Let’s play a game
I like this game. It’s harder than it looks.
You’ll get a series of hints. Slam the buzzer when you know the answer.
An owner calls and says his dog is itchy.
BUZZ! FLEA ALLERGIES!
Ah yes, very good guess, but you haven’t even seen the dog yet.
The dog is not on flea control.
BUZZ! IT’S TOTALLY FLEA ALLERGIES!
Look, I get that is a reasonable assumption, but we need a little more information to make an accurate diagnosis.
The dog is a bulldog.
BUZZ! It’s GOTTA be allergies!
Maybe. It sure would fit.
The dog is five years old.
BUZZ! Maybe atopy?
Some other vet treated him with some stuff a month or maybe two ago, and it went away for a bit but then it came back.
BUZZ! Uh…wait…prednisone? Antibiotics? What was he treated with? Did they do any tests?
No tests.
He looks like this:
buzz- wait- oh my god, what is that? Yeast? Deep pyoderma? Ringworm? Pemphigus? Dermal lymphoma?
I’ll tell you what it is. I have no friggin clue. It could be any of those things because NASTY SKIN ALL LOOKS NASTY NO MATTER WHAT CAUSED IT.
Sure, there are clues- what we refer to as signalment: breed of dog, age; medical history; the physical examination itself. But if there is one thing I have learned, and been burned by more times than I can count, it is that skin surprises you all the time. Without doing diagnostics, you’re just slamming your hand prematurely on the buzzer and playing the odds that you’ll be right most of the time.
And most of the time it works. But when it doesn’t, it can get ugly. Consider this sweet dog, gentle and kind despite his painful looking dermis, whose owner fortunately allowed me to do some testing.
The skin impression has tons of cocci.
BUZZ! PYODERMA! I TOLD YOU IT WAS AN INFECTION!
Yes, but what about the skin scrape?
WHY WOULD I DO THAT? HE’S TOO OLD TO GET MITES! THAT MAKES NO SENSE! WHAT A WASTE OF CLIENT MONEY, YOU ROTTEN MONEY STEALING VET FULL OF UNNECESSARY TESTS!
Here is the skin scrape:
BUZZ! Demodex! ADULT ONSET DEMODICOSIS WITH A SECONDARY DEEP PYODERMA! That’s what I thought all along.
We did finally get to our diagnosis, though it was not the one we all thought it would be. It’s easier, the more you are in practice and the more things you see, to rely on your intuition and experience to make the diagnosis for you, and a lot of people expect that of you. But it’s my job to remind myself every day to be thorough and vigilant. To tell owners, “Look, I think it’s this, but let’s confirm it with x/y/z.”
Had I skipped that one test, the one I had the hardest time convincing the owner to do, multiple things would have happened:
1. There would have been a major delay in getting this poor pup the meds he needed;
2. We would have missed a disease that is a warning flag for an underlying immune suppression.
