Three common presentations encountered in Small Animal clinical practice
So you might be wondering what you will actually encounter when you come over to the UK and start working in clinical practice. Is it the same? Will you find something different? And how will you deal with it? Well, actually for most of it, the problems you find in clinical practice will tend to be quite similar. Here are three common complaints that I saw on my very first general practice job:
1. “My dog/cat has sore ears”
Yeah, bingo! It’s probably no surprise to you that most of the problems seen in clinical practice are actually skin problems, and in my particular case, ear problems. It would be really rare for me to go by a week without seeing one single case of otitis. Which is usually why these animals present.
Now, in cats, otitis was often secondary to parasites (ear mites) especially in kittens. In dogs, however, we would usually be able to diagnose an infection, whether bacteria or yeasts were the cause. Problem – was it primary or secondary? This is where examining the rest of the patient and looking at the records is important. A large percentage of these dogs were actually suspected to have underlying allergies or atopy – they either did this recurrently and seasonally, or they had other skin problems. Most owners didn’t want to spend money on diagnosis. Telling them they have to deal with this problem but likely have recurrences is not what most want to hear, but it’s really important they understand it and are able to follow through. Managing client expectations with this problem is really important. Here are some tips to deal with otitis:
- Always take ear swabs (unless you are strongly advised against it by practice protocol): it takes you 5 minutes to look at when you have experience and you definitely want to see what’s inside that ear(s) so you can gauge how effective your treatment was at dealing with the bugs
- Try to look inside with the otoscope – you want to try to search for foreign bodies (yes, dogs are dogs…) and examine the tympanic membrane because you want to make sure it’s intact if you are going to put drops in. However, in many cases you might need to end up sedating them for this, especially if they are painful (or aggressive *cough*)
- When it comes to applying ears drops, make sure you SHOW the owners how to administer them in consult (if you don’t want to apply the medicated drops, demonstrate with the ear cleaner). Otherwise the drops are gonna go everywhere but inside the ear canal. It’s also useful to show them a diagram with the “L” shape of the ear canal while you explain that if they don’t rub the drops in, the medication is not going to reach all the way down
2. “My dog is scratching/my cat is pulling the hair off”
Ta-da, another skin problem! Very common in dogs to present for “scratching” and “being itchy”. Cats tend to present for biting the fur or going bald. In both cases we are potentially looking at pruritus as a cause for those behaviours. Again, look at history and clinical presentation. And don’t forget to comb these patients! Why? Main causes for skin “itchiness” are parasites (fleas!!! But you can also find mites and Demodex and even lice! True story!). Cats in particular are very good at having fleas and you might still have the owners in disbelief until they see the fleas jumping from the white paper you’ve just combed the hair to. To make matters worse, cats might also have flea allergy dermatitis which tends to be a bit worse in the lumbar area. And it can be really hard to convince the owners to manage it – sure, you will absolutely be able to get a spot-on there and then, the problem is when they go back home and “forget” to put the spot-on 4 weeks later. So, when it comes to fleas, make sure you have a good conversation with the owners. Here are other tips to discuss with the owners regarding flea control:
- Use products that are proven to work and have longer persistence (such as 3 months, rather than just 4 weeks if you are concerned about compliance), or long-acting collars (but you should apply them or make sure the owners know that a loose collar is useless…)
- To improve compliance, suggest that the application of the product can be done at the practice free of charge (if this is the case, of course)
- Discuss treating the environment and all other animals. There are several sprays available to control flea infestations in the house, but make sure the owners understand that all animals in the household have to be treated to break the cycle!
However, parasites are not the only reason why you see “itchy skin”. Depending on the breeds you see, a high percentage of these problems might be related to atopy and allergies (hello, Westies?). These animals will normally have a wax and waning story and you may not have any skin lesions if you don’t have a secondary infection. Pay very close attention to gastro-intestinal signs and the ears! Animals with food allergies might also have signs such as intermittent vomiting and diarrhoea. Atopy will usually present in the ears or areas with less hair (inguinal area, axillary area, ventrum), but the face is usually spared. If you have lesions in the face too, you probably have other things going on, such as a food intolerance too. Although most owners will want a quick fix, others might be very inclined to dig deeper. Allergy testing and immunotherapy are widely available and many owners will be happy to do so, especially if they are insured. Don’t forget though that sometimes convincing the owner to swap to a prescription hypoallergenic diet can be enough to see amazing differences!
And, of course, not all itchy skin is due to allergies or parasites (or secondary infections to them), but I would say a loooooot of them are!
3. Vomiting and diarrhoea
Bleh… yep this is very common, both in dogs and cats. Sometimes you only have one problem, other times you have both. Sometimes your patient is jumping around you while you try to perform the examination, other times your patient will present collapsed. Although it’s a common presentation, it’s also extremely variable, both in cause and treatment. So, make sure you look at the patient, do a thorough examination (don’t forget abdominal palpation!) and plan accordingly. Don’t forget that vomiting and diarrhoea might not be associated with primary GI disease – renal failure also results in vomiting. Here are some other situations:
- We don’t know why there was vomiting/diarrhoea and we never found out!
- Foreign bodies (with complete obstruction there are no faeces)
- Ingestion of foreign material (causing GI upset but no obstruction)
- Renal disease
- Diabetic ketoacidosis
- GI parasites
- Food intolerance
- Suspected IBD
And that’s just a quick overview… common presentation, lots of differentials to consider!
So if you are trying to start somewhere when it comes to studying (or even working!), these are three good areas to dig deeper!
What else do you see where you are?