Internal Medicine

The Lime Trees Cat Clinic is now open!

With access to an in-house laboratory, flexible and rigid endoscopes (gastroscopy, bronchoscopy, rhinoscopy, cystoscopy and laparoscopy), ultrasonography and CT, our highly qualified team is equipped to deal with complex cases.

Examples of cases seen:

Unexplained weight loss, vomiting and/or diarrhoea
Respiratory disease, cough or collapse
Excess thirst and urination
Complex hormonal conditions
Anaemia and blood clotting disorders
Investigation, staging and treatment of cancers including chemotherapy
Urinary tract disorders e.g. persistent/ recurrent UTI, incontinence, haematuria
Hepatic and renal diseases including portosystemic shunt diagnosis

Examples of procedures performed:

Gastrointestinal radiography, endoscopy, ultrasonography and biopsy
Bronchoscopy and rhinoscopy, including sampling
Endoscopic foreign body removal (oesophageal, gastric and airway)
Chemotherapy
Thoracic and abdominal ultrasound examination, including minimally invasive biopsy techniques
Bone marrow aspiration and coagulation tests
Critical care and pain management including trauma cases
Investigation into pyrexia of unknown origin
Diagnosis or management of infectious diseases e.g. FIP
CT with contrast is utilised in many cases. It is especially useful for both upper and lower airway disease or where contrast radiography would once have been used.

Case Studies

Profuse Pleural Effusion in a Border Collie

Buddy, an 8 month old Border Collie male dog, was referred to us with acute respiratory disease cause by a profuse pleural effusion. The referring colleagues drained 800ml of bloody fluid prior to referral. Routine haematology and biochemistry were performed and a further 600ml of fluid was drained from the chest and analysed. It proved to be a modified transudate. A presumptive diagnosis of a diaphragmatic hernia with part of the liver and some intestines in the thoracic cavity was made by the medicine team following thoracic radiography and ultrasonography.

Buddy was transferred at this point to the surgical department. Now stable, we proceeded to a general anaesthetic and an open abdominal approach. The diaphragmatic hernia was confirmed and after careful direction of the adherences, the liver and the intestines were replaced into the abdomen. The diaphragmatic hernia was closed and a chest drain was placed as a preventive measure. A seal was obtained after we drained the chest with the help of the chest drain and the abdomen was closed routinely.

The dog made a good recovery post-surgery. After a night of hospitalisation, the chest drain was removed and Buddy was sent home back to his normal self.

Following discharge, the owner told us that Buddy ran after some sheep and bashed himself on a tractor wheel 2 weeks before, and with hindsight he thought most of the problems started from there!

Pre-Surgery

Post-surgery with chest drain.

PU/PD in an Alaskan Malamute

History: Boris, an 8yr old MN Malamute, was on medication for hypothyroidism which was well controlled. He was presented for PU/PD which had been noticed only very recently by the owners. History was otherwise unremarkable.

Physical examination: Unremarkable overall. HR 74, RR16, BCS 4/9, mms pink, CRT 1.5seconds, good synchronous pulses. No detectable abnormalities on thoracic auscultation or abdominal palpation. No palpable lymphadenopathy.

Bloods and urinalysis: Mild elevation in total calcium; rest of biochemistry (including SDMA) wnl; electrolytes wnl; haematology unremarkable; USG 1.014; sediment and dipstick unremarkable. Follow on ionised calcium confirmed true hypercalcemia.

What are your differentials and what would you do next?

Differential diagnoses for canine hypercalcemia:

Malignancy (most commonly lymphoma, anal adenocarcinoma and multiple myeloma)
Primary hyperparathyroidism
Renal disease
Hypervitaminosis D (e.g. psoriasis cream, rodenticide, jasmine) or hypervitaminosis A
Addisons
Granulomatous disease
Osteolytic skeletal lesions (e.g. osteomyelitis, osteosarcoma)
Excess phosphate in diet

Hypercalcemia can also be a normal finding in young growing dogs and total calcium can be increased artefactually with hyperalbuminemia.

Investigations: Cost was a concern so tests had to be selected carefully. Results from the routine bloods made renal disease or Addisons unlikely. There was no history of toxin exposure and no palpable lymphadenopathy or anal mass. Globulins were normal (usually high with multiple myeloma). Routine imaging of the thorax and abdomen was unremarkable other than several small calculi in the bladder. Urinary calculi are more common with primary hyperparathyroidism and the dog is also likely to be systemically ‘well’ compared to many of the other differentials. Ultrasound of the parathyroid region identified a 2cm hypoechoic nodule. Elevated PTH levels with concurrent elevated ionised calcium are the gold standard for diagnosis of hyperparathroidism but had to be omitted in this case due to cost. Additionally they require special handling (freezing and courier transport to the lab) and are only run weekly at specialist laboratories so turnaround for results can be over a week.

The nodule was surgically excised and the small calculi were flushed out via urinary catheterisation. Calcium levels were monitored post operatively as they can drop but he was discharged without complications and the signs resolved.

This case demonstrates how it is still possible to reach a diagnosis and carry out effective treatment in cost constrained cases by considering history, physical examination, basic test findings and good quality imaging. In practice diagnostic procedures are often omitted due to many reasons such as cost, owner fears, lack of expertise and concurrent disease complications but the risks of these omissions should always be discussed thoroughly with the owners. In this case surgery was undertaken based on a presumptive diagnosis and it was important that the owners were fully aware of this.