My Husky Lost Her Leg (but shouldn’t have) 

Nothing hurts more than seeing your pet getting older or sick

I’m a veterinarian and want to echo what Dr Mike said. Please ask questions! Every pet and owner is different, and one family may want to pursue things aggressively while another family may choose palliative care. Both are ok! Let your vet know your philosophy and goals. Get a second or third opinion if needed to help you decide what’s best for you and your family. I’m glad that Roxy is healing well and that’s an important reminder as well-dogs accept changes like this with incredible grace and resilience. Thanks for sharing her story Dr Mike!

My cat just had surgery and the day after, I noticed that his arm was swollen and that the bandage for his IV was quite tight (and also still on) - I thought back to this video and rushed him back to the vet. They were mortified and were so happy that I caught it before it got bad. All he needs now is some massages and more love. Thank you so much for this video, it came flashing back to me and I knew exactly what I needed to do. 💜

Veterinarian here. I am sorry about your experience with Roxy. I wonder if the tissue necrosis and lack of blood flow was more from the surgery itself though. With sarcomas on a limb there is such limited tissue in the region. It isn't like the scruff of the neck where there is lots of extra skin/tissue for closing up after. So one of the biggest risks with removing masses on limbs is that when you suture the wound closed it will create tension. If you create too much tension with your closure, you will actually cut blood supply to the region and get necrosis. In those cases putting in tension relieving incisions or just trying to heal the wound through second intention rather than closing it should be considered. I don't know how big the mass was that Roxy had or how much tension was present, but I wouldn't be surprised if that wasn't a big part of why the tissue died. It is a possible complication of the procedure and should be explained prior to surgery, with the warning that if that occurs, it could result in amputation of the limb. So generally with a sarcoma like that you have 3 different options off the start: 1. Palliative, monitor it. Monitor its growth. It may never grow bigger or cause a problem before the pet has another life-threatening problem and it may. If it does grow bigger, these can get irritated and fairly awful. I have seen these break open and start bleeding and become infected. So it can become worse with time, but be aware that can happen and choose to monitor until that time comes. (I had one case where the tumor ruptured open and with that rupture it broke open an artery and the dog was spurting blood out and going into hypovolemic shock, this is very rare, only time I have seen that happen). 2. Attempt to remove the mass, making the owner aware of the above potential complication, also if you are going to bandage it make them aware of bandage complications. 3. Amputate from the start. The dog's overall health, age, etc should be considered when deciding, but ultimately it is up to the owner to decide. I don't know what conversations were had between your dad and the vet, but sounds like if you had been able to discuss this with the vet yourself, you would have picked option 1. (If it were my personal pet, I also would have picked option 1). Thankfully, dogs do tend to do quite well with amputations and adapt insanely well. Glad to see she is doing well and healing up.

8:03 She went to high five with her missing leg. You can see her muscles try to move it. But she's smart enough to know she can't and did it with her other one. What a good girl.

Roxy trying to high five with her missing paw broke my heart. You can see the muscles tense and the moment of realization on her face when she realizes "Oh. I need to use my other paw now". Poor baby. It's good to hear she's not having any psychological problems because of this though.

Im glad you talked about quality of life vs length of life. I had a dog that passed away recently from Cushing's Disease, a disease that causes the adrenal gland to over produce cortisol which can lead to various life threatening conditions such as kidney failure, and diabetes. He was 14 when he was diagnosed and the vet said that a surgical procedure would be needed to treat him. However we decided not to do the operation, as he was already starting to lose weight and getting weaker. We were worried that a surgery would essentially kill him with how weak he was. We decided to put him on a medicine for cushings that did help slightly, and we just focused on keeping him comfortable. He went on to live another year and a half, with a decent quality of life until he passed away. I think we made the right choice, with how weak he was, i wasn't sure he'd be able to make it through a recovery from a surgery and felt that it would have badly affected his quality of life.

Roxie's amazement that she acheived a high five without any balance was adorble. She was like, 'I got this, other paw, that's it, come on!' and she made it and was like, 'YEAH YOU SAW THAT, MIKE?!' and it was so cute.

General practitioner vet here. This seems like it was a perfect storm of problems and I’m sorry it happened. However, it is absolutely true that dogs do beautifully with three legs. Losing a front leg is much harder on them than losing a rear leg, because dogs carry 60% of their weight on their front legs. A big reason we remove the entire shoulder blade is so the dog is not having to carry that extra weight on the remaining front leg. I have no doubt she’ll do great!

Her little twitch on her stub when she went to give the high 5 with the missing paw 😭 wholesome

My cat had tumors on her head, but she had max a year left with her other problems. She could of gone blind removing them. We just made her comfy and she was happy as a clam up until the end ❤️ Callie was my best friend, I miss her everyday

I’ve been a vet tech for over 22 years and currently work in oncology. Well said with everything. I’m sorry Roxy had complications, but super happy she is recovering now. Did the surgeon suggest a ct scan of the leg? Just curious. Sending quick healing vibes to Roxy !

This is heartbreaking. I'm so sorry. As a veterinarian, my biggest fear is seriously harming a patient. I will never forget something my resident said to me when I was a student on my surgery rotation and learning to place bandages. Him: What's the biggest possible complication from a bandage? Me:Tissue necrosis resulting in amputation. Him: Nope. Death from sepsis from a necrotic leg. That had an impact on me that has lasted 22 years!

I rescued a kitten with very smashed arm. Eventually had to decide whether to put it down or remove the arm. Surgery was astronomically expensive because she is a kitten. I ended up going through with the surgery with no regrets. Shout out to all the armless animals out there.

she no longer seems bothered that she has three legs i hope she’s healing well

I have to say: the way you handled the reveal on those pre-and post-surgical images was true genius. Very well done. As a dog lover, this story really hit home with me. Isn’t that just the way it goes with our dogs? No matter how badly we feel that we could have done something more for them, they remain completely devoted to their hoomans. 🥰🐕

As an vet student, I’m going to remember this video as I move forward.

8:03 The way she actually tried to give a high five with her missing leg . I'm so sorry this happened to her

Poor pup, I'm surprised that you weren't crying 😭😭😭😭😭

Roxys really is a tough dog here and I am glad that she's doing okay

I work as a tech in the surgery department at a very popular and gold standard hospital. Never once have I seen something like this happen, thank God. All of our surgeons are incredible, and the ones that weren't got fired. I am so sorry this happened, it shouldn't have. I agree the surgery should have never taken place.

As a vet as well, I do want to reassure you that yes, dogs don't care emotionally about losing an eye or a limb. While prosthetic (both for limbs and eyes) do exist, they tend more to be for the benefits of the human than the pets. Unless the pet already had significant problems with their legs, they do extremely well with 3 legs. Keeping part of the limbs often result in pressure wound at the tip because pets will tend to put weight on them if any part if left. I've seen a few pet who had partially amputated limbs (Usually they were adopted like this, either following an old trauma they miraculously survived on their own without medical care or because they were born this way). Most of them end up having a full limb amputation eventually because of the wounds they develop over the partial limb. Pets are also, for the most part (Huskies are indeed huge babies), WAY more resilient to surgery and pain than humans. Castrations and spay (which is often an ovariohysterectomy) is an in an out procedure in most clinics, and like 6 hours post op as their owner picks them up, many dogs will be jumping everywhere. In most cases, the owners struggles A LOT to keep their dogs on rest for even 1 week. That being said. Yea, it seems to me that there should have been better discussion of the whole thing before the surgery. 'Technically', while it's true you'd theoretically want to remove any tumors...for a 12 years old husky, there is a whole discussion to have about the risks vs benefits. As sarcomas generally don't spread much, but are locally invasive and requires wide margin resection. So attempting surgery for a sarcoma on a leg ALWAYS come with a significant risk of amputation or local recurrences... But without being there, hard to say how much of this was discussed. And any kind of bandages on pets are like the worst thing ever. We have to do them often for a various number of conditions, but they are horrible, are prone to just slip up or down due to the shape of the legs and complications are unfortunately frequent. (rarely on this scale, fortunately, but things like pressure wound or skin infection are frequent.

This is the saddest thing ever 😫😫😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭😭

Aww…oh noo! I’m so sorry…!! It hurts to see your pet get sick…💔😔

This breaks my heart to watch... You can tell that he wants to get angry. He wants to blame people. He wants to really let it out. But he is way too kind and professional of a person to do that. Thank you for being a good example Dr Mike. Keep looking on the bright side.

As a Vet Tech, I am truly sorry Roxy lost her leg. Sarcomas can be tricky, I think it’s reasonable to have removed the tumor since they could spread. The photo of the foot looked so bad and my gut says it was a bandage tightness issue. It’s so easy to put one on too tight and this is an outcome. Obviously, other complications are possible too. Hopefully she will continue to improve and still live a full life as a tripod, it’s just so unfortunate she had to be one from a “simple” mad removal 😢❤❤

That’s aggravating. What a nightmare.

Roxie shouldn’t have lost her leg, but she seems like she’s going to be ok! 💪

As someone with a chronically ill cat who has had to fight for her to get proper care here's my advice for those reading: Vets are the medical experts but *you* are your pet's expert. You are the best and sometimes only advocate for them so if you ever have even the slightest doubts trust your instincts and speak up. A good vet will never be upset or take it personally that you are looking out for your pet. Remember that you and the vet have the same goal and want your animal to be healthy but at the end of the day you are the one who knows best what they need to have a happy life.

She is so beautiful and I am very sorry

Sending my best wishes to Roxy on her recovery. My bunny broke his hind leg just less than a year ago, and the vet also suggested surgery. The fracture was at a location where they couldn’t put a cast on, so it’s either having a surgery or betting on luck for it to heal on its own. I’m so grateful that she explained all the possible complications to us, especially since surgeries on exotic pets are difficult and rabbits are very susceptible to GI stasis due to stress. We decided to home care, and he’s fortunately fully recovered

With the high five you can tell she tried to lift the missing paw and was "oh yeah.. hold on" sweet girl.

I'm so sorry, I hope Roxy lives a long and healthy, happy life ❤️❤️❤️❤️❤️🙏🙏🙏🙏

This reminds me of my old beagle who was named Dexter, and suddenly just refused to eat…and if he did, he would puke it up…I was young at the time, and don’t know the reasoning for it but he is and will continue to be missed…RIP Dexter 🕊

As a vet tech I am so incredibly sorry that this is the experience you had. We always aim to be extremely transparent with clients about their pet’s prognosis against the risks/benefits of surgery. I’m so glad she’s doing well after the amputation. She looks beautiful 🖤

I just lost my own 12 yr old husky to metastatic cancer suddenly, so watching this and seeing Roxy so happy and healthy after the surgery makes me so happy

Trust me, dealing with an animal with cancer is just heartbreaking 💔 my kitty passed away from a tumor & I cried everyday for her. Bless Roxy 💜

its so sad to see a dog with one leg gone poor doggy:(

As an RVT (Registered Veterinary Technician), I cannot express how much this breaks my heart. This is a situation that should have been avoided entirely. It makes me uncomfortable that they wanted to go right into surgery. I would not be comfortable with putting a 12yo large breed baby under anesthesia. It sounds like her bandage was far too tight, perhaps incorrect materials were being used. I am so glad she is recovering well after 2 procedures. I wish her circumstances were different and I am so sorry for what happened. My love and support to you and your family💕

You can tell he was irritated, mad, sad, and so many more negative emotions during this video because if you look closely at his hand when he is messing with the toy he is trying very hard not to show his irritation so he is just squeezing the toy hard and also trying to keep his cool for the video whilst doing so

I hope Roxy is OK

This hurts my heart 😢

"Can I have a high five? Or is that messed up to ask?" That _killed_ me lmao Much love for the tripod ❤️

Sorry this happened, but it looks like she is doing great! Good job and good idea asking all those important questions. Dogs are the best!

My dog tore his ACL and it was super hard because he is super active and he had to have many very strong sleeping drugs so he wouldn’t hurt himself. But he accidentally fell and he popped his stitches out, now he has sutures and he is getting them removed tomorrow. He is doing better now❤

So sorry. I actually lost my 16 year old dachshund a couple weeks ago, and this reminded me of it. It also reminded me that today would've been his 17th birthday. He was really old, plus he has had cancer in his spleen for about a year and a half before he died. Make sure that you spend as much time as you can with Roxy, as life may slpit you two apart. Thanks for the video, Doc. Really appreciate it.

I'm so sorry this happened. I know the pain and stress of having your furbaby undergo surgery as a vet nurse. Well done on your recovery, Roxy - one tough Husky!

I'm so sorry. Huskies really are very sensitive dogs to pain and they sure let you know about it! Having had tripod animals myself, the vet was right, animals just accept it and adapt so much better than people. And Roxy looks happy and joyful and content, I'm glad she's recovering.

My mom Roxanne had breast cancer a small lump in her right side but they got to it perfectly in time.

This was so sad I am so sorry not even my dog but I was almost tearing up

As someone who works in the veterinary medicine field, this is deeply upsetting. I’m so sorry for the miscommunication between you and your vet. They were right, it doesn’t happen like this often. And they do recover from an amputation very well most of the time. As for the arthritis, unfortunately husky’s have a high risk for it even with all 4 legs but you’re right this does increase her chances of it. It’ll be an adjustment for sure but i think she’ll be back to herself soon. Fortunately active dogs recover faster, mentally and physically. (Obviously with taking it easy while the wound is healing) I can’t stress it enough- we would rather be asked a million questions about the procedure and aftercare, than just a few. We want you to be well informed about your pets care and be prepared to properly take care of your pet at home.

This is an incredibly important video. I lost my husky a few years ago due to a vet mistake - he went in for a routine checkup, there was a spot on his leg that made him yelp but the vet brushed it off as no big deal. A few months go by and he starts walking weirdly. We take him to the vet and they find out he has stage 4 prostate cancer, and there’s pretty much nothing they could do. We finished out the medicine we had been given (they were expensive and my dog still acted perfectly fine apart from his leg), then he had to be put down. It’s been years and it still makes me cry. Please, advocate for your pets, because they can’t.

❤❤ 😢 God bless Roxy, you and your dad. 🙏🏼

My goodness! I sobbed like a three year old :( hope Baby keeps getting better and Bianca (my German Sheppard) sends your husky a big woof for support!

I’ve been in vet med for 20 years. Sadly, some veterinary surgeons, like human surgeons, are so focused on surgery that they lose sight of age and quality of life considerations. It is unfortunate that you came across a surgeon like this. Please know this is the minority. I appreciate you sending out the message that people should be prepared to ask the tough questions just like you encourage people to do with their doctors and the majority of veterinarians are happy to discuss all of the options and associated risks with clients. Happy to hear Roxy is recovering. Thankfully, dogs do so much better as amputees than humans do and they are so adaptable even in their later years. Appreciate you, Dr Mike.

I am so sorry this vet “let” this happen. As a vet technician I have never seen this happen before and it really seems the vet made a mistake. They should have never continued the surgery without calling you to inform you of the extra risks. I hope roxy continues to be the happy high energy dog she is.

My dog is 15 had a giant lump on his back for a long time. Today it popped my dad found a mini tumour in the giant lump. My dad did not want to know if it was a tumour before this because he said it would not change the way we think or treat are dog. I am happy for the tumour to be out of are dog. ❤

I would rather my dog have a short good quality life than a long bad quality life, I’m so happy that your pupperz is doing ok :)🫶🐕

Pets are everything. My heart just broke when I saw the photos of Roxy's leg and amputation, knowing mistakes were made and it needn't have happened.

Poor Roxy 🥺 she’s forever gonna be one of the cutest huskies to ever walk this earth, tripod or not 🤍🙏🏼 I used to have a husky of my own so this makes me very emotional

This breaks my heart. Last year, I lost my dog because of a surgery that resulted in a severe thermal burn…. At least your vet was honest in the aftermath. I think I most resonate with your point about the vet not considering the dog as an individual. It bothers me so much that people don’t recognize animals as having full lives, even if their experiences are processed differently than ours. I hope her recovery continues to go well!

Roxy is one strong willed dog, and despite her losing one arm, she's still here and kicking. As a pet lover myself, Pet's life span may be short, but the memories from them will never be forgotten. Decisions can be a hard one, but if there's no choice, the choice is inevitable.

Bear will be devastated 😢

I'm a vet tech and I'm so sorry this happened to you and Roxy. She absolutely should not have lost her leg. It sounds like you and your dad tried to do everything right and get as much information as possible while the vet was very gung-ho for surgery. At the hospital I work at, I don't know if we would have done surgery on a stage 1 soft-tissue sarcoma in a 12 year old husky unless the owner absolutely wanted it. Maybe we'd send them to a consult with a board-certified surgeon. I don't know. But I'm so sorry you all had to go through this. The only silver lining is that dogs do adapt really well to being tripods like you said, and it looks like Roxy is doing really well.

Thank you so much Mike! My dog has a bump too and it’s been there for a while. I will try to get him in asap❣️

Thanks for the most useful info! Roxy is beautiful and lucky to have you and your dad as her family!!

I lost my black lab Sadie to cancer. The vets said time and time again the tumor on her hip was benign. It wasn’t. It kept growing and the cancer spread to her whole body. We had to send her over the rainbow bridge at just 5 yrs old. Vets need to do better.

This is why so many, many people want the surgical process to be filmed, despite the medical industry being against it. Praying for Roxy's continued health and recovery ~

Vet here, I'm so sorry this happened to Roxy this shouldn't have happened. It's definitely an all of the above situation, the wrapping around her leg was certainly too tight and played a big part to this. She looks like a wonderful girl Mike and a very resilient dog at that. Thanks for sharing the story. ❣️

I’m sorry about Roxy. Truly/Truthfully. No matter what happens to Roxy, she’ll always be loved❤❤❤

It's heartbreaking

This broke my heart, you could hear the pain in Dr Mike’s voice. I’m so sorry for what happened to Roxy. I’m so glad to hear that she is better now!

8:03 The fact that you can see Roxy’s muscles moving on her just absolutely breaks my heart. I would have hated to see my dog suffer like this. People need better training if they want to become a veterinarian.

Idk if I commented before, but damn... even 8 months later, when I watch this I still almost cry. It's sad to think that all of that could've never happened and it's really sad that id did, but I wish you and Roxy the best and I hope that she'll live her last year-and-a-half happy and problem free. She deserves it I think we're all gonna miss her when the time comes, but until then, I wish you the best -Mike

I once have a dog and i know the pain of losing/seeing your dog get sick, truly a living hell

As a pet owner, I can sympathize. I know how much it hurts to hear there is something "wrong" with your pet.

My 14 year old dog had breast cancer which appeared when she was around 12 years old. The vet didn’t want to operate given my dogs age and told me to keep her as comfortable and as happy as possible. That’s exactly what I did and I had her for 2 more years until she finally couldn’t go on anymore. What happened to Roxy surely is devastating and so senseless. I’m thankful that our vet was honest from the beginning.

I have a rescue dog who went through losing her arm or paw as well so I can relate to this. But I am glad Roxy is okay ❤️

Well said I'm sorry to hear about that.She s gorgeous she looks like she's doing well

I’m so sorry this happened to you and Roxie, as a CVT (certified vet tech) I’m shocked they kept the bandage on for longer than a day. Typically with a mass removal on a leg a bandage is only kept on the day of surgery and maybe the day after surgery while it is still bleeding a little bit from movement. That bandage was definitely too tight! The bright side is that dogs are honestly so much stronger than people and live long, happy, active lives even with a limb missing. One of the vets I that was a professor at my tech school said dogs and cats are basically built to be tri-pods but just given an extra leg. Because thats how well they do with amputations. I’m sorry that you had this awful experience but glad that you are so professional and not hating/blaming the vet industry. ❤️

I'm terribly sorry Roxy lost her leg! This shows why you always need to ask your vets, and doctors about the risks involved in certain procedures. We found out the hard way when after we brought our cat to the vet for castration (we had a female cat as well and didn't want kittens). We didn't know the risks involved and forgot to ask. The vets didn't say anything regarding it either. only, a few days after we found our cat dead, only 3.5 years old, while he was very healthy first. After we go back to the vet, he told us that, Siberian forest cats are very sensitive to narcosis, they shouldn't be put under full anesthetics, but they did. This causes heart injury which can result in a heartfaillure which happened. We were furious and very sad. I never forgave myself for not asking if it was dangerous if we knew, we'd never have let them operate on him. He'd still be alive.

i’m very sorry this happened. it must have been so frustrating but it’s also good to see Roxy still being active and happy. I hope Roxy will be healthy for a long time.

She got this! I have a tripod husky, same arm & shoulder were lost due to gangreen from a wound he got when rescued. He is 10 yrs old now. Just keep an eye on her weight, continue walks so she stays strong, & if you hike, a harness with a back handle allows you to help her relieve stress when going downhill! ❤🐶

It’s tough, but seeing her face this whole video was so sweet. Just “Hi Dad, I’m happy and I love you” the whole time

That high five looked so sad 🥺

This is part of the reason I want to become a vet. To make sure that whatever is done is done right and to make sure that the family understands risks and to help them choose the best option for their dog.

Gotta say dr mike. When you asked roxy for a high five and i saw her right shoulder move up for that phantom limb movement just made my heart bleed and brought me to utter tears. Shes so sweet and beautiful. Reminds me of my own dog thata currently living with my parents and i stress about her daily. Hearing you say they arent immortal as well made my tears worse. I treasure my Niko and always ask my family how she is doing before i ask how my sister is. She was my emotional support doggo but couldnt take her to my current living area... give roxy a treat and ear scritches for me she's a good warrior that will never stop chugging along.

Poor baby!! But thank you for teaching us to be aware of these risks. She is such a happy dog with you though!❤

Thank goodness that she is still alive 🎉🎉🎉❤❤❤❤❤❤❤❤❤❤❤❤❤❤❤❤❤❤

What a beautiful Huskey..

For everyone watching this video, please take this in mind: finding the right veterinarian is just as important as bringing your animal in in the first place. Every vet has different experience and different levels of care for their job, just like human doctors. Every vet has the potential to make mistakes, too. But don't just bring your animal in to the nearest or cheapest vet -- do your research. Seriously. Treat it as if you are looking for a doctor for your own health. And always advocate for your pet's happiness and wellbeing over anything else. They can't advocate for themselves.

I would suggest watching Dr. Cellini’s reaction, DVM, as he brings up some good points not mentioned in this video.

Thank god she did not loose her life!

im just thank full that she survived

CVT here. It sounds like there were so many lapses in communication, and I’m so sorry you all had to go through that. I think it’s also important to note that just because a vet can do a surgery doesn’t mean they should - a mass removal in that area should’ve been done by a board certified surgeon AND a veterinary oncologist should’ve been involved as well. Because you’re exactly right - for a stage 1 sarcoma in an older dog (especially in such a risky location on her body), surgery shouldn’t have been the first choice. It seems like Roxy is adjusting well which I’m so thankful for, and thank you for spreading awareness of always asking questions!! As a pet owner you are a crucial part of your pets treatment team and if you don’t feel that way, find a new vet!

As a registered vet tech who has experience in veterinary physical rehab, it hurts my heart that this was your experience with Roxy. But dogs are thankfully incredibly resilient when a limb has been amputated! You probably already have looked into it, but I highly recommend asking a rehab veterinarian regarding supplements and therapy appropriate for Roxy for joint support to help minimize the onset of arthritis. Most people are aware of glucosamine and chondroitin, but therapeutic levels of high quality fish oil and other supplement injections are definitely helpful. Laser therapy for her joints is also incredible! As she gets advanced in her years and becomes less exercise tolerant to get around, a front end cart may be also be appropriate for her. Wishing her many more comfortable years with you and your dad. ☺️

I'm really sorry for Roxy... As a vet student I feel like some extra exams could have helped prevent this, like maybe a tomography, and have an oncology doctor check on her, also with the biopsy finding out it was a stage one cancer, and considering her age, should have been discussed more about the real point of having the procedure We always want just the best for our pets, and speaking as a future vet, we have to treat them always knowing that they are not just a patient, but the love of someone's life Recently I lost my best friend, and I can't help but feel like some of his issues could have been prevented by having spoken to an oncology doctor before...

Poor Roxy girl! She must be one strong pup to have undergone that at age 12. What a champ! So happy you made this video to educate dog owners on what kind of questions we should be asking our vet when considering surgery and the difference between quality of life and length of life

This is crazy, I had a similar thing happen with my dog! Eventually we figured out what had happened, he had gotten the bandage quite wet by sticking it in his waterbowl, and the inner cotton shrank-cutting off circulation.

I am so sorry this happened to Roxy! Unfortunately cancer is 10 times more prevalent in dogs than in humans and detecting it early can be a challenge. I actually find this video particularly interesting since I work at a company that focuses on early cancer detection for dogs to hopefully give owners more options and time when diagnosed. If you are interested, this could be an awesome opportunity to educate pet owners about cancer in dogs and options for diagnosis.