Monday, September 8, 2014

1488. A 11-month-old Dachshund has watery stools for 5 days

Sunday Sep 7, 2014. Fine sunny and hot day. Electricity for the industrial block was cut off for maintenance from 9 am to 1.45pm.

This young Dachshund passed watery stools for 5 days and so the young couple was worried.
I advised IV drip with anti-diarrhea and antibiotics given.

"The other vet gave an injection and the dog recovered the next day," the gentleman said that the other vet did not even examine the dog. I tried to wrestle the dog's mouth to open for examination of oral ulcers and the dog moved his head here and there Hard palate ulcers seen.  Video to get the ulcers recorded. My assistant Naing said he got it.  Abdomen full of intestinal gas. .

.

Saturday, September 6, 2014

1487. Ear tumours due to chronic infections

Case 1.  For those who love their dogs, continuous head shaking in their pet dogs is a grave concern for them. These ear infections do not respond to treatment and so the owner gives up. As the dog grows old, the chronic infections cause ear tumours.

One example is the 13-year-old Siberian Husky. The tumour was not malignant as it was due to chronic infections. The lab test shows that it is a ceruminous cystadenoma.  The solution was a vertical ear canal resection in this old dog.  No more complaint of head shaking and smelly ears now 2 months after surgery.  Dr Daniel did the surgery.










Case 2. In another case, I did a lateral ear canal resection and the tumours in the vertical canal were numerous.




Case 3.  Greyish ear cells or nodules inside the oldl dog

Friday, September 5, 2014

1486. SCRIPT FOR INTERN RGS - Hypercalcaemia in a 15-year-old coughing dog

Sep 5, 2014
"I am the cheapest vet in Singapore in Singapore," a vet said to me as more than 65 vet practices have been set up in Singapore. "So, no other nearby vets can compete." At the end of the day, there is little net profits for purchase of new equipment or renovations.

In this 15-year-old dog, the family vet prescribed steroids to bring down the soft facial swelling of 5cm x 5cm. "Your dog is too old for anaesthesia. He may die on the operating table. Take some medication."

The dog became very hungry and thirsty but the facial swelling did not disappear. Old dogs do die under anaesthesia. So, the owner must give an informed consent.

In this dog, the facial swelling was a cluster of cysts. A rarity. He had some coughing earlier but the coughing became continuous and worse.

"He could not sleep on his neck," the lady said. "He could sleep with the head turned sideways."  At one time, he could not sleep on his sternum. So what is the cause of this problem?
I advised X-rays. There were sinister findings of multiple nodules inside the lungs. Now the serum calcium is higher than normal. Why? A parathryroid tumour? 

But neoplasia can lead to hypercalcaemia and this neoplasia is likely from the lungs. The dog keeps coughing and has. So, to give him a better quality of life. I prescribed low doses of pred. to stimulate his appetite and relieve some inflammation in the throat. The owner was much delighted.

















1485. Script for 15-year-old JR with carnaissal tooth abscess

Sep 4, 2014


HISTORY
Hi,

I think my 15-year old JRT has fistula with discharge from
carnaissal tooth abscess on his right cheek. Can I check whether it is advisable to do scaling at this age? GA or sedation?
How much is the cost of blood test, scaling,extraction and etc?
Look forward to your reply soonest.

many thanks

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















HOOK

           PROBLEM
A discharging facial wound below the right eye. Pus seeps out. Blood seems out. Wound does not heal. Why?





9316.MOV    On August 25, 2014 - 10 days ago.
0 - 2:32     Right facial swelling. Left face is normal. Evert upper lip. Rotten foul-smelling tooth seen on right upper jaw below the facial swelling. On the left side, the tooth had dropped off long ago.


BE KIND TO PETS IMAGE






INTRODUCTION
Case TP  20970  
13-year-old male Jack Russell - has a hole in the right side of the face for 2 weeks. The first vet had diagnosed a tooth problem.
What is this old dog suffering from? Why is the wound not healing?

9319.MOV.
0.18 - 1.05  
Explain with medical illustration from a book. Malar Abscess.
Oro-nasal fistula (define this).   Wound does not heal as the pus keeps coming out from the badly decayed root of the carnaissal tooth. It is the upper premolar tooth closer to the nasal sinus compared to other teeth. So, the nasal sinus becomes infected and rots. Pus comes out through the skin below the right eye. This is called oro-nasal fistula. Fistula means a connecting channel between two mucous membranes. In oro-nasal fistuala, the membrane of the mouth connects with the nasal sinus, discharging pus above the sinus, below the eye.

1.23 - 1.38  Actual fistula from this 13-year-old Jack Russell

2.40 - 3.19. In-patient Pomeranian. Had same medical problem 5 years ago. Now OK as wound had healed. Dog owner did not bother with dental check up in the past 5 years. So, you can see the teeth are crusted with black tartar.

4.15 - 5.15    Is the Jack Russell coughing? Yes. Check heart. Left heart murmur. High anaesthetic risk of heart failure during anaesthesia. 

9320 MOV
4.19 - 4.53   First blood test taken on Day 1 (first day of visit) by Dr Daniel and put inside the blood tubes. Get some scenes.

                 BLOOD TEST RESULTS
Normal                                    Total White Cell Count    Neutrophils    Absolute
                                                 6-17                                  60-70%         3-11.5

26.8.14                                       30.9                                   79.3%          24.5
4.9.14                                         13.8                                  69%             9.52


I had prescribed antibiotics trimaxazole syrup for 7 days from 26.8.14 to 2.9.14. The 2nd blood test showed it was effective as total White Cell Count and Neutrophils returned back to normal on 4.9.14, before surgery. But there is the bad breath still present as the owner came in for surgery on 10th day.

SOLUTION

ANAESTHESIA
1. Painful mouth - hard to mask and give isoflurane and oxygen gas. Struggle.
Some vets would give sedative injections as a routine to make it easier to operate.
But heart disease - can die of heart failure under general anaesthesia

SOLUTION  Antibiotics past 7 days to kill bacteria in mouth and gums. Reduced inflammation and therefore pain. Gave I/V drip + antibiotic (baytril) + frusemide (clear lung of fluids)

9643.MOV 0 - 2:30
Pre-anaesthetic IV drip + medication. Dextrose saline 1 bottle 500 ml + 5% glucose for 5 minutes. The dog had no fever. Now the dog looks alert. A non-aggressive Jack Russell with the large facial swelling of 4 cm x 4 cm seen below the right eye. The oro-nasal wound is now dried up as compared to 10 days ago when there were yellow pus discharging out.

9720.MOV   0.0 - 1:50
No struggle when the dog is masked. The right upper carnaissal tooth (Premolar 4) is extracted out easily. This enable any pus accumulated inside the root area and sinus to drain downwards. Surprisingly no bleeding during extraction as you can see from the video. Another right upper Premolar 2 is extracted easily.


9723.MOV   0.0 - 2:03
The left jaw. The left upper carnaiissal tooth (Premolar 4) had dropped off earlier, so none was seen. Premolar 3 is extracted. Dog wakes up fast under gas. Mask dog to give gas so he can sleep and not feel the pain. Extract the other loose teeth. Scaling of teeth done on the canine teeth. Dog wakes up. Cries.  Gives gas. Change to bigger mask as there is lots of bleeding after extraction of some teeth.

9734.MOV  0.0 - 0:46
One hour after anaesthesia and surgery. The dog is alert. The facial swelling below the right eye has almost disappeared. 11 decayed teeth in a plastic bag are put inside a plastic bag and given to the lady owner who took them home. The young lady is most happy with the outcome.  Her mum is satisfied as it was her daughter who was much worried about the anaesthetic risk. I said it was 50:50 but this is only a guideline. Each old dog with heart disease reacts differently and so it is hard to predict. In many cases, the old dog survives if the anaesthesia is just gas and of short duration.




Not to operate was not an option as pus kept discharging from the wound (known as oro-nasal fistula) below the right eye.


POST OP E-MAIL FEEDBACK FROM THE OWNER

SEP 9, 2014
Hi Dr Sing
My dog had done the extraction of teeth on thursday by you. He is eating well and moving around normally. However, he has some involuntary movement on his cheek/mouth area.

Please take a look at the video that I took.

Kindly advice thanks

REPLY FROM DR SING

Involuntary lip/mouth movements after surgery could be due to painful contraction of holes in the gums after extraction of 11 teeth.


FOLLOW UP 2 WEEKS AFTER DENTAL EXTRACTION
The 15-year-old Jack Russell is back to normal, active and eating.
 

Thursday, September 4, 2014

1484. Third eyelid cyst or lump in a 2-year-8-month-old dwarf hamster.

"She weights 67 g," I said to th".

1483. The real carnaissal tooth abscess - 15-year-old Jack Russell

Sep 5, 2014

Today, the real carnaissal tooth abscess Jack Russell of 15 years of age was operated by me.

The owner was supposed to come back 7 days after my first consultation as I had prescribed 7 days of antibiotics and heart disease medication. But she came on the 10th day (today). The oro-nasal fistula was no longer seeping with pus and had closed. So, the young lady did not want the risk of anaesthesia and thought of not taking the surgery to extract the carnaissal tooth. The dog had bad breath now since the teeth were much rotten and the antibiotic (trimethoprim) had been consumed.

"But the facial swelling is still there," the girl's mum said.
"It will come back," I referred to the seeping wound.
It was hard for her. The younger ones are more caring of the old dog and worried more. She wanted to be present at the surgery. "No," I said. "I want to focus 100%, not to be distracted. In any case, I don't permit viewers as the operating room is so small." 

She wanted me to inform her when surgery started. This was after the IV drip with baytril and furesemide. I told her she could wait outside the reception room but she did not turn up.


GAS ANAESTHESIA
The gentle dog was OK for mask anaesthesia as his mouth is not so painful after antibiotics for 7 days. The challenge is when to extract the teeth. Too soon, the dog would feel the pain. Too late, the heart failure might kill the dog. The right carnaissal tooth was loose and I could pull it out easily. The left one was missing as it had dropped out some time ago. 

Four  canine teeth had more than 50% gum attachment gone but they looked solid.
"Dental scaling would be done," my assistant Naing said.

"Actually they are loose at the roots," I gripped the canine tooth with the forceps and gave a twist. The tooth came out easily. A normal canine tooth cannot be twisted or dislodged so easily. It was best for the dog not to have scaled loose canine teeth as they would become infected again.

In all, 11 btownish black teeth were extracted and put inside the plastic bag for the owner as evidence of extraction. . One carnaissal, 3 premolars, 4 canines and 3 incisors. All easily extracted. Much better for the dog to have no teeth than decayed ones with lots of bacteria.

The owners would feel otherwise. "How is the dog going to eat food?" the mother asked. "With rotten painful teeth, the dog just swallows the food rather than chew or bite," I said.

The dog woke up from gas anaesthesia fast and I had to change to a bigger mask. Blood spilled from the holes of the extracted teeth into the mask and the connecting tubes of the anaesthetic machine. Blood came out from the extracted rotten teeth.

The dog survived and was alert as if nothing had happened within 10 minutes of the end of surgery. It was good news. A dead dog is no good for the vet or the owner.

Follow up 2 weeks later revealed that the dog is back to normal with no bad breath, active and eating.  .


 

Tuesday, September 2, 2014

1482. Vertical ear canal tumour (lump) in a 13-year-old Siberian Husky with a smelly ear

FINAL REPORT ON SEP 2, 2014
------------------------------------------------------------------------

 July 3, 2014  An uncommon case of a Siberian Husky with a growth on the top 1/3 of the vertical ear canal. The dog had been shaking his ear for the past 2 years. The family vet referred the owner to two other vet practices for a total ear canal ablation. He consulted me at Toa Payoh Vets. From my palpation of the vertical canal, there was pain and a hardened lump.

 

The vertical ear canal had a tumour and the family vet presumed that the whole ear canal (horizontal and vertical ear canals) were
full of tumours.

Vertical ear canal resection (VECR) is the solution. In Dr Daniel's opinion, the smelly ear tumour in the top 1/3 of the vertical canal seen only during VECR surgery might be cut off. This is a difference in opinion as 10 vets would have differing opinions on how to handle this case.

For example, the family vet advised total ear canal ablation and referred the owner to two other practices.

To lower medical costs, no X-rays were done. During VECR, the tumour at the upper 1/3 of the vertical canal could be seen. It was around 3 cm x 3 cm and rotting. If it was excised, the other parts of the surrounding areas may erupt a recurring tumour assuming this was malignant.

The better alternative is to excise the upper 2/3 of the vertical canal lessening the chance of recurrence. Not every vet will agree with me as this is part of the diversity of life and medical opinions in real life.

I got Intern Shan to edit the video and in that way, she would understand what the operation was all about.

The surgery images were quite confusing to her but she could understand after my illustrations. Once in a while I get to meet an intern much passionate in veterinary surgery. Shan would make a very good vet. It would take another 4 to 5 years to graduate. That would be 2019!







INFORMED CONSENT.
High anaesthetic risks for a 13- year-old. Dr Daniel operated and removed the vertical ear canal. There was a big tumour at the top 1/3 of the vertical canal.


It is hard to see inside the hairy vertical canal. The canal wall was hardened and painful. After medication for 2 weeks, 2/3 of the upper vertical canal is removed. The lower 1/3 was cut into two parts. One part was stitched downwards and the other part stitched upwards to allow the opening of the horizontal canal to drain out. The skin edges where the upper 2/3 of the veritcal canal had been excised were stitched.

As at 1 month after surgery, the dog is OK. This surgery is called vertical ear canal ablation (VECR). There was a big rotten tumour in the upper 1/3 of the vertical canal causing pain and infection. Hence there was pus inside the ear canal for the past 2 years.

There is another more common surgery called lateral ear canal resection (LECR). In this surgery, the side (latera) wall of the vertical canal is excised. It is an easier surgery. But this Husky had a tumour on the top 1/3 of the vertical canal and so it is best to do VECR in case the tumour recurs.

Sep 2, 2014. Acknowledgment

A big thank you to a bubbly young lady Shan
.
Video was produced by Intern Shan who is very keen on veterinary medicine and surgery. She posted this video from her University in Australia into my "Dropbox" and I download it to my hard drive before uploading it to Youtube..

LEARNING EXPERIENCE. The illustrations were too distant to be viewed. My explanation of the stages of the surgery could have been zoomed in.

 
VIDEO IS AT:


http://youtu.be/CCjPtc0bQzc


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


FIRST REPORT FOR INTERN SHAN TO PRODUCE THE VIDEO 
images




Jul 3, 2014  Changi Airport Terminal 2,   4.07pm

I met the owner of the 13-year-old Siberian Husky this morning. The first vet referred him to two other practices as she does not perform the ear surgery. "Unable to examine the ear canal due to tumours." The owner had bad experiences with the first surgery recommended and did not go to the second.



The dog's left ear was full of pus. The vertical canal was hardened and painful. The right ear was OK.
"What caused this ear problem?" he asked me.  "Was it due to ticks?"
"It is usually a small ear infection and the owner ignores it over several months. So the bacteria and yeast cause inflammation and the vertical walls hardened like tumours." I pressed the canal and the gentle husky winced in pain.

"Treatment would be surgery to take out the whole of the vertical canal," I said. "This dog is old and a blood test is needed."

"My dog is healthy," he said.
"You are likely healthy unlike an old man," I replied. "This dog is old and I don't know whether she has kidney or liver disease till a blood test is done."

He agreed to a blood test and 2 weeks of drug treatment to bring down the inflammation. I will see the dog in 2 weeks' time and do the vertical ear canal surgery if the wounds have had healed. "The cost of surgery is $1,000 as it takes a long time and the dog is bigger in breed," I estimated the cost.

It would be better if the owner had not delayed early ear infection treatment but he was overseas studying. Medical costs would be much less if there was no surgery. 

The young man really turned up for the surgery done on Jul 17, 2014. The 2/3 of the vertical canal with an abscessed cartilage tumour 3 cm x 3 cm x 1 cm were excised. Lots of bleeding. 20  hours later, the wound is washed. The dog went home with pain killers and antibiotics on Day 2 of surgery.

So far, so good.



Vertical ear canal resection (VECR) is the solution. In Dr Daniel's opinion, the smelly ear tumour in the top 1/3 of the vertical canal seen only during VECR surgery might be cut off. This is a difference in opinion as 10 vets would have differing opinions on how to handle this case.

For example, the family vet advised total ear canal ablation and referred the owner to two other practices.

To lower medical costs, no X-rays were done. During VECR, the tumour at the upper 1/3 of the vertical canal could be seen. It was around 3 cm x 3 cm and rotting. If it was excised, the other parts of the surrounding areas may erupt a recurring tumour assuming this was malignant.

The better alternative is to excise the upper 2/3 of the vertical canal lessening the chance of recurrence. Not every vet will agree with me as this is part of the diversity of life and medical opinions in real life. A veterinary educational video is shown below:










































FOLLOW UP
Over 3 months after operation, the Husky came as he had severe diarrhoea.
The Husky has not experienced any ear shaking or rubbing as the offending vertical ear canal had been cut away, together with the smelly canal tumour.
 
 











HISTOLOGY RESULTS:    

The vertical canal right ear tumour, 2 cm x 1.5 cm x 0.7 cm,  is compatible with ceruminous cystadenoma. It is not malignant.


CONCLUSION
With old age, tumours appear in dogs. It is best to get tumours removed by your vet when they are small. In this case, the large tumour was deep inside the vertical ear canal and was infected. The only solution was to excise the whole vertical ear canal. Some vets may not wish to perform such operations and will prescribe ear drops. These will not help to clear the ear infections as the tumour is traumatised by the dog rubbing and scratching the irritating ear.



 

Monday, September 1, 2014

Air urocytogram is useful -- Shih Tzu dribbles urine for the past 7 months

Sep 1, 2014

"Vet 1 didn't advise anything," the owner said that his 7-year-old male shih tzu had dribbled urine for the past 7 months but could not pee today.
"X-ray is necessary," the owner did not want blood tests. "Urine test too."

Bladder swollen as big as a mango, indicating urethral obstruction.
A narrower cathether could be passed in. Yellowish urine flowed out and also dribbled out.
After emptying the bladder fully, the cathether was taken out. Around 30 ml of air was pumped and the dog was X-rayed 30 minutes later.


An air urocystogram makes it easier to differentiate between the bladder and prostate and to see the thickened bladder wall and any calculus or uroliths.

Method
I asked my assistant to drain the urine, pumped in 30 ml of air.
A 74-year-old vet who visited me was quite impressed with seeing the thickened bladder wall.


UPDATE ON SEP 8, 2014

The dog's urine was positive for amorphous phosphate crystals. pH = 7.0. Blood present.
Acidurin tablets were given as an alternative to surgery. These were used to dissolve the stones. As at 7 days after prescription, no complaint of urethral obstruction.
 

Sunday, August 31, 2014

REVIEW - 4 weeks after traumatic proptosis - 15-year-old chihuahua

Aug 30, 2014  Anorexia and diarrhoea. Saw the eye condition and took images


HISTORY

Chihuahua, F, spayed, 15 years

Jul 28, 2014   Traumatic Proptosis  A X-bred jumped on her. R eyeball prolapse. Cornea dried, dirty about 1 cm diameter
Jul 29             Replacement of globe. Tarsorrhaphy
Aug 3             Stitch out   eyeball inside socket  white central cornea 1 cm diameter  red spot at 6 o'clock  cleaned eye  (5th day). Sticky pus from ant chamber flowed out from red spot of around 4 mm across ventral cornea

 Aug 4         Tarsorrhaphy again
Aug 11         Goes home.  Tried to rub eye.  E-collar

Aug 30        Dog came for diarrhoea and images taken. No more ulcer and rubbing. Brown scar 1 cm diameter. Eyeball appeared a bit shrunk. Lateral canthotomy stitches x 4 taken out today.The dog still has an eyeball as compared to the whole eyeball taken out.














Aug 30, 2014   No eye ulcer. Fluorescein eye stain negative

Saturday, August 30, 2014

1480. The two RI interns - Interns must deliver

Friday Aug 30, 2014

The two RI interns presented me illustration of thanks for internship. I was surprised. "Interns must deliver results," I had said to both of them during their 2-week internship. "Just like any service providers, including vets.

For example, in the case of the 15-year-old dog with facial cysts, I had to ensure that the old dog die not die under anaesthesia and resolve the problem of his coughing by correct diagnosis." This real-life case could have been a good illustration of "delivering results".

The following tips I gave to them:

1. Eye contact. "You don't see lawyers typing and looking into his screen while consulting," I said to one intern who uncles are lawyers. "You see Dr Daniel doing it. Some doctors in hospitals do that too to key in case records. More time should be spent on eye contact."  This is because one intern kept keying in rapidly the discussions into his smartphone. Obviously he lost the meanings of what we discussed as he focused on typing. He could not see the body language.

2. "Amateurs use multiple colours in the video production and layout of reports." One intern loves different fonts and colours in his text. 3 colours would be best. Headings should be consistent in size and colour.

3. "Rule of third and cropping" in digital photography. No point showing the wide area of grass land when we want to show the butterfly's beauty as the background will be distracting..

4. Being meticulous. "Mis-spelling is not good."  One intern typed "pyometra" as "pyomettra" and I was so angry that he was not meticulous.  "Don't disgrace the name of RI," I said. "Many interns don't edit before submission of the work to me."