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Date:   28 August, 2011  

 Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
The Labrador has a "double chin" - cardiac tamponade - Part 1
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS 
Be Kind To Pets
Veterinary Education
Project 2010-0129
"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.
subcutaneous swelling - edema - cardiac tamponade - heart base tumour likely - toapayohvets, singapore subcutaneous swelling - edema - cardiac tamponade - heart base tumour likely - toapayohvets, singapore subcutaneous swelling - edema - cardiac tamponade - heart base tumour likely - toapayohvets, singapore subcutaneous swelling - edema - cardiac tamponade - heart base tumour likely - toapayohvets, singapore
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 farms."

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 upside down.   

"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 subcutaneous edema.    

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