Clinical Workups: Expect the Unexpected – Dr. Kate Bruce

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Hi, my name is Dr. Kate and I’m a veterinary surgeon (BVSc Hons) in my third year of practice at a 24-hour GP, emergency and house-call small animal clinic in Brisbane, Australia. One important lesson I have learned so far in my career as a veterinarian is to always expect the unexpected, as I have been surprised numerous times by cases that seemed innocuous and actually resulted in rather sinister diagnoses.

weimaraner therapy dogMy latest was a young Weimaraner, presented after being knocked by a car. His owners brought him in ‘just in case’, as they believed he seemed fine except for a few superficial scratches. We performed x-rays as a precaution to assess for internal bleeding or injury and were shocked to find nasty pulmonary haemorrhage and a pneumothorax. The patient decompensated rapidly, and spent the next 3 days on supplementary oxygen, fluids and pain relief while his internal damage healed.

These types of cases are not out of the ordinary. I recently had another patient present after a nasty dog attack. X-rays showed a fractured scapula, but also incidentally a large splenic tumour taking up a significant portion of his abdomen, assumed by the owners to be just a little holiday weight gain.

Another patient was seen for mild wheezing, which was not audible within the clinic, only at home. That patient was found to have a mediastinal mass the size of his heart and was referred to a specialist for major thoracic surgery.

I try to remember each of these cases every time I make assumptions about a diagnosis purely based on the presenting complaint, mostly out of fear of missing something critical like these.

Dr Kate surgeryWhen presented with any patient, a good veterinarian will be able to develop a list of the most common differential diagnoses based on symptoms and physical exam findings, and will be able to act on instinct to treat those common pathologies. A great veterinarian however, acknowledges that they don’t have a crystal ball and are not expected to make a diagnosis on the limited and sometimes deceptive information before them.

One of the most valuable pieces of wisdom my bosses gave me when I first started out was “you don’t have to know what it is, just what tests to run”. Since then, I have never doubted the value of running diagnostics as I have been surprised time and time again by the outcome. In university we’re taught ‘when you hear hoof beats, expect horses and not zebras’. While this may run true most of the time, never forget that zebras exist!

I must include a small disclaimer here as I’m writing from a position of privilege. I work at an extremely well-equipped 24 hour hospital with an exceptional client base, that more often than not are able to financially follow through with the majority of tests (including blood analysis, urinalysis, radiography, ultrasonography, endoscopy, or referral to local specialists for further workup).

I understand that this is a rarity, and until pet insurance or universal doggy healthcare is the norm, most vets must do their best within their means and unfortunately cannot always practice gold standard medicine. However, every client (regardless of prior assumptions we may make) should always be at least presented with gold standard options so that they are able to make a well-educated decision.

Dr Kate with puppiesThis comes down to thorough communication, and time to achieve it. Again, I’m spoiled in my clinic with standard 30-60 minute consultation blocks (including home consults) compared to the industry average of 10 minutes. We may sacrifice the opportunity to fit in more vaccinations each day, but achieve much better outcomes for our patients through proper communication with their owners.

There is an outdated attitude from some members of the public and even professionals within the industry that this is ‘over-servicing’. While I understand that the gold standard approach must be taken with a heavy dose of pragmatism, I often wonder if these same people would be happy having their own GPs miss a potentially fatal diagnosis because the tests were never even offered. We recently ran an approximately $1500 workup on a patient with polydipsia (excessive water consumption), only to come up negative on every test and reach a conclusion of psychogenic polydipsia. While this may seem like a waste to some, this is the best possible diagnosis we could have achieved and the owners were able to make informed decisions at every step and be happy with the outcome.

Dr Kate with a puppySimilarly, it is a standard in our clinic to run non-negotiable blood tests before every routine desexing procedure in puppies and kittens. While 99% of tests come back completely normal, we can rest easy knowing we saved the 1% which identified with a portosystemic shunt or juvenile kidney disease or a blood disorder etc.

While there are some days I’m tempted to take the easy way out and dismiss clients in 5 minutes with medications that will ‘probably’ help, I always remember that for my own sanity and restful sleep, I have to know that I haven’t skipped any steps and have done for my patients what I would want done for my own family members, including my pets.

The satisfaction of seeing that Weimaraner go home alive and on the mend with incredibly grateful owners makes it all worth it.

Dr. Kate Bruce – Veterinary Surgeon BVSc (Hons)





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