Saturday, August 30, 2008


i am such a night person. i have switched to days and ack! i just don't like getting up at 7am. i never will. it's always going to be anathema to me. daytime work is so different. i shadow and work with 2 internal medicine specialists. one of them is a professor/clinician from my alma mater - which is great. i love her dearly. the other internist is also fantabulous, albeit very soft-spoken. sometimes i feel like i need a hearing aid to figure out what the heck he's saying - but otherwise, he's great. very good at what he does.

days are a bit on the dull side. my job is to 1) follow around the internist and learn about case management and 2) manage patients that presented to the ER service the previous night and need to say in the hospital. those 2 things in and of themselves are not dull...but...the days have been slow. the only patient i've had to manage on today and yesterday is a post-op gastric dilatation and volvulus (stomach bloat and rotation = cut off blood supply. another day, another post).

oh - i had a true lepto case. i mentioned back a couple of posts my renal failure dog - the only bright spot in a bad 2 days. when he came in, he was very very sick and his kidney values were crappy (acute renal failure). he also had elevated liver enzymes. at the time, i highly suspected lepto. leptospirosis is a bacteria that is water-borne (ponds, rivers, creeks, the like). it's hard to diagnose for a variety of reasons. you can't test for antibodies very well because most dogs in the southeast have been exposed and have antibodies. a good analogy: if you were to be tested for antibodies to chicken pox right now, you would probably have them. but you don't have chicken pox at the moment. it's indication of prior infection or exposure. further, vaccines cause production of antibodies - and around here, we routinely vaccinate for lepto. one way to get around this is to do paired titers. take a sample now. if you get a high value - great. but that's not necessarily diagnostic. you treat the dog, and then you test again in about 2 weeks. if that number is dropping - then you probably had true infection before. there are other tests for lepto - PCR (polymerase chain reaction) and the like. all fraught with their own errors and problems.

so what do we do? we combine our clinical suspicion (acute renal failure, very sick outdoor dog, very high positive antibody test to lepto) and make a diagnosis. treatment is antibiotics, so even if we don't know for sure that lepto is the cause of a dog's acute renal failure, we always start lepto antibiotic therapy.

every dog that is admitted to the hospital with acute renal failure is put on "lepto watch". lepto is contagious to people (zoonotic) through urine contamination. thus, you have to be very careful with workers if you have even the slightest suspicion that lepto may be the inciting cause of kidney failure.

when i saw this dog - incredibly sick, incredibly dehydrated, in renal failure with elevated liver values, i immediately suspected him to be a true lepto.

i received my antibody tests back yesterday - and he had VERY high titers to a specific strain (serovar) of lepto. he actually had lepto. i had a real lepto dog! i had a moment of clinical genius and warned my coworkers when he was admitted that i thought he was a true lepto, not a "fake" lepto. it was a nice validation. i have developed some clinical judgement. finally:)

it makes up for the 150 ways every HOUR of the day i feel dumb and ill-prepared to be a doctor and like i will never, ever be good enough!

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