Sunday, May 31, 2015

2178. Clinical Research on methone. Day 3 - sharp bladder stone Shih Tzu goes home

June 1, 2015

Bright sunshine blue sky day. Vesak Day. The couple is free to bring their 3-year-old Shih Tzu home today as they are a working couple. Nobody at home.

Yesterday on Day 2, this dog had ripped out his urinary catheter. I checked that he had tried to bruise his surgical wound near the flank of the penis, with his e-collar. I gave him methone inj. 10mg/ml at 0.3 ml SC. He also had Rimadyl 25 mg tablet.  I checked his surgical area. There was little pain on palpation and less bruising. He ate the U/D can and was very active. I videoed him peeing normally without one leg up.

At 3 years old, he appeared "obese" but actually he was broad-chested. The first vet had provided a good detailed examination report. She had said he was obese with body score BCS 8/9.  She said he could have "urate" crystals and that X-rays of the bladder stones were too radio-dense to be urate stones.  Urate stones are said to be radio-opaque in some reports but it is not true.

Free catch urine dipstick. pH 8, Protein 3+, blood 4+, leucoyctyes negative, "rest wnl."

The dog was super-active today and went home with instructions (Video on urination)

1.  not to feed any more dry food as he may have a familiar tendency to develop bladder stones.
 2. pee more than 2 times per day. Not practical as the couple works and nobody is at home during weekdays. So the dog holds his urine from 8 am to 8 pm waiting to go downstairs.

3. to measure volume of water drank/24 hour and record. Drinks lots of water.
4. to use dipstick monthly to measure pH, blood, etc and let me know
5. to send urine for lab test 6-monthly and if there are small crystals, I can flush out the bladder.
6. stones sent for analysis
7. U/D diet can be expensive. Eat canned food exclusively. No dog treats, rice, bread.

I don't know how many of the abovementioned instructions the couple will comply with.

Saturday, May 30, 2015

2177. Gigantic breast tumours in a 2.5-year-old cat

SUNDAY'S UNUSUAL CASE

A 2.5-year-old female rat with massive breast tumours of around 4" X 3" came in.  She was eating well despite this gigantic tumour. I found it hard to believe but she was not emaciated and looked good.

The couple decided on surgery to remove the breast tumours despite the high anaesthetic risks. I prescribed antibiotics and pain-killers for 3 days before surgery. Surgery was done with Zoletil sedation and isoflurane gas maintenance. The rat was OK within 24 hours. Now the problem was the biting of stitches. She bit off two stitches. I advised daily cleaning and covering with a bigger plaster rather than several small strips. The wound should heal by granulation.

This is an unusual case of an older fancy rat surviving anaesthesia. Do not wait till the breast tumours become bigger or malignant before removal as anaesthetic risks are higher.  Early removal saves lives.  

2176. Clinical research injectable anaesthesia in a dog

Sunday May 31, 2015
My tried formula for a deep anaesthesia and good analgesia lasting 30 minutes, enough for a spay or neuter in a dog, is as follows:

Young dog (less than 2 years, healthy on physical examination)
10kg
Domitor 0.4 ml, Ketamine 0.5 ml IV.


Today, I have Max, 7-month-old Bull Terrier X, male to be neutered.
At 16 kg, this young dog was given below the formulation dosage
Domitor 0.4 ml, Ketamine 0.5 ml IV

The dog moved his head at around the ligation of the first testicle, around 10 minutes.
I gave 5% isoflurane + oxygen gas at 3 lit/min  for 2 minutes and that was sufficient anaesthesia to complete the neuter.

CONCLUSION
The under-dosage was given to reduce anaesthetic risk but this was insufficient dosage without the need to top up with isoflurane.

Surgery must be speedy, accurate and complete. Proper planning is needed to be efficient.                   
 
Two ligatures of the spermatic blood vessels were performed on each testicle. No bleeding.
Baytril and tolfedine 2ml each was given post-op.






Friday, May 29, 2015

2175. A spayed cat still caterwauls. Why?

May 30, 2015
A mother and her young adult daughter brought in 2 two-month-old kittens for vet examination.
They were grey Maine Coon X bought from a home-breeder, a male and female. There were so much wax that I would advise ear irrigation rather than putting ear ointment and massaging. With ear irrigation, the large chunks of black wax get syringed out.

"I have another cat spayed by a vet," the mother said. "She keeps coming on heat, meowing loudly. The vet said it was natural and prescribed some tablets which stopped the caterwauling. Could she have not done a proper spay?"

"It is hard to say, but generally, any ovarian tissues or ovary left inside during spay will cause this caterwauling!".

"What is the solution?"

"To open up the abdomen and look for the ovary near the end of the kidneys," I said. "It will be a long incision."

The owners prefer no surgery and asked about the side effects of the pills given to prevent heat given by the vet for the last 2 years.

"After prolonged use, there may be breast enlargement or pus inside the stump of the uterus, called stump pyometra."

"Other solutions?"

"Injections of hormone every 3 months as in Myanmar cats will stop the caterwauling," I said. "The side effects are stump pyometra."

2173. VIDEO. A young Shih Tzu has a bladder full of stones and an abdominal testicle



POLLIKIURIA AND HAEMATURIA IN A SHIH TZU
 -----------------------------------------------------------------------

Case report
May 30, 2015

"The dog bites," the couple said as I palpated the kidneys and the bladder. The dog reacted to kidney palpation as if there is kidney pain. The bladder was empty of urine and was the size of two grapes packed with hard gritty stones.

Vet 1 had taken urine tests and X-rays.
Urine pH 8 and numerous crystals suspected to be urates??
X-rays of bladder stones were too radio-opaque to be urates.
Had advised removal of retained abdominal testicle in one surgery as bladder stone removal.

"A retained testicle can easily be seen around the neck of the bladder," I told Dr Daniel. "It can be excised promptly by ligation in less than 2 minutes."

As this dog is "obese" at 8.5 kg, any prolonged anaesthesia is risky but abdominal cryptorchidism needs to be done at the same time to save on having to open up the abdomen again. As for the descended testicle, this can be removed another day to reduce risks.













Operation will commence after lunch and the dog will go home in 3 days, providing all goes well with anaesthesia. Stones need to be analysed as the prevention depends on the composition of the stones.

In the meantime, no dry food and give the dog plenty of water to drink.


SURGERY ON MAY 30, 2015
Red swollen bleeding bladder showing inflammation and damage from sharp bladder stones stuck inside the mucosa.  Every fragment had to be flushed out after picking out as many as possible with forceps. The dog's urinary bladder was catheterised but he pulled out the Elastoplast-taped catheter overnight, despite wearing an Elizabeth collar.  

The stones are sharp and may be urates as suspected by Vet 1. They will be sent for analysis.

To reduce anaesthetic time, no neutering was done.







FOLLOW UP POST OP

Sunday, May 31, 2015

2178. Clinical Research on methone. Day 3 - sharp bladder stone Shih Tzu goes home

June 1, 2015

Bright sunshine blue sky day. Vesak Day. The couple is free to bring their 3-year-old Shih Tzu home today as they are a working couple. Nobody at home.

Yesterday on Day 2, this dog had ripped out his urinary catheter. I checked that he had tried to bruise his surgical wound near the flank of the penis, with his e-collar. I gave him methone inj. 10mg/ml at 0.3 ml SC. He also had Rimadyl 25 mg tablet.  I checked his surgical area. There was little pain on palpation and less bruising. He ate the U/D can and was very active. I videoed him peeing normally without one leg up.

At 3 years old, he appeared "obese" but actually he was broad-chested. The first vet had provided a good detailed examination report. She had said he was obese with body score BCS 8/9.  She said he could have "urate" crystals and that X-rays of the bladder stones were too radio-dense to be urate stones.  Urate stones are said to be radio-opaque in some reports but it is not true.

Free catch urine dipstick. pH 8, Protein 3+, blood 4+, leucoyctyes negative, "rest wnl."

The dog was super-active today and went home with instructions

1.  not to feed any more dry food as he may have a familiar tendency to develop bladder stones.
 2. pee more than 2 times per day. Not practical as the couple works and nobody is at home during weekdays. So the dog holds his urine from 8 am to 8 pm waiting to go downstairs.

3. to measure volume of water drank/24 hour and record. Drink lots of water.
4. to use dipstick monthly to measure pH, blood, etc and let me know
5. to send urine for lab test 6-monthly and if there are small crystals, I can flush out the bladder.
6. stones sent for analysis
7. U/D diet can be expensive. Eat canned food exclusively. No dog treats, rice, bread. Stone analysis to confirm urates will be available in one week's time.

I don't know how many of the above-mentioned instructions the couple will comply with.

Thursday, May 28, 2015

2172. Ap Alert sensor

March 29, 2015 

The vet's wife wanted to buy an Ap Alert sensor as her husband considered it very useful. If the dog stops breathing, there is the warning and if it breathes regularly, there is the regular beeping sound. She contacted another vet whose receptionist told her that she must wait till the product comes in from Australia. It would cost $35.

The supplier I sourced for her quoted $250. Her husband said to buy two as his wife did not answer the phone or called me back. I confirmed two but the wife said one would do. The supplier was angry at this change of mind and despite my confirming two, he would not sell.

"Some years ago, she ordered some equipment with price agreed at $580. My girl delivered it to her office," he said." She wrote a cheque of $500. My girl accepted it as she would have wasted her taxi fare in bringing it back. "This $58 meant a lot to me as I had few customers."

In another instance, she asked him to keep the equipment for her but did not buy it. He said another vet asked him for quotations and even asked him to inform other suppliers about the new premises. In the end, this vet did not buy anything from him nor inform him of his failure to secure any business.
Some vets would ask for quotations and buy elsewhere or directly from Australia but would phone him for repairs. One even used another telephone as he did not respond to her call.

2171. The guinea pig's head tilts left - review after 1 week

May 29, 2015

I did not expect to see the busy father after the treatment of the inappetant guinea pig with the left head tilt 7 days ago. The 3-year-old guinea pig was eating 50% of the food and was very thin at 700grams bodyweight.

He turned up with his two daughters today on May 29, 2015 and I was surprised as most owners do not bother or care for a review when their rabbit or guinea pig has head tilt.

"There is much improvement as she tilts her head less," he was glad that the bodyweight is now 752 grams and the guinea pig was eating. He fed Vitamin C tablet crushed in powdery form and bought wood and mineral blocks, but the guinea pig ignored them.

"No more left nostril pus after your antibiotic treatment, but the left eye is still cloudy."  He cared for this guinea pig much despite his busy travelling. "After 3 days of ear drops, she would object strongly to any more ear cleaning."

"I need to irrigate the left ear under isoflurane gas anaesthesia," I advised this procedure as the guinea pig had had painful ears with black soot-like substances. "To flush out the black sticky dirt inside the ears as the guinea pig had no ear cleaning for the past 3 years. Did you give her more space to exercise?" 

"This time, I extended the living space by placing her bottle at a far end of the pen. In this she's got to walk a longer distance to drink."

Under anaesthesia, I checked the molars using my fore-finger to feel for molar spurs. No sharp cheek teeth. The front teeth was trimmed 2 mm shorter.

The guinea pig's left eye cornea was cloudy but much less. She would rub her eyes whenever eye drops were applied.

As there is less head tilt, we will wait another 7-14 days after the ear irrigation and another type of ear drop dripped into the left ear to check whether the head will no more tilt to the left.

Wednesday, May 27, 2015

2170. Video production for a FLUTD cat in Singapore


  draft for intern to produce a video




Recurring Feline Lower Urinary Tract Disease in a Cat in Singapore
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
D
ate:  28 May, 2015




HOOK
Dysuria, pollakiuria and haematuria
Recurrence of above signs after a vet has successfully cured him. Why?
(VIDEO FOOTAGE OF CONSULTATION TO TOA PAYOH VETS)

TITLE








THEME
Feline Lower Urinary Tract Disease in a cat in Singapore's apartment









INTRODUCTION
Pollakiuria, Dysuria and Haematuria can be present in the Feline Lower Urinary Tract Disease cases as follows:

1. Feline Interstitial Cystitis
2. Urethral Obstruction
3. Bladder stones
4. Other conditions such as parathryoid hormones


MIDDLE


Case  5-year-old male neutered cat had recovered from FLUTD after treatment by Vet 1 three months ago but now, same clinical signs of dysuria and going to the litter box many times again.  "Did you see blood in the urine?" I asked the mother and adult son. "Can't see as he goes to the litter box to urinate!" she said.




Diagnosis
Physical exam.  Bladder pain and enlargement, bladder pain and size, genital area for uethral plug and inflammation

Urine test. pH, SG, crystals, bacteria, red and white blood cells, protein
Blood test    Urea & Creatine. Phosphorus and calcium. Leucocytosis.
X-ray. Kidneys, bladder to urethral opening views
Ultrasound


Treatment
Drip
Pain control
Antibiotics
Catherisation
Surgery - cystotomy and perineal urethrostomy






Prompt treatment advised. Kidney failure or infections.

Prompt veterinary treatment - stabilise and pain control with
Diet  - wet food, good quality protein

Environment - Litter boxes, water intake, multi-cat household, change of diet or environment, male neutered cat

Follow up and regular urine tests at half-yearly are rarely done by the owner.













In this cat, painkiller and antibiotics were given. No urine or blood test or X-rays of the bladder and kidneys to lower medical costs this time as Vet 1 had done the first 2 tests 3 months ago and hospitalised the cat for 5 days.

There was no pain or swelling in the kidneys which were not palpable. No painful or swollen bladder. No inflamed genital area or swollen purplish penis. Therefore, I would not push for the tests now.

Overall, this cat could pee but frequently and with difficulty. Blood in the urine could not be ascertained as the cat peed in the litter box.

FOLLOW UP ON DAY 3
The owners were happy as the cat was now "not moody".  He was affectionate again and could pee with lesser difficulty. The mum had no complaints. Two litter boxes and separated sleeping rooms at night. This cat sleeps in mum's bedroom which has a bathroom where the litter box is. As for the new C/D diet, not eating. I advised slowly add 5% and hand feed. It will be successful if the owners persevere.  Ideally, it would be best to test the urine for struvite or oxalate crystals, but in real life, the costs need to be lowered as much as possible.

 




 


CONCLUSION
Recurrence
Diet - struvite or calcium oxalate?
Look into Environmental Factors such as Stress.  One more litter box than number of cats in the household. Privacy quiet area. Bullying.

USUALLY SEEN IN
Male neutered cat
High rise indoor living
Dry cat food

Multiple cat household (bullying, shares litter box, food and water bowls)











---------------------------------------------------------------------------------------------------------------------------------------------
Setting
Singapore - busy hectic city living for people






















Other cases
A 7-year-old cat has bladder stone
http://2010vets.blogspot.sg/2013/02/1303-bladder-stone-in-7-year-old-cat.html


A 12-year-old cat in Turkey has bladders stones
sinpets.com/F6/20130819bladder_stones_cat_Turkey.htm



FLUTD in a male neutered cat

http://2010vets.blogspot.sg/2013/07/1029-flutd-in-young-male-neutered-cat.html


Case studies
1. A bladder stone cat followed up 79 days after surgery. No recurrence on C/D diet but no time for even one monitoring.
2. Urethral obstruction in a male neutered cat recurred 50 days later
bekindtopets.com/stories/20130301cat_bladder_stones_toapayohvets.htm

Prompt treatment of urethral obstruction means faster recovery this time- recurring FLUTD in a 3-year-old male cat. Feeding C/D only no recurrence.
kongyuensing.com/folder5/20130116Recurring_FLUTD_cat_3years_toapayohvets.htm



Cairo cat has stone-packed bladder
http://2010vets.blogspot.sg/2014/12/email-from-cairo-cat-with-flutd-part-2.html


Urethral obstruction cases
http://www.asiahomes.com/singaporetpvet/0707cat_urolithiasis.htm

Perineal urethrostomy as a final resort for recurrent urethral obstruction




Feline Lower Urinary Tract Disease in Cats in Singapore
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
D
ate:  28 May, 2015

2015 cases
May 2015  Recurring dyshagia and pollakiuria in a 5-year-old male neutered cat
http://2010vets.blogspot.sg/2015/05/video-production-for-flutd-in-cats-in.html

May 2015. A young cat still has haematuria after discharge by Vet 1
http://2010vets.blogspot.sg/2015/03/1157-kidney-disease-flutd-cat-passes.html
Painful kidneys
http://2010vets.blogspot.sg/2015/05/an-old-cat-has-painful-kidneys.html


--------------------------------------------------------------------

A cat has bladder stone
http://2010vets.blogspot.sg/2013/02/1303-bladder-stone-in-7-year-old-cat.html


A 12-year-old cat in Turkey has bladders stones
sinpets.com/F6/20130819bladder_stones_cat_Turkey.htm
 

FLUTD in a male neutered cat
http://2010vets.blogspot.sg/2013/07/1029-flutd-in-young-male-neutered-cat.html

Case studies
1. A bladder stone cat followed up 79 days after surgery. No recurrence on C/D diet but no time for even one monitoring.
2. Urethral obstruction in a male neutered cat recurred 50 days later
bekindtopets.com/stories/20130301cat_bladder_stones_toapayohvets.htm

Prompt treatment of urethral obstruction means faster recovery this time- recurring FLUTD in a 3-year-old male cat. Feeding C/D only no recurrence.
kongyuensing.com/folder5/20130116Recurring_FLUTD_cat_3years_toapayohvets.htm



Cairo cat has stone-packed bladder
http://2010vets.blogspot.sg/2014/12/email-from-cairo-cat-with-flutd-part-2.html


Urethral obstruction cases
http://www.asiahomes.com/singaporetpvet/0707cat_urolithiasis.htm


 


BE KIND TO OLDER DOGS & CATS --- GET TUMOURS REMOVED EARLY --- WHEN THEY ARE SMALLER.  More case studies, go to:  Cats  or  Dogs

Make an appointment with your vet. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements. 



Copyright © Asiahomes
All rights reserved. Revised: May 28, 2015
Toa Payoh Vets

Friday, May 22, 2015

2169. Eye trauma in a young abandoned Persian cat

May 22, 2015

After 7 days of antibiotic and painkiller treatment as an in-patient, this rescued young Persian's damaged infected eyeball was removed by Dr Daniel.


2168. VIdeo: A 16-year-old has an obnoxiously smelly armpit wound - 3rd opinion

The very old dog had an armpit wound. It is very risky to tranquilise this old dog. So Vet 1 prescribed medication. The 2nd opinion vet bandaged the left leg and anchored with Elastoplast to cover up the armpit wound. His antibiotic injection was said to last 2 weeks. The owner did not return every 3 days to change bandages.

There was a strong obnoxious smell when I removed the bandage and the swabs which contained a green discharge of rotten smell.
As this dog is very old, anaesthesia is not advised. My solution was to sedate the old dog, wash the wound thoroughly and let it heal by granulation. Potassium permanganate powder sealed up the bleeding.
Injection to bring down the swollen left limb due to tight bandaging. Antibiotics and sleeping tablet sedation to let the dog have peace and sufficient rest.

FOLLOW UP 3 DAYS LATER.
The old dog's limb was much less swollen and the wound was not smelly. "Sleeps a lot," the owner was satisfied with this open wound method to prevent stench of smelly bacterial infection.
In this old dog, the armpit wound is very difficult to stitch up as it is a mobile high tension area. In this video, I proposed 2 surgical approaches.  The Z-plasty and making another new skin incision further behind the armpit wound.

Z-plasty is used to release tension and the stitched area looks like a "Z" after stitching.
In the 2nd approach, the newly created skin incision is left open. It releases tension so that the debrided armpit wound can then be stitched. The new skin incision is not sttiched but left to heal lby 2nd intention. Antibitoic cover. These are my 2 surgical approaches if the dog is still young. Otherwise, lit takes months to heal a large armpit wound as in this case..

2167. VIDEO. The obsessive compulsive cheek pouch storage dwarf hamster

Some people hoard things till the whole house or garage is cluttered. Do hamsters hoard food inside their storage compartment, known as cheek pouches inside the mouth on the right and left sides? They pack the cheek pouches to the maximum and sometimes the cheek pouches become injured by the sharp shells from the seeds and are painful. The hamster is unable to dislodge the contents and rubs his swollen cheeks hairless.

I have a handful of such cases, but the following one is most memorable. He is the teacher's pet.

The black hamster was obsessive  in storing and packing his cheek pouch with food. The lady owner came 3 times for right cheek pouch impaction. This pouch was excised at the 3rd visit and there was no problem for the next few weeks.

Now, lthe hamster scratches his face till hair drops off the top and sides of the face, leaving his eye area still hairy.  Clearing the left cheek pouch is done. The hamster will be restricted to around 5 seeds per day. No large seeds. Sunflower seeds are shelled out before feeding to him.

FOLLOW UP ON MAY 22, 2015. Around 1 week later. "No more creamy discharge from his eyes," the owner was happy to report. "No more wet face!". She fed around 5 seeds e.g. shelled sunflower seeds and corn. The hamster would store the seeds inside his left cheek and eat them later. So his pouch is never impacted causing itchiness when large seeds are stuck inside. 

Thursday, May 21, 2015

2166. The teacher's pet hamster looked like Lone Ranger

March 22, 2015
"How is your hamster now?" I asked the young lady who is a teacher.
"No more creamy discharge from her eyes," she was happy.
"That would be pus," I said. "Are the hairs growing back on her face. The areas around her eyes were all bald and so she looked like she was wearing a mask, like Lone Ranger!"
"It will take some time for the hairs to grow. Previously, her face was wet, wet, wet but now it is dry."
"Was it water from the water bottle?" I asked.
"No, I don't think so."
"It could be from the eye tears," I assumed.

Now she restricts the hamster to a strict die. Around 5 seeds like corn and peeled sunflower seeds. No coloured star pellets and others.So the hamster would not stuff her left cheek.\

I remember this black hamster very well because she had caused much distress to the teacher with the right cheek pouch impacted 3 times. The last time I had it excised and there was no more problem. Till this creamy eye discharge.


2165. A busy father spares time for the left head-tilting guinea pig

Mar 21, 2015

"No, you have not been prompt in consulting me," I said. "The head tilt has been present for 2 weeks."

What is the cause of this left head tilt in this pretty female 2-year-old guinea pig much loved by the daughter. "There is also pus from the left nostril," the father said. "And something white in the left eye."

The lungs had sounds on ausculation, more on the left side. The eye cornea did not stain green with fluorescein stain test and this white central elevated patch across the middle of the eyeball could be a scar. Everything seems to be on the left.

So, was there an injury or infection to the left side of the body? The guinea had lost 50% of the appetite and the rectal temp was 36.4 (hypothermia). The ears had never been cleaned and there was black soot in both ears. The creature squealed when I palpated her ears.

She weighed 700g. What was wrong with her?  

Most likely a middle ear infection. Will need to follow up after antibioics.

2164. Mammary adenomas in an American Cocker Spaniel

TOA PAYOH VETS
toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
22 May, 2015
  Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits
 
Mammary adenomas in
an American Cocker Spaniel

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 21 September, 2012
Upd
ate:  22 May, 2015
 "Why did you  delay seeking surgery till the breast lump is gigantic in size, like two tennis balls combined?" I asked the Buddhist temple teacher who taught Buddhism and morals to over 800 children of devotees.

"The breast lumps grow very fast in the last 2 weeks," she replied. "Nobody in the family wants to bring the dog for surgery. My brother said to let her die."
The solution was surgical removal but the family did not want to pay the medical costs. She was kind to enough to bring in this old dog for surgery at Toa Payoh Vets.
Breast adenomas grow rapidly to sizes of 4 large oranges in this American Cocker Spaniel.
After mastectomy, the dog was eating and normal
"Walk-in" sutures holding the skin edges tightly and the haematoma on the left MG5 was treated by opening up the area via removal of 2 stitches. Healing by granulation was uneventful. 
The 8-year-old dog was not spayed.  Mammary adenoma was diagnosed. No malignancy, according to the histology report. I was surprised as it was a massive tumour. Dr Daniel and I operated. I took over the stitching to ensure that the stitches were tight.

I tacked in "walk-in sutures" through the muscle layer and then the skin,  using 2/0 sutures to ensure that the large long wound would not break down..
The dog came back 4 days later. There was a swelling at one end of the tumour. "

"There's
seepage at the left Mammary Gland 5 area," I said to Dr Daniel who is in charge of the case. "Just cut off two stitches," I said to him. "In this way, the serum can drain out. No need to re-stitch."
After that, we had no more visit from the Buddhist teacher. I was glad that this dog was not abandoned when she had the tumours. Such incidents do occur in Singapore. It is best to spay the female dog when she is young as breast tumours are less likely to develop in spayed dogs.
BE KIND TO OLDER DOGS & CATS --- GET TUMOURS REMOVED EARLY --- WHEN THEY ARE SMALLER. 
More case studies, go to: 
Cats  or  Dogs

Make an appointment with your vet. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements. 

Copyright © Asiahomes Internet
All rights reserved. Revised: May 22, 2015
Toa Payoh Vets

Wednesday, May 20, 2015

2163. Recurring urolithiasis in a Shih Tzu - 5 surgeries to resolve the problem

TOA PAYOH VETS toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
21 May, 2015
  Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits
Recurrent urolithiasis - 5 surgeries for a recurring bladder stone problem


Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Case written: January 7, 2013       Update:  21 May, 2015
 

Taking images of cases with the camera phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon.

There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review. This is time-consuming and that is why most doctors and vets don't bother as images must be taken and filed properly.

For example, in the complicated case of the Shih Tzu with 5 bladder surgeries.
He had 2 surgeries to remove the bladder stones several weeks ago. Two vets (Vet 1 and 2) removed the bladder stones in two separate surgeries.

However, the Shih Tzu had bladder stones and Vet 3 operated on him.   
 with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. See image on the left.
This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catherised with a smaller sized urinary catheter

Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid. According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage. 

This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones). The owner came to Toa Payoh Vets as his daughter was a classmate of my son. So, Vet 4 (Dr Daniel) was tasked with the resolution of the dog's urinary problem. 

How to resolve this problem with the least cost to the owner? That is the tough part. Will a 2nd urethrostomy and closure of the first urethral stoma and scrotal ablation as suggested by Vet 3 resolve the problem for once and for all? 

Dr Daniel (Vet 4) at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg. He stitched up the urethral stoma (first urethrostomy done by Vet 1) so that the dog could pee as a normal dog, from the tip of the penis. Would this resolve the problem?

Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid (I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days. Vet 3 had likely ruptured the urethra leading to leakage of urine and blood in the left inguinal area.  

Large left inguinal swelling due to urine + blood accumulationProblem and surgical solution explained by illustration for the owner
Inguinal fluid and urine for lab analysis  Surgical plan from Dr Sing Kong Yuen
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Dr Daniel. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area. It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means money expenditure for the owner. "

As Dr Daniel had to go overseas, I became the Vet 5 as I took over the case and reviewed the complicated urine leakage problem. This involved talking to Vet 3 as to what had been done.

Vet 3 said: "We did an ultrasound and saw fluid inside the scrotum. This was not recorded in the case report as the owner was not charged."

Ultrasound can reveal fluid in an organ but will not be able to tell whether it i urine or blood or both.

This is where the perineal swelling in this image substantiated a possible urine leakage. I proposed a dye test but it is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.

So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem to the owner's satisfaction and to the dog being able to live a normal life without difficulty in urination.

What should I do? This is a complicated urinary tract problem due to urine leakage presumed to be from a tear in the perineal urethra (see image of perineal swelling above) and subcutaneous fluid presented daily along the left side of the penile length.

I thought hard. The dog had gone through 4 anaesthesias and surgery. Veterinary expenses were considerable.

My surgical approach was to extend the urethra stoma made by Vet 1. This  had been closed by Dr Daniel as he wanted the dog to pee normally from the tip of the penis. Then I did a scrotal ablation (cut off the scrotal sac), close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.

The dog still had difficulty in urination after Vet 3's surgery. My surgical approach to post-op complications from Vet 3's surgery
which had removed the bladder stones
Open up the woundScrotal ablation
Enlarged Vet 1's  urethrotomy incisionEnsure urethra is patent
Healing of the surrounding areasGoes home with prescription diet S/D
Dog is able to pee via the original enlarged urethrostomy for the past 3 months and as at Jan 7, 2013. Dog eats prescription diet C/D. Urinary analysis and X-rays on a regular basis are recommended. Will the owner comply?  
In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.

UPDATE as at Jan 7, 2013

The dog pees through the first urethrostomy without any difficulty. The owner came to buy the C/D canned food. It is good news.  Post-op urine and blood tests and X-rays are advised but owner compliance with regular monitoring will be difficult due to various reasons.

P.S.  Urethrostomy = a hole is cut into the urethra (passage for urine from bladder to the tip of the penis). 


Yearly blood and urine tests may detect early presence of bladder and kidney stones in your dog and cat.  For urinary health screening appointments, tel: 6254-3326, 9668-6468
e-mail
judy@toapayohvets.com
.

Copyright © Asiahomes
All rights reserved. Revised: May 21, 2015
Toa Payoh Vets

2162. Carnaissal tooth abscess treatment in a Pomeranian - follow up 6 years later

TOA PAYOH VETS toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
21 May, 2015
  Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits
A Facial Wound did not heal: Oro-nasal fistula follow up 6 years later
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: November 15, 2007      
Update:  21 May, 2015

"Why didn't you come for the surgery?" I admonished the lady owner of the Pomeranian. "You wasted more money buying more antibiotic powder from the pet shop to dust onto the facial wound, hoping it would heal. You can see the wet wound under the left eye in the image below. It is a classic presentation of an oro-nasal fistula, also known as malar abscess or carnaissal tooth abscess. 
Wound for many months. Oronasal fistula. Maxillary PM4. Toa Payoh Vets

"For ordinary skin wounds, the antibiotic powder would heal them, but I had already explained to you why the wound would never heal without dental extraction of the infected tooth."

Her 4-year-old Pomeranian had a weeping wound of around 0.5 cm in diameter below the left eye, above the maxillary 4th premolar tooth. It did not heal over the past weeks despite various medications and powders she had sprinkled on.
Some 14 days ago, I had patiently explained to her by illustration how the infection from the root of the maxillary 4th premolar had spread into the nose from the diseased gums to the skin below the eye.

The bacteria from the decayed roots of this premolar had dissolved the nasal bone area and made a hole. This condition is called an oro-nasal fistula. Dental surgery to remove the infected premolar would resolve her Pomeranian's non-healing wound problem once and for all.

"The vet did a slick sales presentation to make me spend money unnecessarily" the husband of the dog owner must have told her. "How can a rotten tooth inside the mouth cause a hole on the skin below the left eye. This doctor is nuts and is desperate to make money. Mouth and nose. So far apart. How can there be a connection?"

Back to the present, I said, "Surgery was to be done 7 days ago after 7 days of antibiotics. But you did not turn up till today --- 14 days later!"

The middle-aged lady shook her head.  I forgot my bedside manners by scolding her. The customer is king. The general anaesthesia and tooth surgery was affordable for her as I had discounted my fees. That savings  could buy another sari from Niven Road's sari shop.  

I was annoyed because there was an optimal time to do extraction of the infected and decayed tooth. It was after 7 days of antibiotics and she had not kept her appointment nor cancelled it. 

She just did not turn up as there was less weeping of the wound due to antibiotics. However after the course of antibiotics, the bacteria in the infected teeth had resumed their attack and the facial wound became wet and bleeding again.

The lady pulled up her fine and most colourful sari and smiled sheepishly, "My husband wanted to use the money for the dog's anaesthesia and surgery to go to India for holiday lah!"

Now that the dog is no longer on antibiotics, should I operate? There was no urgency in the sense that it was an emergency. But it would be in the best interest of this poor dog to be cured as soon as possible. 

The Pomeranian's teeth were not brushed at all as this is a common practice in Singapore. 

Initially bacteria attacking the food debris on the tooth gum line would die in 3-5 days to form a plaque on the tooth surface. As the dog's teeth were not brushed daily or at all, more plaque accumulated on the surface of the teeth.

Soon they become tartar (calculus). The gum became infected, leading to gingivitis. The root of the 4th premolar tooth of the upper jaw became abscessed due to bacterial attack. Abscess tracked upwards towards the nose and side of the face. Soon a facial wound appears to form a connection (oro-nasal fistula) between the tooth and the skin, discharging pus daily. As the pus and fluid from the mouth is discharged daily, the wound can never heal as it is always infected.

The decayed 4th premolar and lst molar became loose as their roots had been exposed as the diseased gum diseased shrivelled. The supporting structure of the teeth was weakened by the bacterial attack, leading to a loose tooth that would fall out in time to come. 

At this time, there was no choice but to extract these two loose teeth. Otherwise the Pomeranian would suffer from daily toothache as the owner's husband might thwart her from doing the right thing for her dog. I put the Pomeranian under general anaesthesia gas and got the offending teeth extracted and scaled the other good teeth to remove the tartar.

BLOOD TEST & OTHER PROCEDURES. There was no pre-anaesthetic blood tests to assess the liver and kidney functions and blood cells of this younger Pomeranian. Veterinary costs would be additional $150.
Most likely the poor Pomeranian would not receive any veterinary attention if an increase of $150 was added to the veterinary expenses.  Therefore I did not require blood tests to lower the medical costs.   

Physical examination of the Pomeranian indicated that there was no cardiac problem and there should be no death from general anaesthesia. The dog's anaesthesia was uneventful. He went home on the same day and had no more facial wound below the eye since 2007 to 2013I was fortunate to get an image of the Pomeranian in 2013 as shown below: 

2007 image of the Pomeranian
Pom Oronasal fistula, premolar 4 root infection, Toa Payoh Vets

The image below showed the Pomeranian just after removal of the bad teeth.
 
Pom Oronasal fistula, premolar 4 root infection, Toa Payoh Vets

The facial wound closed after a few days when I phoned the lady owner to follow up after extraction of the infected teeth.
"You are a good vet," the lady surprised me with her compliment especially after my admonishment.

She was free from the chore of having to clean the facial wound daily. Her dog was more active and has a livelier demeanour. And what more joy could a lady have than to see her companion having a higher quality of life?
 
2013 image of the Pomeranian
with no oro-nasal fistula
UPDATE IN FEB 2013
I have not seen the Pomeranian since 2007. He was 4 years old then. In Feb 2013, the owners came with the Pomeranian asking me where to board the dog for Chinese New Year. I took the following image of him with a face that has no more oro-nasal fistulas for the benefit of readers.

As at May 21, 2015, I have not seen this dog since Feb 2013. More interesting cases of dental problems in Singapore dogs are at:
Toa Payoh Vets Clinical Research: Mouth problems in Singapore's dogs



Yearly dental check-ups may prevent tooth decay and gum infections and painful eating for your dog and cat.  For dental check-up and scaling appointments, tel: 6254-3326, 9668-6468
e-mail
judy@toapayohvets.com
.

Copyright © Asiahomes
All rights reserved. Revised: May 21, 2015
Toa Payoh Vets

Tuesday, May 19, 2015

2161. Teaching the child to be kind to hamsters

May 20, 2015

"My mum keeps putting eye drops," the 11-year-old girl said again when the 2nd worst case of eye abscess hamster is discharged after 4 days of in-patient treatment.

The slim little girl is bright as she topped her Science examination but she confessed she failed her Maths. The mother had told me she applied eye drops but the dwarf hamster's lower eyelid kept growing bigger and bigger. "Pus leaked out from her eyelids," she said to me. So, she texted and emailed me to get an appointment.

The little girl could not understand why the mother was doing the hamster treatment but in the real world, many mothers would do that, to save money as a family expense in Singapore is very high.

The left lower eyelid was full of bacteria and pus kept forming. On the 2nd and 3rd day and even on the 4th day, I had to lance the residual pimple on the upper right eyelid and the lower conjunctiva.

The mother brought the daughter to visit the hamster on Day 3 and decided to wait another day for the pus to go away.





The worst case was seen in 2008 documented in my webpage at:
 
http://www.bekindtopets.com/animals/20080917Hamsters_Eyelid_Abscesses_ToaPayohVets.htm