INTERN Inguinal hernia with strangulated uterine horns - Miniature Schnauzer

Miniature Schnauzer, Female, Not spayed, 7 years



HOOK

MEDICAL HISTORY
The owners were busy and delayed the scheduled operation. Within a week, the swelling became bigger. The black patch of skin became gangrenous. The dog was given antibiotics for 7 days before the operation.

PRACTISE EVIDENCE-BASED MEDICINE

1. Blood test was not done to reduce medical costs. However, I prescribed 7 days of spiramycin and metronidazole antibiotics (Stomorgyl) before surgery.

2. X-rays and ultrasound.
The owner went to another vet for a second opinion. The vet performed X-rays and ultrasound and confirmed inguinal hernia with pyometra and a bladder stone. X-ray is shown below:

SURGERY - OVARIOHYSTERECTOMY BY Dr Daniel Sing. Domitor and ketamine IV at 0.33 ml and 0.4 ml for an 8.5 kg old dog. This was  followed by isoflurane and oxygen gas. Antisedan IM was given to reverse the domitor effects. IV drip was given during and after surgery. Methone pain killer injection was given SC. The dog was not in pain post-operation. 

Gangrenous skin seen as black patch before surgery. This indicated blood supply to this area of skin was compromised, leading to death of skin cells. 

A foul rotting smell was present in the operating room as the gangrenous uterine horns were taken out.  

The time taken between first skin incision (12.59pm) and completion of skin stitching (2.12 pm) was
73 minutes. 2 packets of Monosyn were used.

The owner was WhatsApp the gangrenous uterus and omental tissues that packed the inguinal hernia. This would update her on how serious the dog's medical condition was. Gangrene can kill a dog after surgery as the toxins cause multiple organ failure. .

CONCLUSION

Surprisingly, this dog survived the operation and anaesthetic.






Hernias are best repaired when they are small. It will be much less costly and worrying about anaesthetic death on the operating table as in this case of a sick dog being operated upon.

If the dog had been spayed when she was young, she would not have got pyometra (pus in the uterus).

This is a very rare case of strangulated uterus being herniated through the inguinal ring and becoming a gigantic inguinal hernia. It is also a rare case with a happy ending. Much depends on the state of health of the patient, when to do surgery and the skills and experience of the veterinary surgeon and his or her team.

2911. Strangulated uterine horns inside an inguinal hernia of 4 years in a MIniature Schnauzer

Jan 10, 2016

Miniature Schnauzer, Female, 7 years, not spayed

The owner had shifted to North East Singapore where there are many veterinary clinics. So I was surprised to see the dog with this gigantic mango-sized swelling.

"Around 4 years ago, the swelling was soft, but in the last 14 days, it became hard. There is a wound on it as my dog licked it," the mother said.

"Did the swelling go inside the body or become smaller?" I asked.
"We never observe it and so do not know," the mother and young adult daughter with the tattooed hands said.

Based on the medical history and location, I diagnosed an inguinal hernia. I prescribed antibiotics for 10 days before operation as the dog was still active and eating.

The owners took to another vet for a second opinion on Jan 4, 2016. The vet confirmed inguinal hernia with pyometra and bladder stone from the X-rays and ultrasound scan.   

So, today, Sunday, Jan 10, 2016, the owners were free to get the operation done. The dog was still standing.
"She was eating after the course of antibiotics," the mother reported happily.

Surgery.
Strangulated 90% of the swollen, reddish-brown uterine horns surprised me. The dog was still alive. The strangulation had occurred less than 4 days ago and the good antibiotics had eliminated the bacteria inside the uterus. A strong smell of rotting flesh pervaded the op room on opening up the herniated sac.

CONCLUSION
I have not seen strangulated swollen uterine horns in a dog that is still alive and standing. The other vet told the owner that the Miniature Schnauzer was one hardy dog. And he is. 

2910. INTERN CLARA. CASE 1. A 14-year-old cat pees frequently outside the litter box. CASE 2. A 7-year-old cat has kidney failure

Jan 7, 2016

A rough script is written below. The intern has to edit,  integrate and present a compelling narrative with text and images first. Then the video to further enhance the veterinary education.


CASE 1

HOOK

(Video of consultation)

BKTP




In Singapore, most cats live in high rise apartments (3 images below) as around 80% of the population is resident in apartments. The cats have been adopted and are much loved as family members. 

INTRODUCTION
 
A 14-year-old female cat would not pee inside the litter box. She would pee drops of bloody urine outside the litter box. This was the first time this cat had pollakiuria and haematuria and the lady owner quickly brought her to Toa Payoh Vets for examination.

"Do you have another other cat in the apartment?" I asked as the cat could be stressed by other cats, leading to the urinary tract condition known as FUS (Feline Urological Syndrome) or FLUTD (Feline Lower Urinary Tract Disease).

"I have only one cat," she said.

I examined the cat (video).
The cat's nose and gums were pinker than normal indicating dehydration. I palpated her kidneys and bladder. She did not show pain. A few drops of blood-tinged urine scattered onto the examination table.

"I can feel a hard bladder the size of a fish-ball or 50% the size of a golfball," I told the lady who probably do not play golf.. "It can be either a bladder stone or tumour. An X-ray is needed to confirm the stones."

PRACTISE EVIDENCE-BASED MEDICINE
There are several laboratory tests needed to gather the evidence to confirm the tentative diagnosis of urolithiasis and to differentiate it from bladder tumours which are rare in cats in Singapore.

1.  The X-rays showed an empty bladder packed with small stones. The bladder walls are thickened.  The kidneys have a few small stones.

Such an old cat. High anaesthetic risk. Not to operate will mean kidney failure later.

2. Ultrasound to check out the abdomen and bladder. I did not advise this to lower medical cost. 

3.  Blood test - Abnormal findings were low platelets, slightly high blood urea and creatinine indicating acute renal failure.

I advised operation the next day before the cat gets acute kidney failure. She was not eating much but had not vomited yet.

I gave the cat a subcutaneous drip, antibiotics and painkillers on the day of consultation.

4. Urine test. There were a few drops of urine available. The crystals appeared to be urate.

5. Stone analysis.  The stones removed from the surgery have been analysed for its chemical composition.  Positive for magnesium, phosphate, calcium and oxalate. But not for ammonia.
Most likely calcium oxalate stones.  

VIDEO. blood collection and X-ray

RISKY ANAESTHESIA
A very old sick cat. High risk of anaesthetic death. The owner was informed of the risks. She consented and the cat came in the next day for  cystotomy by Dr Daniel.





He needed time to clear the bladder of small smooth brown stones. The surgery took around 50 minutes.

CONCLUSION
The lady owner consulted the vet promptly when her old cat had abnormal urination. Surgery to remove the bladder stones was done early. The cat survived the anaesthesia and surgery and is at home recuperating.  Everyone is very happy especially the lady owner.

Early detection and surgery save lives. If there was a delay, the old cat would have got kidney failure and a successful outcome of surgery would not be possible.

Follow up on Jan 16, 206
Cat likes to eat wet food nowadays. No more peeing outside the litter box like before the operation. This is what concerned the lady owner. Drinks normally. Stools normal. Overall normal.

In the past 5 years, ate commercial food -  Science Canned Diet Mature Indoor Cat  7 years and above canned food
Royal Canine dry for older cat 7 years and above indoor cat.

5 years ago, went to Toa Payoh Vets for constipation. Fussy cat. Does not eat other types of food.
Now feeding old canned Royal Canine and dry Royal Canine S/O.

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 CASE 2
A vomiting cat that cried when I palpated the kidney area. 
X rays show kidney stones. Blood test showed kidney failure (high urea and creatinine).
I advised home dialysis for 7 days, SC drips of 200 ml per day, after having done one in the surgery.

The owner did not believe my diagnosis and went to another vet who made the same diagnosis.

The cat went to ICU of the other vet and passed away 3 days later.

2909. A dog passes fishy urine for the 3rd time after medication given by 2 vets

Jan 7, 2016

"I did not go back to Vet 1 because my dog passed fishy urine before the completion of the medication as compared to Dr Daniel's" the lady said to me today when I followed up on her dog, a 7-year-old female, not spayed Maltipoo treated by me 7 days ago.

I was Vet 3 and since the dog was having medication, she could not comment on my failure or success after consultation dated Dec 31, 2015 (video).

"At least Dr Daniel (who was Vet 2) had medication which stopped the fishy urine smell during the course of treatment," the lady laughed.  Dr Daniel had done a urine test on Dec 8 and had recommended Urinary S/O to acidify the urinary pH which was 9. Blood was 3+.  However  the owner claimed that she was not told not to feed the dog with other kinds of food.

So, the urinary S/O still gave a urine pH of 9.0, nitrite +, protein 2+, blood 4+, bacteria +. There were amorphous  phosphate+ and triple phosphate + on the urine sample tested on Dec 31, 2015.

This time, I needed an X-ray done as the dog had a very painful anterior abdomen. She had dysuria, haematuria, vulval swelling but no vomiting. Fishy urine again.

X-rays show a ureter stone. That accounted for the acute painful cries when I palpated the anterior abdomen. After pain-killers, the dog was OK and as Jan 7, 2016, he was not passing any fishy urine. I advised feeding S/D for 1-3 months to be followed by dry C/D to acidify the urine.  As for urinary S/O fed on the recommendation of Dr Daniel, the owner claimed that he was not told to feed solely the S/O and had fed various other food. Hence the urinary pH was still 9 when I tested the urine on Dec 31, 2015.

Time will tell whether the dog will be passing fishy urine after this consultation. Now he is still on medication. 







 

2908. INTERN - ENUCLEATION

HOOK





BKTP image

MEDICAL HISTORY

Right eye ulcerated. Vet 1 prescribed eye drops and reviewed for 2 times.
2 images from the owner

2015 case
TREATMENT BY VET 3
Conjunctival flap

NARRATE THE 2 IMAGES OF MEDICAL HISTORY

WHATSAPP IMAGES TO DR SING K Y ON DEC 29, 2015
for advice and query on how much it costs to get an artificial eye ball.  The owner had paid for Conjuctival flap surgery by Vet 3.     

The owner has to decide
on enucleation (removal of eyeball). An artificial eyeball add to medical and surgical cost.

CONCLUSION

No vet can guarantee successful eye surgeries as there are many factors involved, including post-op care by the owner. Some owners want the dog back home on the same day of surgery
but do not know how to nurse the patient. In many of such cases, the surgical outcome can be poor.

In this pug, the owner considered that the surgery had a poor outcome.
The eyeball had popped out and become bigger.  This is one side of the story. The other side from the vet has not been asked
  .
An image of a successful conjunctival flap surgery





FOR MORE INFORMATION

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EARLY TREATMENT OF ONE PUG WITH DEEP CORNEAL ULCER IN 2011

Medical history

Some vets advised enucleation (removal of the eyeball) as in the 2015 case above

Illustration of my surgery - 3rd eyelid flap and tarsorrhaphy on Mar 24, 2011
This surgery had been performed in a 14-year-old Silkie Terrier in 2015. The video is at toapayohvets.com.videos.htm

The pug's eyelids are sewn up after the 3rd eyelid flap surgery. In-patient for 3 days.
Eye ointment is given daily via the gap in the medial canthus

14 days - stitch removal. Scar bridges over the ulcer

42 days after eye surgery

42 days after 3rd eyelid flap. The ulcer is healing slowly as it is deep and extensive. On the 42nd day, the owner came for a review as the dog's eyes were reddish. However, the vertical ulcer has healed but not fully while the 6-8 o'clock corneal ulcer has changed to a white spot.
 
No more visits from the owner as the pug's eye injury has healed.

2907. PAINTINGS FOR SALE

Contact:
David Sing   +65 9668-6468, 99pups@gmail.com

2906. INTERN. Saving the eye of a 14-year-old Silkie - 3rd eyelid flap and tarsorrhaphy

Jan 5, 2016 (10th day of surgery)

Dogs suffer from injuries to the eye. In this dog, he had a deep corneal ulcer (deep ulcerative keratitis).

All vets have their own techniques and ways to treat deep ulcerative keratitis in the dog. In this case, the vet advised total removal of the eyeball (enucleation) as the dog had been suffering for around one month of eye injury and pain.  The owners sought me for a second opinion and to perform the enucleation.  I advised a 3rd eyelid flap and tarsorrhaphy to save the dog's eye. As eye injuries are emergencies, this operation will have been most successful if performed within 24 hours.

But the corneal ulcer was deep and had extended for the past month.

Day 1. The dog was present as in this image. I gave the dog an injection of antibiotics and anti-inflammatory.

Day 2. The dog's eye before surgery (3rd eyelid flap and tarsorrhaphy). You can see much inflammation of blood vessels radiating into and surrounding the corneal ulcer.

Video of surgery

https://www.youtube.com/edit?o=U&video_id=NVXJzauUUNQ


Day 14.  The eyelid stitches are taken out.

The dog is at home after 10 days of in-patient. The son wanted the dog home on the 3rd day but finally decided not to as the stitches will breakdown due to rubbing. The dog will be rubbing his eye against the bed and table legs when at home moving around. In the surgery, the dog's eye is checked twice a day, eye drops are applied, antibiotics and painkillers Rimadyl tablets are given for 4 days.

Unless the owner is skilful in nursing, an excellent outcome can only be achieved by in-patient treatment for 10-14 days.