Idiopathic Issues

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Zebras are Everywhere

Posted by Jessica Gramlich on August 17, 2015 at 3:08 PM
Jessica Gramlich
Dr. Gramlich is a 2008 graduate of North Carolina State University College of Veterinary Medicine. After completing a one-year emergency internship in Rhode Island, she spent five years working as a small animal general practitioner in New Hampshire.
hooves
There is a saying in veterinary medicine, when you hear hooves, think horses not zebras. It’s so clever. The whole point is that common things are common and they should be first on your list of differentials. When you are a student and you have just finished learning about all kinds of cool diseases it is easy to come up with a really rare differential. It’s hard to know what is typical and what is unusual because you haven’t seen a lot of patients yet. During my internship some of my differentials were so outlandish that they would actually be laughed at during rounds. That coughing dog in Ontario could have Spirocercosis but without a travel history that is pretty unlikely.

It is extremely important to keep an open mind. It is easy when you have been practicing for a long time to get caught in a trap of the same old same old. Well, that looks like a really bad case of superficial pyoderma. Here are some antibiotics and steroids. Oh whoops, it’s cutaneous lymphoma or MRSA or scabies! The list goes on. It’s important not to pigeon-hole yourself into a one track mind. Yes, if you live in the northeast like I do, that febrile, painful dog probably has lyme disease, but is it the only possibility? No, turns out that poor dog could have discospondylitis or neoplasia or trauma.

It gets hard out there in the trenches because most owners want answers as quickly and cheaply as possible. You are under constant pressure to produce a diagnosis on physical exam alone. Sometimes clients try to get a diagnosis over the phone skipping the exam entirely. Once you start to get some experience under your belt you may start to take short cuts. Your inexperience is sometimes valued by your future employers. They like that you run a lot of tests. Financially it makes up for your newbie inefficiency. I remember being in school and job shadowing on an externship. A patient came in with diarrhea, the vet took a history, did a thorough physical exam and sent the dog home with metronidazole. “But it could be anything!” I questioned, “how do you know this dog doesn’t have roundworms or whipworms or an intussusception or something else without testing?” The seasoned vet smiled, had his tech made a fecal smear, and wouldn’t you know it, on that slide there were clostridial organisms everywhere. He was right and his experience showed.

It is extremely important to learn what is common and what is normal. Dogs get hypothyroidism, cats get hyperthyroidism, except when they don’t. There are always exceptions to the rule. Those zebras are out there and it is important to keep a good list of differentials so you don’t miss something important. When you are in clinics and you are asked to write a page long list of possible disease processes I highly recommend that you take that task seriously. After being out of school for only a few years I became really impressed with my recently graduated coworkers when reading their SOAP notes. They were so detailed! Don’t forget DAMN IT-V

D = Degenerative or Developmental
A = Anomalous or Autoimmune
M = Metabolic, Mechanical, or Mental
N = Nutritional or Neoplastic
I = Inflammatory, Infectious, Ischemic, Immune-mediated, Inherited, Iatrogenic, or Idiopathic
T = Traumatic or Toxic
V = Vascular

Keeping an open mind when you see a sick patient will help you to not get fooled and help you to avoid looking like a fool in front of your clients. A common phrase that my clients would often get is, “In my professional opinion your pet likely has _______, but it could also be the following _______, ________, or ________. Here are the other signs that we need to watch out for.” With experience it is easy to say these things to your clients and still look smart, because you are smart, you are keeping your options open. Telling your client that without a definitive diagnosis, the prognosis for their pet could rapidly change is not just being honest, it is also good medicine.

When you do come across those zebras it is really fun to tell your veterinary friends all about it. Cocktail parties and family barbecues will never be the same! There is always a cool case to discuss because veterinary medicine is awesome, all the way from the horses to the zebras.

Topics: Differentials

 

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