"You are one of the
two vets I know," the Labrador Retriever owner had fixed
a 10 am appointment to consult me. "Vet 1 had taken an
X-ray of the abdomen and said there was nothing wrong in
the stomach and intestines. He had prescribed
antibiotics and pannadol for the skin infections in the
swollen skin under the chin.
"That was around 2 weeks ago. But my dog is very tired
and the skin swelling is still there.
"Look," the owner pointed to the skin puffing out from
the side of the two mandibles. "The right side of the
chin is even more swollen. See the right front paw. It
is swollen compared to the left paw!"
I could see that both front paws are 20% more swollen
than both hind paws. The male Labrador Retriever also
had loose flabby skin hanging out from the right and
left side of the jaws, such as you would see in people
with double chins.
Cardiac Tamponade - The
pericardial sac is filled
with fluid. The skin under
the chin and other parts of
the body is oedmatous. Vet 1
said blood test showed that
the kidneys and livers were
normal and the dog had a
skin infection. Ultrasound
confirmed cardiac tamponade
In August 2011,
there are three vets at Toa Payoh Vets and owners have a
choice of who to consult. I have not retired but it is
time to hand over to the younger generation and Dr
Vanessa would be on duty from 11 am to around 7 pm
usually on weekdays. I would usually be around from 9.30
am to 12noon and at other times agreed upon by the owner
who wanted to consult me.
This was no more a skin infection at first presentation.
Somehow, this dog's condition reminded me of a cow
presented by my professors in 1974 when I was in the
final year of vet studies in Glasgow University. It was
a case of mediasternal tumour. Blood flow to the heart
was obstructed and skin swelling or subcutaneous oedema
in the side of the face appeared. Could this be a rare
case of mediasternal tumour in an older dog?
It was 1974 and now it is 2011. But certain interesting
rare cases are never forgotten by me. "Have you seen
such presentation of swollen folds in cattle in
Myanmar?" I asked my assistant Mr Min and his friend Tun
who are qualified vets from Myanmar. "It was a case of
mediasternal tumour in a cow I had seen when I was in
Vet School." They shook their heads and probably didn't
know what I was talking about. Mediasternal? What the
hell is it? Where's the mediasternum and what is it? The
owner asked: "Are they treating cows in Myanmar?" I
said: "I don't really know but I presume most vets treat
farm animals like cows and buffaloes as Myanmar has many
Two assistants put the dog onto the examination table. I
palpated the abdomen. No liver or kidney swelling or
pain. I turned the dog to the right side, to the left
side and upside down. The dog did not mind or had any
increase in breathing rate. He was just a very nice
Labrador Retriever and looked at me quizzing why I did
all these maneuvers. I wanted to check for swellings of
the lymph nodes and to look for the suspected
mediasternal tumour or tumour near the thoracic inlet.
Nothing was found. "The prepuce and penile sheath is
very much swollen," I said to the owner when the dog was
"This dog would be suffering from diseases affecting one
of the 3 organs," I said gravely. "It could be the
heart, liver or kidney. More tests would be needed. Are
you OK with having tests like ultrasound, X-ray and
blood and urine tests done?"
I asked for permission as the tests could cost the owner
a bit of money.
The lady owner showed me a piece of the laboratory test:
"Vet 1's blood test said there was no liver and kidney
problem. I would like to know what's wrong with my dog.
He is still young. Only 56 years old in human age. But
he has lost a lot of weight. I had also reduced his food
intake tought. However, he is breathing faster than
normal. Not his usual active self!"
The Labrador preferred to sit on his chest rather than
stand up on the consultation room floor. Occasionally he
wagged his tail. I could see his chest movements of over
90/minute which is faster than normal and coached my
assistant how to take the respiratory rate/minute based
on number of respirations per 6 seconds x 10. This case
is part of a teaching case as it is a rare medical
condition presenting as skin swellings in the face,
front limbs and penile skin. I coached my assistant how
to take the pulse rate. The pulse was barely palpable
and of poor quality.
After the general observation, I got the dog to be put
onto the consultation table and did the routine checks.
Significantly, the heart sounds was barely audible.
"Give me another stethoscope," I said to Min who handed
me another stethoscope.
I asked Min: "How come the Littman stethoscope was
broken? And who broke it?" Min was silent.
One new auroscope's cover was cracked. The
electro-surgical handle insulating the hand from
electric shock had disappeared without a trace and Min
did not know what had happened. The new Shoreline
operating table surface of less than one year and
costing me around $7,000 was scratched in several
places. Rust would set in if the scratches are deep. I
had replaced a new isoflurane vaporiser as the previous
one had leaked some gas in its side tubing. Some of
these damages should not happen. I mean, how could a
Littman stethoscope disappear? Bitten off by a dog?
A heavy hand from the staff? Or wear and tear? I am
asking a consultant to do an audit of the anaesthetic
and other equipment.
I auscultated the Labrador's heart with the 2nd
stethoscope. "The heart sounds are barely audible," I
asked the owner whether Vet 1 had checked the heart.
"The dog needs an ultrasound and X-ray of the heart to
confirm what's causing this problem. Normally, I can
hear heart sounds clearly and loudly. In your dog, I can
barely hear it."
In reply she said:
"No. Vet 1 must be getting old." Vet 1 had
diagnosed skin infections of the chin, or more
precisely, under the skin of the chin. The symptoms
might not be obvious at that stage 2 weeks ago. I could
be at the right place and the right time for the dog to
exhibit subcutaneous edema leading to a "double chin."
Vets are not Gods. No vet can be 100% correct in
diagnosis especially when veterinary medicine throws in
a surprise every now and then. This was a case of
cardiac tamponade, a very rare disease encountered in
practice. The presenting sign in this case was