1026. Spaying a breeder's Chihuahua with pyometra

June 15, 2012

The "Voice For Dogs" refered the owners who adopted a breeder's Chihuahua to Toa Payoh Vets. All teeth encrusted with tartar. Pus dripped from the vulva.

"What's the age? She is very thin, at 2.2 kg" I said.
"We don't know," the couple said.
"When's the last heat? 2 months ago?"
"April 14, 12"
I diagnosed open pyometra and advised spay the next day, after IV drip and treatment. The dog's temperature was 37.2 deg C.

ANAESTHESIA
Dom + Ket at 25% (0.02 ml + 0.03 ml) as the dog is old and thin. A bit of isoflurane gas. Intubated. Maintained at 1-2%. Swollen uterine horns 1.5 cm in diameter.
Ovarian fat very fragile. Ligated and both broke loss. Bleeding seen.


A: Induction Drugs injected IV at 25% calculated dosage: 10.07am
B: Isoflurane gas first given: 10.09am
C: Isoflurane gas stopped: 10.51 am
D: First skin incision: 10.18 am
E: Last stitch: 10.44 am
E-D = 26 minutes.
Swollen uterus was seen easily and hooked out.
Dental scaling and extraction after that.

Complication: Bleeding. The ovarian fat was "watery". The suture ligation broke in both. Some bleeding. Owner was told of the risks of bleeding.

BLOOD TEST RESULTS
Normal.
Total WCC 14.4 (6-17).
N=59%, L=21%,M=15%, E=2%, B=3%
Total RBC 6.9 (5.5 - 8.5). Hb 16.6 (12-18).
This case illustrates the high risk (bleeding) of operating a thin, old Chihuahua with pyometra. It was not recommended to delay surgery as the pus was toxic. Pyometra can be diagnosed based on history of estrus 2 months ago and vaginal discharge of pus. Blood tests, ultrasound, X-rays add up to the costs but are usually necessary. In this case, the total WCC was still normal though vet books say that WCC will be increased in pyometra..

1025. The Schnauzer pees 5 urinary stones

TRUST AND AUDIT CASE STUDY on Jun 14, 2012 by Dr Sing at 6.50 pm at Toa Payoh Vets

An interesting case

XXX, Miniature Schanzuyer, Female, 5 years

May 3, 12. Dr Daniel's case. Haematuria (end stream) and stranguria,  increased frequent urination. Diet brown rice and dry dog food.

May 7, 12  X-ray & urine test. S/D diet given 2 cans. Antibiotics.
>5 urinary stones. Advised surgery to remove stones and diet change to low protein diet*.



The couple spoke to me as I was the original vet who had treated the dog earlier. They wanted spay and urinary stone removal in one surgery. I advised against doing two major surgeries in one in case of complications from infections, bleeding, death due to prolonged procedure. I did not want to do it. The couple left. No news from the couple.

May 25, 12. I was in Hong Kong and got a phone call saying the dog could not pee at all. She had passed out 5 urinary stones but was now in distress. I referred to another vet practice. Vet 1 x-rayed and catheterised and the dog could pass urine. It was a Saturday and she had said that fees,  would be higher, but Vet 1 could do spay and urinary stone removal. The owners were willing but since the fees would be higher on a Saturday, she advised another day. On Sunday, the dog was peeing and was OK. The owners decided against the operation.







"Could it be the high fees quoted?" I asked Vet 1. "How much did you quote?" She did not reply.

Jun 12, 12. I spayed the dog as requested. No urinary stone removal as requested. History from owner today. No haematuria since May 26, 12 after treatment by Vet 1 on May 25, 2012. The husband showed me 5 urinary stones that had been peed after the dog took 2 cans of S/D diet. I palpated the empty bladder. A hard mass of around 1.5x1 cm in size indicating that the 3 stones were still inside the bladder. Advised S/D diet for one month.  The owners wanted only 6 cans.  Previously, the owner wanted only 2 cans in case the dog does not eat the food.

Weighed 4.8 kg on Jun 12, 12. Had lost weight as her weight was 5.1 kg on May 3, 2012. The 5 stones could be sent for analysis to confirm struvites but due to economic reasons, I did not advise.

SPAY. Ovaries enlarged 8 mm x 8 mm x 6 mm. On heat? The owner said the dog was on heat 4 months ago.
4.8 kg
10.28 am  Dom 0.19 ml + Ket 0.24 ml IV
10.33 am - 11 am Isoflurane gas
10.40 am Skin incision - 11.07 am Last stitch = 27 minutes
2/0 absorbable x 1 pac
11.20 am - Antisedan 02 ml IM wakes up the dog.


URINE TEST MAY 7, 12

Significant results
pH  7 (5-8)   
SG 1.026  (1.005-1.030)
Nitrite Positive (Negative)
Protein 3+ (Negative)
Blood 4+ (Negative)
White blood cells 558
Red blood cells  >2250
Bacteria +
Crystals  Triple phosphate occasional


CONCLUSION.
1. The owners asked me whether Vet's 1 advice that the stones will rupture the bladder if not removed by surgery is correct. "Unlikely to do so," I said. "They are not that large. But they will irritate the bladder causing infections. "
2. Will S/D diet dissolve the remaining 3 big stones? "Not likely as they are large." I said.
So, presently, the status is that the stones are still there. Some dogs do not need stone removal but in this case, removal and prevention using prescription diet are the best course of action. The problem here is that the owner does not want to feed the S/D diet for at least one month as he took only 6 cans of S/D diet.

Jun 14, 12 Meeting

*In theory, lower protein, less ammonia produced, less likely to form struvite stones. My contention is what "low protein diet" means and what is the % of protein that constitutes "low protein" diet in practice? What practical advice should the vet give to the owner?

My meeting with the vets at Toa Payoh Vets today regarding consistent advice in a struvite case. The advice should be consistent from all vets at Toa Payoh Vets. Some owners may not want X-rays. In urine test, once there are 3 factors - alkaline pH, bacteria and struvite crystals, the recommendation should be a prescription diet like S/D diet or equivalent for 1 month and switch to C/D diet for 3 months to dissolve the stones


E-mail from owner dated Jun 13, 2012

Hi Dr. Sing,


attached is a picture of the bladder stones passed out together with the urine by XXX

The stones started to show up 2 days after putting her on the (S/D( diet prescribed by you.

The largest of the five stones came out on 24 May 2012. That was the day before she had difficulty to urinate and we sent her to your referred vet.

1024. Follow-up. CKC still has skin problems but ears are fine

Jun 14, 2012, a young man came to buy the green shampoo again as his CKC is still scratching his body after his groomer clipping the coat short a 1-cm length as requested by his mum. That is, no balding look.

"The dog's ears are OK. No more ear odour," he told me that the lateral ear resection canal had been effective. I took out the thick file of 27 medical records from Jul 18, 2009 to Apr 20, 2012.


SIGNIFICANT CLINICAL FINDINGS FROM CASE FILES

CKC, Blenheim, Male, DOB Apr 2, 2008
Jul 20, 08  Neuter
Apr 3, 10  2 years old. Two ears infection
May 3, 09  Pus in ears. Ear irrigation
Jul 11, 10  Ear discharge
Jul 11, 10  Left ear canal resection. Dr Sing
Sep 6, 10  Right ear canal resection. Dr Vanessa
Sep 20 10 Ear infection
Oct 18, 10 Ear scratching and head shaking
Oct 19, 10 Lab test. L ear swab Candida krusei isolated after 2 days of incubation
Jun 6, 11  Ear ointment x 1
Oct 21, 11 Ear ointment. Smell from the rear
Apr 6, 12  Generalised skin infections
Jun 14, 12  Came for anti-fungal wash for skin rashes which develop when the coat is long. However, he is very satisfied with the ear surgeries done as there is no more foul ear smells.

CONCLUSION
Many dog owners don't bring their dogs for further check-ups for skin infections and prefer to take medication like drugs or shampoos in the belief that these will be sufficient. I advised actual examination as the dog may still have a generalised skin fungal and yeast infection.

1023. Adopted young cat with low platelet count spayed

On Wed, Jun 13, 2012 at 9:18 PM, <...@gmail.com> wrote:

Hi Dr Sing,

XXXi appears almost recovered from surgery already.

Her appetite is tremedous, and she has finally pooped tonight.

A lot !

Attached is a picture of her belly.

Sorry we couldn't get a more overt and clear one.

She appears & behaves normal.

Are there any signs we should look out for, that might indicate otherwise ?
We were also wondering when we can remove the e-collar, and also when can we let her out of confinement ?

She is getting progressively faster in trying to escape.

Like a game !

Thank you so much, and looking forward to your reply.



EMAIL REPLY FROM DR SING DATED JUNE 14, 2012

Hi


I was quite busy past 2 days. Thanks for 2 emails. Low platelets and low total white cell count indicate that the cat had some toxicaemia a few days ago. It is hard to say what it is but the eosinophils of 5.5% is high. There is the eosinophila granulomatous complex in cats (mouth ulcers, salivation) but this may not be the disease in your cat.

Your cat was FIV negative and that is good news.

Blood tests are an aid to diagnosis and the clinical signs are much more important. Presently, she is in good health and so that is the present status.

Can't see anything in your image of the surgical wound area. Please clean it and apply a new plaster for the next 10 days. E-collar can be taken out after 7 days if the stitches are strong and if the cat is not bothered. Best wishes.

Total WCC 5.3  (5.5 -19.5)
N   63%
L    28%
M   3.5%
E    5.5%
B   0.1%

RBC  6.8 (5-10)
Platelets   38   (300-800)
No platelet clumps seen
Large platelets present

Fed on Barf Diet changing from canned commercial diet and was losing weight compared to previous check up at 2nd vaccination.


E-MAIL TO DR SING DATED JUN 15, 2012
Hi Dr Sing,

Thanks for the comforting reply. Good to know that there's nothing to worry about.

Hopefully, the next time she has to see u is when she is due for her annual vaccination.

Once again, thanks very much.

1022. Sunday June 10, 2012 interesting cases

Sunday June 10, 2012
Bright sunshine, blue skies.

Case 1. Golden Retriever shakes and trembles after Antisedan IM injection.
As the electricity supply to Toa Payoh Vets and nearby tenants was cut off due to the need to maintenance by the Landlord, it was too dark to do 3rd eyelid irrigation and right elbow granuloma injection.

So I did it outside. This was not ideal but the lighting from the morning sun was good.

At 10.15 am, the 28kg GR was given Dom + Ket at 50% IV by Dr Daniel. The dog fell asleep fast. I got the table outside the surgery where there was bright sunshine. Time was of the essence and I hurried my assistant Min, intern Sally and Dr Daniel to move on with the preparations. There was no isoflurane gas back up now as we were outside the surgery and the couple (owners) were watching.|

The GR was still asleep. So I decided to give Antisedan 1.0 ml IV. But Dr Daniel and then I could not locate the cephalic vein. Around 4 clients with barking dogs and a cat came and there was no time to waste. I gave the Antisedan IM. Nothing happened for 2 minutes. "It takes a longer time to wake up when IM injection is given," I said to the concerned wife. Then the dog inside the waiting room held his head up. There was much barking from other dogs. A contractor across the block was using his machine to drill something.

The GR started to shake and tremble non-stop. He panted. He could not get up to walk. "He is excited by the barking and the machine noises," I said. I rushed into the Surgery to get the atropine injection and gave him IM. Still his whole body was trembling.
"Put the dog inside the boot of the SUV," I said. "He needs to be far away from the barking dogs." The owner drove the dog to the other end of the block and parked the car there. The dog was still trembling but much less. I brought a bowl of water. He did not want it, as if afraid of water. "His head keeps turning right and left," the wife said. "It is part of the excitation effects of the ketamine," I explained. "Normally, the dog should wake up in a quiet place at the back of my surgery, but this morning was unusual in that there was so much barking from the other dogs." 

After 30 minutes, the dog had stopped trembling, drank his water and was sent home. This side effect of excitation by ketamine after Antisedan reverses domitor, during recovery is rare but does occur. The vet must know what to do as it can be quite stressful to the owner. It is best to let the dog wake up in the back of the Surgery, away from the crowds and barking dogs.

Case 2. "The Westie's skin disease is much better due to a change of diet," the man in his early 30s said to me as he did not want any steroid injection. He had been to Vet 1 to treat the Westie's lacerated interdigital D3-D4 left hindpaw. Vet 1 had given injections and the paw wound is much less inflamed. "What injection did Vet 1 give?" I asked. "I don't know," he said. "My Westie has much steroid to cure his skin disease (lower body) and I don't want him to have any."
"It is because of the steroid that his skin disease is under control," I said.
"No," the man said. "It is due to a change of diet."
"If it is due to the change of diet, then the Westie should not have any steroids for the last 6 months. Just purely the diet. Has he got the steroid in the last 6 months?"
"Yes," the man said. "But not much."

"I am just trying to educate pet owners. Steroids are to be used carefully and they help to relieve the dog of itchiness and injuries due to licking and scratching. Many owners and younger vets seem to think that steroids are to be avoided at all cost as they suppress the immune system. Many diseases, even in people, need careful dosage of steroids to live a normal life."    

As he just wanted antibiotics for the lacerated wound and washes, I gave him what he wanted and a wash. The dog had an e-collar and should recover after many days. However, the lacerated wound between Digits 3 and 4 was long and between the digits, stitching up would be best option but it was declined. Healing by granulation could work.

Case 3. The 5-year-old Jack Russell passed fresh blood copiously yesterday. The owners wanted Dr Vanessa but she was off duty on Saturday. So it was Dr Jason Teo and myself. Anyway, I got them to see Dr Vanessa in the consultation room since she was present. "Dr Vanessa would not know anything about this case," I said. "The dog is more active and has not passed blood due to the drug injection. Blood test and stool test results would be known tomorrow. I did not feel any abdominal pain or foreign body and so no X-ray is done. It will take 3-5 days to know whether the dog has recovered from ulcerative colitis (bleeding from the colon).

"Did the dog eat chicken bones?" I asked again.
"No," the wife said. The husband and young adult daughter came.
"He eats wood, plastic and anything," the husband said. "Could this be the cause of the bleeding?" The dog had vomited once and passed stools followed by red fresh blood yesterday. This seemed to indicate that there was a foreign body lacerating the rectal area, causing large amounts of bleeding at the anus. Parvovirus test was negative and that was good news.

We had 2 or 3 cases of dogs passing blood in the stools recently.  My ideal treatment would be IV drip with IV to prevent dehydration and antibiotics and anti-spasmogesic in the drip to give more effective and prompt cure. Other vets may prefer antibitoic and anti-spamogesic SC as in this case. "The dog bites," the owner had warned Dr Jason Teo and I on Saturday (yesterday).

"Muzzle the dog and give IV glucose saline 500 ml as it is more effective," I said when Dr Jason suggested drip SC.  The dog was quite lethargic and would not bite when muzzled. The dog had stayed overnight. "I am worried that the dog may feel home-sick," the wife had told me as she wanted an injection and take the dog home. But the mucus and tissue from the rectum had red blood and we collected a sample to send to the lab for check up of parasites and abnormal cancer cells.

"Well, it is not the dog that is worried. He is already so sick and will prefer to rest quietly. It is the owner who feels it. If the dog goes home after the drip and wanders around the apartment, he cannot rest and recover fast. Worse of all, he may pass more blood and then there will be extra after-hours emergency costs."  So, it is best to hospitalise the dog with bloody stools at least overnight.  This dog was much active today on Sunday and the wife had great difficulty in muzzling him so that my assistant Min could remove the IV cathether. The dog had been eating all wood and other things from a young age. So, there could be chronic damage to the colon and ulcers form, leading to ulcerative colitis with profuse bleeding on Saturday yesterday.  

UPDATE Jun 15, 2012. 6 days later.
"My dog is passing black stools, once a day instead of twice a day," the daughter said today. "He doesn't poop more than twice a day as before. The stools are black. Why?"
"Your dad says your dog eats wood, chews wood and any plastic. Some of the big chewed pieces would have cut the small and large intestines. The small intestines bleed and the blood becomes black when it arrived at the anus. Hence you can see black stools."

"But my dog was passing lots of red blood," she said. "So scary. What is the cause of this red blood?"
"Most likely the rectum or the area near the anus had been injured by a large piece of wood or object. So the bleeding is fresh red blood and lots of it."

The dog had recovered from anal bleeding. "Stool sample showed RBC and WBC. That means there is infection in the intestines." I said.

The dog had been chewing wood from young. How to stop him is a problem. Lifestyle changes are needed. The owner bought canned food for the dog for the time being.

  

1020. Caterwauling cat with low platelet count spayed

Case study on this Sat Jun 9, 2012 morning at Toa Payoh Vets.
Cat spayed yesterday against medical advice. The cat had been caterwauling noisily for the past week and the owner took the risk to spay despite my advice that a cat losing weight (from 2.55kg on April 29, 12 to 2.40 kg on Jun 8, 12, day of spay, Friday).

Blood test reviewed and the owner informed.

BLOOD TEST RESULT - Significant results
Total WCC 5.3 (5.5 - 19.5) & very low platelet count.
I was surprised to see the very low platelet count of this adopted young female cat, around
10 months old. The owners came for Vit K1 tablets to be given for a week.

SUNDAY JUNE 10, 2012  3 pm. I phoned the owner at his home as both he and his wife had not answered their handphones. "The cat is active. Eats, drinks, pees but has not pooped." So, it is good news.

As to the cause of the low platelet count, it is a mystery. Could it be the "Barf diet"? The owners had changed to this diet instead of the commercial canned cat's food. There was really a weight loss over the period of time stated above. To be safe, I advised using commercial canned food for a month. The cat was losing weight and the spay was done with informed consent of the risks of dying.

1019. Old Border had a large ear tumour

"I will operate for free to cut off the 1/3 of the ear," I said to the owner of the 12-year-old Border Collie. The ear tumour was 2 x 3 cm, disc-shaped wart-like and there were two other warts in the face and I had advised sectioning off the ear with the tumour on the first consultation on May 13, 2012.

Surgery would be in 7 days after a course of antibiotics. However, Dr Daniel saw the case. As each vet or doctor has his or her own way of handling a case of an ear tumour and my way was not the other way, Dr Daniel decided to excise the ear tumour when he was presented the case and I was not around. Blood test was declined.

The owner's daughter agreed to a histopathology. Diagnosis was squamous cell carcinoma.

WHY I ADVISE SECTIONING OF THE EAR?
Old dog, the ugly-looking large ear tumour looked cancerous. The owner wanted the least cost treatment and that meant no blood test or biopsy of the tumour or histopatholgoy.

Cutting off the 1/3 of the ear would ensure that any cancerous cells would be cut off by a wide margin. Healing would be easier.  Excising off the wart would leave a big wound and lead to long healing. This was the case.

Each vet has his or her own mindset and experience. There is no one surgical approach in ear wart surgery. Usually the warts are excised but not a portion of the ear. In old dogs, it is best to cut off part of the ear to ensure no spread of the cells and early recovery. A large  hole after a large tumour excision of the ear is hard on the old dog as it is itchy. Healing by granulation takes a longer time, since the dog is old and the healing is slow. But the dog still has his ear shape!