Tuesday, February 28, 2017

3041. A 20-year-old female red-eared slider is lethargic, not eating, not moving for over 10 days

Red eared slider, F, 20 yrs

egg binding

Egg binding is most probable cause of lethargy and not eating for over 10 days.
Owner took home and provided a sand box for egg laying for the next 6 days, but no eggs were laid.
The slider usually laid eggs in batches of 3 in the water in a tank shared with a male slider, during the past years, but this year, she had not laid any eggs.

X rays show around 13 eggs.
The vet advised oxytocin injections for the next few days but the owner wanted the slider home.
Feeding orally the Critical Care from Ox bow 6 times a day. "She was able to walk a while, after
eating, but soon became lethargic," the lady owner told me yesterday, Mar 7, 2017.

I advised warm water and putting her back to the tank in which she used to lay eggs in the water durng the previous years.

As at March 8, 2017, the slider had not laid any eggs in the sand box. So

3040. A 3-year-old cat is diabetic

The complaint was a big lump in the hind leg of this 3-year-old cat that was limping. Blood test showed high blood glucose. Urine test showed glucose. The lump would be due to hind limb neuropathy which is a symptom in diabetes mellitus in cat.

On further questioning, the owner said that the cat was always looking for food, drank and peed a lot.

After insulin injections, the cat's lump disappeared and she was no longer ravenous, thirsty or urinating a lot.


3039. A 9-year-old Westie fell and broke his right hind leg - tibia and fibula. Skin disease

Feb 26, 2017

Chronic skin disease
Old dog with poor immune status
Under new drug for skin disease for the past 2 weeks

Seen by Vet 1 on Feb 26, 2017
X-rays  Spiral fracture of tibia and fracture of fibula - Right hind.

Seen by Toa Payoh Vets on Feb 28, 2017.
Proximal tibial fracture from fall
Closed fracture

Blood supply to diaphysis.

Open fractures are surgical emergencies.
Debridement of necrotic tissues and irrigation to remove bacteria and prophylactic IV antibiotics to be done within 6 hours of open fractures to decrease infection rates.

1.  Cast treatment is non-operative method. Most closed tibial fractures can be treated without surgery with good results. Wait 3 days to let swelling go down. 6 weeks. X-rays.  Non-displaced fractured tibial shaft ideal.

2.  Surgery.  Open reduction and internal fixation (ORIF) e.g. intramedullary nailing, external fixation, plating
and in some cases, amputation.
3. Intramedullary rod therapy.

Cast treatment has fewer infections than ORIF
ORIF has a higher union rate as there is more fracture stability.

Fracture stability and infection risk must be considered..

Surgical fixation is required when fractures are unstable.
Cast treatment isbest in a young patient with a non-displaced fracture.

No union
Mal union

Intramedullary nailing is generally used to treat many types of tibial shaft fractures.

This Westie has chronic dermatitis for many years with no resolution when given steroids and coconut oil. However, in the last 2 weeks, he was given Oclacitinib (Apoquel by Zoetis) 16 mg divided into 4 parts. For the first 2 weeks, he took 1/4 tablet twice a day. He will be taking 1/4 tablet once per week for the next 2 weeks.

The owner was happy that the Westie responded very well with no itchy scratching just within the 2 weeks of Oclaitinib.

Oclacitinib, an immune suppressant drug is used for the control of pruritus associated with allergic dermatitis. The healing of the fractured tibial shaft fractures will be adversely affected if this drug is to be used  as it suppresses the immune system.

Owner warned that open reduction will result in bacteria from skin infections getting into the fractured bones resulting in osteomyelitis, pain and possible loss of leg via amputation. Also the
 high financial costs and worries if infections occur after open reduction using intramedullary nailing surgery.

The dog is old and his immune system is poorer than a young one. He had been on Oclacitinib for the past 2 weeks and this further depress his immune system.

Cast treatment is advised as the proximal tibial shaft fractures are minimally displaced and look stable on X-rays. Wait another 2 days for the swelling to go down. Antibiotics are given. No more Oclacitinib for the next 6 weeks when on cast. The dog may feel itchy and scratch again, including the right hind leg skin!    

UPDATE ON JAN 22, 2019
The Westie came in as he had a gigantic lick wound above his right elbow. Pus and raw flesh and fat were seen. Blood test showed high total white cell count indicating bacteraemia. The dog is an inpatient for 7 days to get the infection under control and cleaning of the wound. He was clipped bald and given anti-inflammatory injection of pred. He need apoquel 3.6 mg two times per day for 14 days and then 1 time per day for another 28 days, together with antibiotics. Not possible to close the wound.

Sunday, February 26, 2017

3038. A 12-year-old Miniature Schnauzer scratches and licks for the past 12 months

Feb 26, 2017

"I tried changing diets and shampoos for the past 1 year," the young man could not resolve the continuous scratching and itchiness of the old dog. "Bad body odour," he told Dr Daniel. The skin is full of pustules, rashes and ringworm-like lesions. Paws are licked red and limbs are pigmented from constant licking.

Generalised dermatitis with ringworm, bacteria and yeast are the main cause. Whether there is food allergy or not, is another possiblity. Neck alopecia and inflammation. Anal sac area hyperpigmented.
Otitis externa and anal sacculitis compounded the severity of the skin disease.

After clipping bald and around 10-16 days later, the owner came back for a review. He was relieved that the dog's skin had improved.

10-16 days after treatment

The owner is satisfied with the outcome. It will take at least 2 months to know whether the Schnauzer has fully recovered. Monthly reviews with the vet are important.

Saturday, February 25, 2017

3037. A 5-year-old Guinea Pig has a golf-ball sized swelling (cyst).

Sat Feb 25, 2017

A young couple visited Vet 1 near their home. Vet 1 inserted a needle into the soft golf-ball sized swelling behind the left ear and above the left shoulder. Clear fluid was aspirated. "It is a salivary cyst," Vet 1 said.

The swelling did not disappear. The couple surfed the internet and came to Toa Payoh Vets. "We saw a Youtube of a guinea pig with a swelling done by Toa Payoh Vets," the gentleman said.

"This looks more like an ordinary cyst rather than a salivary cyst," I noted that the location of this large swelling is distant from the sublingual and submandibular salivary glands. "It is possible to be a salivary cyst but unlikely. Fluid need to be sent for laboratory examination to check for cells," I advised.

Dr Daniel operated. The cyst was large (see picture) but ruptured, spilling clear fluid.


Thursday, February 23, 2017

3036. A 6-month-old stunted red-eared slider has 2 ear abscesses - self treatment by owner.

Feb 23, 2017

A young couple went to Vet 1 to get the terrapin treated for ear abscesses. Vet 1 gave an "injection"
into the area between the neck and shoulders. The owners did not know what injection it was.
"Anyway, the abscesses still remain!", the lady said.

"There's a red bruise in the swollen left ear," I asked the lady whether she did it herself treatment.
"I pricked the swelling and a bit of pus came out," she said.
"The pus is cheesy in a terrapin's swollen ear," I said. "Pricking it will not rupture the abscess."

Under some gas anaesthesia, I had the swollen ears lanced by a scalpel, used a curette to
excavate the thick pus thoroughly. There was bleeding. The wound was irrigated and drained.

"Why did he get ear infections?" the lady had 2 siblings. The smaller one is now twice the size of this patient.
"Most likely, this terrapin hides inside the water most of the time to avoid the big bully," I said. "So, bacteria get inside the ears over time."
"Yes, he does spend most time inside the water," the lady confirmed. "I change the water every day and sometimes more than once daily."

"The older big-sized sibling is OK eating as many pellets as given, more than 16 pellets per day.
"You need to house this one separately and give plenty of space to bask," I advised. "The terrapin will be in for 3 days to ensure no residual bacteria."

Ear abscesses are a common surgical condition in terrapins in Singapore.   

Wednesday, February 22, 2017

3035. What to do with a large liver cyst?

Feb 21, 2017

Routine blood test. Liver enzymes slightly elevated.
Ultrasound & MRI. One large liver cyst of around 12 cm across and smaller ones.

3 Gastro-enterologists in private practice.

Liver cysts are common. Computer screen shows graphic of liver.
Liver cysts are mostly benign. 3 options.
1. No treatment.  MRI 6 months later to say whether enlarged.
2. Keyhole surgery for histopathology. Not advised as not 100% of cyst wall can be sampled.
    If benign, does not mean no malignancy.
3. Surgery.
3.1 Usual risk of anaesthesia, bleeding, infection. Also pneumonia as painful to breathe post-op, phelgm accumulates. Exercise before surgery. Breathing tools. Patient may regret surgery done if cyst is benign 100% and be able to accept this possibility.
3.2  Will not take out the smaller liver cyst
3.3 Needs 2 surgeons and an anaesthesist for liver surgery.
3.4 I should have sufficient liver tissues to lead a normal life. The liver "regenerates" by enlargement, not really growing new liver cells!

4. Cost $30,000 - $40,000.
5. Need more cancer marker tests and ECG.

1. Classmate of Dr Chua Seng Chew, my GP who referred me to him. He does not perform surgery. 
2. Reviewed ultrasound and MRI. 
3. Reviewed colonscopy and gastro-duodenal scopy done by Dr Eu Kong Weng. Advised
stools pre-scope to flush out residual stools affecting scope. 2-yearly scope will do. 
4. Physical exam of right upper abdomen. No pain. Took weight.
5. Refers to Specialist 3 who is a surgeon for another opinion.

1. Specialist 3 who is a surgeon.
2. Only 2% of liver cysts become cancerous as most are benign.
The largest liver cyst he operated had filled up the rib cage and causing breathing distress in a patient.   
3. Inserted ultrasound CD into computer and and showed me the "echogenic" materials floating inside the
large cyst. This material and walled cyst could develop into cancerous cells. I was surprised as he had seen the MRI. "Ultrasound provides more information than MRI," he explained patiently.
4. Not Echinococcal cyst as there will be many daughter cysts. As a vet, I might have been exposed
to Echinococcal parasites.  
5. Surgery takes 2-3 hours.
6. Usual risk of anaesthesia, bleeding, infection. Also bile leakage despite closing all major bile ducts during surgery. Need to insert a "drain." I did not ask how this drain will resolve bile leakage. Enquired whether I had hepatitis vaccination or hepatitis in addition to health issues.
7. Will take out the other liver cyst too although I did not ask him.
8. Cost $30,000 - $40,000

I requested a routine blood test to screen my cholesterol levels and end up with discovery of
liver cysts from increased liver enzymes. What is the next step?

Monday, February 20, 2017

3035. A red-eared slider can see much better now.

Feb 19, 2017

The owner said, "He is more active and eating. He can see better now."
I took a close-up of the eye but had no macro-lens. Much of the cloudy corneal areas had cleared since I treated him a few weeks ago.

On close up, his upper eyelid starts to swell again as he must be rubbing.
Eye drops and medication.
Also not to submerge in water 24 hours a day. Feed separately.

3033. A 5-year-old X-bred has a large armpit tumour

Feb 20, 2017

Factory dog. Male, not neutered, 5 years
The dog came with a large subcutaneous swelling. Abscess or tumour or both?  X rays done.


Dog was not co-operative during X-ray to get the cranial dorsal views.
No sedation as he may have heartworm disease.

Dr Daniel excised the tumour measuring 5" x 7" x 3 ". A fat cell tumour or mast cell tumour?
Owner did not want histology.


X ray of a Bearded Collie's upper arm haematoma. Dog has fully recovered after surgery to drain

Saturday, February 18, 2017

3032. A 3-year-old heavily pregnant English Cocker Spaniel could not stand up for over 24 hours

Feb 8, 2017

The breeder said, "No hope for the dam. She collapsed over 24 hours since yesterday. So, I will wait till midnight to do a C-section."

It was 6.45 pm and I was driving to a dinner invitation as Lunar New Year has 15 days starting from Jan 27, 2017 which was the eve.

"No waiting," I ascertained the dam had copious amount of milk and was 58th day pregnant. No vets like to C-section a dead dam and by then the puppies may be dead too. The breeder might have other plans as later at the Surgery, I noted he had attempted glucose IV. He might want to wait and see and did not let me know. The other vet charges around $300 for a C-section and he would prefer the less expensive option. "Your c-section can permit me 3-4 dams to be C-section by the other vet," he used to let me know. Breeders, like large corporations can demand and do get lowest rates.

Some 10 years ago, I charged $300 per C-section at any time of day or holiday. I neglected my private patients and failed to build up Toa Payoh Vets. When another vet offered cheaper rates, I was out. This is a fact of business life.

I cancelled my dinner and I felt great joy in seeing 8 puppies and dam alive. The reason this breeder uses my service is that I had not given him any dead dam or puppies during C-section and so he has had confidence in me.

Use isoflurane gas only. Stabilise the dam with IV glucose and Hartmann's or even add calcium an hour or more before C-section for weaker dams.

4 days later, I visited the patient. She recovered her appetite after 2 days and is ravenous and active. Her 8 pups are nursed by 2 other dams. Her nipple sizes are large and so the older Spitz puppies would be nursed by her although they are old enough to be eating solid food. 

 The surrogate dams are younger and accept the pups.


The breeder's desired outcome was a living dam and all puppies alive and vigorous after C-section. He was most happy and satisfied. 


More images


3031. Sex hormone dermatosis?

Feb 18, 2017

"He bites the family members too," the couple said to me. This male, not neutered, 9-year-old Jack Russell X was treated by me some 6 months ago. Hair loss on both sides of the flanks (truncal alopecia, itchy armpits and paws and lots of scales.

"Not so much scales nowadays," the owners did not continue feeding the anti-allergic dry dog food. "We clip him bald and that is why the hairs do not grow back." The 2 images show the recent condition.

The armpits and paws were inflamed red. Hairs do not appear to grow on the body or were clipped bald. The owners did not come for a review one month later.

"You use some oil?" I asked.
"Yes, we use coconut oil."

I advised neutering. This dog is very aggressive and would bite anybody who stood near his lady owner, including her grandfather. Neutering could cool him down and might resolve the hairs loss problem if it was due to excessive testosterone levels.

The owners would think about it..

Friday, February 17, 2017

A 13-year-old female Schnauzer pees blood in the urine.

2 years ago, operated to remove large bladder stones. Owner did not believe in prevention using prescription diet. Now leaking bloody urine. Stabilised with IV dextrose saline + baytril 4 hours pre op. Operated at 2.30 pm Sat Feb 18, 2017 by Dr Daniel.  

A 13-year-old tortoise vomited blood

Feb 17, 2017

Vomited fresh streaks of blood from the mouth.
Had bought a liquid medicine from pet shop to "increase appetite" when this 13-year-old tortoise stopped
eating. Syringe medicine into mouth.  Vomited lots of fresh blood for last 2 days.

X-ray. No hook or sharp metallic objects inside throat.  Died after vomiting more blood streaks.

Thursday, February 9, 2017

A 6-year-old male neutered pug passes blood in the urine this month, twice.

Nervous pug
Sedated for x-ray  xyla 0.3 ml ketamine 0.2 ml IM    effective, last 30 minutes
To review blood and urine test.

A 19-year-old red eared slider lays eggs every year for the last 10 years has smelly diarrhoea

New food
Milk bread causes irritation of gut --- diarrhea --- cloacal prolapse yesterday -- cloaca prolapse traumatic injury  -- profuse bleeding and blood clots.

Today, no prolapse but foul smelling stools

Baytril 0.2 ml IM (1.4 kg), Oxytocin 0.1 ml IM and trimeth PO for gastroenteritis.

Jan 14, 2017
Still has bleeding from cloaca but less. Active.
Eats salmon with medicine, otherwise hard to medicate. Eats vegetables but not pellets. 
No eggs passed.