"My dog could
not stand up yesterday," the son took time off to
drive his mum, an woman in her late 50s and the
family Maltese to consult me. He is really a good
son as many grown up sons don't bother or delay.
"Today, she can stand. But she is not eating."
HISTORY
This is the type of history the average
Singaporean owner would tell the vet. The vet need
to ask pertinent questions like vomiting (vomited
2x), polydipsia which is -drinking a lot of water
(yes).
PHYSICAL EXAMINATION
 Rectal
temperature was 38.5C. Normal. Mucous membrane
slightly cyanotic and pale.
A large distended abdomen was obvious. An old
female dog not spayed. The first diagnosis was
closed pyometra. Examine the vulva. A red spot of
blood hung out from the vulva gave me the clue.
PALPATION OF ABDOMEN
No pain at all. Pain in the lower 1/3 of the
abdomen is said to be present in closed pyometra
and the swollen uterus can be palpated. The whole
abdomen was just a swollen balloon and so it was
difficult to palpate the two internal uterine
horns. There seemed to be various swellings, some
big. some small.
X-RAYS
X-rays can be done to show the swollen uterine
bodies and to increase the income for the
practice. A diagnosis of closed pyometra by
history and clinical findings will cost the owner
less. I did not milk the owner by getting X-rays
done to protect myself from litigation.
However, I insisted on a blood test to ensure that
the dog's kidneys and liver are in good condition
since the dog was vomiting. Vomiting could be due
to high blood urea or liver disorder from the
toxaemia.
 BLOOD
TEST
An
increased white cell count is said to indicate a
high bacteria infection.
However, a
normal white cell count does not mean that the dog
has no pyometra as will be discussed in another
case. I had blood test done in this case. There
was a marked decrease in white cell count. A
decrease in platelet count. Blood test is an
ancillary
aid to
diagnosis and should never be relied upon to
advise
the owner on the closed pyometra case. If the
owner wants to save money, I don't insist on a
blood test but would advise the owner that he had
been informed.
DIAGNOSIS
What is the instant diagnosis? Normal temperature
and no fever. A drop of bright red bloody vaginal
discharge. Just not eating much or not eating for
2 days. But there is polydipsia, polyuria and
vomiting.
BE BRUTALLY FRANK ABOUT THE PROGNOSIS.
Due to the tendency of a few Singaporeans to
complain and be litigious when outcomes are not to
their satisfaction, I am nowadays brutally frank
to dog owners when their dog's lives are in
danger. Cut to the chase. I said to the son, "Your
dog has a very serious womb infection. She will
die within 2 days if you don't operate. If you
operate she may die on the operating table as she
is very old. Had you got her spayed when she was
young, you would not have this worry."
"What are the chances of survival?" the son asked.
"50:50," I estimated. "If you permit her to be
operated soon. Not wait till tomorrow."
"So low?"
"For most dogs in the same age group, I give less
than 50%," I said. "Your dog is in good condition
and not skinny. She has no fever and was sick only
'2 days'. She has no heart disease but I don't
know about the liver and kidneys." This dog looked
well fed and could be considered a bit on the
plump side. But since she collapsed yesterday and
could not stand up, this was a warning sign not to
give optimistic predictions. Blood test show
toxaemia and yet this dog had a normal rectal
temperature and looked bright. Most owners are
worried about the poor chances of survival. So
they delayed surgery or took their dog to another
vet for another opinion and costing. This is OK if
the dog is not in a toxic stage but who can tell?
TWO CHOICES?
"So, we have 2 choices," the son said. "To operate
and not to operate."
PROPER COMMUNICATION IS IMPORTANT
"You have no choice," I said. "Your dog is going
to die if you don't get her operated. Your mum may
be seeing this dog for the last time before I
operate today. It is very important I do it today
as the womb is very swollen with toxic pus.
EMERGENCY SURGERY
In this case, I operated within one hour after
giving her an IV drip. The dog ate the next day
and is normal as at day 3 when I write this
report. Soon, she would be going home. The surgery
is illustrated in pictures below.
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"Why you
said the uterus is going to rupture soon?"
the young intern asked me. It is good to ask
why. The browning of the uterine walls
indicated cellular necrosis and death.
Within 2-4 days, the uterus would rupture
leaking out pus and killing off the dog. If
the owner procrastinated, don't blame the
vet. The vet must give a letter of advice
to protect himself or herself against
frivolous complaints, should the owner want
the dog discharged to seek a second opinion
and the dog dies at the 2nd vet.
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EARLY
DETECTION, DECISIVENESS OF THE OWNER AND TRUST IN
THE VET'S DIAGNOSIS AND SURGICAL COMPETENCE.
A happy outcome in this case was not due to luck.
When old dogs survive a toxic closed pyometra,
surgery, it is not a matter of luck. It is knowing
the fundamentals and the technicals of the
diagnosis of closed pyometra, the anaesthesia,
surgery and IV support and in excellent
communications with the owner.
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TOA
PAYOH VETS
