a very chronic skin infection.  In a dog with these signs (fever lameness, lethargy), the first test we will run is a Lyme test. Her test: NEGATIVE!. This surprised most of us. Next test was a CBC/CHEM as we did with the kitty above. All NORMAL.  
I didn't really want to sedate her since she was not feeling well so we are treating her symptomatically too - a fever reducer, an antibiotic, an anti-flammatory and long term anti-fungal meds for her skin. 


If she doesn't turn around in the next few days: sedation and x-rays are in her future.


The good thing is that often we do get good results even without knowing the original cause of the problem. This is especially true in the many cases of vomiting/diarrhea that we see in our pet dogs (gastroenteritis can be caused by 1000 things!). 


Pet owners don't always understand this and of course, when the costs of tests add up without answers, they too can get frustrated. However, I try to remind them that the GOOD NEWS is that we have ruled OUT some very bad things (ie, in the cat case above - kidney failure). The other thing I tell them (and often times they can relate to this) is that this happens in human medicine too (I have MY own personal story to share if NEED be on this one).