Like you, I am frightened by Donald Trump’s hair. I can’t explain it. I don’t know where it came from, how it happened, or what it will lead to. No doubt some of you feel the same way about neurological cases. That is a shame, as neurology is Problem Oriented Medicine, in a nutshell, by which I mean, it is (usually) very logical. The problems start, I think, when signs could be caused by more than one body system. To this end, I present to you a short list of The Great Pretenders I have seen recently.
The dog, lying still, barely responsive to the environment, clearly doesn’t have a normally functioning brain, but is that a primary or secondary problem? Hypoglycemia: if the brain does not have fuel, it will not function normally. (It is always worth doing a full profile on an animal with an altered mental state. It is always worthwhile looking at the results too.) Altered perfusion from cardiac disease, from hypovolemia (I’m looking at you Addisons…), will deprive the brain of fuel too. Metabolic disease can cause coma, so always check that possibility first. Sepsis can really “flatten” an animal: years ago I saw a dog with pyometra that had been referred for MRI of the brain. It didn’t have that MRI…
My advice regarding a collapsing dog is to give a large estimate as collapse is caused by derangement of many a body system and it may take a while to discover the cause. It is also the type of case that benefits from a multidiscipline referral centre. The history and signalment should guide you to what could be the most likely body system responsible. One interesting case I saw the other week was a young male cockerpoo with back pain and a sudden inability to use the hindlimbs. You might be thinking this was a spinal case, but physical exam ruled that out. Multiple joints were painful, and the joint fluid obtained had a six-figure non-degenerate neutrophil count. It was immune-mediated polyarthropathy, with a dramatic presentation. Another very odd presentation I once saw was a cat referred for “hitting her chin against the ground”: to cut a long story short, “Talula” was collapsing and had narcolepsy.
You wouldn’t think this presentation could be difficult to diagnose but it can be as the event is often over by the time the animal is presented. Clues that the event was a seizure include a post-ictal period of ataxia, restlessness, disorientation, sleeping, and maybe being immediately hungry or thirsty after the event. Urination indoors by a house-trained animal, or salivation causing wet fur around the face, or acting oddly, might be the first (post-ictal) signs seen by the owner. Balance loss can be confused by the owner for seizures. Do not rely on owners to notice nystagmus or describe the animal accurately (i.e. eyes held open do not signify consciousness; this is such a common misunderstanding). Animals with vestibular disease, in contrast, usually still have the signs when they are presented to your practice.
The overall message would therefore be: do not skimp on the basics! Always examine the animal, several times if necessary. Take a probing history, encouraging the owners to describe what they saw, so that you can draw your own conclusions. These skills will take you far.
If you need any help, then please contact Sue Fitzmaurice on email@example.com or 01962 767920. We are very happy to assist.