"My other dog has been treated by Vet 1 for the past 12 years," the owner said he had no veterinary report from the vet who had treated the presented Shih Tzu of 4 years old for coughing. "I feel bad to ask Vet 1 for the medical records and X-rays for this Shih Tzu."
"How long has this Shih Tzu been coughing?" I asked.
"5 months. My domestic worker says the dog has a tongue ulcer."
"There should be no problem with Vet 1 sending over your dog's records as this is a common practice. Shall I phone on your behalf?". The owner agreed and Vet 1 sent his report over. The coughing started 3 months ago and blood test and X-rays of the chest and abdomen were normal.
What's the cause of this persistent coughing? There was a tongue ulcer at the tip and one on the hard palate. I shone my torchlight at the ulcers to show the owner. The dog just would not cooperate, but the owner already knew of the existence of the ulcer. I palpated the dog's throat. It was very painful.
"My dog sometimes throw up liquid," the owner said. This is quite a complicated case as the heart and lungs were normal on auscultation using my stethoscope. What is the cause of this persistent coughing?
To complicate diagnosis, the right and left submandibular and popliteal lymph nodes were much enlarged. I let the owner feel the lumps. Could this be a concurrent case of lymphoma or lymphosarcoma?
"Did your tongue lick some poison?" I asked. "Tongue ulcer at the tip of a normal tongue usually indicated something corrosive had burnt the tongue. Like insecticide."
Persistent coughing for 3 months. Weight loss. Why?
"Well my dog has licked shampoo used to treat his dandruff."
Blood, urine and X-rays of the throat, chest and abdomen are being done as this are necessary to aid in the diagnosis of persistent coughing even though some tests were done earlier by Vet 1. Throat X-ray was not done and is usually not done in cases of coughing.
However, this must be done as there may be a piece of bone stuck inside the throat, leading to persistent coughing and weight loss as the dog ate little. The tongue ulcer could be due to licking of the shampoo over the last 3 months. Wait for the new X-rays to be done today.
"Dog owners may want to be loyal but the vet must be able to get the dog's problem resolved within two visits," I said to my associate vet. "Good bedside manners are great but repeat visits cost the owner money and time. So they go for 2nd opinions if the family vet can't come to a correct diagnosis and treatment."
"Why did Vet 1 not able to diagnose the case?" the man asked me twice after I had shown him the X-rays and asked him and his wife to palpate the enlarged submandibular and popliteal lymph nodes. It is show, not tell nowadays.
"Vet 1 is an experienced vet," I said. "The lung X-ray was normal and the lymph nodes have probably just enlarged in the last month. He did blood test and the result was normal as he had told you."
The second opinion vet has the benefit of the progression of the disease. I warded the thin dog. He did vomit white frothy mucus around 3 times per day and ate little. So, what is the diagnosis and what is the cure?
Use evidence-based medicine and do a thorough physical examination including turning the dog upside down and checking all lymph nodes and doing abdominal palpation. There was no fever, increased respiratory rate or anaemia or other abnormal signs other than the enlarged lymph nodes and tongue ulcers and severe weight loss. The X-rays were useful but the vet must take more than one X-ray. Vet 1 did one X-ray, the quality of which was not so good.
Take more than one view of a site but some vets just do one view to reduce veterinary costs to the client. This may not be in the interest of the canine patient. Study the X-rays again in the privacy of your home and review your case again and do research on similar cases, discuss with peers. This will make you a better vet over the years. There is no short-cut to be a better vet and veterinary medicine and surgery cannot be mastered even with a life-time of practice as the subject of the whole canine body has too many diverse medical and surgical conditions. Human medical or surgical specialists just focus on one area of the human body. Vets have to be know it all!
This is likely a case of canine lymphoma at an earlier stage. Late stage would show images as described in:
http://www.sinpets.com/F5/20110319canine-lymphoma-eye-bleeding-toapayohvets.htm. Due to economic reasons, more detailed tests cannot be done. As to the cure, chemotherapy is needed. Prognosis is not good and the owner knows it. He and his wife were quite satisfied with the diagnosis using evidence-based medicine.
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