Which test should you do first?

Sometimes that seems obvious.  If a patient is having blood in the urine, you ought to examine a urine specimen.  So the folks bring their baby in, and she takes a little walk outside with our top urine-catching technician, and back they come with a dandy sample.  She’s emptied her bladder and you’ve got a great specimen to analyze.  Whoops! The analysis shows rafts of weird cells along with the blood cells when you look under the microscope.  We need to perform an ultrasound scan of the bladder, and for that, we need the bladder to be full…you know, the bladder we just emptied.  Nuts.  This happened yesterday, and we wound up keeping the dog overnight and performing the ultrasound this morning.  The scan confirmed my suspicion of a tumor in the urinary bladder.  Fortunately, we were able to remove it surgically with no trouble (though pathology results may very well send us to chemotherapy follow-ups).

Last month, a huge Rottweiler comes in with complaints of occasional blood in the stool.  He looks great and seems to feel great otherwise.  Stool exam shows nothing out of the ordinary.  The owner says she can’t afford a lot, so we start with a broad-spectrum de-worming (Panacur/fenbendazole), and a course of metronidazole (an antibiotic that has an anti-inflammatory effect on the colon wall, while killing bacteria that thrive without oxygen, as well as killing many giardia, the one-celled intestinal parasites).

That didn’t work.  We’ve got persistent (if intermittent) blood in the stool.  We need to do a colonoscopy. We love that, especially the multiple enemas needed to clean him out first.  Oh, well, at least he’s so big that it will be hard to deal with the size of the mess.  Wait… that’s not a positive.  Anyway, we get it scheduled.

He comes in today, and we find that he no longer feels great.  He hasn’t eaten for the last two days.  He still looks great, though he’s lost a couple of pounds (from his big 120 fighting weight).  We give him a couple of enemas, then take an X-ray to see if he’s empty.  He’s empty, and we don’t see much remarkable.  Next step, light anesthesia for the colonoscopy.  Hey, I think I’ll just take a quick peek around his abdomen with the ultrasound before we send the scope up the back way. 

So we have him asleep, on his back, and I smear some gel on his tummy.  Well, now, I’ve tried to examine his abdomen on previous visits, but this is the first time he’s really been relaxed enough for me to get a good touchy-feely on his tummy. I feel something big and hard and not-supposed-to-be-there.  You can’t really see it on the X-ray, so it must be about the same density as normal tissues. No colonoscopy for you, pal.  It’s time for exploratory surgery.  Jeez, if I’d only anesthetized him to feel his abdomen on the first visit I could have skipped all these other tests.

Have you ever heard that silly question, "Why is it when you’re looking for something, it’s always in the last place you look?"  What we’d like is for the first place we look to also be the last place you look (when you find it, naturally, you stop looking).  The bottom-line take-home message here is that the only way for me to know which test to run first would be for me to already know what the problem is.  Of course, then I wouldn’t need to run the tests.

It takes us back to how much testing is enough?  You can’t have irony-poor blood in this profession.

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