Contextualised/Pragmatic care case example - what would you do?

RE: Contextualised/Pragmatic care case example - what would you do?

janine redman — Mon, 20 May 2024 08:58:52 GMT

Sorry I interpreted the mass as in perianal region pressing on caudal rectum .
perhaps they didnt return because some improvement?

RE: Contextualised/Pragmatic care case example - what would you do?

Anthony Dennison — Mon, 20 May 2024 08:53:56 GMT

[quote userid="12930" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244630#244630"]Description of compressivng rectum at 9-12 o'clock: I'm unclear if this is same mass as palpable in caudal abdo, or separate mass and I'm a bit unclear on how far in it is, and whether it is the 9 o'clock to 12 o'clock portion of the mass compressing the rectum (and indeed whether this is definitely the rectum or the colon - how long are Anthony's fingers - I don't know but I'm guessing quite long) ie ventral to the colon like a prostate, or is it clearly dorsal to the prostate and compressing the 9-12 o'clock portion of the rectum[/quote]

Hi Beats,

It was definitely the same mass I could feel externally, and the compression was the full final quarter of the clock at the level I would normally palpate the prostate. It could have been a massive prostatic abscess/cyst on that side.

[quote userid="9440" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244621#244621"] I would suspect a perianal adenocarcinoma with lymph node metastasis [/quote]

No perianal masses on clinical examination.

[quote userid="5012" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244629#244629"]

Increased resp rate, slightly increased resp sounds bilaterally, and extremely pyrexic with a t40.8c.

Not unreasonable to think infection is on the list of ddx's here, and to prescibe a first line of use antibiotic.

[/quote]

I agree, which is why I chose it. What else should I do, do a swab/FNAB the owner can't afford and leave the dog suffering?

RE: Contextualised/Pragmatic care case example - what would you do?

Beats — Sun, 19 May 2024 16:55:17 GMT

[quote userid="29221" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244625#244625"]Whatever is going on, there is no indication for antibiotic treatment here.[/quote]

Temperature of 40.8'C in a 12 year old entire male dog and a description of a painful caudal abdominal mass and no description of what the prostate feels like. No urine sample and no use of ultraosund.

Description of compressivng rectum at 9-12 o'clock: I'm unclear if this is same mass as palpable in caudal abdo, or separate mass and I'm a bit unclear on how far in it is, and whether it is the 9 o'clock to 12 o'clock portion of the mass compressing the rectum (and indeed whether this is definitely the rectum or the colon - how long are Anthony's fingers - I don't know but I'm guessing quite long) ie ventral to the colon like a prostate, or is it clearly dorsal to the prostate and compressing the 9-12 o'clock portion of the rectum

Feeling is believing, but based on the report to-date, I am not confident that this is not a bacterial prostatitis; as a bacterial prostatitis is probably the only significant differential that is likely to be cured simply, then based on what I know I would have given TMPS and meloxicom and seen back. That would be an indication for antibiotic treatment in my opinion.

[quote userid="29221" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244625#244625"]BSAVA PREVENT[/quote]

These look much improved, but I think have always been significantly behind the curve, and I think still encourage a needless over-use of clavulanate, and don't include oxytet as an option for UTI's for some reason. And what is going on with e.g. "orbital abscessation"? Is washing dogs in chlorhexidine really responsible? What happened to erythromycin as an option for pyoderma? I have NEVER needed clavulanate in an anal sac abscess. I'm not convinced that culturing ears is helpful. Oxytet and TMPS missing from resp section re KC and pneumonia, but clav fine for KC apparently? Cefuroxime (have you looked at the PK/PD data in dogs?) and amox/clav (ditto have you looked at the PK/PD data for clav in dogs?) iv can cause relatively frequent reactions in dogs. Consier "cephalexin and enrofloxacin" for an unwell pyo??? Clav for lepto??? I'm unconvinced clinically by the SSI section.

RE: Contextualised/Pragmatic care case example - what would you do?

Clive Ansell — Sun, 19 May 2024 11:07:32 GMT

Increased resp rate, slightly increased resp sounds bilaterally, and extremely pyrexic with a t40.8c.

Not unreasonable to think infection is on the list of ddx's here, and to prescibe a first line of use antibiotic.

What other evidence should we gather prior to antibiotic usage?

[quote userid="29221" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244625#244625"]Antibiotics should only be used where there is evidence of systemic infection.[/quote]

Given the dog was very unwell, and the degree of pyrexia, would it not be reasonable here to begin antibiotics pending and lab results, which could take days?

RE: Contextualised/Pragmatic care case example - what would you do?

Davina Anderson — Sun, 19 May 2024 09:13:15 GMT

I think one has to be careful making judgements on age -it isn’t an indication for no treatment. I have seen small breed dogs with prostatic abscess treated successfully at this age and died 4-5 years later if something else, that is another 25% years’ good quality of life. Of course you do then have to make sure you are only dealing with one problem and you have to explain that at that age something could be around the corner -we don’t have the benefit of a crystal ball. All this explaining is time consuming and hard to fit into one busy morning’s consult list. However, It is up to the owners to decide how they want to proceed and our job is to explain the options and possibilities as well as the drawbacks. I give owners an ‘opt out’ by saying “ you may want to consider if you are asking too much of him” - then they can consider the dog’s welfare and emotional needs as well as their own,

RE: Contextualised/Pragmatic care case example - what would you do?

Davina Anderson — Sun, 19 May 2024 09:05:29 GMT

Whatever is going on, there is no indication for antibiotic treatment here. Antibiotics should only be used where there is evidence of systemic infection. We are trying valiantly to hold back the development of resistance so we need to try to stick to the BSAVA PREVENT guidelines whenever we can. Although I acknowledge it is hard sometimes….

RE: Contextualised/Pragmatic care case example - what would you do?

janine redman — Sat, 18 May 2024 12:49:57 GMT

So on the basis of the history and clinical examination I would suspect a perianal adenocarcinoma with lymph node metastasis . Weakness could be due to calcium imbalance or nerve compression .
if that is the suspicion then it’s probably analgesia and poor prognosis . In fact even with referral surgery and a lot of expense the prognosis is poor .
I would do an in house fna of perianal mass and check neoplasia more likely than inflammatory. If so would assume mass in abdo likely enlarged sub lumbar lymph nodes .
if so analgesia and offer euthanasia

RE: Contextualised/Pragmatic care case example - what would you do?

Anthony Dennison — Thu, 16 May 2024 14:00:45 GMT

Well, annoyingly they didn't turn up for their RV appointment yesterday, and are hanging up the phone on me when I try to call for an update, so I'll guess we'll never know.

I would never have pushed for a full work-up in this case, but the client was very much the type of person that wanted everything doing but couldn't afford it (asking for payment plans etc). It was more for their closure; rather than just euthanise the dog because it was old and unwell, the client felt like they were doing something and at least trying. I find it often helps clients with the 'what if' side of things.

RE: Contextualised/Pragmatic care case example - what would you do?

Mayank Seth — Wed, 15 May 2024 12:10:29 GMT

I think we agree! I would very much open with expressing a guarded/poor prognosis!

RE: Contextualised/Pragmatic care case example - what would you do?

Clive Ansell — Wed, 15 May 2024 12:07:13 GMT

[quote userid="11020" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244603#244603"]

Clive Ansell said:
My go to for palliative care is preds and Pardale-V rather than NSAID's

I would try NSAIDs first - if this is a carcinoma they may directly slow the tumour progression as well as palliate. Steroids have the potential to be more permissive of infection or metastasis as they are more directly immunosuppressant, but I agree they are a more effective anti-inflammatory so would reach for these if NSAIDs didn't work or if I felt they were contraindicated.

[/quote]

Six of one, half a dozen of the other, and either is fine in this case, or rather it's better than nothing at all.

Then there is the male cow poo that some colleagues will not dispense a NSAID unless blood work has been done, even though it is going die fairly soon anyway.

Somewhat academic in this case, as the owners will not pursue a diagnosis anyway. Just needs PTS.

[quote userid="8991" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244602#244602"]A scan would *probably* give an indication what is affected but equally may throw up more questions - and lead to more tests. So the question is if the treatment is going to be roughly the same why are we pursuing a diagnosis (or rather doing a test which is unlikely to lead to a definitive diagnosis in itself) - in fact there is an argument that a scan wouldn't tell you any more than you already know...[/quote]

A scan, certainly in the hands of a good operator, may differentiate between non neoplastic prostate disease that may be treatable, and neoplasia that likely would not be.

Again, academic in this case, as the owner will not investigate.

[quote userid="11020" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244603#244603"]I would respectfully ask what is wrong with advising owners that you have significant concerns about the prognosis for their pet and then making them aware of a range of options that don't cause patient harm.[/quote]

I agree with Michael, in that I don't think a 12 years old dog should be subjected to endless investigation and treatment for cancer, but ultimately it is the owners decision. If I though this dog had neoplasia I would give a poor to guarded prognosis and tend towards euthanasia. If the discussion was going down the route of "what can we do" I would mention referral.

I think one has to be careful not to give false hope when talking about referral medicine, there is no magic wand or miracle cure, and I will often say that the outcome is very likely to be the same.

RE: Contextualised/Pragmatic care case example - what would you do?

Mayank Seth — Wed, 15 May 2024 11:42:36 GMT

[quote userid="8663" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244596#244596"] I can’t see what value empirical treatment with antibiotics or steroids (almost no logic for that) gives[/quote]

I refer to my comments above. This is very likely to be neopalstic but it could still be an abcess or similar. Even if it is a tumour then it is large, painful and associated with pyrexia so secondary infection of a necrotic region is a consideration. Antibioitcs may help to palliate.

[quote userid="5012" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244594#244594"]My go to for palliative care is preds and Pardale-V rather than NSAID's [/quote]

[quote userid="8991" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244602#244602"]So the question is if the treatment is going to be roughly the same why are we pursuing a diagnosis [/quote]

What if this was a fluid filled abcess? While less likely, that information may change the approach compared to steroids and wait for it to progress? I agree that if an ultrasound is not available due to cost concerns then it is less likely to change the picture.

[quote userid="3169" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244593#244593"]No. Ethically it's not right to be putting a 12 year old dog through all of that just because we could.[/quote]

I would respectfully ask what is wrong with advising owners that you have significant concerns about the prognosis for their pet and then making them aware of a range of options that don't cause patient harm. There are differential diagnoses here that can have a prognosis of many months of good quality of life, but they will involve cost and further veterinary intervention. Not right for everyone by any means, but not wrong either, in my opinion. As someone that has worked in a non-affluent part of the country as a first opinion vet and as a Specialist, I have seen owners get frustrated both ways. If they get referred because "there is something bad going on" and then it becomes rapidly apparent they don't want to pursue extensive investgation/treatment, they get frustrated with the time/money wasted. Equally, I have met many owners that get frsutrated that they weren't offered a referral several weeks before I meet them. Isn't that the very definition of contextualised care?

RE: Contextualised/Pragmatic care case example - what would you do?

David Mills — Wed, 15 May 2024 10:52:23 GMT

Pain (probably inflammatory), pyrexia - steroids will help both.

Sounds acute presentation so prostatitis (normally bacterial component) is reasonable especially with pyrexia and pain - antibiotics.

Ddx prostate, bladder, lymphadenopathy, neoplasia, other.

Essentially treating the symptoms in absence of a diagnosis - as long as the client understands then don't see an issue with it at all. Make aware may not improve, may worsen, but may also get better.

A scan would *probably* give an indication what is affected but equally may throw up more questions - and lead to more tests. So the question is if the treatment is going to be roughly the same why are we pursuing a diagnosis (or rather doing a test which is unlikely to lead to a definitive diagnosis in itself) - in fact there is an argument that a scan wouldn't tell you any more than you already know...

RE: Contextualised/Pragmatic care case example - what would you do?

Clive Ansell — Wed, 15 May 2024 08:29:03 GMT

[quote userid="8663" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244596#244596"]I can’t see what value empirical treatment with antibiotics or steroids (almost no logic for that) gives, even if they are cheap[/quote]

Corticosteroids with their anti-inflammatory effect may give temporary relief and make the patient feel better. Unsure about antibiotic use here.

Given the owners will not investigate, probably just needs PTS.

RE: Contextualised/Pragmatic care case example - what would you do?

Alasdair Hotston Moore — Wed, 15 May 2024 08:05:00 GMT

Ultrasound is ideal. Offers excellent bang for the buck. I can’t see what value empirical treatment with antibiotics or steroids (almost no logic for that) gives, even if they are cheap

RE: Contextualised/Pragmatic care case example - what would you do?

Clive Ansell — Wed, 15 May 2024 07:18:26 GMT

[quote userid="3169" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244593#244593"]Why? How is that in any way relevant? Jumping to that conclusion is what is wrong with the profession, these days.[/quote]

But there are financial constraints, and they are relevant.

If this owner is unable or unwilling to even pay for a conscious US scan, the only avenue open to us and them is symptomatic treatment, suck it and see. From a welfare viewpoing, if not able to investigate at all, maybe just offer PTS?

[quote userid="11308" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244591#244591"]

Clive Ansell said:
Conscious US scan if possible

I offered a scan, this was declined due to costs.

[/quote]

[quote userid="3169" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244593#244593"]I may scan, but unsure what a chest xray is going to add.[/quote]

I'd suggested chest rads, but for clarity I would attempt conscious US scan first, and if that gave sufficient information (end stage cancer for example) I wouldn't proceed any further with radiographs if they were not going to add anything useful.

[quote userid="3169" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244593#244593"]Put on steroids and antibiotics (my feeling is the steroids do more in these palliative cases).[/quote]

Me too. My go to for palliative care is preds and Pardale-V rather than NSAID's

[quote userid="3169" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244593#244593"]I'd have told them the dog has cancer.[/quote]

We don't know for sure this dog has cancer yet, although I agree it it is probably op of the list.

15cm or so painful mass dorsocaudal abdomen, pyrexia, could be a prostatic cyst? paraprostatic cyst? prostatitis? +/- infection +/- pain?

Increased bilateral resp rate and sounds could be pain? pyrexia? metastatic spread? primary and unconnected chest pathology??

RE: Contextualised/Pragmatic care case example - what would you do?

Michael Woodhouse — Wed, 15 May 2024 01:07:18 GMT

[quote userid="11020" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244590#244590"]You haven't explicitly said that the owner has significant financial constraints but from the title we would assume so? [/quote]

Why? How is that in any way relevant? Jumping to that conclusion is what is wrong with the profession, these days.

[quote userid="11020" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244590#244590"]discuss extreme ends of the spectrum including referral for imaging, aspirates and oncologist guided treatment vs euthanasia.[/quote]

No. Ethically it's not right to be putting a 12 year old dog through all of that just because we could. I don't think I would specifically discuss referral unless a very young dog, specific set of circumstances or owners specifically asked. I may scan, but unsure what a chest xray is going to add.

I'd have told them the dog has cancer. Put on steroids and antibiotics (my feeling is the steroids do more in these palliative cases). See how he responds, but don't go buying big bags of dog food.

RE: Contextualised/Pragmatic care case example - what would you do?

Anthony Dennison — Tue, 14 May 2024 15:49:38 GMT

I was at one of our consulting branches, so no access to imaging unfortunately. If I was at a branch with a scanner I would have stuck a probe on quickly to check what was going on and not charged.

How very astute of you! Yes, there were financial constraints.

[quote userid="5012" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244588#244588"]Conscious US scan if possible[/quote]

I offered a scan, this was declined due to costs.

[quote userid="12930" url="~/f/clinical-questions/30951/contextualised-pragmatic-care-case-example---what-would-you-do/244589#244589"]I'd give TMPS and meloxicam and recheck tomorrow.re pyrexia.[/quote]

I gave co-amox and meloxicam, and he's got an appointment to be checked tomorrow. Will update you all then

RE: Contextualised/Pragmatic care case example - what would you do?

Mayank Seth — Tue, 14 May 2024 10:06:08 GMT

I assume no travel history? Strong pulses? Eating/vomiting/diarrhoea? Any tensmus/dysuria?

Assuming no to travel history I would put a strong bet on neoplasia. You haven't explicitly said that the owner has significant financial constraints but from the title we would assume so? I think it is fair to advise a very guarded prognosis and discuss extreme ends of the spectrum including referral for imaging, aspirates and oncologist guided treatment vs euthanasia.

Assuming that both of those are declined then I think it depends on how far you are allowed to go. A brief ultrasound probe may be useful to get abetter idea what you are dealing with. In that location and with dosrolateral rectal compression I would assume a lymph node unless there is something about your exam that makse you suspect otherwise. I am also assuming AGs and distal limbs seem normal?

With the cardivascular exam described then haemorrhage doesn't seem like a likely exaplanation for the weakness. With the fever I would assume either secondary infection of a necrotic tumour or just tumour associated inflamamtory cytokines. On that basis the a tier 1 broad spectrum antibiotic (amoxyclav) would be a reasonable trial drug with an NSAID if the dog's GI tract seems ok. If NSAIDs were contraindicated or didn't work AND if there was no response to antibiotics after 24 hours then probably a healthy dose of dex as a last ditch effort.

Who said specialists need to spend money all the time

RE: Contextualised/Pragmatic care case example - what would you do?

Beats — Mon, 13 May 2024 17:50:29 GMT

I'm a bit unclear on whether this is a prostate or not, but in the absence of palpating it myself, I'd give TMPS and meloxicam and recheck tomorrow.re pyrexia. Might splash some meths and put the ultrasound on if I was unsure.

RE: Contextualised/Pragmatic care case example - what would you do?

Clive Ansell — Mon, 13 May 2024 14:52:41 GMT

Top of the ddx list. Neoplasia

I think my first of call would be imaging. Conscious US scan if possible, and set of chest rads.

If he is full of tumours little point in much else.

Is he urinating and does he have 2 scrotal testes?