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Second Opinions…and you didn’t think of this…WHY???

Ever realize your mental field of vision has some blind spots? Like you don’t think of the MOST obvious things, just because the circumstances were outside the routine parameters?

Like, for example, one of my Standard Operating Practices. To wit:

Whenever a doctor utters some pronouncement, always get a second opinion.

During the late, great boob adventures, I learned that one in spades: always, ALWAYS get a second opinion.

Seems like common sense, doesn’t it? You could even say it seems, yes, “obvious.”

Well. Then howcum it’s not obvious to get a second opinion when the person uttering the pronouncement is not a medical doctor but a veterinarian?

Even when that veterinarian is a very smart vet, a very excellent vet, indeed quite possibly the best vet in the Valley? His opinion is highly informed. Highly smart. Very likely right. But still…we are lookin’ at one man’s opinion here. One man’s highly lucrative opinion…

Comes the crack of today’s dawn, Cassie is really not well. Although her cough is gone, she’s visibly very sick. This pining away began slowly in the days after I began administering the Valley fever drug fluconazole, and as of today, she has developed a limp. She’s still eating, but not with normal corgi enthusiasm. She has become intermittently incontinent: if not taken outside often, she may urinate, apparently involuntarily. Yesterday, when I came home after a 3-hour absence, I found her sitting at the door in a lake of urine.

But the cough is gone.

But…the cough was gone before we started her on this stuff…

What if the drug itself is what’s making her sick now?

The reason she’s on the drug, even though the Valley fever test came back negative, is that MarvelVet doesn’t believe the test. He says (correctly) that the test often produces false negatives. Looking at other elements of the test results — neutrophil, monocyte, and albumin levels — he deduced enough probability that she might have Valley fever to justify putting her on fluconazole.

Hm. Izzat so?

With this nagging thought in mind, I called my son’s vet and got an appointment tomorrow. Then trotted over to MarvelVet’s office to pick up the new bottle of pills he’d ordered up…and, while there, asked for a copy of the test results. These, I intend to offer to the Second Opinion Guy, along with a raft of questions…

Why might a lowly editor in mathematical biosciences question the diagnosis of a graduate of a fancy university veterinary program? Well…

  1. Neutrophil and monocyte levels can be elevated (as Cassie’s are) by any infection. She had a severe cough for a couple of weeks, which could have resulted in these elevated readings.
  2. The albumin level was low but not outside the reference range. Here, too, any infection can affect albumin level, as can liver damage. Fluconazole elevates liver enzyme levels, often an indicator of a liver damage. Also, at 12 years of age, this dog is elderly; “normal” values shift in older animals.
  3. No symptoms of disease were ever evident before this episode. The dog shows normal signs of aging – slowing down a bit, a little grizzled around the muzzle – but has been active, playful, alert, and always ready to eat, until the current coughing spell occurred. The coughing could be caused by Valley fever, but it also could be caused by a severe respiratory infection. So, I suspect, could the elevated neutrophil and monocyte levels.
  4. A contagious bronchitis has been going around the Valley, to the extent that on first hearing about the cough. Dr. B assumed that was the issue. In a daily mile-long walk, Cassie sniffs a lot of dog pee and often greets other peoples’ dogs, and so it is reasonable to believe she was exposed to a contagious disease.
  5. The incontinence and lethargy are classic signs of fluconazole side effects. She experienced neither before exposure to the drug. I’m concerned about keeping the dog on a drug with many unpleasant and dangerous side effects for 6 to 12 months, especially since there appears to be a possibility that the problem is a bronchial infection, not Valley fever.
  6. Where humans are concerned (not dogs), the Mayo Clinic states the first line of treatment is rest, even in the event of severe symptoms:

Rest
Most people with acute valley fever don’t require treatment. Even when symptoms are severe, the best therapy for otherwise healthy adults is often bed rest and fluids — the same approach used for colds and the flu. Still, doctors carefully monitor people with valley fever.

The dog improved notably when I started tricking her to ingest more water. She cannot drink well because, like many corgis, she chokes when she tries to drink. However, when a small amount of kibble is floated in water, she manages to take in the whole bowl of 1/4 to 1/2 cup water without gagging. When she drinks more water, she seems to feel better. As long as she’s not sinking below the waves in a lake of pee…

So the questions to address with a) Second-Opinion Vet and then, depending on what S-OV has to say, with b) First-Opinion Vet are all what-ifs…

What if…the coughing really was caused by the bronchitis that F-OV originally diagnosed? What if…the reason the cough persisted so long was simply that she’s 12 years old: a very aged dog. By one account,that would make her between 69 and 74 years old, in human years. And that assumes that she really is 12 years old. She could be significantly older…remember, I got her at the Humane Society. Ever watched dog rescue folks at work? They have only the vaguest clue. When asked what a dog’s age is, they come up with a number based on such things as the condition of the dog’s teeth and its overall appearance. Typically they’ll say “two” because people think that’s the age at which a dog is house-trained and stops eating the furniture. If she’s just one year older than that, then she’s in the range of 74 to 78 human years. Two years older, and we’re lookin’ at the equivalent of a human in her late 70s or early 80s.  Which, we might add, is exactly how this dog is acting.

So what if she actually had a severe case of bronchitis and took longer than a week to throw it off, a) because it was a bad bout of it and b) because she’s an old lady and old ladies don’t get over sh!t very fast. If that were the case, it would explain the high neutrophil and monocyte levels and the low albumin level.

And given that we can’t really know, one way or another, if that’s true in the face of the unreliability of the Valley fever titre test, what if the Mayo Clinic is right? What if the best first-line approach is to leave her alone? Would she be harmed by taking her off the side-effect plagued drug and watching to see what happens?

Do we really want to put a dog that’s at the end of her natural life span on a drug with many unpleasant and dangerous side effects for 6 to 12 months? That is, for longer than, under the best of conditions, the dog is likely to live?

Seriously?

 

 

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