Wednesday, April 30, 2014

1360. Time is running out - closed pyometra in an old dog

When the vet said that the dog has very low chances of survival on the operating table and the medical costs are high as in this closed pyometra case, it is very difficult to justify paying for a probable anaesthetic death. The owners decided to bring the dog home to die. But there was this 12-year-old boy who cried his heart out. Usually vets don't follow up as the owners had decided but this little boy did love this 14-year-old dog very much and knew the outcome. I phoned the owner the next morning. The dog was still passing bloody vaginal discharge and was inactive. He decided to get her operated and I reduced the surgical costs to give this high anaesthetic risky canine a chance to live. Time is running out on her,

If she survived the anaesthesia and surgery, the little boy would be most happy to get his companion back to health and that was what mattered in this case.  "Don't wait till you have finished work this evening to bring the dog down," I advised the father. "Bring her down now while she still has a fighting chance to live."  Time is running out. Dr Daniel operated, removed a gigantic womb filled with brownish-red pus, about to burst if surgery is delayed.

The little boy was most happy to have his companion back home the next day.

This would surely be how a vet can make a difference if he makes time to follow up before time has run out for a little boy's best friend. Happiness in the boy's face when the dog went home the day after surgery would be hard to describe. "Are you happy now?" I asked him as he sat at the back of the car with this old dog. "Yes," he nodded vigorously. Time was running out but the father's decision to operate and the intensive IV drip and medication given prior to surgery stopped the time running out.    

Thursday, April 24, 2014

1358. An old Miniature Pinscher can't pee

"It is always best to get an X-ray done rather than just unblocking the bladder," I said to Dr Daniel as the owner of the overweight Miniature Doberman Pinscher dribbling urine wanted to save on medical costs and so the dog was warded for 2 days. So today, I got the dog X-rayed. Several big urinary stones obstructed the urethra at the os penis area and many more were in the bladder.

"The bladder is about to rupture," I advised an emergency surgery. "Around 10 stones in the os penis and more than 16 inside the bladder!"

The owner had delayed seeking veterinary treatment for many weeks. Blood tests showed kidney failure, thus explaining the persistence of daily vomiting by the dog.

The owner gave permission for the emergency surgery. The dog survived anaesthesia and surgery done by Dr Daniel. However, he passed away 3 days later.

Chances of survival after surgery are much lower if owners have been dragging their feet in getting their dog treated early by the vet.  

1357. An old Miniature Schnauzer leaks urine soiling his belly

On Good Friday, this 12-year-old, male Miniature Schnauzer came in the morning. A strong urinary smell. "My dog has not been eating for two days," the owner said. I palpated an enlarged bladder half the size of a mango and diagnosed "bladder being blocked." Dr Daniel told me that he did not think for reasons I don't remember. He inserted a catheter and confirmed "urethral blockage." As he did not tape the catheter, it came out.

The next morning, after breakfast, the owners came to check on the dog when I was exercising him. I brought the dog out and he lifted his back left leg to pee. We waited. No urine at all. The young adult son and daughter were much worried. "Go ahead with the surgery," the mum said. The dog was still lethargic owing to being infected with bacteria in his blood stream and urinary system as confirmed by lab analysis of the blood and urine.

It is always highly risky to operate on such an old dog. That is why the young adult children were worried.
I gave him 2 bottles of IV drip, with amino acids, baytril and spasmogesic on the day before surgery to be done by Dr Daniel. To strengthen him.

I got the dog X-rayed using air-contrast to check for bladder wall tumours as well. No tumours.

"There is no need for surgery as the stones are small," Dr Daniel commented.
"It is possible that the stones can be dissolved by dietary management," I said. "But the owner has to be diligent to monitor and get X-rays and urine tests done. Most Singapore dog owners just don't have the time to do monitoring and testing."

During surgery, the stones were small and gritty and 7 were found. The biggest was 4 mm across. The dog stayed for 5 days and went home able to pee freely.    

Monday, April 21, 2014

1356. An old pug X in the quarantine had black turbid urine

On Sunday, I received a phone call to treat a 12-year-old pug X in the Sembawang Quarantine.  I asked Dr Daniel to do the house-call but the Quarantine is closed on Sundays.

"Bring along a container to collect the urine," I said to him. Usually, no urine is collected as the vet just gave the antibiotic injection.  He went on Monday and got a bottle of black turbid urine. Black urine indicated a serious infection. 

Today, April 22, 2014, I phoned the Quarantine. "No blood seen in the urine," AVA officer Bong told me. I phoned the owner at 11.45 am to tell her the results of the urine test. She said: "The dog is much more active today, after the injection."

Urine black, turbid
pH 9.0  SG 1.005, Protein 3+, Blood 4+, WBC & RBC >2250, Crystals triple phosphate occasional, bacteria 3+

1. As the dog still has 3 weeks in quarantine, the infections of the bladder may return.
2. S/D diet is recommended if the urinary stones are small, but no X-rays can be done yet as the dog is in quarantine.  S/D diet will not dissolve the stones if they are large and X-rays are needed to confirm.
3. The owner decides to wait and see.  S/D diet does acidify the urine too preventing recurrences to a degree. It is hard for the owner to understand the factors causing triple phosphate or struvite formation including an alkaline pH of 9.0 and bacteria urease.  

No more blood in the urine. The dog is active and is in Sembawang Quarantine till the end of April. An X-ray has been advised, to check if there are urinary stones. The owner said she would do it.

Saturday, April 19, 2014

1355. 7 small bladder stones in a 12-year-old Miniature Schnauzer on Good Friday

April 20, 2014

"The stones are so small," Dr Daniel commented from the X-rays taken on April 19, 2014, a Good Friday which was a working day for me. "They can be dissolved using dietary management as in Gatsby who was fed S/D diet and is now OK, without any surgery required." The biggest stone was around 4 mm across. Not the usual big pebbles. 

"Each dog is different," I said. "I have not seen Gatsby's X-rays and any routines and instructions on the on the dietary dissolution of stones must by complied by the owner.  Yesterday, you unblocked the bladder. The urinary catheter came out when the owner's daughter visited. This morning, the parents came. The dog lifted his leg and no urine came out. So, his urethra was blocked again. The parents consented to surgical removal and I had advised on the high anaesthetic risk of dying."   

Yesterday, on April 18, 2014, this 12-year-old male, not neutered Miniature Schnauzer came with a history of not eating for the past two days. "He had never been sick in his life," the wife told me. "He went to Vet 1 for the usual vaccinations, but 2 years ago, he passed blood in the urine. Vet 1 gave me a course of antibiotics, saying that this dog was too old for anaesthesia and if the medication worked, there would be fine. And he had no more blood in the urine since then!"

The dog was lethargic but had no fever. His body smelted strongly of urine. The stench of urine not easily washed off by bathing as he was incontinent. I suspected urinary stones as Schnauzers are prone to this condition. I palpated the bladder. It was as full as an orange. "Is he able to pee normally?" I asked the maid. "No," she shook her head. "Very difficult and urine drops here and there."

Dr Daniel would unblock the bladder. He commented that the bladder would not be obstructed but I said it was. Only urethral catheterisation confirmed my findings. 

Dr Daniel flushed the stones back into the bladder and removed. I noted the surgery took around one hour. The bladder was bright red and inflamed. The bladder wall was 5 mm thick. He stitched the mucosa and the wall.

On April 20, 2014, now, a Sunday, the parents came in at 9.30 am after breakfast. The dog was jumping for joy inside the cage. I showed them a video of the dog peeing freely outside the clinic, plain yellow urine without blood, taken just 10 minutes ago. 

The parents wanted to take an image of the dog active with their handphone for their 26-year-old son studying in England. "Take a video," I advised and got the container of the small urinary stones for the mother to video.

This story has a happy ending but it is not guaranteed as the dog was 12 years old and lethargic.

Blood tests showed high total white cell count and neutrophilia as follows:
Total white cell count 28.5   (normal 6-17)
Neutrophils  95.5 %    (normal 60-70%).
Neutrophil absolute 27.2  (normal 3-12)

Urine tests
pH 9.0, protein 2+, blood 4+, white blood cells 33, red blood cells >2250,crystals triple phosphate +

1. Fluid therapy 2 bottles of Hartmann and dextrose saline  + amino acids and glucose IV
2. Baytril + Spasomogesic for first day.

3. Fluid therapy during surgery.on 2nd day. The dog was much more alert.
4. X-rays x 3. First X-ray showed stones in os penile urethra. I had a the dog's bladder evacuated of dark red turbid urine and given 20 ml of air to get two better X-rays. The two bigger stones were obviously seen as a guide to the operating surgeon Dr Daniel who took out 7 small stones. 
5. Stones for chemical composition.
6. Dog to be warded for 7 days.
7. Bad teeth with thick crusty tartar should be removed 7 days later.

It is likely that this dog will be OK. Medical dissolution of stones was not realistic as the dog's penile urethra keeps getting obstructed and the dog was incontinent and dysuric. The first vet had not taken any urine tests but just prescribed antibiotics which cured the blood in the urine. It will be good practice to get the urine tested in cases of haematuria but owner economics or the vet's personality might not lead to this practice being done.  

UPDATE ON MAY 1, 2014.
The dog came at Day 14 after stone removal for stitch removal. He is very active. Dental scaling of the thick crusty golden plaques were done by Dr Daniel on this Labour Day (May 1, 2014) afternoon. 2 decayed premolars were removed. Surprising the other teeth were strong and not loose. See the video: "The dog with the golden teeth."

Everybody in the home including the domestic workers were extremely happy with the outcome. No more urine-smelling odour on the belly of this dog now as the dog is no longer incontinent. Urine shot out normally.

A happy ending is not guaranteed if the owner had delayed seeking veterinary treatment as the kidneys could be damaged severely as in the case of "The Miniature Pinscher" with kidney failure due to multiple urinary stones obstructing urine flow for many months.

Thursday, April 17, 2014

1353. Youtube videos at

Nowadays, most case studies are posted as videos as they are more interesting for the viewers. See for the videos.

1352. A Golden Retriever collapses suddenly - stroke or heart attack?

April 16, 2014 7.30 pm

Goldie, the Golden Retriever, Male, 10 years ate his food at 6.30pm as usual, after being outdoors. 15 minutes later, he could not stand up. Just lay down on his chest for he next 15 minutes. So, the owners brought him to see me at around 7.30 pm. The parents, two grown up sons and two lady friends came, together with a plastic folder of the dog's past medical records.

"The dog can walk now," the father said. In fact, the dog had leaped off from the back of the small van, as usual. "Could he be having a stroke?"

I got the dog weighed and the rectal temperature taken. No fever.
"His gums are very cold and cyanotic," I could feel the chill in his gums, an unusual feeling. I pressed his spinal area from the neck to the tail. No pain. The dog was standing on the table and showed no pain when I checked the abdomen. A blood test showed nothing abnormal. An increase in SGOT/AST was the only finding. I auscultated the heart. There was a machinery murmur. I palpated the throat and the dog coughed.

"This dog likes to eat from the grass," the mother said. Could he have swallowed some stones?
"He also ate his food very fast, all in one go," the mother told me. So could he have choked himself?
The dog was quiet and laid down on the table, as if he was very tired.

So, what's wrong with this dog? With scans and ECG tests, this would be hard to say. I treated him for a  heart disease with Fortekor 5 and Lasix tablets to be given once orally for 2 weeks..The dog was very lethargic as he preferred to lay down on his chest. But he leaped onto the back of the van.

"What drug did you give him," my nurse Julia asked. "He was lying on the waiting area after treatment and was breathing hard. Yet on gong home, he leaped onto the back of the van!". This dog does that when he is healthy as he leaps on and off the van during outings..

April 17, 2014
The next morning,  I phoned. "The dog is 70% more active and has eaten all his food," the father said.
In the evening, I phoned. "The dog is standing and walking unlike yesterday," the mother said as the father was out playing badminton. "He is 10% better. When he came home from Toa Payoh Vets, he was so tired and just lay down the whole night."
"Has he eaten all his food?" I asked.
"Yes," she said.
"Did he drink water, pass stools and urine?"
"Yes," he did. "He drank water, but no stools. He pees outdoor and so I don't know."

So what is the cause of this dog's lethargy after dinner?
It is very difficult to say. I would consider that, since he swallows his food very fast since puppyhood, he could have choked. A small piece might have gone into his lungs and the lungs shut down in reflex protection. So he was not able to stand up for 15 minutes after surgery. Or he could have a heart attack or stroke. For reasons of medical costs, no further tests were done.

A very strange case as his blood test showed all values normal except for an increase in SGOT/AST. This might not be significant. A review 2 weeks later would be needed.

Monday, April 7, 2014

1351. Biopsy of breast tumour in an old cat

Female cat, spayed 12 years.

Right armpit area - a lump was detected and excised by Dr Daniel in Oct 2013. The owner stated it was a cyst. To me, it looked like a skin tumour and I recorded this down. No histology was done.

On April 5, 2014, the owner came with the cat not eating and a bigger lump. Now, around 4 cm x 2 cm x 1 cm. He wanted a biopsy done by Dr Daniel and sent to the lab.

Results from the lab
2 strips of tissue 1.0 cm x 0.4 cm x 0.2 cm.   

Diagnosis: Aypical ductal proliferation suspicious of low-grade ductal carcinoma.  What's App the report to the owner.

1350. Tarsorraphy in 2 Shih Tzus

Some vet books, vet professors and vets are not in favour of tarsorrhaphy. I encountered a recent Murdoch Univ vet graduate who said to me that it is a waste of time.

In this case, Shih Tzu (Shih Tzu 2), male, 10 years, first time corneal ulcer went home on the same day. Today, the 7th day, I noted that the tarsorrhaphy procedure seemed to be successful for the following reasons:

1. Early detection. Probably one to two days when the parents came back from overseas and saw the 10-year-old Shih Tzu with right eye closed. The dog was cared by the daughter.

2. Keratitis traumatic - 3 classifications. Superficial, penetrating and perforating. This case is penetrating unlike the first Shih Tzu (Shih Tzu 1) which is perforating as I saw some anterior chamber watery liquid squirting out and the red basement membrane bulging out, a Descemetocoele.
Both dogs were operated by Dr Daniel.

3. Shih Tzu 2 was closely supervised at home by the retiree parents unlike Shih Tzu 1 who was left alone. He was crated on the first day. Cried to get out. So, the next 6 days, the elderly parents stopped their taiji exercise to take care of him while he roamed around the apartment. They complied with nursing instructions to give eye drops 2- 3 x/day, painkiller tolfedine 60 mg (1/2 tab /day),  vibravet 100 mg (1/2 tab/day 14 days) and multi-vitamins.

4. So, today, they came for a review at the  7th day. Eyelids still closed by stitches. A 2-mm gap is seen rather than loose sutures.

5. The dog was examined and there was no pus inside the eye. A small gap on the medial side allowed eye drops to be instilled. I prescribed Rimadryl 75 x 2 tablets at 1/2 tab per day from tomorrow. Another bottle of eye drops. 2 bottles have been used.

6. The final proof of good surgical outcome will be at the 14th day. Another 7 days later, the stitches were removed. His central ulcer was healed. However he had a fluorescein-green ulcer from 4 to 7 o'clock and pigmentation on the lower left quadrant. "He must be wiping his e-collar on the floor," I said to the retired couple. "He  was supposed to be crated for at least 10 days, but he was free to roam." In tarsorrhaphy cases, it is best to hospitalise the dog but tnis owner wanted the dog home.  

In Shih Tzu 1, the dog was warded for 7 days and crated. Nursing care was given as above. The stitches came loose around the 7th day and were taken out. There was cloudiness in the central corneal ulcer due to corneal edema. This was part of thel corneal healing process. .