Dr. Hoffelmeyer came to me with this information and her thoughts on the differential diagnosis list…and the question, "How do you want me to proceed?" Top on her list of possible disease processes was Cushing's disease.

Cushing's is a disease in which the adrenal gland secretes high levels of cortisol continuously. It causes all the clinical signs I had observed gradually expressing themselves over the prior few weeks. Other less obvious pathology occurs, namely reduced immune response, poor wound healing and GI upsets.

Dr. Hoffelmeyer and I went over possible further testing that could be performed to arrive at an exact diagnosis and I agreed to additional blood work with ultrasound and radiograph of the anterior abdomen and lungs. I was watching my dog become more unsteady on her feet as each day went by and was anxious for more information but did not want to put her through an invasive surgical procedure. On we went.

Base cortisol levels were high and remained high eight hours after the administration of a low dose of dexamethasone. This confirmed the diagnosis of Cushing's disease. Next an endogenous ACTH test was run and the results indicated that the source of the cortical was from an adrenal cortical tumor.

What now? Dr. Hoffelmeyer informed me that 50 percent of these tumors are malignant and that surgery is risky. I asked her to do ultrasound and radiographs -- again, nothing invasive -- to see what they might tell us.

Unfortunately, the news was not good. M had a large diffuse mass in the area of the left adrenal gland. There were many small tumor nodules in the lungs. Obviously this was a very aggressive tumor that had metastasized to the lungs and probably other organs of the body.

At this point, as M's owner I talked with the rest of my family and other staff members so everyone was on board. That evening I euthanized her and set her free from her pain. She just lay there and let me give her the IV injection.

She seemed so accepting. Just as she knew putting her in the kennel of the truck or in the johnboat or beside me at the farm pond was the right thing for me to do, so she seemed to know that I had chosen the right time for her to go. And there I was again conflicted by being both her veterinarian and her owner.

I did not share this episode in my life as a plea for sympathy or compassion but rather to help each of you better understand your relationship with your veterinarian and how he or she can help you work your way through a problem. Complex diseases such as Cushing's disease develop in a slow insidious manner that makes them especially hard to diagnose in their early stages.

As I related, the steps to a diagnosis include history taking, physical exam, appropriate laboratory tests and the development of a workable treatment plan. Your place in this process is very important in the history component. Obviously a dog cannot talk. A physical exam on an annual basis with some basic blood work may also catch a problem before it gets too far along.

As the owner of the dog, you should make decisions as to what tests are the most cost effective and are the least invasive. Your veterinarian should give you good information to help you make these decisions. Once a diagnosis is made then a treatment plan will in fact arrest the disease process and alleviate the suffering. If not, then you must consider at what point in the progression of the disease you will elect euthanasia.

The next morning Dr. Hoffelmeyer did a post-mortem exam of M's body and found a large tumor mass surrounding her kidney with multiple tumors in her lungs. The pathologist found on microscopic examination that the largest mass was an adrenocortical carcinoma and the others were metastatic tumors from it.

M was cremated and her ashes now sit next to those of several other dogs on a shelf in my office.

I remain at htholcombdvm@qwest.net for your questions or comments.