1336. Myanmar stories: Tonsillolith. Fortune teller's prediction was accurate

Feb 19, 2014

Khin Khin had profuse bleeding in her mouth, with "large clots" coming out while she was in Myanmar for a few weeks to attend to her 92-year-old aged mother's affairs and business. She consulted the famous fortune teller whom I had met in Feb 2014 on a visit to his farm with Khin Khin. "He said not to worry, nothing serious."

I have an open mind. Some people may have the gift of telling the future. In Singapore, the kind-hearted Dr Chan from SGH's Otorlaryngoloy Department examined her early instead of Mar 19, 2014. She was worried about oral cancers growing in her mouth and sought my help to get an earlier appointment. "Nothing to worry about," Dr Chan told her. "If you wish, go for a neck MRI but it is not necessary. You have got a tonsillolith in your right tonsils." That is the diagnosis. For Khin Khin, the explanation was a "stone". A stone in the crypt of the tonsils causing bleeding which has stopped recently.

"Why is it that I can get a tonsil stone?" Khin Khin asked me.

"I don't know," I viewed the image of the tonsils taken by Dr Chan's nasal endoscopy to look for the stones. "Some people get bladder stones or gall bladder stones. I have not heard of anybody getting tonsillar stones. His report says it is on the right tonsil. Did you bleed from the right side of the mouth? "
"Yes," she felt her right mandibular area. "Right side."

1335. AUDIT. A female Sheltie had blood in the urine 6 years ago

TP XX761

Sheltie, F, Born Sep 28, 2006

Feb 18, 2014. Owner came to buy a small 2 kg bag of canine C/D.  His last purchase of a small bag was in Nov 29, 2013. I met him and he explained that he purchases C/D from the associate vet in Jurong whose practice is near his office and only when there is no stock, he would come to Toa Payoh Vets.

So far the dog is OK but no urine tests have been done.
"It is difficult to collect the urine from a female dog," he said today when I advised urine test.
Some owners can do it but it needs patience. The vet could collect using urethal catheterization but most owners are not keen.

"Use a syringe to suck up the urine after she pees," I said since this was a compromise. "Will it be suitable for testing?"

"It is cheaper to buy the C/D diet," the man in his late 50s told me. "The operation done by your vet in Jurong costs me $2,000. A big stone of over 2 cm plus several small ones were removed and also seen in the X-ray." I got the clinic to send over to me the stone analysis and tests. The stones were struvites. The dog could not pee and so the owner wanted an urgent operation in April 5, 2013.

On review of the medical records, the dog had "smelly urine" in Aug 3, 2008. The owner had some antibiotics and did not have any complaints till April 2013 when the dog could not pee. It is hard to get owners to do the urine tests which will be best practice to check for urinary tract infection and pH.

They prefer just to buy the prescription diet and that's it.

1334. AUDIT. An old male dog passes blood in the urine

TP XX803  Male, toy poodle, white, not neutered
Feb 17, 2014

"My dog passes blood in the urine at 7 am today. Not eating today too. Very tired looking." the woman said.
"Did he drink a lot?"
"I don't see him drinking but the stools are OK."
I palpated the bladder area. The dog winced in pain. The owner did not want a blood test but gave permission for the urine test and X-rays.

"My dog had a blood test before," she said. I checked the records. The dog had a high total white cell count of 49.2 (6-17) on Sep 8 2013. The complaint was blood in the urine, licking of the penis, diarrhoea and not eating for 2 days. Two years ago, Vet 1 had said that the dog would die under general anaesthesia if dental extracton of the rotten loose teeth was performed. Vet 1 said she was old, had heart disease and so would die on the operating table.

The owner did not do it. The dog had foul breath for the past 2 years and was drooling in this Sep 2013 visit. But drooling was present in the past 2 years too. Regular dental check up from 2 years of age every year would have prevented this situation from developing. Dr Daniel had the loose teeth extracted and the dog was OK as the owner said: "It is the bad teeth causing drooling and the high white cell count!"  Owners are quite sophisticated as regards blood test results.  



   

1333. An emaciated paralysed dog in Singapore

"Just have a look and tell the AVA that the dog is OK," the man  brought in a very thin rib-showing cross-bred. He finally had a summons if he did not get the dog a veterinary examination.

"The dog is paralysed in his hind legs with two foot sore but that does not mean that she will become so thin," I got some pain in the thoraco-lumbar region and weak pedal reflexes of both hind limbs. "Unless he is not given sufficient food or has a disease. Paralysed dogs can gain more weight as they don't walk much. I need to do a blood test. "

"Please don't tell the AVA that I have ill-treated my dog," the man had reared the dog from puppyhood and now she is 13 years old. That would be considered aged.

"Was there a car accident earlier?" I asked.
"She ran out of the house 2 years ago but came back OK. Later she was wobbly and after that paralysed."

The blood test showed high ALT and urea levels but the haematology was normal. There was spinal pain at the T9-11 area and the pedal reflexes of the hind paws were poor. Two bed sores on each hind paw were large at 2 cm x 3 cm. The dog looked alert and her coat was in good condition.

"My dog does not like dry food," the man said that his dog at 50:50 wet and dry food. He would bring samples for me to see.  It is hard to assess whether this is a case of under-feeding or the dog being a fussy eater over the years, leading to this condition.

I advised more dry food of good quality to be fed and warm water to shampoo off the urine smell off the back area. I would submit a report to the AVA care of him. X-rays, faecal worm tests, neoplasia checks of abdomen, exocrine pancreatic deficiency were not done as medical costs were a concern. This is a case where the owner shows that he cares for the old dog as others would just euthanase her.  

"Some concerned animal lovers may have reported you to the AVA," I said to the man. "Your dog is paralysed and very thin. It can be a case of dog abuse and so the AVA needs to respond to the public complaint. The AVA is very busy with budget cuts nowadays. So I don't think the officers go around Singapore checking on the dog's health."  

Overall, the dog is in "good" condition as regards blood test and alertness. It is just that she is very thin.

On Feb 20, 2014, I submitted a veterinary report to the owner for the AVA. This is a strange case as paralysed dogs do put on weight if they are in good health or fed much more. I can't say whether he has underfed his dog or the dog is a finicky eater.

Sunday's interesting case - A papillon with fits from Tampines is active now

TPXX284

Sunday Feb 16, 2014

"Do you remember my old dog with fits for 2 days and kidney failure?" the woman in her late 30s walked in and told me the name of her dog. "A small black and white dog" she held both hands apart to indicate the size of the Papillon.

"I can't remember as there are many old dogs with kidney failure and fits," I took out the medical records while the lady had her own 2 receipts. The dog had 12 rotten teeth extracted on Jan 12, 2014 by me. Blood test had indicated kidney failure with high counts of urea at 64 and creatinine 260. Neutrophil % was high at 86% but total white cell count was normal. Blood calcium was low but glucose was normal.

"Cha Cha has good appetite and is very active," she said. "Luckily I didn't put her to sleep!"
She syringed 50 ml water 2x/day daily and fed k/d canned food with rice and minced chicken. The dog just ate all.

I did not expect to hear from owners. After all this dog was aged at 13 years old. But he is as active as can be.

"I think the fits are due to his rotten teeth," the lady said. I agreed as there were no more fits since dental extraction. No more lethargy and staggering. A positive outcome and no euthanasia as advised by her friends justifying that the dog was old and had fits.

I advised k/d for 3 months and take a blood test. It is difficult to advise based on recovery. This was a case referred by her friend to me and only positive outcomes can generate referrals in medicine and surgery. Fortunately the dog did not die under general anaesthesia (using isoflurane gas only). Otherwise, no happy ending from the lady in Tampines as the vet gets the blame when death on the operating table occurs.

Yearly dental check up will be best for dogs over 5 years but Singaporeans are too busy to do it. So, many aged dogs have foul breath and loose teeth. Painful mouth ulcers and tooth ache can lead to fits. This was a surprisingly good outcome case as I thought old dogs with fits will not live long. But here he is. Good appetite and active.

The leg tumour grows from grape size to kiwi to apple to mango size in a few weeks

Likely a malignant mast cell tumour as it reappears at its original site on the left hind limb. 5 years ago, Vet 1 excised a small tumour with 1-cm resection margin. Histology shows neoplastic cells at the edges of the excised tumour.

5 years later, a grape-sized tumour was discovered on the same spot. Vet 2 did a fine needle aspirate which drew no cells. The tumour grew from small grape sized to kiwi ro apple and now mango-sized when they came to Toa Payoh Vets.
Vet 2's senior surgeon said that FNA could have caused the tumour to expand. I disagreed as it was a recurring malignant tumour and so do grow aggressively. The senior surgeon gave 2 choices with no guarantees of success:  1. amputate the left limb    2. excise the tumour. The dog could die on the operating table owing to old age high anaesthetic risks. The owner decided not to operate and the tumour grew to the mango-sized when they came to Toa Payoh Vets. Dr Daniel was the surgeon for this case.

1330. Video: A white dwarf hamster is very itchy

Feb 14, 2014. Valentine's Day & 15th day of Chinese New Year.

The dwarf hamster had been scratching for the past few weeks. "Keeps scratching her elbows. Very itchy," the lady took leave from work in her Jurong office to send the hamster for treatment. I checked the past records and on Sep 8, 2013, there was an inflamed right elbow.

Now both elbows and inside the two thighs and above the knees are hairless and red. There were bite marks. The hamster was anaesthesized and the hairs around the inflamed joints clipped and washed. Oral pred was given and the hamster is restricted to eating seeds but no more orange and green coloured pellets common in the hamster food. The bedding is paper now.

It is hard to know the cause of the allergies. The colouring in the food pellets may be a cause as the hamster is not given sand bath nor shampoo or spray.

"Is it serious? Is it serious?" the young lady asked me.
"Yes, if the hamster keeps scratching non-stop to relieve the itch. Sometimes, they pull out their body hairs as I had one case earlier!"

Follow up in 4 weeks.

Video.