My car smells like the necropsy floor, and other smart things I did this week.

Once in a while, I’m stumped by a case. (Shocking!)
True story. It may also surprise you that I ask for help when lost (in medicine, not directions, c’mon get serious) and had the great pleasure of working with a very bright colleague for the last 2 years. Let’s call him CPT K.
(see what I did there?)

Often we would bounce cases off each other and discuss diagnosis and treatment plans and basically get better at the practice of medicine. One of the banes of my existence, along with ophthalmology and tact, is my ability to interpret radiographs, or as my non-vet peeps say X-rays. 
CPT K & I conferred regularly over rads and shared our thoughts about what the squiggles and shades of grey meant. (Anyone thinking about that quasi porn-for-women book can please, show yourself out)

Since CPT K left, I’ve been bereft of a second set of eyes on X-rays, and have had to make do. Haven’t killed anything, well, nothing dies in radiology anyway, but what I’ve had to look at has been straightforward. 

I had a situation arise where I wanted another vet to look at some rads....I had the great/awful idea to crowd source reading the rads to my Facebook friends. 

I was ‘emotionally compromised’ in this case as it is my dog, the lovely retired working dog Nouska. 

She’s retired for a reason.  More on that in a second. Since many friends know something about Nouska I decided to give minimal information with the pictures. To be truly scientific, I should have given no information. Just look at these---what seems abnormal??




But I kept it uber basic. And luckily several friends responded. And some of those responses left me scratching my hairless head. But I digress, here is the full rundown of this patient, for the six of you still following the story. 

Nouska is a 6 or 7-ish yo FS Belgian Malinois, former EDD for the Navy. She was retired in April 2013 for the following laundry list of badness: 

1. Marked bilateral hindlimb ataxia/CP deficits/LS pain.
2. Radiographic changes (CT as read by boarded radiologist)
1. Severe diffuse thoracolumbar and lumbrosacral spine degenerative changes with foraminal narrowing at L6-7 and L7-S1. Compressive radiculopathy secondary to osseous changes at L6-7 (L6 nerve root) an the left and L7-S1 (L7 nerve root) bilaterally.
2. Articular facet OA/DJD, most severe at L3-4, L5-6, & L6-7
3. Bilateral sacroiliac joint enthesopathy and OA/DJD
4. Ligament dystrophic mineralization or IVD disc degeneration at T10-11 and L6-7 without evidence of IVD protrusion

For the lay person, a LOT of arthritis in the back, and ‘pinched’ nerve roots, causing pain and a lack of function in the muscles that control how the legs move. 

Her retirement has been mostly without incident. She is on a buffet of drugs (below) and she has been active and happy. A couple of months ago, I noticed a quarter-sized (3cm²) firm, raised mass on her chest. She was due for a dental cleaning, so while she was under for her teeth, I removed the mass and sent it off for Pathology. It was read as a Grade 2 MCT-low grade. So it could spread, but not likely. Local recurrence was possible, but my margins were clean. 

So far so good, but in early August, she started to lose energy rapidly on walks. We walk at a very moderate pace due to hills and humidity here. Jethro sprints everywhere, but since I believe Nouska to be closer to 8 or 9 years old than 6 and her back end is mush, we take it easy. Still, she was quitting and lying down more and more on walks. And it wasn’t behavioral. Her respiration rate was elevated, but HR and Temp were normal. 

She progressed rapidly from lying down once every few walks, to once per walk, to several breaks per walk over the course of 3 weeks. Being Dad, I’m thinking the worst; Being a logical Vet, I scheduled her for full workup. 

Did she have tumors in her lungs? Maybe in her liver, affecting her diaphragm? Had her back gotten so much worse over a few months? Were we playing too hard? 
So many questions...so we loaded up in my new-to-me car that doesn’t have a name yet, and drove up to Andersen AFB. (my clinic doesn’t have X-ray processing at the moment.) 
We did a 3-view chest series to look for tumors, 2 abdominal views for the same reason, and 2 lower spine views to see how her osteo-arthritis was progressing.

I did my survey of the pictures, but had a few question marks...I knew so much about the dog, the case, her problems, I started seeing things that weren’t there, or I saw things I expected given the history. I couldn’t look at the X-rays without my pre-conceived notions getting in the way of objectivity. Hence the crowd source idea. 

If you are reading this, you got here from my Facebook, so you can go look at the rads if you haven’t seen them. I will list her current medications:

• Rimadyl
• Tramadol
• Gabapentin
• Adequan (when available; last series in May)
• Dasuquin
• Omeprazole

Pending Lab Work from Antech: CBC/Chem/Lytes/ Baseline cortisol

And here are the responses I received from FB friends:

• Heart worms? (not a vet BTW)
• Its not a Diaphragmatic hernia? breathing difficulty, exercise intolerance, later Vomiting...???(also, not a vet)
• Splenic mass?
• I'm underwhelmed.
• EKG? PCV? BP? I think it may just be artifact but that left lung field catches my eye on the VD.
• It appears to me that the intestines are being pushed ventrally by a possible mass-
• Maybe lung lobe torsion-
• I vote heartworm also...
• Is it an MWD? SHOULDN"T be heartworm. But that's my guess
• And I'm assuming you mean besides all the SD in her spine, and the massive amount of peri-renal fat.
• Holy painful back! Poor girl 
• My two cents: worth an abdominal explore! Funky gas pattern, either ridiculously excellent contrast with abdominal fat or a possible pneumoperitoneum. I can't follow the colon all the way around, and gas that looks like cecum is on the wrong side. Spleen looks a little big, liver looks a little small. Some sort of obstruction/torsion/perforation. Exercise intolerance and tachypnea because of abdominal pain. I'm going to hit 'enter', then spend the next several hours second guessing myself and wondering if I passed my radiology exam.
• I agree the gas pattern around the pylorus seems funky but that could be because of the pexy. Heart size...eh. Do a VHS and then decide if its worth running down. An ECG is quick, plus since you're likely going to do a abdo US you could do a quick echo. How are lung/heart sounds? Dog could always have a painful lesion associated with the spine causing ex intol and tachypnea, you know with the spine radiographic signs don't always correlate with clinical signs. 

So here’s my two cents..a non-vet, and several veterinarians, went with heartworm disease, and I think it’s because of the brief history I gave. (7yo FS Belgian Malinois, hx of exercise intolerance & tachypnea). Description bias?  I was so happy to have the oncologist call the rads boring. Best news today.

My questions for y'all:

1. What are you seeing that makes you say HW dz? 
2. Same question re: splenic mass and lung lobe torsion?

I am by no means calling anybody out. This is a learning thing for me. 
NB: This dog has been gastropexied, as many working dogs have. Therefore cranial abdominal organs aren’t in the ‘normal’ locations so much. Liver is kept tucked up in the right crura by the tacked stomach, and the spleen has more space to play with on the left side.

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Lastly, I did a smart/stupid thing this week. As I have reported, there is a LARGE feral dog population here, commonly referred to as boonie dogs. Driving to work last week I noted a dead dog on the side of the road, HBC no doubt. A largish black dog with a white belly, no obvious wounds on my first view, but very clearly dead. I didn’t give it a lot of thought, except to notice that the dog was still almost in the road, with its head sitting on the lane line. Sure enough, next time I drove by, the head had moved due to high energy impact from a vehicle. Plus it’s Guam, so hello 90 degrees with 90% humidity. By the afternoon of day 2, I decide I’m getting the damn dog out of the road. Really don’t need to see him turning to burger little by slowly while commuting. So I pull over, hit the flashers, grab two poop bags for gloves, and prepare to drag said dog 2 feet away to the jungle edge. He’s good and bloated by this point, and foul smelling. But I expected this. I grabbed a back leg with each hand and pulled him into the tall grass, taking a quick look at his destroyed face. Said a quick prayer and was getting up to leave when I saw the red nylon collar in the grass a foot away. 

Fuck. 
Picked up collar and of course, no tags on it all. Worn, but not terribly old. This dog was owned in the recent past. Maybe up to last week. Everyone lets their dogs run loose here. So frustrated at bad owners, sad for a family that may have actually cared that the dog went missing, and a bit sick from the smell in my nose, I walked back to the car. I took the baggies off my hands and threw them on the floor of the rear seat and drove home. 
Distracted. Mad. Sad. Gross smelling. 
No wonder I forgot to throw the baggies out when I got home. My car was pretty ripe the next day I tell you what.