Thursday, March 19, 2015

1141. Two cases. 1. Pyometra - vomit and "bloody" diarrhoea. 2. Hyperestrogenism - Swollen vulval area

A young lady's 10-year-old Cocker Spaniel had vomiting and bloody diarrhoea for around one week.
"There is a smell of blood," I said. "The blood test showed low red cell count and haemoglobin. The white cells increased showing bacterial infection. The platelets are low, showing septicaermia. The signs are not good."

I advised inpatient for 2 days with IV drips. Tests for Giardia, coronavirus and parvovirus were negative.

The lady wanted her dog back on the same day. At home, the dog continued vomiting and passing bloody stools. "She is having her heat period now," she said. The next day, the dog passed away at home when I called.

This could be a case of closed pyometra with "heat" being observed by the lady on the day before the dog died.

The dog reacted wanting to bite me when I palpated her lower abdomen. She was overweight and so I could not feel the distended uterus. Septicaemia would result in vomiting and diarrhoea. However, the lady did not want the dog to be warded and this is the owner's wish.

This death could be prevented if the dog had been spayed at a young age. But many owners prefer not to spay their female dogs. The illness and death stressed this young lady considerably. It affected me too as I would like all pyometra dogs to live.

However, I could not operate as this dog was unfit for surgery. Blood transfusion would be costly and there was some financial concerns in this case.  Prevention by spaying the dog would have been much cheaper but many owners do not expect their female dogs to suffer from pyometra.


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Mar 19, 2015.
Another case of suspected pyometra today. The 4-year-old Shih Tzu licked her vulval area till it became 10X larger than normal (video). Some female dogs are very clean and would lick off every small drop of vaginal discharge till the vulval area became much swollen, as in this dog. Another possibility is hyper-estrogenism.

The owner confirmed that this dog was very clean. She had fuzzy memory of the onset of the last heat. "Maybe November," she said.
"When was the earlier heat?" I asked.
"May," she said.
"So it is March now," I replied. "However, not all dogs come on heat exactly 6 monthly."

Antibiotics now. Spaying 2 months later is advised.

BLOOD TEST
2 abnormal results
Blood glucose  12.1  (3.9-6.0)
Monocytes 18.3% (3-10),  Absolute  1.94 (0.15 - 1.35)








1140. Pyometra in a Miniature Schnauzer

Thursday, March 19, 2015

The 6-year-old Miniature Schnauzer just could not stand up during the last 2 days before pyometra surgery.
"He could stand up when I carried him," the owner came on the 2nd day. The dog was recumbent and not active.
Blood test showed blood bacterial infection

Two days of IV drips and antibiotics. No immediate operation as survival rate will be very low. Owners expect miracles.

On Mar 18, 2015, he was operated by Dr Daniel. Thick dark brown pus (video).
Today, Mar 19, 2015, 11.15am, he was back to normal self (sitting up) see video and should have a good chance of survival. (Video).



Tuesday, March 17, 2015

** 1138. A 1.5-year-old cat has kidney failuare - nephritis & proteinuria. Had FLUTD 10 days ago.

10 days ago, the 1.5-year-old male, not neutered cat had obstructed bladder. A vet had relieved the blocked bladder after hospitalising the cat for 5 days. Now, the cat "cannot walk" and has throat pain.

The other vet's history showed the cat had septicaemia and kidney disorder (high creatinine).   The cat is very thin, at 4.1 kg now and hypothermic. The cat had dropped around 1 kg of bodyweight since 10 days ago.  The cat still peed blood but had no blocked bladder. 

X-rays showed enlarged kidneys. .

The first vet had  prescribed resistant antibiotics. When the cat was lame 4 days ago, the vet prescribed Tramadol 50 mg (1/6 twice a day for one week.).

But the cat was peeing blood.
Urine tests showed protein 3+, bacteria, blood, and white cells, spermatozoa + (cat is not neutered).

The vet had discharged the cat after 5 days of inpatient treatment. He prescribed clavamox 62.5 mg 1 table two times per day and Danzen once a day. The clavamox is usually given orally to cats by most vets in Singapore. In this case, it was ineffective based on the antibiotic sensitivity test (see below).

Hence the cat still passed blood in the urine for the last 10 days, became weaker and the inflamed penile area was really painful. So, the cat could not walk properly. The penile area was still inflamed and enlarged (see x-rays). The kidneys became more inflamed and hence palpable as 3X enlarged. The kidneys were damaged as protein is found in the urine test.

No blood test was done again to reduce medical costs. The first vet had done blood test showing septicaemia and kidney disorders.


BACTERIAL CULTURE AND SENSITIVITY TEST
At this stage, I did a bacterial culture and sensitivity test. Sometimes, there is the cost considerations and the test is not routinely done.


Bacterial culture of urine - showed Enterobacter aerogenes bacteria  resistant to amoxycillin+clavulanic acid (clavulox, clavamox), cefuroxime, nitrofurantoin, ampicillin + sulbactam and ampicillin.
It was sensitive to ciprofloxacin, gentamicin, cotrimoxazole, fosfomycin.


KIDNEY FAILURE means that the kidneys is unable to remove waste products from the blood. The kidneys have not stopped working and making urine. Early clinical signs are increased thirst and urination. Advanced kidney failure cause uraemia and signs include loss of appetite,vomiting, diarrhoea, very bad breath and ulcers in the mouth.

A high blood urea nitrogen (BUN) and creatinine levels mean kidney failure. 


TREATMENT
Thin lethargic, dehydrated.
In patient 2 days.
1. Diuresis.  At least 200 ml of sucutaneous fluids twic a day are given to "flush out" the kidneys. The flushing process is called diuresis is used to stimulate the kidney cells to function again. If enough kidney cells are functional, diuresis "restart" the kidneys. Replacement of various electrolytes  esp. potassium must be done. Proper low protein nutrition and drugs to control vomiting and diarrhoa.


2. A low protein diet to decrese the work load on the kidneys.
3. A phosphate binder to prevent phosphorous accumulating in the blood.
4. Fluids subcutaeously given at home. Not done in this case..
5. A drug to regulate the parathyroid gland and calcium levels.
6. A drug to stimulate the bone marrow to produce new red blood cells if the cat is anaemic.  
Baytril and drips.


MAR 24, 2015 FOLLOW UP - (7 DAYS AFTER CONSULTATION AT TOA PAYOH VETS).
1. No more blood in the urine since my treatment on Mar 17, 2015 (10 days after treatment by first vet).
2. Cat needs to be hand fed.
3. Cat does not poop.
Admitted: Wt 3.5 kg. Lost 600g since 7 days ago as the cat did not eat.
Temp 35.1 C compared to 36.7C 7 days ago. Severe dehydration. R lip commissure abscess, R gum ulcers behind R U canine tooth, central tongue ulcer. Rehydrate. Check FIV, FeLV but these were negative.  Poor prognosis.

Need to order only Royal Canin Dry Food for kidneys (no pork). The Royal Canin canned food and the Science diet K/D can and dry has pork.


4 cats in the household. This cat was the new introduction but had been with the other 3 cats for 15 months.

CAUSE OF FLUTD

The vet had diagnosed FLUTD (Feline Lower Urinary Tract Infection). However, the vet's blood tests showed septicaemia and kidney infections. This means that this cat has a much more serious illness than the ordinary FLUTD cases where, after relieving the bladder obstruction through catherisation, the cat bounces back and starts eating.

The owner had changed Fancy Feast to Pro Nature dry food 3-4 days before the bladder obstruction. There was no Fancy Feast available.  A change of diet suddenly may cause FLUTD leading to bladder obstruction. The other 3 cats were not affected. The husband could not recall till I asked him to recall and he confirmed that there was a change of brand of dry cat food. The vet had recorded this in his case sheet.

With kidney pain, the cat cannot walk normally. I felt an enlarged kidney but no pain. This is because the vet had prescribed oral Tramadol for the last 2 days. 









Urine test showed bacterial infection of the bladder. After 2 days of inpatient treatment with drips and medication, the kidneys have reduced in size by 50%. The cat can sit up and ate a bit of the other vet's prescribed diet for struvites. He could sit up and meowed.

The owner confined him at home, away from the other 3 cats and hand feed 6X/day, mixing Fancy Feast with prescribed Royal Canin Renal diet. Water is available freely.

FOLLOW UP ON APRIL 23, 2015
The cat is back to normal health and eating Royal Canine Renal Diet. The Science Diet K/D contains pork and so cannot be given on religious grounds.

FOLLOW UP ON MAY 12, 2015
The cat was back to normal. The daughter brought him in for neutering. "I thought your father likes him as a non-neutered cat as he responds to his attention," I said. She wanted him neutered to prevent any pregancies. So, he was neutered. His kidneys were no longer painful. I presumed he had recovered. No blood or urine tests were done to save on medical costs.  

Tuesday, March 10, 2015

1137. The dwarf hamster led an active life after surgery

March 10, 2015.

An early phone call from the worried lady. "There is a big hole under my hamster's right armpit," she announced. "Should I see you at the Clinic?"

The dwarf hamster had a big SC lump excised by Dr Daniel 5 days ago. The hamster climbed up and down 4 levels, a luxurious type of housing. The stitch broke down and now, I advised secondary healing. No point re-stitching.

1135. Unbelievable story: Multiple Myeloma - 4 years to live

March 9, 2015

"I googled the internet," the senior citizen said. "The life expectancy of multiple myeloma patients is around 4 years. Now, it is 10 years. When I was diagnosed, I hoped for 3 months to settle my personal matters.  I developed kidney failure, with creatinine over 1000. I was shivering and had lost considerable weight. My skin was red and I looked terrible.

"A friend suggested that I pray and after my prayer, my body was at peace and I recovered. Not fully but I surpassed the life expectancy of 4 years. "

I was glad for him. I had met a relative of this senior citizen just 1 day ago at an Association lunch. She said that he lived so long because he could afford expensive drugs.  A woman with the same diagnosis died after 3 years.

So, was it the faith or the expensive drugs that prolonged his life? He had his belief now.


Tuesday, March 3, 2015

1133. The male cat had urethral obstruction 7 years ago - kidney failure now?

On July 8, 2013, a grey male neutered 12-year-old cat had difficulty in urination for 2 days. I palpated the bladder. It was not swollen and so there was no urethral obstruction. 7 years ago, he had urethral obstruction and was catheterised by a vet and had recovered. He was fed dry food mainly and BURP canned food since 4 months ago.

I gave antibiotics. I advised dental work and change to feline C/D diet.


Then in Feb 4, 2014, he had dysuria again for one day. He lost appetite. He meowed a lot after urination and so the owner brought him to see me. The bladder was painful on palpation but was not distended to omuch. No vomiting or drinking or peeing excessively. Blood test showed a higher level of urea 14.8 (7.2-10.8) and creatinine 177 (71-160). Platelets were low at 238 (300-800).

I gave dextrose saline SC, irrigated the bladder with saline, gave antibiotics and Vit K1. X-rays showed a swollen left kidney (tumour or swelling?).

I phoned 2 days later and the grey cat was back to normal. He could control his bladder.

No news from the lady owner till today Mar 2, 2015, asking about the price of dry food, Prescription Diet K/D and wanting to buy feline C/D.


In November 2014, she had consulted another vet. The cat had started to vomit prior to boarding him for 2.5 weeks from Sep to Oct 2014. He vomited more often and became thinner. So, she consulted the other vet who took a blood test which showed slightly elevated urea and creatinine levels.

He prescribed K/D.
"How long did it take the cat to recover from vomiting?" I asked the working lady in her late 40s. She had rushed back from work to buy the food.

"he took 2-3 weeks to recover from vomiting and now had put on some weight. No more vomiting. I just wanted to stock up the dry K/D and buy 2 cans of feline K/D."

The cat was fed another brand of dry food and BURP in the past but now she switched to dry K/D.

"My cat prefers the wet food nowadays," she said when we met today.
"I did advise dental work as the gums will be painful when the cat eats dry food."
"Too old," she said the cat would be 15 years old in Dec this year and so no point spending money on dental. 

The cat would be on one tablespoon of K/D canned, canned BURP with low salt day and night and dry food K/D available. The cat did not have abnormal drinking.

It is a cat's destiny as to whether he has dentistry to relieve his tooth ache. Just like people as to where we live and earn a living. One client told me his friend's 11-year-old girl was missing for the past 3 days after going to the cinema in a country outside Singapore.   

This cat may not have kidney disease as there are no signs of drinking excessively.

If the cat had dental work 2 years ago to extract the rotten loose teeth, he would have a better quality of life but cat owners do not want to incur medical costs. A cat can live a longer life if his diet and health is monitored closely together with your vet.  Vomiting and weight loss are signs of poor health, not necessary kidney disease as the cat does not drink a lot of water. It could just be bacterial infections from the rotten teeth and a simple dental work by the vet would have made this cat much more lively.       



Monday, March 2, 2015

1132. The Golden Retriever's hind leg keeps swinging

Mar 2, 2015  7.07pm  Bishan library

This 5-year-old male neutered Golden Retriever was very itchy. "I couldn't sleep since he had been scratching the whole night, waking me up! That was why I phoned you to see him this morning."


The dog had been itchy in 2012 and I had resolved the problem and so the working lady owner came back to me for diagnosis and treatment.

"Do you remember this dog? He exploded anal sac oil straight into Dr Daniel and onto the walls of the consultation room!"

"Yes," I had recorded this incident in the case sheet. I cannot remember every dog's explosive anal sacs as this was not the only one. For the past 4 years, the anal sacs had filled up and nobody had expressed them.  So, they were time bombs of foul-smelly oil, spreading bad odours in the consultation room. This scent makes you want appreciate perfumes.

"Did you express the anal sac weekly or before bathing?" I asked the sun-tanned lady.
"No, no, but I sent him to the groomer every 2 months and this famous pet shop charges expensively. They groom the dog, clean the ears and express the anal sacs"
"How much?"
"$160 for every visit, but as Chinese New Year was in Feb 19, I did not send him to the groomer. I put some ear drops bought from the shop and did the ear cleaning myself! But my dog gets more and more itchy every day. His hind leg will swing back and forth in mid-air (see video).

The dog's ears were relatively clean but were painful to my touch. I could elicit the hind leg motions whenever I touched the lower ear area. So, this was a case of ear pain causing this behavior. The dog had to bite his backside and back legs to relieve the continual itchiness. The whole right back was very red as well.

Was this a case of allergy to the commercial ear wash? I had the skin and hairs checked for ringworm and demodectic mites. Ringworm was present in those red inflamed backside but no demodectic mites from 4 skin scrapings.

I got the dog sedated and the coat clipped bald. The ears were thoroughly irrigated.

"The hair will take 6 months to grow," she lamented.
"3 months if there is no more skin infections or itchy skin," I told her. This dog had chronic anal sacculitis and skin infections and so the coat was sparse.