Friday, March 4, 2011

354. Chihuahua with Acute Abdomen.- Part 2

On March 4, 2011, Dr Vanessa and I discussed the case. The dog was Ok - active, eating and had passed stools and water. I noted that this dog had more dripping of urine on the floor of the consultation room as seen on March 2 when he was admitted and I. She phoned the owner to take the dog home.

The owner was reluctant to keep the dog in Toa Payoh Vets as Vet 1 charged around $35/day for hospitalisation according to the bill of over $75 for 2 days.

"We charge $15/day," I sensed that the owner just wanted treatment and bring the dog home. He had said that he could not afford Vet 1's veterinary bills. He was told by Vet 1 who had said: "Some owners had spent $3,000 - $5,000 and still the vet cannot tell what's wrong with his dog."

This was a case which had puzzled Vet 1 and so it would be in the interest of the dog to be warded for observation and urine testing via catheter.

There was no urine in the bladder (palpation) during admission as this dog urine-marked. In any case, he had urinary incontinence and was dripping large drops of urine on the floor of the consultation room when I placed him on the floor to assess his mobility. He could walk normally but was a bit depressed due to the effects of Tramadol given by Vet 1.

One has to be observant as the dog can't talk. I asked the owner: "Does your dog dribble urine onto the floor?" He said: "All the time, since young."

Now, if you take the owner's word at face value, you would think that there was nothing wrong with this dog. What the owner meant was that the male dog urine-marks, by spraying urine onto vertical areas since young. What I meant was that the dog has urinary incontinence which is not normal. It was a clue - a urinary tract infection which persisted despite 2 days of hospitalisation and treatment by Vet 1. Vet 1 had not performed a urine analysis but he had done blood test, X-ray with barium meal, plain X-ray without barium meal and an ultra-sound.

According to the owner, Vet 1 had said that nothing abnormal could be detected in his dog. After spending nearly $1,000 for 2 visits, the owner expected an answer as to why his dog was lethargic, not eating and had difficulty standing on his hind legs. His wife had remembered my vaccination card which was recorded for the puppy vaccination in 2003 and the husband phoned me to get a second opinion about his dog having a swollen "stomach" with no definitive diagnosis from Vet 1.

I had said: "Not all cases can give answers to the owner despite many tests. Such tests are expensive and therefore the vet bills can be high. Get all the records from Vet 1 if you can and let Vet 1 know one day in advance rather than taking the dog out immediately."

So, 2 days after hospitalisation at Vet 1, the dog came to me. Seeking 2nd opinions is a common occurrence and all vets do encounter such situations. It is best to provide the records to the owner directly. That was why I asked the owner to do it with kindness rather than abruptly taking the dog out from Vet 1 to cut costs.

When the owner came, I asked about the veterinary report. He said: "It will take a week for Vet 1 to write the report." I was surprised that Vet 1 would not provide him the report as is common practice. However, the blood test result, the ultra-sound and the CD of the X-rays were available and those were good enough. After all, Vet 1 had already said that he or she was puzzled by the case and so I let sleeping dogs lie.

I introduced Dr Vanessa to the couple and was also present as the couple wanted to consult me. Usual weighing and temperature taking, history taking and general examination were done by Dr Vanessa. I palpated the dog's abdomen after she had done.

During my palpation, the dog reacted in mild pain from the liver to the bladder and prostate area despite being given Tramadol (an opiate derivative) injection and tablets by Vet 1. I remembered my Glasgow Vet Professor calling the presenting sign as "Acute Abdomen". That was nearly 40 years ago and you can see how ancient I have become.

So, what are the differential diagnosis? This was a tough nut to crack as the dog had been given pain-killers by Vet 1 and was "eating" again according to the owner. He was also walking on 4 legs now. Except that he was dribbling urine onto the floor of the consultation room.

To make diagnosis more difficult, Vet 1's blood test showed an increase above normal of neutrophils and granulocytes (which consist of neutrophils, eosinophils and basophils) but with NO increase in white cell count. Normally in bacteraemia, the white cell count would have also increased. The L/N ratio was normal too. So, what was going on inside this dog's abdomen? Due to economic reasons, I did not suggest another blood test. I tried to diagnose this cost with as low cost as possible as the owner had said he could not afford to pay the vet fees anymore.

His wife would be giving birth soon and understandably there are much more expenses. "Will she be giving birth at Mount Elizabeth Hospital?" I asked as this is said to be the top dog in private hospital services. "No, no," he said.

Back to the dog. I tried to reduce as low as possible the costs.
Back to basic. I asked the owner again: "Was your dog unable to stand on his two hind legs?" He had said something to that effect but then all sick and anorexic dogs are lethargic and would not want to stand up at all or take a long time to stand up. But he had said "hind legs." So, that is one clue. It could be presented as a case of paraparesis.

On admission, the dog was walking and standing up on his two hind legs without problems! So, there was nothing to talk about. However, this dog had been given Tramadol pain-killers and since he had no pain, he would be standing on all legs. I was suspecting intravertebral disc lesions, normally at T/L or L or L/S spinal discs at this age. I would expect this Chihuahua to leap from sofa to floor for the past 8 years of his life and now would bear the consequence. Like joggers who pound the pavement when they are young. They get knee pain in middle age. So, this dog could have suffered IV disc prolapse but not on a serious mode yet.

With the dog standing on the consultation table, I pressed the spinal area from neck to tail. Despite Tramadol, the standing dog winced slightly when my two fingers depressed the lumbar area. I repeated the action and elicited the same reaction in front of the couple and Dr Vanessa. So, there was something wrong with this dog's spinal area and he might have got a painful disc. That was why he suffered paraparesis - an inability, temporarily, to stand up on his hind legs.

Pain diffused to cause his stomach to bloat as he could not pass stools normally. He also could not pass urine well and together with gas inside the intestines, leading to bloated stomach. Pain was diffuse causing acute abdomen as the pain of a partially slightly prolapsed IV disc hurt him badly. So, he did not feel like eating and moving. The owner's mother was worried and sent him to Vet 1.

All these hypothesis needed to be confirmed. As I was under the constraint not to add more vet cost to the owner, I asked Dr Vanessa to zoom in on the disc area of the X-ray of the dog's abdomen where barium meal was given and found in the large intestine.

Dr Vanessa put in Vet 1's CD in her lap-top. Suddenly Mandarin songs and music blasted out (Part 1 of the story) to our amazement. It was as if there was a bugle call to attention to soldiers for the forth-coming commander. It was unexpected and therefore quite funny.

In any case, the zoomed area showed some cloudiness over L1/L2 and L2/L3 IV area and slight narrowing of the IV space. With financial constraint, this was my approach to viewing this X-ray instead of a proper X-ray of the spinal disc. One has to be understanding of the owner's financial wishes as vet tests can add up.

However, the urine test was compulsory. It showed ph 8.0, bacteria ++, amorphous phosphate crystals ++, indicating an INFECTION-INDUCED STRUVITE UROLITH. Now, there was protein +++ in the urine which could indicate cystitis (thick-walled bladder felt by me during palpation before the dog goes home). This was another medical problem and needed to be followed up.

The dog was OK and went home with instructions of no more jumping from the sofa at all, antibiotics and advice to neuter (to prevent prostatic hypertrophy, infection or tumour). The dog needed urine analysis review. Old dogs need more care and annual health screeing if the owner wants the dog to live to a ripe old age and not to incur expensive vet bills. But sadly, most Singapore owners do not bother.

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