RANT HERE thread

[LetItSnow]

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I'm assuming you would have said this if it were available, but was there any imaging?

CAVEAT: I have been out of vet school for 2 years at this point and feel like I've forgotten everything beyond what a puppy looks like, so if I say something exceptionally stupid, I'm blaming it on the PhD thing for now. Although I'm confident in my ability to diagnose osteosarcomas at this point (full disclosure: not a differential for this pup).

I'm wondering about AHDS/HGE and would want imaging, PT/PTT, and imaging of some sort (US or rads probably). Are there any fecal smears/floats available? Or cytology?

Also wondering about parasites --> intussusception

Sorry, I missed part of your post. AHDS/HGE is reasonable, but I will say they don't usually present with that high of a WBC count, and the TP/ALB/GLOB didn't really line up with it well.

PT/PTT were not performed because problem was identified.

You can have imaging if you tell me why. FAST is noted above.

Fecal NPS.

Cytology was later performed (we do path reviews on all CBCs, but it takes usually 12-24 hours), but attending didn't have that info at the time, so you don't get it. 🙂

As an aside, I think HGE is overdiagnosed and that at least some percentage (small) of 'HGE' cases are actually anaphylaxis. I'm fairly convinced of it, actually.

 

[LetItSnow]

Idk, blood smear and a coombs?

Initial blood smear seemed consistent with the analyzer. Full path review came after the diagnosis was made, so you don't get the luxury. 🙂

Coombs was not performed. Slide agglutination negative.

 

[LetItSnow]

Did Puppy get into anything? Wondering about anticoagulant toxicity causing hemorrhage into the GIT (and maybe other spots).

Hematochezia was frank blood? Maybe intussuseption (spelling....) or foreign body damaging the mucosa to bleeding point?

Also with regard to this, your thinking is great. You just need to keep going. You have enough info to tell me exactly (or close, anyway) what's going on. Keep at it! 🙂

 

[PippyPony]

...ANA?

I don't even know if we can run those.

(Obligatory "it's never lupus")

 

[TheGirlWithTheFernTattoo]

Initial blood smear seemed consistent with the analyzer. Full path review came after the diagnosis was made, so you don't get the luxury. 🙂

Coombs was not performed. Slide agglutination negative.

Were spherocytes, ghost cells, or Heinz bodies visible in the slide?

Was there hemolysis or icterus in the plasma of the tube?

 

[TheGirlWithTheFernTattoo]

Also did the hematochezia clear up in hospital while the HCT kept decreasing or were these concurrent the entire time?

 

[LetItSnow]

...ANA?

I don't even know if we can run those.

(Obligatory "it's never lupus")

You definitely can run an ANA. We didn't. 🙂

Were spherocytes, ghost cells, or Heinz bodies visible in the slide?

Was there hemolysis or icterus in the plasma of the tube?

There was mild icterus noted in the tube. Patient's TBili was WNL (all Chem was WNL).

Spherocytes, ghosts, heinz bodies were not reported. But patients don't always read the book, and all cytologies are not accurate.

 

[LetItSnow]

Also did the hematochezia clear up in hospital while the HCT kept decreasing or were these concurrent the entire time?

It continued.

 

[PippyPony]

Next diagnostic step: ask LIS and/or phone an internist friend

 

[supershorty]

No dietary indiscretion is reported, but of course you can decide whether to trust an owner on that.

No screening tests for coagulopathy were performed.

Hematochezia is by definition frank/fresh blood.

Intussusception is a reasonable differential, especially if you are thinking perf/sepsis. Subsequent gFAST was negative for peritoneal effusion, palpation did not identify an intussusception on PE or recheck PE, and the person who performed the gFAST likely would have identified an intussusception.



Agreed - off the top of my head I don't recall a parvo case with 55k. That said, I recently saw someone post something along the lines of "it isn't parvo if they have a neutrophilia" and that is 100% absolutely no-questions NOT true. MANY parvo patients start out with an initial neutrophilia (perhaps even most, I don't know, but by the time I see them they are typically normal or low). But I agree, 55k is too high for parvo. This patient did not have parvoviral gastroenteritis. (At least, its clinical signs were not caused by it.)




Lol. Sure.



Thrombocytopenia was not identified, and no coag screening tests were run (primarily because the problem was identified).



Imaging was not performed as primary diagnostics. gFAST was performed upon re-evaluation of the patient.

What would you be looking for with imaging, and what modality (we have x-ray/US/CT/MRI available)?

Comments on intussusception above. It was ruled out via PE and gFAST.

------------

Couple more comments:

1) I gave you all the initial diagnostics;
2) Now you have the gFAST results (consider intussusception ruled out);
3) If you want another dx, you have to tell me what you're looking for that you're spending the owner's money;
4) Not all cases have all the classic characteristics; and
5) Some things that may be noticed in a perfect setting (for instance, on pathology review or something) are commonly missed in the early stages of a case.

Good thoughts, but keep going. This is a case that if you practice SA medicine (especially ER/referral) you will see. I see one a year or so.

Hmm I would have wanted US because I had intussusception/perf as a differential. But.

Going to keep thinking.

 

[cdo96]

missing any change lately? I know the zinc in pennies can cause weird hemolytic anemia.

Abdominal radiographs would be very helpful in localization of pennies if so

edit: oh and the zinc salts cause GI upset

 

[cdo96]

missing any change lately? I know the zinc in pennies can cause weird hemolytic anemia.

Abdominal radiographs would be very helpful in localization of pennies if so

specifically pennies after 1982 I believe.

or other weird zinc related items like game pieces, zippers, id tags, bolts, etc

 

[TheGirlWithTheFernTattoo]

So into initially think through hematochezia: blood is frank so it needs to be originating in the large intestine (ruling out gastric or duodenal ulcers). Things that can cause bleeding are either things that prevent coagulation (rodenticides, other coagulopathy, thrombocytopenia, thrombocytopathy), or damage to the mucosa. Damage to the mucosa could be ulcerations/necrosis from infectious causes (parvo, HGE, parasites), trauma (foreign body, intuss., neoplasia (unlikely in this puppy)r immune mediated issues. Anaphylaxis I will dump under immune mediated. I’ve seen some cases of hematochezia come through our IM department that were due to severe IBD, but I wouldn’t expect that in a puppy of this age.

Now the secondary concern is the decreased HCT several days later. This means we either have decreased production or increased loss (remembering we need at least 2 days before a regenerative response will kick in). In that note, do we see reticulocytes or signs of regeneration on the most recent CBC? Decreased production could be issues with kidneys (low erythropoietin), marrow suppression, low iron, secondary to sepsis (iron sequestration). Increased losses could be from hemorrhage or hemolysis (immune mediated secondary to disease, medications, anaphylaxis, other. Really IMHA can be secondary to anything or idiopathic).

This puppy has been sick several days and is negative on a FAST, so I think foreign body, intussusception, neoplasia, etc are less likely. Did they check the gallbladder for a halo sign? (Anaphylaxis). I think this makes it more likely our initial issue was either to do with coagulation or the immune system/infectious causes.

Does the owner have Aspirin, medications for clotting, etc at home?

 

[Lawpy]

Man the vet forums are awesome

 

[TheGirlWithTheFernTattoo]

The bilirubinemia supports either extra vascular hemolysis, liver dysfunction, or cholestasis/outflow obstruction. With this case assuming liver values are normal I would lean extravascular hemolysis.

 

[Trilt]

Parvo snap: "weak positive" (I'm not a fan of 'weak' anything. It's either positive or negative. But that's how it was reported, so deal with it. 🙂)

I always get on assistants about this. "if it would give me a heart attack on a pregnancy test, it's just POSITIVE, no weak about it!"

 

[LetItSnow]

Next diagnostic step: ask LIS and/or phone an internist friend

*changes phone number* ;-)

Hmm I would have wanted US because I had intussusception/perf as a differential. But.

Going to keep thinking.

It's interesting. In this case, a quick radiograph would have solved it (and eventually did). However, with rad costs of $399 and US costs of $485 (or something like those), there's a general sense of "skip the rads and do ultrasound to get more utility."

Had this been my case, I would have taken the rads on suspicion if I were paying attention, or, even if I missed the right call, I would have taken a placement rad when I placed an NG tube and would have caught the answer at that time.

missing any change lately? I know the zinc in pennies can cause weird hemolytic anemia.

Abdominal radiographs would be very helpful in localization of pennies if so

We have a winner!

Next doctor in line said "huh. this looks like a metal case" and took rads.

Puppy ingested 2 pennies and a nickel. On radiographs, it looked like a battery, but the three coins were scoped out. Puppy was discharged a bit earlier than ideal due to cost constraints, but with an expectation that it will do well.

Nicely done, people!

Point, really, is .... you're gonna talk about cases like this in vet school. And they're going to tell you what you'll see on cytology or clinical signs or whatever.

And in the real world, those "textbook" cases are the exception rather than the rule. In this specific case, it didn't have all the right diagnostic pieces (like a heinz-body anemia). And it had this 'weak parvo positive'. It did have a VERY strongly regenerative anemia with a marked leukocytosis with no slide agglut, which is a major clue because you should be saying "what causes regenerative anemias in dogs?" Also, the attending was overloaded and just plain slid into "well, it's parvo positive so I'm rolling with that." I know this person, and it's a good doctor. So don't be thinking "*I* wouldn't make that mistake" because the clinical setting can be a real challenge. 🙂

Thanks for the replies, peeps. Y'all really had nice thinking on it. Kudos.

 

[TheGirlWithTheFernTattoo]

Ah dammit. Fell into the no Heinz body trap.

I’ve never seen a zinc case, though I always hear the clinicians talk about them.

 

[TheGirlWithTheFernTattoo]

Was the initial hematochezia from caustic damage to the large intestine?

 

[cdo96]

I love weird ER dumpster fires. Give me all the dumpster fires, please and thank you.

- she says as she finalizes her application for the match to subscribe to at least one year of dumpster fires and then possibly 3 more years of an ECC residency with even more dumpster fires

 

[JaynaAli]

Ah dammit. Fell into the no Heinz body trap.

I’ve never seen a zinc case, though I always hear the clinicians talk about them.

Sometimes Heinz bodies are very subtle too. I had a path review CBC today on a cat where I saw a few HBs on the regular slide but on the New Methylene Blue slide more than 60% of the erythrocytes had them. They just weren’t the beautiful nose-like projections we show in class...they were extremely pale clearings on the perfectly round cells. Not obvious at all, and I look for them all day! (Well, at least the portion of my day I’m doing blood reviews...)

 

[LetItSnow]

Was the initial hematochezia from caustic damage to the large intestine?

Perhaps the severe inflammatory process associated with it impacting the GI tract, but ... *shrug*

@supershorty -- you would have stumbled into it with your "I want my rads" that you started early in the process, but I didn't want to give it to you without an explanation of what you were looking for. You don't get to spend the owner's money on fishing expeditions. 🙂 🙂

 

[Trilt]

I've had a parvo positive puppy have a duodenal perf that we caught several days in and had to surgically repair, and another (older dog, so we're suspicious the parvo was secondary to immune suppression) that required multiple transfusions and still has basically zero platelets and WBCs like two months into pred and mycophenolate. It's really not fun to decide to give a parvo positive dog immunosuppressants!

 

[LetItSnow]

Sometimes Heinz bodies are very subtle too. I had a path review CBC today on a cat where I saw a few HBs on the regular slide but on the New Methylene Blue slide more than 60% of the erythrocytes had them. They just weren’t the beautiful nose-like projections we show in class...they were extremely pale clearings on the perfectly round cells. Not obvious at all, and I look for them all day! (Well, at least the portion of my day I’m doing blood reviews...)

And, there is a world of difference between a clinical pathologist doing a CBC review and what happens on the floor of an ER. I don't care how good the clinician or technician are, on the floor of a busy ER I value my manual diffs but hold them with a degree of skepticism.

We are fortunate to have an in-house pathologist who reviews all smears/CBCs within a day or so. It's a wonderful resource.

 

[supershorty]

@supershorty -- you would have stumbled into it with your "I want my rads" that you started early in the process, but I didn't want to give it to you without an explanation of what you were looking for. You don't get to spend the owner's money on fishing expeditions. 🙂 🙂

My struggle these days is my brain knows it wants something but then is relatively good at talking myself out of it because I go on the whole "you've been out of vet school for a while and all you know is how to amputate mouse hind limbs so you're probz wrong" tangent, so I was seriously doubting my wanting rads for FB. Lesson learned, maybe.

However, if anyone finds themselves in the unenviable position of needing to amputate a mouse limb, HMU.

 

[DVMDream]

Was the initial hematochezia from caustic damage to the large intestine?

Zinc is very irritating to the GI tract, was likely from zinc absorbing out of the pennies and that zinc passing along the GI tract at the pennies remained in the stomach. I'm not sure I'd call it caustic damage we don't expect ulceration or perforation from it usually.

Zinc is often found in diaper cream, while it typically won't cause the anemia of metallic zinc, dogs that ingest it often start vomiting fairly immediately and severely, it is that irritating.

 

[PippyPony]

Ugh, the match. I want what comes way after that; I don't want the short term.

 

[LetItSnow]

Zinc is very irritating to the GI tract, was likely from zinc absorbing out of the pennies and that zinc passing along the GI tract at the pennies remained in the stomach. I'm not sure I'd call it caustic damage we don't expect ulceration or perforation from it usually.

Zinc is often found in diaper cream, while it typically won't cause the anemia of metallic zinc, dogs that ingest it often start vomiting fairly immediately and severely, it is that irritating.

I had to tell DVMDream to not reply to my initial post because I was pretty sure she'd say "go take radiographs" right away. 🙂

 

[JaynaAli]

I was searching for a correct gif to display my feelings of “I think I know but I can’t say” when they started getting close, haha.

 

[DVMDream]

I had to tell DVMDream to not reply to my initial post because I was pretty sure she'd say "go take radiographs" right away. 🙂

It wasn't super obvious from your first post it was a toxin, but wasn't off the list either. I had a short list of metal vs onion/ garlic but followed far behind by rat bait.

When you said cause was found metal jumped up because kind of hard to "find" onion/ garlic that many days into the illness.

 

[LetItSnow]

I was searching for a correct gif to display my feelings of “I think I know but I can’t say” when they started getting close, haha.

Hehe. I forgot that you were here. I didn't want DVMDream to even reply because as soon as you or her would say "I KNOW!" it would point people toward your particular areas of expertise. 🙂

 

[Trilt]

Me, over here:

Maybe that'll be my 2021 vet resolution. I've been spoiled basically sending everything off for years and now I have had to make a truce with the CBC machine...

 

[DVMDream]

Here's a good follow up question. (I mean won't happen with LIS' case as financial concerns and always remember we do the best we can within the owner's means).

How long do you need to follow up this patient for post removal of zinc? How long can the HCT continue to drop for post removal?

 

[LetItSnow]

Maybe that'll be my 2021 vet resolution. I've been spoiled basically sending everything off for years and now I have had to make a truce with the CBC machine...

Techs ask me to come look at a smear nowadays and I'm like "Um... I gotta go check something in ICU.... yeah... just write down what you think... I'll see what the clin path doc thinks..... kkthxbai"

I know a lot of GPs like doing cytology and whatnot. I just never got in the habit and never got good at it. And now there's too little time / too high of a caseload. I'd LIKE to, but ... ugh ... when I'm looking at our ICU and I own 14 of the 20 cases, and there's 10 people waiting in their cars for a call from me, and .... bleh. Just no time, no time, no time. It's all I can do to get a PE done, talk to an owner, throw some orders at some techs, and move on.

I do think it's cool. Some day when this covid caseload settles down I've got a resolution to spend time with a book and microscope and get back the skill.

 

[TheGirlWithTheFernTattoo]

Here's a good follow up question. (I mean won't happen with LIS' case as financial concerns and always remember we do the best we can within the owner's means).

How long do you need to follow up this patient for post removal of zinc? How long can the HCT continue to drop for post removal?

I think that depends on whether you try chelation therapy?

 

[DVMDream]

I think that depends on whether you try chelation therapy?

I don't think it makes a difference but also can't say for certain. I've yet to see chelation used for zinc. I've done it once for an iron case, if I remember correctly.

 

[TheGirlWithTheFernTattoo]

I don't think it makes a difference but also can't say for certain. I've yet to see chelation used for zinc. I've done it once for an iron case, if I remember correctly.

What would you use for a small animal? Our tox prof talked about penicillamine for heavy metal toxicities, but he taught them in a large animal focus so I’m not sure if it would be the same.

 

[DVMDream]

What would you use for a small animal? Our tox prof talked about penicillamine for heavy metal toxicities, but he taught them in a large animal focus so I’m not sure if it would be the same.

Depend on the metal. I'm not looking at the zinc info but I think EDTA, but it isn't benign, if I recall correctly it can cause gastritis too.

 

[DVMDream]

So how long are you monitoring the HCT for?

 

[TheGirlWithTheFernTattoo]

So how long are you monitoring the HCT for?

I can’t find an actual answer anywhere. Half-life of blood zinc is 7.6 days. So I’ll just guess 21 days?
Edit I think that half-life I pulled off VIN is wrong....every other one I’m seeing is a few hours.

 

[DVMDream]

I can’t find an actual answer anywhere. Half-life of blood zinc is 7.6 days. So I’ll just guess 21 days?
Edit I think that half-life I pulled off VIN is wrong....every other one I’m seeing is a few hours.

So after removal of the zinc objects, the HCT can continue to drop for up to 72 hours.

 

[vetmedhead]

*changes phone number* ;-)



It's interesting. In this case, a quick radiograph would have solved it (and eventually did). However, with rad costs of $399 and US costs of $485 (or something like those), there's a general sense of "skip the rads and do ultrasound to get more utility."

Had this been my case, I would have taken the rads on suspicion if I were paying attention, or, even if I missed the right call, I would have taken a placement rad when I placed an NG tube and would have caught the answer at that time.



We have a winner!

Next doctor in line said "huh. this looks like a metal case" and took rads.

Puppy ingested 2 pennies and a nickel. On radiographs, it looked like a battery, but the three coins were scoped out. Puppy was discharged a bit earlier than ideal due to cost constraints, but with an expectation that it will do well.

Nicely done, people!

Point, really, is .... you're gonna talk about cases like this in vet school. And they're going to tell you what you'll see on cytology or clinical signs or whatever.

And in the real world, those "textbook" cases are the exception rather than the rule. In this specific case, it didn't have all the right diagnostic pieces (like a heinz-body anemia). And it had this 'weak parvo positive'. It did have a VERY strongly regenerative anemia with a marked leukocytosis with no slide agglut, which is a major clue because you should be saying "what causes regenerative anemias in dogs?" Also, the attending was overloaded and just plain slid into "well, it's parvo positive so I'm rolling with that." I know this person, and it's a good doctor. So don't be thinking "*I* wouldn't make that mistake" because the clinical setting can be a real challenge. 🙂

Thanks for the replies, peeps. Y'all really had nice thinking on it. Kudos.

My roommate was talking to one of our ECC residents about differentials for hemolytic anemia and forgot Zn/pennies on this list. His hint to her that she was forgetting one was "Pepto bismol", which we all found cryptic as hell lol

Turns out Pepto bismol makes tablets and they're also radio-opaque? So if the owners gave that to their dog for vomiting then it can look kind of like pennies on the rads at a quick glance

Anyway I remember that about Pepto bismol and ER histories now. I've learned so many strange things on clinics

 

[allygator13]

I had to tell DVMDream to not reply to my initial post because I was pretty sure she'd say "go take radiographs" right away. 🙂

What I would've said too, for being an imaging resident and also just any time a puppy starts vomiting I want rads for the possible FB or intussusception haha

 

[PippyPony]

Mini-rant:

I just went to the dunkins near my house, and it is THE WORST dunkins on the face of the earth. They are consistently incapable of making simple orders to the point where I started using the mobile app just to have something to point at. I just went in there, and despite having the receipt in front of their faces, they forgot 1/3 of my order and started making about 6 other ones while they just watched me stand around holding two giant coffees. When I went up to the counter with my receipt, the lady behind the counter leaned over until her face mask fell off and she was breathing INCHES FROM MY FACE with no mask. Then she actually accidentally spit at my face asking what kind of munchkins I wanted.

Looked behind her and the server making sandwiches had her mask down below her nose.

GROSS

 

[LetItSnow]

What I would've said too, for being an imaging resident and also just any time a puppy starts vomiting I want rads for the possible FB or intussusception haha

Yeah, and there are differing opinions on this, but note my comments above about rads vs AUS. Given that the cost of rads is so expensive and AUS is only slightly more .... some people are shifting and a bit less aggressive about rads.

Especially in a patient you suspect to be parvo positive, it is not at all unusual to forego rads for practicing ER/CC clinicians. This is a combination of 1) thinking you know the dx, 2) cost of care (at least for us, a parvo patient is not unusually a $5000-7500 case) making it ideal to limit costs any way you can. Most of us feel confident we can identify an intussusception in a puppy via palpation or FAST. But you're right - it makes missing a FB (radiopaque or not) more likely.

When I diagnose parvo, I still recommend standard 3-view abdominal rads. However, because of costs it is very common for me to end up dropping the rads and then sneaking my abdominal rads in when I place an NG tube (I place them very early in the case - either at admit, or after 12 hours if the puppy is not showing signs of improvement). I know you radiologists hate dog-o-grams, and I understand why and try very hard to avoid it, but when a clinician is backed into a corner ..... I can at least look at the abdomen if I take larger-collimated pics for my placement rad, since the placement rad fee is lower. In theory, the placement rad fee is lower because it's supposed to be a single lateral view from the larynx to the caudal aspect of the stomach; I often just turn it into a 3-view series and do what I want and charge the owner the placement rad fee (which really means that we break even because that fee essentially covers the policy-required radiology interpretation).

This is all KINDA my point with that case - in gold standard medicine, rads would have been taken early on and the problem would have been identified quickly. In the REAL world, you frequently don't get to do that, so you need to be able to use the data you have to make good decisions. In this case, the information was there - right smack in the CBC. You didn't actually need imaging to arrive at a very short differential list.

(But it also brings up a pet peeve of mine about corporate medicine and policies. I think it's absurd that we require a radiologist - absolutely no offense intended - to interpret every placement radiograph. I'm perfectly capable of interpreting a feeding tube placement rad. Making the owner pay $100 for a radiologist to tell me it's in the esophagus and extending to whatever point I want is frustrating given how high costs have risen. But because somewhere once some clinician botched it now there's a policy effecting every owner whose pet gets an NE/NG tube. It's dumb. On the other hand, it protects my license when some DACVR signature says it's appropriately placed and I can play dumb and say "gee, I dunno, the radiologist said it was fine." So *shrug*)

 

[LetItSnow]

Mini-rant:

I just went to the dunkins near my house, and it is THE WORST dunkins on the face of the earth. They are consistently incapable of making simple orders to the point where I started using the mobile app just to have something to point at. I just went in there, and despite having the receipt in front of their faces, they forgot 1/3 of my order and started making about 6 other ones while they just watched me stand around holding two giant coffees. When I went up to the counter with my receipt, the lady behind the counter leaned over until her face mask fell off and she was breathing INCHES FROM MY FACE with no mask. Then she actually accidentally spit at my face asking what kind of munchkins I wanted.

Looked behind her and the server making sandwiches had her mask down below her nose.

GROSS

One of my kids goes to a charter school that kinda sits in a business area with nothing around it. A year or two ago, Dunkin plopped down a store literally in the parking lot of the school.

So evil. So good.

But your experience.... ick.

 

[PippyPony]

One of my kids goes to a charter school that kinda sits in a business area with nothing around it. A year or two ago, Dunkin plopped down a store literally in the parking lot of the school.

So evil. So good.

But your experience.... ick.

The dunks over by the vet school is awesome, so at least I have that one to sustain me most days of the week.

The beyond sausage sandwiches are really good -- I'm not a vegetarian but I still eat way too many of them. Highly recommend. (As long as the servers are wearing face masks.)

 

[LetItSnow]

My roommate was talking to one of our ECC residents about differentials for hemolytic anemia and forgot Zn/pennies on this list. His hint to her that she was forgetting one was "Pepto bismol", which we all found cryptic as hell lol

Turns out Pepto bismol makes tablets and they're also radio-opaque? So if the owners gave that to their dog for vomiting then it can look kind of like pennies on the rads at a quick glance

Anyway I remember that about Pepto bismol and ER histories now. I've learned so many strange things on clinics

That's the tough part about vet school. You learn all about hundreds of those little gotchas ... and it's almost impossible to remember them all. Especially in the pressure of practicing.

A few years ago someone who graduated a year or two ahead of me called me one afternoon. She was working GP at the time and called about transferring a neuro case to me. She's telling me she has this 3-year-old FS Boxer who is having these intermittent episodes of "focal facial seizures" where his head just bobs up and down. She tells me it's really weird - when the owner starts talking to the dog, it stops. It's initial baseline dx testing is all boring. She's wanting to send it for neuro consult.

When you're in vet school, you're sitting up in your seat shouting "IDIOPATHIC HEAD TREMORS! C'MON PEOPLE! ARE YOU DUMB?!"

A few years out in practice? Maybe you remember it. In this case, that clinician is SUPER SMART (trust me on this). Like, her memory for zebras, all their clinical signs, interpreting bloodwork, all that jazz --- she far exceeds my capabilities. But in this one case? She forgot one.

So I muttered "{Name], the dog has idiopathic head tremors. Send it home. Consult with Neuro if things change." End of the case, dog lived happily ever after, I'm sure.

That, unfortunately, is the real world. 🙂

And yes, pepto bismol tablets are radiopaque. You'll see one once every few years and be like "what the heck??" until the owner cops to having given it right before coming in.

 

[LetItSnow]

The dunks over by the vet school is awesome, so at least I have that one to sustain me most days of the week.

The beyond sausage sandwiches are really good -- I'm not a vegetarian but I still eat way too many of them. Highly recommend. (As long as the servers are wearing face masks.)

So it actually tastes like reasonable sausage? I've been afraid to try.

 

[PippyPony]

So it actually tastes like reasonable sausage? I've been afraid to try.

I think so, but I also eat weird foods