Internal Medicine

Find out more about internal medicine referrals at Lime Trees Vets

Internal Medicine referrals are seen by Hywel Parry BVM&S CertSAM MRCVS and Rachel Meakin BVetMed CertAVP(SAM) MRCVS. Hywel and Rachel are available to support you with no obligation and free advice including x ray and laboratory results interpretation.

We are happy to accept cases for a complete referral, or if preferred, we can work with you. This could mean complex components such as tru-cut biopsy, bone marrow sampling or advanced imaging would be carried out by ourselves, but with follow up by yourselves. In these cases we would aim to maintain an ongoing line of communication to allow the case to continue to be managed by both parties.

We endeavour to deliver an excellent certificate level referral service which is friendly, reliable, local and independent. As many of you know, ‘Vets Now’ Stoke service runs from our hospital in Meir Park. This means all our cases receive 24 hour Veterinary Care should they require it from an experienced expert team of emergency vets lead by Rafal Boron, who recently completed his certificate in emergency and critical care training.

Examples of Cases Seen

  • Unexplained weight loss, vomiting and/or diarrhoea
  • Respiratory disease, cough or collapse
  • Excessive thirst
  • Hormonal conditions
  • Anaemia and blood clotting disorders
  • Investigation, staging and treatment of cancers including chemotherapy
  • Urinary tract disorders
  • Liver and kidney diseases
  • Critical care and pain management including trauma cases

Examples of Procedures Performed

  • Gastrointestinal radiography, endoscopy, ultrasonography and biopsy
  • Bronchoscopy and rhinoscopy, including sampling
  • Endoscopic foreign body removal (oesophageal, gastric and airway)
  • Chemotherapy
  • Urinary tract disorders e.g. persistent/recurrent UTI, incontinence, haematuria
  • Hepatic and renal diseases
  • Critical care and pain management including trauma cases
  • Thoracic and abdominal ultrasound examination, including minimally invasive biopsy techniques
  • Bone marrow aspiration and coagulation tests


"Our beautiful Irish Wolfhound puppy has just been discharged home having spent over a month in the expert hands of the Lime Trees team. She had complex problems that were dealt with using skill and compassion and excellent communication with us at each step. The Lime Trees team and ourselves found ourselves between a rock and a hard place on a few occasions during Sybil’s journey but together with expert guidance , understanding and faith we have a lovely survivor back home with us.

We will never forget the kindness and professionalism shown by every member of the team whether in person or over the phone or pictures by email or messenger. Sybil looks forward to returning in a month to have xrays and visit her friends and fans at Lime Trees." 

Sybil's Mum (review from Google)

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!


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.

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