Thursday, 25 July 2013

The Easy Diagnosis

It's been a week of textbook bashing. Where is this oedema coming from? Why is he insulin resistant? Is the GGT value significant? The kind of cases that make me tear what little hair I have remaining out, and pray to Hippocrates for a nice, simple diagnosis.

I've forgotten a fundamental truth about the easy diagnosis, though.

*

'... just not been quite right for few weeks. I know it's probably the hot weather, but we thought it would be best to check.'

I'm nodding sagely as I reach into the box, and even as I'm lifting the cat out I've got alarm bells ringing; under it's long hair, it feels like a skeleton wrapped in a thin blanket. I place it on the table to see that it's lost weight everywhere - everywhere, that is, except for it's abdomen, which is incongruously swollen.

'We thought he might have lost a bit of weight?' the old lady adds. Her husband nods helpfully and smiles.

'We just wanted him checked,' he says, adding with a chuckle, 'don't know what we'd do without you, littlun.' He reaches across and tickles the cat's chin, who starts purring. I smile up at the old couple then look back down at the cat, my hands reaching down to palpate it's abdomen. It doesn't take much squeezing before I feel the large, knobbly mass just behind its liver. We're seconds into the consultation and already I have a fair idea about what is going on. There is, of course, a chance that the mass I'm feeling is nothing to do with my patient's weight loss and inappetence, but that's not too likely.

'We thought that maybe he needed worming?' the old lady says, while the cat contentedly rubs his face into the old man's hand.

Whatever happens from here, the cat is going to need blood samples, x-rays, scans, possibly exploratory surgery, and there is a fair chance that whatever we do it's not going to make it. There are going to be difficult decisions about whether it's fair to put him through any of that at all, and their are going to be tears in the night, far from my surgery, over a companion who probably isn't going to journey along with his owners for much longer. All this I know within the first sixty seconds of my consultation.

It's hard to just blurt out that I'm pretty certain that we're dealing with cancer before the old couple have realised I've started examining at all, so I continue my checks. The rest of my clinical exam ticks more worrying boxes; mild jaundice, a low-grade heat murmur, pale mucous membranes. I return my hands to the abdomen, not really because I need to feel the lump again, but because I need to owner's to see that I'm starting to get concerned. I grow quiet, my usual smiles and nods tailing off, as I feel. If I was consulting with anyone else at the moment, I would say to the couple that I just want to 'take him out the back for a moment and ask my colleague for another opinion, because I'm just wondering if I might be able to feel something unusual here'. I don't really need the second opinion - the tumour isn't subtle - but it gives the enormity of what I'm about to tell the clients a little preparation. As it happens, this afternoon I'm consulting on my own. I briefly consider saying the same and taking the cat into the prep room for a moment anyway, but it feels too much like deception. Instead, I weigh the cat, and allow a concerned look to creep across my face. I return to the abdomen, and palpate the tumour while the cat purrs for a good thirty seconds; enough time for husband and wife to grow silent, and look at each other nervously. I take my hands off the swollen belly, and open my mouth to speak...

*

'You tell him, Emma, he's yours, after all!'

The young girl - maybe eight? I'm never good with child's ages - lifts the wriggling white rabbit from the box, and drops him onto the table. I swiftly grab him to stop him from bouncing straight back into his box, or, even worse, several feet onto the floor.

'What... er...,' I say, trying not to show how hard I'm having to grip the rabbit, 'what can we do for Dillon today?'

The little girl goes silent, and looks shyly at her mum. The young woman rolls her eyes, grinning. 'Okay, okay, but next time you say!' The girl nods, and the young woman looks at me. 'He's fine in himself,' she says, 'but Emma found a little lump around his mouth. I thought it might be a cyst.'

While she's speaking, my hands have found the little lump. It's about eight millimetres in diameter, attached to the bone of the jaw, firm, tense and unwelcome as hell. I look at it, seeing the skin stretched taut over it, so thin as to appear transparent. The parts of it that aren't bony are filled with what appears to be a thick, white fluid. It's not a cyst. It's not a tumour. It's an abscess. It's going to mean a long, protracted course of treatment and probably multiple surgeries and if we're very, very lucky, it might just not kill Dillon. It probably will, though.

The young girl finds her voice. 'We think it's a cyst,' she says, then turns back to her mum.

*

'She's just been a little lame the last few weeks. I thought it was probably the hot weather, it's been hard for her, of course, at her age.'

The greyhound stands at the edge of the consulting room, looking at the door. You might think she was aloof, but I've owned greyhounds, and I know they're just nervous with new people sometimes. It's partly why I like them; they're just like me.

'I was told you know a little about greyhounds, so I wanted to come and see you,' the woman says. 'I was thinking it might be time to start on some arthritis treatment, maybe? She's already on glucoasmine, of course.'

Of course. Everyone is nowadays. I smile, and start to feel down the left fore leg. It's not far before I feel the swelling in the bone.

'I had wondered about cod liver oil too,' the woman continues, 'but I thought... oh!'

I've squeezed the lump in the bone, gently, and the greyhound has yelped and turned to her owner. Painful on palpation. Ten year old greyhound. It'll take an x-ray to confirm it, but I'm already almost certain that I'm dealing with an osteosarcoma - a bone tumour. There's something like a sixty percent chance that it's already spread to the rest of the body, but even if it hasn't, we're talking amputation plus chemotherapy, with a very low survival rate. If we don't do anything, the tumour will erode through the bone until, one day soon, it will just snap - a pathological fracture.

Standing in the consult room, I remember the sunny day when I felt that same lump in the humerus of my own dog. I remember standing by the x-ray developer with Kerry next to me, both of us hoping against hope. I remember the very next day, Kerry looking at me with tear-filled eyes, cradling her head in her lap while our colleague finished injecting, whispering the words unbelievingly, 'Beattie's dead.'
I look up at the woman, and wonder if she will the remember the words I am about to say for the rest of her life too. I take a deep breath...

*

Here's the truth. Sometimes the easiest diagnosis is the hardest one to make.

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