870. A 12-year-old Jack Russell coughs fresh blood for last 2 days

This case illustrates the importance of using relevant evidence-based medicine to provide a standard of veterinary care affordable and expected by the sophisticated younger generation of Singaporeans. This google generation knows much more than the baby-boomer generation and wants answers quickly as to what is the cause of the problem with their sick pet. Not more than one visit will be the best as Singaporeans are time-pressed.

Yesterday morning, I was the vet on duty. A young man came with his 12-year-old Jack Russell which was in excellent body condition. "He coughs blood in the last two days."

The dog's gums were slightly pale. Rat bait poisoning? Unlikely as the dog was supervised when outdoors and there were no rat baits used in the apartment. This was a much loved dog as he would try and attack the newspaper delivery man every morning but not his family members and the family's friends. He was a puppy when the young man was in Primary 5 or Primary 6 and now 12 years or more had flown by.

"Is he a scavenger?" I asked as the Jack Russell started coughing when I palpated his throat from the larynx downwards. The dog coughed and retched. Fresh red blood with white mucous came out from his mouth onto the floor of the consultation room.

"Yes, he swallows any food he would find in the house." the young man asked me for tissue to clear the mess.

"Is he like my son's Bichon who waits for some chairs not pushed inside the dining table to jump onto the table to eat the chicken bones?"

"Yes, yes, he is like that!" the man said.
"As the throat is so painful, it is possible that there is a chicken bone poking the throat and causing coughing and bleeding. I will need to X-ray the throat, lungs and stomach area."

The owner must be given the advice and if he does not want the X-rays, this must be recorded in the case sheet. He wanted the X-rays and complete blood test.

"My dog had a fierce cancerous lump removed from his neck skin at another vet clinic," the owner said to me. He phoned the vet and they faxed over the report in the afternoon. It was a sebaceous gland carcinoma which had grown red and fast on the dog's lower neck 2 years ago. The skin in that neck area was hairless but no recurrence of tumour was seen.

So, was this a case of chicken bone trauma or not? I got the X-rays done. "Pleural effusion," commented two vets as the X-ray of the lung showed radio-opacity instead of black spaces as for normal lungs. Based on clinical signs and the history of a cancer as well as diffuse nodules seen on the X-ray, I advised the owner that it was most likely metastases of cancer cells to the lungs. Bronchoscopy and lung biopsy could be done but this would add to the cost.

The owner decided on euthanasia and was present when I administered the injection. It was sadness in the evening but he was satisfied with the evidence-based medicine done. If the vet had just given some injections and drips without advising X-ray, this coughing of blood would continue and the owner would become much unhappy with another visit. Therefore, the vet must know what to do in a case of coughing blood. In retrospect, this dog had been coughing for the past year but had not coughed blood till the last 2 days.

Blood test revealed an increase in total white cell count suggesting a bacterial infection, red blood cells and haemoglobin in the lowest range of normal values, suggesting blood loss probably from the lung bleeding. I explained the findings to the owner. He had to decide what to do further.

The diagnosis of tumours in the lung due to metastases from the sebaceous gland carcinoma is quite possible. Veterinary costs need to be minimal so I did not suggest bronchoscopy and lung biopsy to confirm the lung tumours as this would prolong suffering in this dog. Coughing of fresh blood is very likely from the lungs as the amount was much more and persistent.

869. Update: Miniature Schnauzer with recurrent urolithiasis

Recurrent urolithiasis
1. First time - calcium oxalate stones
2. Second time (now) - struvite stones

If the owner is careful and listen to veterinary advice, this case can be prevented using dietary management (prescription diet), monthly urine testing and 3-monthly X-ray of the bladder.

However, most Singaporean dog owners don't bother with the monthly urine testing and X-ray though some do come for the prescription diet.

In one male Miniature Schnauzer dog that I mentored a vet in his first urinary bladder operation of his vet clinic assistant's dog (see Toa Payoh Vets - Dogs - Urinary problems), this dog is fed commercial dry dog food which is less expensive than prescription diet, there is NO recurrence even a few years after surgery. The clinic assistant does not bother with all these advices of monthly urine tests and 3-monthly X-rays!

Website with updates and pictures at:
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm

Importance of stone analysis - Calcium phosphate urinary stones at recurrence

In my review of this recurrent urolithiasis, for the benefit of dog owners, the vet did not perform a stone analysis in the first cystotomy done 12 months ago. This was probably due to the owner's instructions to reduce costs. In the recurrent case, operated by at Toa Payoh Vets by Dr Vanessa, I insisted on a stone analysis. The results were as follows as this ought to be done to know the type of stones present and hence a preventive program using prescription diet or other ways to manage and prevent recurrence.

12.1.12 At Vet 1
after midnight emergency


Shih Tzu, Male, 8 years old



BLOOD TEST
URINE TEST
X-RAY
WBC high 24.48 (5.5 -17)
Neutrophils 82%, L=3.6%, Mono = 12.9%
Absolute High for Neutrophils, Monocytes, Basophils, Platelets, BUN, ALKP.
Dysuria urine pH = 7.2, USG 1.015




3.1.12 at Toa Payoh Vets

SURGERY
URINE TEST
STONE ANALYSIS: Calcium Phosphate.


Urine pH 7.0, USG 1.012
Protein 2+, Blood 4+, WBC 468 RBC 25, Bacteria 3+, Crystals Nil.

Do proper planning before surgery to save on manpower time and resources and to reduce length of anaesthesia, ensuring better survival outcome for old dogs.
No crystals in the urine do not mean no urinary stones inside the bladder or kidneys
Negative for oxalate, urate, magnesium, cystine, ammonia, bicarbonate.
In conclusion, most Singaporean pet owners don't bother with prescription diets, monthly urine tests and 3-monthly X-ray to detect small urinary stones which can be flushed out using urohydropropulsion and thereby saving on surgery and higher costs. However, it is THE DUTY of the veterinary surgeon to record in the case sheet that such advices have had been offered to the owner to prevent misunderstanding when there is a recurrence.

Younger Singaporeans may be much more sophisticated and educated and may understand the need for such preventive tests. But many Singaporeans are time-pressed. Till the dog can't pee or pass blood and then they may consult the vet. I hope this review will provide some information to owners who wants more information on prevention as I do know of some owners who would just euthanase the dog when there is a recurrence.


Website updates and images:
http://www.sinpets.com/dogs/20120219recurrent-urolithiasis-urinary-stones-toa-payoh-vets_Singapore_ToaPayohVets.htm

866. Pug needs dry S/D

Today, I phoned owner of a pug to follow up on the pug's fits and why she still needed S/D cans for past few months. The pug has this urinary tract infection if fed home-cooked or other foods.

"SD diet cannot be given for more than 3 months," I advised. "You need to change to CD". I ordered dry CD for her as it is more economical. She had ordered SD diet from a vet in Toa Payoh and when she came, she was told no S/D dry. I made an investigation. S/D dry is not available from the supplier and the vet had not updated her. All vets are to record orders in a book from now.

As the vet in charge, I need to get feedback and this is one such feedback when I followed up with the owner. She had not wanted to "complain" about this lack of service from my associate vet who had promised to order the S/D for her and she came but was told none available.

PUG Male, 3 years
26.1.11 dysuria

23.8.11 Urine test. pH =5 (5-8), SG=1.016 (1.005-1.030.) Nitrite +ve, Bacteria 3+

10.9.11 Urine test pH =8 (5-8), SG=1.029 (1.005-1.030.) Nitrite +ve,
Protein 3+, Ketones trace, Blood 4+, Bacteria 3+. WBC >2250, RBC >2250
Crystals Triple phosphate 2+.
S/D advised.

17.10.11 Urine test. pH =6.5 (5-8), SG=1.006 (1.005-1.030.) Nitrite -ve, Bacteria Nil. Blood trace, WBC 20, RBC 3. Crystals Nil. To acidify urine.

9.9.11 Fits April and Sep 2011. Blood in urine. Follow up today Feb 8, 2012. "One fit episode, no point consulting the vet," she said. I said I was phoning regarding the S/D diet being fed for some time.

10.9.11 Blood test Total WBC high 22 (6-17). N=84% L=7%.
17.10.11 Blood test Total WBC normal but N=10%, L=22%, Monocytes=53%, Basophil =14%. Chronic infection/inflammation likely.

865. Calcium phosphate urinary stones - Xhih Tzu

Review of one case
Shih Tzu, Male, 8 years old
12.12.10 Dysuria urine pH = 7.2, USG 1.015



12.1.12 At Vet 1 emergency
WBC high 24.48 (5.5 -17)
Neutrophils 82%, L=3.6%, Mono = 12.9%
Absolute High for Neu, Mono, Baso, Plt, BUN, ALKP.

13.1.12
Urine pH 7.0, USG 1.012
Protein 2+, Blood 4+, WBC 468 RBC 25, Bacteria 3+, Crystals Nil
STONE ANALYSIS: Calcium Phosphate.
Negative for oxalate, urate, magnesiu, cystine, ammonia, bicarbonate

864. Performance counts - no repeat consultations

Sheltie, F, 8 years. Copious purulent nasal discharge on left nostril. There might be slight discharge from right nostril.

Feb 7, 2012 visit today. Case handled by Dr Daniel Sing with me. I did mentoring as I have to ensure that service is done efficiently and up to my standard."

It is Feb 7, 2012 now. The 2nd visit was on Jan 7, 2012. Vet 1 had extracted 9 teeth again. But bad breath still remained as I checked the mouth and noted that the gum of M2 on right upper jaw was inflamed. The tooth appeared shaky but I could not confirm it.

What to do with this case? I took over as the man wanted results.

1. Nasal swab for bacteria and fungus. culture and antibiotic sensistivity test.
2. X-ray of nasal area and lung to check for tumours, abscess or infections.
3. Extraction of the loose teeth as bad breath still persisted.

"This is my 3rd visit for the same problem," the owner said. "I want the vet to be pro-active.
The 3-rooted molar on the right upper jaw was shaky and I extracted it within a few seconds. There could be bacteria entering the nasal passages on the right side causing daily mucus production and pus and right nostril discharge. Altogether I extracted 7 teeth.

Will have to wait and see as persistent nasal discharge is hard to treat if it is caused by fungus and/or infected tumours.

An unusual case: Calcium oxalate stones, then struvite stones 4 months later

This case illustrates the importance of doing urine analysis for urinary stone cases. Sometimes, some vets may not do it to reduce veterinary costs for the owner. This is not good practice unless the owner rejected this test.



FIRST REPORT - SEP 2011 - Calcium oxalate urinary stones
http://www.sinpets.com/F6/20110920retrograde-hydrouropropulsion-singapore_ToaPayohVets.htm. The owner decided to feed just home-cooked food after the surgery.

SECOND REPORT - FEB 2012 - Struvite urinary stones despite giving "home-cooked food".
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm