Sunday, September 29, 2019

3294. INTERN. A pug swallows a fish hook.



VIDEO CREATION BY INTERN. The 2-year-old Pug vomited after swallowing a fish hook. 



HOOK

Many Singapore dog owners take time to walk their companion daily. The Lentor area in North Singapore is a leafy residential suburb. Houses with their manicured gardens and plants. Birds tweeting. It is a pleasant place to enjoy a brisk morning or evening walk with your dog.







As the young lady appreciated Nature in an evening walk, her pug swallowed an object attached to a 90-metre long nylon string.  She did not see the pug swallowing the fish hook but only a long green nylon string hanging out from her favourite dog's mouth.

She tugged but the string stayed stuck inside the pug's mouth. The pug vomited but nothing came out of his mouth. The green nylon string was still hanging loose from his mouth. Suspecting he had swallowed a fish hook, she rushed him to Toa Payoh Vets.





This is a Be Kind To Pets Veterinary Educational Video sponsored by Toa Payoh Vets




A pug swallows a fish hook







SURGERY at Toa Payoh Vets

Gastrotomy by Dr Daniel Sing under general anaesthesia.


Stomach is over-distended with gas and froth due to the penetration of the fish hook



Dr Daniel incised a 1-cm stomach incision.  He inserted a long tissue forceps into the stomach to grasp the fish hook. He could not get the hook out. He extended the stomach incision and used his 2 fingers to unhook the hook from the stomach mucosa. The stomach was stitched up. Then the abdominal muscles and skin were stitched up.  


Post-operation - Day 1. Skin stitched up. 



A fish hook is taken out from the stomach. No X-ray was done as the owner saw the fish hook being swallowed.


The dog recovered well after 2 days and went home. He was not confined to a small cage. He jumped and scratched his operation area with his back legs. He could not bite his stitches as he wore an Elizabeth collar but his back legs were free.

On Day 3 after surgery, a big subcutaneous swelling bulged under the skin stitches. The owner phoned as there was blood coming out from the stitched area when they changed the bandage. So they had to bring the dog in for examination. 

The stitches were not breaking down. There was a big swelling (another video) below the stitched area. The "blood" accumulated under the skin stitches. The vet slowly compressed the swelling and removed the blood and fluid.


The pug goes home after 4 days of in-patient nursing. However, the owner complained of seeing blood leaking out from the operation site when changing bandages. This was on Day 6 after operation. The pug struggled to prevent the change of dressing. So, the owner had to bring the pug down to Toa Payoh Vets for examination of the "bleeding".

There was indeed blood under the skin as shown in the video. The blood was expressed and the pug bandaged round the abdomen. (see video, edit video).  He was in-patient again for the next 3 days. 



VETERINARY TIPS AND ADVICES

1. POST-OPERATION BLEEDING

The pug was not confined to a small cage for the next 14 days after surgery. He jumped and scratched his operation area vigorously with his back paws. There was a large skin swelling by Day 4 and blood oozed out from the wound.

Pug is active and eating 4 days and more post-operation


POST-OP COMPLICATIONS
Bleeding from the wound is a post-op complication. The pug was active in the home. Although he had worn an e-collar, he could use his back legs to scratch the operation site. This resulted in a large swelling filled with blood as seen in the video below:



Sep 29, 2019, Day 4 after surgery to remove a fish hook from the stomach. The pug came in as the owner complained that there was bleeding from the wound. The pug was not confined to the cage and was using the back legs to paw at the operation site.



Oct 3, 2019. The pug goes home after being hospitalised for 4 days at Toa Payoh Vets.
Very little bleeding. There is no stitch breakdown and swelling has reduced considerably.
The owner bought a cage to confine the pug for another 10 days.









CONCLUSION


Today is Day 9 after surgery (see video, edit footage). The pug had been warded for the past 4 days. . He is active, eating and has no fever. There is little "bleeding". He goes home.

The bleeding is caused by the pug using his hind paws to scratch the operation site. The traumatic injury caused bleeding and swelling. Blood leaked out when the bandage was changed.
Since the pug was hospitalised for the past 4 days in a confined cage and given painkillers and medication, his bleeding had stopped and he was able to go home to rest in a cage. He will wears his E-collar for at least 10 days.

CREDITS
include Intern's name

vet assistants x 2








FOR MORE INFORMATION























































Saturday, September 28, 2019

3293. A 14-year-old red-eared slider has a spreading backside abscess




Small wound above the tail. Bacteria entered the wound from the environment and waters. Spread under the skin sideways. Yellowish skin patch kept growing bigger.










Owner's photos above
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Bald patch, dry and spreading from original wound.
Only the smaller one is affected.




Free-roaming on toilet floor|
Drink water onlhy when fed 2 tablespoonfuls of pellets every 3 days in the water.





Sep 29, 2019
Washed area. Smelly necrotic skin.




















CAUSE

Cause - traumatic injury. Bitten by the bigger slider?


VIDEOS



Overview



Friday, September 13, 2019

3293. A 10-year-old red-eared slider stopped eating pellets.

Eats only pellets, but for the past 1 week, she stopped eating. Pale tongue and oral mucosa and bad breath are signs of stomatitis. I could smell a fishy odour from the mouth on closer examination of this 10-year-old female slider.



Pale tongue, whitish floor of mouth, bad breath



Inflamed hard palate?




VIDEOS.
DAY 1. CONSULTATION
Not eating any pellet for around one week. This slider eats only pellets. No other food.
.


DAY 3. INPATIENT. OWNER WANTS HER HOME BY DAY 3.
Ate 2 pellets. Owner does not want X-rays yet. X-rays can reveal egg problems, constipation or foreign bodies and gas in the intestines.


ORIGINAL FILES





Thursday, September 12, 2019

3292. INTERN. A 28-year-old red-eared slider has "bloodworms" and a white tongue

Thur  Sep 12, 2019

A rare case of midge larvae (blood worms) was present in a 28-year-old female red-eared slider.

The slider also had a snow-white tongue which indicated a severe anaemia and swollen limbs. She had not been eating for the past 1-2 months and is very lethargic.

Several midge larvae and pupae were extracted from inside the skin folds of the slider, under the collar and on the limb folds. Those worms that were seen as bright red are called "blood worms".

They are able to survive in the soil and debris inside the fresh water of reservoirs and lakes. They are sold as bait for ornamental fish trade. They are not the usual worms in that they have hairs and are larvae of midge.


The owner phoned me as she did internet research which showed "blood worms" being common in turtles. She  asked if this slider who was fed vegetables only for the past 20 years could be infested with "blood worms" The worms seen in this turtle are likely midge fly larvae. The newly hatched larvae has blood (red blood cells) inside their transparent cylindrical bodies and hence are described as "blood worms." They are classified as insects and not as blood worms.



The slider had swollen neck folds and skin folds between the hind legs. These are signs of odema relating to retention of fluid under the skin. Causes may be heart, liver or kidney diseases. The severe anaemia resulted in a snow-white tongue which is softer than normal.

.
Larvae of midges in the tank of this slider





TONGUE COLOUR - WHITE. SEVERE ANAEMIA







Normal tongue is pink in colour




CONCLUSION
A rare case of a red-eared slider infested by midge larve (video and image).
The slider was housed in a tank in a balcony and so was exposed to the midges for the past years. These midges are adult flies and are present in large numbers in areas where there are lakes and reservoirs.

These midges are a nuisance to residents living nearby. They are non-biting as adults unlike mosquitoes. The larvae flourish in the waters of the tank and suck blood from the body of this slider for many months or years. The slider became anaemic as shown by the whiteness of the tongue. A normal tongue should be pink in colour.



See Reference:
 https://www.pub.gov.sg/Documents/Midge%20webpage%20guide%20PDF.pdf







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

VIDEOS x 3 below.
to be edited. Show combined footages of the "blood worms" in the tank and on the body of the slider.
Most likely, the heavy infestations of these midge larval sucking blood from the slider over the past months resulted in a severe loss of blood. Hence the tongue is snow-white in colour. The slider is very ill now as she has swollen limb, neck and collar folds suggestive of heart, liver or kidney failure.

  

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ORIGINAL IMAGES

Wednesday, September 4, 2019

3290. A Golden Retriever vomited for 4 days. Anuria. Why?

Case study: Golden Retriever, MN, 15 y
Vomiting  4 days and painful right armpit.

Sunday. Painful right armpit and large swelling (haematoma). Bruised skin further down the sternum is evidence that the dog injured himself when startled and over-extended his right elbow to get out from the front of the car.

The dog loved to sleep with front half of the body below the car bonnet. On that day, he rushed out from below his car, causing himself probably overextension of the armpit, a very painful right armpit area and a large swelling.






The next 3 days, he vomited and was not able to stand up. No appetite. Blood test showed acute renal failure.

 
1. Acute renal failure & urinary tract infection. No urinary stones (holding urine in bladder overnight inside masterbedroom for years - stasis of urine - bacterial growth to blood borne bacteria infection, leucocytosis ). 2. Haematoma (blood swelling) of right armpit and chest area due to sudden exertion getting the front half of the body from under the car (his habit of sleeping this way is to be discouraged).  Prognosis is poor as dog has anuria (not passing urine despite 1500 ml of IV drips).



Sep 5, 2019 Thursday. Day 4 of injury and vomiting.



















Peritoneal or haemodialysis is needed when
BUN = or more than 100 mg/dL
Serum creatinine = or more 10 mg/dL
Convert mmol/L to mg/dL = x18



Tuesday, September 3, 2019

3389. 2013 Case study with follow up. The 9-year-old cat had bladder stone removed at Toa Payoh Vets

tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS
toapayohvets.com

Date:   12 May, 2013  
 

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
Case 1:  A cat has bladder stones
Case 2: A cat could not pee  
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate:   12 May, 2013  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129

Case 1:
A CAT HAS BLADDER STONES

Wednesday Feb 20, 2013
"Can you operate today?" the owner of this 7-year-old with a disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me by his vet friend working in Biopolis.  I had asked him how he came to know about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is about to open in Singapore.

"I can operate today, but you may have a dead cat at the end of surgery," I showed him the high total white cell count and neutrophils of the cat's blood test taken earlier in the day. "These data showed that the cat has a generalised blood infection of bacteria and is not in a good health state to be under anaesthesia and surgery. He may die on the operating table."

"But Vet 2 told me that my cat is suffering from a serious kidney failure. She said I should operate soon and any delay will result in death." Vet 2's blood test result show BUN as "---", creatinine and phosphorus as exceedingly high.  "---" denotes that the value is too high to be read. This indicated an acute renal failure.

"It is best to stabilise this cat first," I had read the medical reports and viewed the X-ray. "Was there any antibiotic injection given to the cat? Any fluid therapy? Any urine test? Any fever?"

"I don't think so," the gentleman is typical of the increasingly educated and well informed pet owners in Singapore putting vets on their toes as he would have done his internet research on his pet's urolithiasis with one click of the mouse. "Otherwise my bill will have this item charged. Vet 2 did say that the cat was slightly dehydrated."

The cat was now furiously hissing and the owner could not handle him. I did not want to provoke this frightened cat further as the cat would go crazy and very aggressive. I asked the owner to hold and talk to him while I gave the Baytril antibiotic injection SC.

 I assessed that this cat would not need the fluid therapy as he was drinking and peeing. Only that he was not eating for a few days and the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked him to return again if the cat had not recovered but Vet 1 closed on Wednesday and so he remembered Vet 2 whom he had consulted before.

Vet 2 told him that she was not sufficiently experienced to operate and her senior vet's surgical bookings were full house. So he had to find another vet. He phoned his vet friend who works at the Biopolis. She referred him to me. I don't know this vet friend and so it was a great surprise.   

The operation would be done the next day. Weighing the cat, taking the rectal temperature and giving SC drip would be out of question as the cat was quite fed up with Vet 2's blood taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had managed well. I presumed she X-rayed first, otherwise it would be very difficult to restrain this little tiger.

Feb 21, 2013
The main worry was the possibility of death under anaesthesia as this cat was just not fit for surgery based on Vet 2's blood test of a severe kidney disorder. I would say it would be acute nephritis but this cat had no history of vomiting.

Would this cat die on the operating table? This was one of those hot potatoes vets prefer not to handle as death may result in bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to operate myself under such negative conditions of impending death of a cat.

Ideally, the cat should wait 3 or more days before surgery. But the owner was much worried and the kidney disorder may worsen to severe vomiting and death owing to delays. The kidney enzymes were exceedingly high. To wait would be risky as a cat in deteriorating health would die anyway. 

So, I was holding the hot potato one way or another. To operate or to wait more than one day. What safe anaesthesia to give so that the feline patient is delivered alive to the owner? A surgeon must deliver. A cat alive at the end of surgery. No excuses.

1394. Follow up. Sunday. Cat with bladder stone

Before I forget, the Thursday surgery in brief is as follows:

ANAESTHESIA
5 kg bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one syringe. Isoflurane gas top up was necessary for a short while. Rectal temperature was 36.8 C after sedation as the cat was angry and we could not want to antagonise him more.

SURGERY to remove bladder stones seen on X-rays taken by Vet 2.
1. Catherise the bladder
2. Withdraw urine for urine analysis
3. Inflate bladder with 40 ml normal saline so that it is palpable.
4. Incise skin and linea alba.
5. Press out the distended bladder.
6. Incise at apex of 8 mm as I know the stone was around this diameter.
7. I insert an artery forceps to grab and take out the stone without making too big a bladder incision.
8. My assistant Min pumps in more normal saline as I closed the wound for a while.
9. 3 small pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and blood.
10. More irrigation of the bladder.
11. I stitched the mucosa 3/0 absorbable - inverting layer
12. I stitched the serosa similarly - another inverting layer.
13. To check leakage, I asked Min to pump in more saline via the catheter to inflate the bladder. No leakage.
14. I put the bladder back into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0 nylon).
14. I put the bladder back.
15. Post-op baytril and tolfedine
16. Cat goes home in the evening as the cat was quite ferocious and nursing at home would be better as the cat would be hand-fed food (K/D) and medication.


Blood Test showed high total white cell count. X-ray showed >1bladder stones

Friday - Day 1 after surgery. I phoned the cat owner.
"Vomiting one hour after food and medication," the owner reported as he had given medication on the evening of the surgery. I advised not giving the tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by hand.

Saturday - Day 2 after surgery
Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due to the high BUN kidney disorders," I said. "That would account for vomiting. Feed less amounts."

Sunday Feb 24, 2013 - Day 3 after surgery.

6.23 pm Yishun public library to type this report
Communications post-op is most important. The cat owner phoned me twice and left his name and phone number. My receptionist reminded me to phone him after my consultations. I was kept busy with the owners of a cat from an American couple regarding removal of the claws, a rat with nasal swelling on the right and a large skin lump on its back and a rabbit from Woodlands for "spay" from a Malay family who had stated incorrectly the gender.

Two big terrapins came yesterday for Dr Jason Teo - one would not eat and the other one had puffy eyes and I had them cleaned and given eye drops and bask in the bright morning sunshine. I had to supervise a new vet technician as Mr Min would be moving on to better future after having worked two years with me, increasing his value to the new employer as an experienced vet technician.

Back to the cat with the bladder stones operated 3 days ago. The owner phoned me yesterday and today to provide me feedback and that was important.

"My cat did not vomit after eating food. He drank a lot, around 375 ml of water and peed a lot," he said. "He laid on his urine and so his surgical wound is very red."

"It is good news that he pees a lot," I said. "This shows that his bladder is normal." I tried not to joke that this showed that his bladder was not leaking after my surgery.

"What should I do to the red area of his wound?" the owner asked.

"It is very difficult for me to know what you are describing," I said. "Was the cat licking the wound since you did mention about taking off the e-collar?"

"No, he is still wearing the e-collar."

Since the owner was working, I suggested that he changed the plaster covering the wound and replace with a new square one. "It could be the blood clot from the skin after stitching," I said. Will wait and see.

It seems that the cat with the renal impairment based on blood tests taken by Vet 2 on Wednesday (4 days ago) is doing well.  He did not vomit his food. I asked the owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet yesterday. He has a good maid and with home care, this cat should thrive. 

Day 7 after surgery.

Feb 27, 2013 - I phoned the busy gentleman owner of the cat with the bladder stones as I was reviewing the past few days' cases. All cases done by associate vets and be me are reviewed by me as much can be learned from cases done. But this takes a lot of time and time is not much when there are many other things to do.

"My cat is back to as good as normal," he said that the cat was jumping and his stools and urine were normal. He had told me the day before that the cat drank less. I explained that the cat was fed canned K/D diet and canned food has a lot of water.

"Does he eat on his own?" I asked this important question.
"He eats a bit and does not mind spoon-feeding by my maid." This was a moment of great joy to know that a surgical patient who was having kidney disease based on blood test by Vet 2 had recovered almost fully. The stitched bladder with a 8-mm cut by me to extract the 8-mm diameter stone must have healed well, otherwise this cat would be dead.

Follow ups are much appreciated and great learning lessons for any vet but we seldom have much time to do it. It creates an excellent customer service experience.

This owner loves his grandmother as he did bring her to take the cat home the day after surgery. Grandmothers are most loved as they usually spend most time with the grand children while the parents are out working and surviving in the corporate jungle. His grandmother was over 80 years old and her mind was sharp and alert.

"Remember the S/D can of food given by Vet 2?" I asked the owner. "It may not be useful as the cat's urinary pH is acidic at pH=5.0. That means that the bladder stones are unlikely to be struvites as S/D is for prevention and dissolution of struvites stones. Most likely, they are calcium oxalate stones but we have to wait for the results of the stone analysis."

This info was obtained when I collected urine before opening up the bladder for stone removal. It is important that the vet performs this procedure as it may not be possible to collect urine from an angry non-sedated cat earlier. That could be one reason Vet 2 did not do a urine analysis and just prescribed S/D of one can. It is best to practise evidence-based medicine by doing urine analysis. In this case, there were no crystals in the urine.

A 4th year vet student from the top Portugal Vet University was with me and I asked Catarina Mateu : "No crystals in the urine test means no bladder stones. Many vets will come to this conclusion. What about you?"
"Yes," she replied. "I also think this way." 

UPDATE ON MARCH 1, 2013. Day 9 after surgery
I phoned the owner to inform him that stone analysis revealed calcium, oxalate and magnesium in the bladder stone. I advised canned C/D food for at life. But it is relatively expensive compared to the usual canned foods. 

He said: "My cat is ok now. Only that he is inactive when he wears the e-collar. When do I come for stitch removal?"
"Your cat has never worn e-collars before. Once the skin stitches are removed on this Sunday, your cat will be free of the burden of this collar."

UPDATE ON MARCH 5, 2013, Day 13 after surgery

The cat's nylon skin stitches were removed by me. The owner said that the cat was withdrawn and quiet when he was wearing the e-collar but would be more active when he was not wearing it. "No need to wear the collar now since I had removed the stitches."

UPDATE ON MARCH 10, 2013. Day 18 after surgery
The cat with the bladder stone surgery came for stitch removal on Sunday, March 3, 2013. No need to wear e-collar. The owner got 48 cans of C/D for his cat and will buy from the vet near his apartment later.  No further news from the owner.  As for the cat with urethral obstruction, no recurrence and no news from the owner.

UPDATE ON MARCH 22, 2013, Day 22 after surgery7.22 am from home, as I review this case to be produced as an educational video. No news or complaint from the owner. No news is good news in the case of the cat with the bladder stones removed. It is good to know that the cat is back to normal. The owner will be buying his feline C/D from Vet 2 as the surgery is across his home.

UPDATE ON APRIL 21, 2013. Day 52 after surgery
No news is good news or phone call from the owner. The owner complies with the medical instruction to feed the cat only C/D and nothing else. I did not phone him as I had much work to do and much time was expended on my "dying" car. My 8-year-old Mercedes E200 had leaked coolant again and had cost me over $6,000 of repairs in the last 2 years and spending time in car workshops. 

My mechanic had told me that it would cost $4,000 to repair and there was no guarantee of leakage or other faults as the car was aged. If I de-register it by April 30, 2013, before Feb 2015, I would get a COE rebate of S$33,600. I decided to scrap it. I could sell the body for S$2,000 and a vet friend bought it from me. He would get it repaired in Malaysia. This car reminded me of aged sick dogs that have no cure.

Now I rented a Mitsubishi for $1,500 per month and need not bother about installment payments, insurance and repairs.  

UPDATE ON APRIL 22, 2013. Day 53 after surgery
Whenever I am free, I will be present at around 7-8 pm during weekdays as some of my interesting cases present themselves.  I would ask Dr Daniel to go home since there is no need to have two vets at one time.

At 7.45 pm today, Monday April 23, 2013, the gentleman suddenly came in while his mother waited inside the car. He was in his usual rush to buy the feline cans of CD for next 14 days. His cat ate around one can/day and he is now out of stock.  

"How's the cat?" I asked.
"Back to his naughty self. Scratching everywhere and jumping. He has put on weight. He still has loose skin below his belly."

"It is good news." I said. "I discussed your case with Dr Daniel recently comparing the outcome of treatment of a Pomeranian with right perineal hernia of 2-3 months' duration. The Pomeranian had similar very high abnormal kidney disorders based on blood test. He passed away 4 days after surgery. In this case, the owner had waited 2-3 months before seeking veterinary attention and the bladder had herniated and been trapped inside the perineal hernia."

"Your cat had a very high Blood Urea Nitrogen (Vet 2's machine could not read values as they were excessive) and creatinine >30+ (normal 0.3 to 2.1). Phosphorus was >20+ (normal 3.4-8.5). Dr Daniel said to me yesterday that this cat could not have survived the surgery! His creatinine level was >15X the higher range of normal! Yet he is fine today."

The gentleman was the one who was most worried about the serious kidney disorder and wanted immediate surgery. I had postponed the surgery for one day and given antibiotics to the cat as the other vet did not do so. The cat survived the surgery and is very naughty now, 60 days later.

"You can buy the C/D from the other vet near your house," I said as this man complained of distance of my surgery from his home. "You don't need a prescription letter from me. I am sure he will understand as he had treated your cat before. I don't stock up C/D as they expire. Demand is not high. I will fax the prescription to your vet when you need to buy from him.

"You are an exceptional owner in that most cat owners could not be bothered with feeding the special food and get recurrence of stones again!"

"You advised feeding 3 months of C/D" he said.
"If you do regular 3-monthly urine tests," I said. "You may be able to stop feeding feline C/D and give commercial cat food. If not, give canned C/D. The cat is thriving on C/D. Perhaps, you can mix it with dry C/D which is less expensive as one can of C/D costs S$5.00."

"It is a miracle," he said. "I prayed for him before surgery."
"Yes, it was a miracle as he had a serious kidney disorder and was operated early before he gets chronic kidney failure."