Thursday, February 23, 2012

883. Lateral saphenous artery - Golden Retriever tumour in front of knee

The case of the old Golden Retriever with a large knee tumour.

"Your vet quoted $300 for the operation," the mother said.
"Who was the vet?" I asked as the surgery to excise this large knee tumour will take a long time, at least one hour. I had quoted $500. The owner did not want blood test or histopathology of the tumour and that would save some money. Still, $500 for the whole procedure including drugs, e-collar and post-op care was very low.

ANAESTHESIA
50% of domitor + ketamine IV according to my guidelines written previously.
The dog was old and at 50% was really knocked out. A whiff of the isoflurane gas + O2 after 5 minutes of sedation enabled intubation.

SURGERY
I demonstrated the surgery to Dr Daniel by operating together as this would not be a simple surgery as removing a tumour from the side of the body where there is a lot of skin. Here, the tumour was massive at 7 cm x 8 cm x 5 cm and if the textbook advice is to be followed, a wide resection meant insufficient skin for stitching. A wide resection is important to remove all tumour cells but an big knee wound due to insufficient skin area to close is deadly for the dog post-op as bacterial infection comes in over time.

Use marker pen to know how to excise.

BLEEDING ARTERY
There is one spurting artery of around 2 mm in diameter from the skin surface lateral to the tumour. "It is the lateral saphenous artery," Dr Daniel said. I advised a "purse-string" suture with the 2/0 absorbable and he did it. The bleeding stopped. But profuse bleeding from all other tissues continued. Swab, swab, swab, swab.

"A bi-polar electrode will be most useful," he said.
"In old dogs, the faster the surgery is done, the safer it is for this 8-year-old. I excised the tumour fast and started stitching. The bleeding continue unabated as there were numerous veins and smaller arteries. In theory, the bi-polar electrode would be used to coagulate. I could also use the coagulation electrode by switching to it from excision electrode."

"Look, the tongue and gum colour of the Golden Retriever is getting purplish," I said. In theory, it is best to stop all bleeding. This prolonged anaesthesia and the dog dies.

In practice, I stitched up the wound and used bandaging. A live patient is what the owner wants, not a clean no-bleeding surgical wound. This is the good outcome that is what text books don't teach.

You can see pictures at www.toapayohvets.com now. Will update again.

Myanmar tourism has exploded as at Feb 2012

On Feb 22, 2012, I spoke with my Myanmar travel agent partner about the latest in Myanmar tourism since the U.S has made contacts with the politicians and Aung San Sui Kyi is allowed to be in politics openly.

The following are the latest happenings in Myanmar tourism.
1. A sudden surge in tourist arrivals

2. Very difficult to find 4- and 5-star accommodation in Yangon's hotels due to the increase in businessman visitors from the Middle East and from Non-Governmental Organisations. The Middle East tourists rent the whole floor and pays 50% more, according to my partner.

3. Therefore, there is insufficient hotel rooms for tourists who want 4- and 5-star hotel. There are 2- and 3-star accommodation and they are safe, decent and clean too.

4. The administrators want to build a subway in Yangon and had approached the governments of Singapore and Japan as both have the experience.
The investors are given the land to build and both share the profits.

Tuesday, February 21, 2012

881. Blood in the guinea pig's urine again. Why?

"UTI" the owner said the previous vet had diagnosed UTI when her guinea pig had passed blood in the urine.

No urine test was taken by the first vet. She wanted another opinion from me.
"UTI is common," I said. "I need to ward it and do a urine collection to check the urine."

How to collect urine from a guinea pig? I remembered my sheep metabolic studies lectures in Animal Nutrition in the 3rd year. That was 4 decades ago. Improvise. I looked for a clean pan, not the usual pee pan. I found two. See images.




Will update later.
Tentative diagnosis is traumatic injury as the guinea pig still has good appetite and has not passed blood in the urine on 2nd day of hospitalisation after being treated with medication.

Image from link from toapayoh vets as blogger.com seems to have some problems in layout when images are posted directly to it.






Monday, February 20, 2012

880. Sunday's interesting cases at Toa Payoh Vets

Feb 19, 2012
Bright sunshine day

CASE 1.
"My guinea pig has UTI. He passes blood in his urine," the young lady's GP carrier had two large spots of blood spread onto the white tissue paper. "He had passed blood before and recovered after antibiotics," she had the GP treated by 2 vets elsewhere a few weeks ago. The GP of one year old had excellent appetite and was bright.

"Was urine collected for analysis?" I asked as I shared the case with Dr Daniel. Seldom do vets collect urine from a GP. It is just not the thing to do. I mean, how do you collect urine from a 500g GP? Male dogs can be catheterised to collect urine. But a GP?
"No," she said.
"A urine analysis is most important," I said. "I need to ward the GP for 2 days to observe and collect urine."
How to do it? I used two clean plastic tray covers under the grated floor. See image.
Fresh red blood. Bright red as if there was some bleeding internally inside the bladder. Or kidney? More passed. I wondered if the GP would bleed to death.

1. UTI? That's the primary diagnosis. The other vets had diagnosed UTI and so the owner assumed UTI.
2. Certain types of food causing reddish blood. But this was pure red blood.
3. Coagulopathy? Dr Daniel suggested.

The GP passed more than 10 ml of blood. I collected 1.5 ml from the tray and sent to the lab.

URINE ANALYSIS
Blood+++. pH=9.0. Negative for bacteria, crystals, WBC.

The GP did not pass blood after 24 hours. He ate only fresh apples and vegetables.

Sunday, February 19, 2012

Update on the Chihuahua had "died" article

876. The Chihuahua had "died"

Yesterday, Tuesday Feb, I did an unusual Chihuahua spay cum teaching session to Dr Daniel in the afternoon. In the evening, the mother phoned Dr Daniel and said the Chihuahua had died. I was shocked and very sad. However, the Chihuahua had given birth to 2 dead 52-day-old pups.

Today at 10 am, she phoned me to ask whether she should continue feeding egg yolk to the same Chihuahua. "Hold on," I said as I went to ask Dr Daniel as to what was happening. "She said the dog had died."

I asked the mother. "Oh, the dog was dying. She fainted but I could see her breathing. After 2 hours in this position, the dog woke up and is now OK."
This was incredible as I could not understand why the dog had died. Her death was on my mind this morning. She did have a cyanotic tongue on picture taking. She was taken home 2 hours after my surgery and Dr Daniel had checked she was OK.

BACKGROUND
Tuesday Feb 14, 2012 (Valentine's Day)
Home breeder Mr Lim phoned me to ask about Caesarean cost. I had charged $250-$300/Caesarean for breeders some 7 years ago and that was how he knew me as I was in the breeder Caesarean section business doing over 100 dystocias.

"The fees were too low," I had stopped servicing the breeders some 4 years ago. "It should be around $800 - $1,000."

VET 1 TREATMENT. Mr Lim was in Malaysia and so he sent his mum to Vet 1, a vet to get an IV drip first as his mum said the dam was dying since giving birth to two dead pups discovered on Monday morning. Now, it was Tuesday 1 pm and many hours had passed.

Vet 1 also did a blood test and ultrasounds. Possibly two dead fetus according to the ultrasound. I palpated the abdomen. There was a small firm lump of 8 cm x 8 cm which would be just the uterine body as a pup would be 2x larger. In any case, the mum said there were dead pups and so Caesarean was needed. But Mr Lim had instructed that I did it, and so the mum and daughter carried the Chihuahua and the IV drip bottle of 5% glucose saline, ultrasound and blood test from Vet 1 to my Surgery.

Home breeders want the least cost Caesarean sections and he just wanted Vet 1 to give the dog an IV drip first before sending to me. But he had the ultrasound and blood test. It was more costly now.

I spoke to Mr Lim by phone and advised spaying as the dog is 6 years old and had difficulty giving birth now. Mr Lim agreed and so I used this case as a demonstration of how I did a spay on a pregnant Chihuahua to Dr Daniel who had joined the Surgery after his recent graduation.

There was milk in the glands and so it was a surprise that Mr Lim said the pups born premature were 50-52 days. But he is a professional experienced home breeder and so I would accept his calculation.

The dog was severely dehydrated. She was extremely weak as she had not been treated by any vet after her premature births of 2 pups. Therefore Vet 1 had given the glucose saline drip as instructed by Mr Lim. It is a mystery as to why Mr Lim phoned me to perform a Caesarean section for his dog as I had not seen him for over 4 years after I had given up on providing $250-Caesarean section to the Pasir Ris dog breeders as I was barely making ends meet and had no time for pet owners unlike now.











5057 - 5066. How to operate on a very weak Chihuahua after 2 premature births
The ultrasound report from Vet 1 indicated one or two dead fetuses. This is where X-rays would be more useful as the skeletal features of the fetuses would be visible. Or there could be a mis-interpretation of the ultrasound by Vet 1. Abdominal palpation by me did not reveal any hard lump of dead pups. Yet, there was the ultrasound report from a "brand-name" veterinary practice stating the existence of one or two dead fetuses. I advised a spay. The dam went home 2 hours after the spay and two hours later, the mum had phoned Dr Daniel saying that the dog had "died." The next morning, I answered the phone and she asked whether she should feed the dog "egg yolk" or not.

So, this was an unusual case of a Chihuahua that had not really died and had been operated for some 10 minutes without the need of isoflurane anaesthesia, indicating that she was near death's door. Normal dogs and any person will need the anaesthetic gas as they will feel the pain of tying the ovarian ligaments, clamping and incisions.

She had a bottle of IV glucose saline before and after Caesarean section. As at Feb 19, 2012 as I write this report, she is OK. Chihuahuas are very fragile dogs and when stressed out or hypoglycaemia, many don't recover despite treatment. So, anaesthesia can be fatal in such situations. In this case, the vet has to make a judgment as to whether to operate or not. If the dog dies when a Caesarean section is requested due to dystocias, the vet is to be blamed for not operating. If the vet operates and the dog dies, the vet is also blamed sometimes. It is best to give the IV drip of glucose and antibiotics for some 15 minutes before surgery and get the whole surgery from start to finish in less than 15 minutes.




In this case, 19 minutes were taken but that was as fast as I could do as the dog did struggle when she woke up in the last part of surgery - ligating the uterine body. So there was a delay as she was given low doses of isoflurane at 1% and I stopped surgery for a while. Do not attempt to give 5% isoflurane in such situations as that could be fatal.

Updated webpage and more images at:
http://www.sinpets.com/dogs/20120232emergency-casaerean-section-chihuahua-Singapore_ToaPayohVets.htm

878. Follow up on Chinese New Year 2nd day's cases

Feb 19, 2012. Time flies. I have written a follow-up on the interesting cases I saw on Chinese New Year 2nd day on Jan 24, 2012. The webpage and images are at:

http://www.sinpets.com/F5/20120231chinese-new-year-2nd-day-vet-cases-Singapore_ToaPayohVets.htm



839. Chinese New Year 2nd day - salivation - stinks the whole apartment
Tuesday Jan 24, 2012
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed

I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration.




5052 - 5055. A stray cat's serious fight wounds. I got a video produced by Nicole and this is at:
How to clean a badly wounded cat's paw wound, demonstrated by Dr Sing Kong Yuen
INTERESTING CASES

1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.

"Whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"

"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."

"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever. Dental work advised.
UPDATE: Feb 19, 2012. The owner did not return for review.
2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye. What is it?"









4990 - 4999. Abscess caused by two maxillary molar teeth. High fever. Anaesthesia to extract the two loose right maxillary molars was very risky. IV drips, antibiotics and anti-fever 24 hours first  
No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked.



"Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth.



Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.

UPDATE: Feb 19, 2012. The owner did not return for review of the right cheek wound. I presume it had closed by granulation as it would be too big to stitch up. I suspect this case is due to a flesh-eating bacterial infection as it is not typical of a malar abscess.

3. Persian cat of a son who is studying overseas. F, 13 years, not spayed. EMACIATED. Drooling. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.





5067 - 5071.
LPGS - lymphocytic plasmacytic gingivitis stomatitis in an old cat

UPDATE: Feb 19, 2012. To my surprise, the mother reported that the Persian cat was back to normal, eating and putting on weight. Her son, studying in Australia was happy as this was his cat. LPGS (lymphocytic plasmacytic gingivitis stomatitis) is diagnosed by biopsy of the ulcerated oral tissues, but this would cost the owner more money.






Therefore, I did not practise defensive medicine as I did not insist on getting this test done as the signs and symptoms were quite clear. The causes of LPGS are varied as there is no one cause known. It included stress, viral and bacterial infections (FIV, feline leukemia, feline calcivirus, Bartonella henselae bacteria, genetic predisposition, sensitivity of gums to bacterial plaque by provoking the aggressive inflammatory response sending large amounts of lymphocytes and plasma cells (two types of white blood cells) into the gums and oral tissues).

4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."
UPDATE: Feb 19, 2012. The guinea pig started eating but died "suddenly" around 3 weeks after my treatment. The owner requested an autopsy. The stomach was full. The lungs were infected and the chest had a lot of blood tinged fluid, causing great difficulty in breathing and death.

Guinea pig not eating for weeks


5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope to check the hamster's lungs. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.

"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."

"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.
UPDATE: Feb 19, 2012. The owner did not return for review.
In conclusion, on this Chinese New Year 2nd day, January 24, 2012, I had a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.



The updated webpage and images are at:

http://www.sinpets.com/F5/20120231chinese-new-year-2nd-day-vet-cases-Singapore_ToaPayohVets.htm

Wednesday, February 15, 2012

Guinea pig couldn't breathe. Autopsy.

The young girl who brought the guinea pig on 2nd day of Chinese New Year is a medical undergraduate for not eating for some weeks. She had consulted Vet 1 earlier and was given antibiotics but the pet still had no appetite. I anaesthesized it and clipped the overgrown lower premolar and molar teeth which had arched over the tongue.

She texted me today, February 14, 2011, at 7.30am for an urgent appointment as her GP was not breathing well. When I saw her at 9 am at the Surgery, the GP had just died.

"Why?" she said the GP had been eating on his own since she ordered the Critical Care from online petshop that delivered on the 7th day of CNY. The GP was hand fed and was eating well till yesterday, around 21 days after the teeth were clipped.

"An autopsy will give some answers," I said. She wanted one done and I asked Dr Daniel to do it with me. Significant autopsy findings were:

1. Stomach was full of Critical care mashed food and so the GP was really eating.
2. Gas in the large intestines could be normal and food seen in the caecum.
3. Some greenish mashed food inside the mouth. Could be after death.
4. Trachea was very clean, so no inhaled food from hand feeding.
5. Lungs severely congested.
6. Massive hydrothorax (reddish fluid splashed out) and this would cause respiratory distress and death.
7. Left lung had white fibrinous adhesions on the posterior lobes. The GP was not a healthy one and had pneumonia some months ago and had recovered, the owner said.
8. Heart had fibrinous pericarditis as the pericardium seemed to have small yellow nodules (abscesses?)

The young girl asked me what was the cause of sudden difficulty in breathing and death. "Hydrothorax is the cause and may be associated with cardio-respiratory infections in the past," I said. "The GP could have weakened immune system as he was not eating for many weeks."

"Is his sickness infectious to the other GP?" the girl asked me. The other GP was fat and ate well. She had just disinfected the crate. But I asked her to do again esp. water bottles and feed bowls.

CHEEK TEETH
I checked the cheek teeth as I had clipped the bottom premolars and molars under general anaesthesia around 21 days ago. I present the image for the benefit of GP owners and GP anatomy for vet students. The guinea pig has 20 teeth. The dental formula is I1,PM1,M3.




VETS TO NOTE
Many cases of the rabbit and guinea pig not eating are due to malocclusion. However, the teeth involved may be the inside premolars and molars, usually the bottom ones in the guinea pig. The overgrown teeth arch over the tongue and cause ulceration on the other side. Palpate the top of the premolars and molars with your finger to feel the sharp edges of malocclusion if possible or under anaesthesia. It is easier to do in the racehorse, but the principle of palpation is the same.

Wrap the guinea pig or rabbit in a towel and use a buccal separator to open the mouth for inspection. I used isoflurane gas anaesthesia for a few seconds to permit me to do the job of clipping the teeth. It is difficult to clip the teeth without anaesthesia as the tongue is in the way and may be accidentally cut.

Guinea pigs, hamsters and rabbits are not the favourite patients of many vets and there are some any internet postings from non-vet experts in the above-mentioned pets cursing the veterinarian for being incompetent and ignorant. Pass the case to other vets if you are not keen on treating such creatures rather than just give antibiotics for inappetance.

GUINEA PIG OWNERS
Check the mouth esp. the inner teeth weekly. Feel the cheek for painful reaction indicating an oral ulcer or abscess. Weigh your guinea pig weekly and if it is losing weight, consult your vet and ask for the teeth to be checked.





UPDATES will be at:

http://www.sinpets.com/F5/20120230guinea-pig-malocclusion-anorexia-inappetance-Singapore_ToaPayohVets.htm