Blinders

In my training, the most frustrating part of my ability to practice medicine is the rampant opportunities to put on blinders, and my too frequent decision to put them on. Blinders are points in the medical exam where I can make a decision to rule in or rule out a possible diagnosis, always prematurely.

Sometimes blinders are handed to me right at the get go, with a presenting complaint oddly specific or extremely vague. It can be very challenging to ignore that a client brings their dog in for constipation, when he actually hasn't even been trying to defecate. Of the cat that won't eat dinner but did eat breakfast.

Other blinders occur when a physical exam finding pops up, which makes you shut down a line of reasoning prematurely. If a dog comes in for diarrhea, and you find loose feces on rectal exam, don't stop looking at the urinary tract to rule out cystitis or bladder stones which can lead to straining, and sometimes lead to secondary diarrhea.

Diagnostic tests can make you stop in your tracts. Elevated total biliruben may indicate gall bladder disease as an underlying cause of not eating in a cat, but don't discount that it may indicate hepatic lipidosis (fatty liver disease) which is secondary to anorexia.

That niggling voice in the back of your head is not a reason to see slightly abnormal electrolytes and diagnose Addison's Disease in the young male dog obtained from a shelter 4 months ago.

And for the love of god, if your patient has pigmented urine and mild anemia, always keep IMHA on your differential list - do not go down a wild goose chase of urinary infection or bladder stones leading to hematuria as the cause of the anemia.

In every case listed above, I have put on blinders, and missed the diagnosis initially. The constipated dog had a T3-L3 myelopathy. The anorexic cat had a pyothorax. The diarrhea dog was a female dog obstructed by bladder stones. The cat with the high total biliruben had pancreatitis which was leading to partial obstruction of the bile duct as well as early hepatic lipidosis. The young dog had intestinal parasites which were not diagnosed until they were passed after empiric deworming. And I have missed IMHA with the provided description more times than I want to admit.

Every animal was properly diagnosed because I have good colleagues, because I went back and performed the physical exam again, because I asked a question I hadn't planned on asking, and because I am at a teaching facility where we bounce our cases off each other and mine each others' brain for insights which we can't see. I have many opportunities to put on blinders where I chose to leave them where they lay, and those choices are increasing with each month of training. Thank goodness.