926. Follow-up - The guinea pig that squirted white cloudy urine

http://www.sinpets.com/F6/20120329guinea-pig-websites-singapore_ToaPayohVets.htm
is the website as the following copied report from the above-mentioned website below cannot show the images.


Friday, March 16, 2012
909. Two guinea pigs not eating - white viscous urine, blood in the urine
Yesterday Mar 16, 2012 (Friday), I saw 2 cases of guinea pigs with urinary problems and reviewed the case with Dr Daniel as part of my mentorship program.

We had met an interesting and friendly experienced Australian banker who had travelled to all over the world to work, at Liang Seah Street at 11 am today. "How old are you?" he asked Daniel. He then told Dr Daniel that 20% of the young men of his age and new graduates are jobless in Ireland. He told me that my handshake was weak, compared to Dr Daniel. "Have you been to Timbuktu?" I asked him. "No," he said. "But I have been to various places in Africa. I was sad to see so many homeless children and the poverty."

P.S
I used to study English phases in primary school in the 1960s and there is a phase referring a distant place as Timbuktu which is actually present in Africa. I doubt I have a chance to visit it. One of the guinea pig cases is written and followed up below:

Case of the Guinea Pig squirting out white cloudy urine

March 16, 2012
Not eating. Abdominal swelling obvious. The owner had seen me some months ago. "No more skin infection," she said. "My guinea pig is not eating."
Dr Daniel palpated the swollen abdomen. I did that after him. The swelling covered almost 90% of the abdomen. Soft distended bladder, in my opinion. I don't know what Dr Daniel thought. Was he thinking of ascites? Definitely, ascites present this pendulous abdomen.

Before I could speak further, the guinea pig squirted out white cloudy urine onto the stainless steel consultation table top. "The urine is not normal," I said. "I would take some for urine test." I took a new syringe to suck up some urine. The guinea pig voided much more urine. Thick cloudy liquid. As if the bladder had lots of white sand.

"Is it possible that my guinea pig has bladder stones?" the lady asked. "My other guinea pig had bladder stones. The vet removed it but then said another surgery had to be done."

"Why was there a need for a second surgery?" I asked.
"The first one was not done well," she said. "So, another one had to be done."
"What happened to the guinea pig after bladder surgery?" I asked.
"She lived for a few days and then died."
"In this case, the guinea pig might have or might not have bladder stones. We will wait for a few days and get the urinary tract infection treated first."

A follow up the next 2 - 7 days would be needed. X-rays would be needed to confirm bladder stones.
March 19, 2012
This Guinea Pig was not eating and had a grossly swollen bladder. Dr Daniel and I palpated the abdomen. Looked so much like ascites although I could feel the faint outlines of a very full bladder as big as an orange. Suddenly whitish cloudy urine dribbled out. More and more urine was released like a storm flood. I got the urine inside a syringe and sent to the lab.
Lab Results: Amorphous phosphate crystals +++, bacteria + and urine pH = 9.0.

Evidence of urinary tract infection caused by amorphous phosphate +++. So what to do now?
"In dogs, amorphous phosphate is also known as struvites. Acidify the urine or give S/D diet," I said to Dr Daniel and Dr Vanessa. "What to do for a GP with struvites in the bladder?"

The lady owner returned my text message this morning. She had left all medication to the sister who stays at home. After 3 days, the sister stopped the antibiotics as the GP was eating and drinking.

"But he sits in a corner," the young busy career lady said. "When can I send him down for another check up?" I scheduled next week. She has only one GP and believed that her sister had increased the intake of Vit C tablets to 1.5 tab/day causing the GP to stop eating.

Overdosage of Vit C can lead to kidney stones in people. In this case, the GP had a UTI. Medication was not given for a sufficient number of days.
March 26, 2012
Now, the guinea pig is crated in the Toa Payoh Vets for urine collection (see images below). The urine has been collected and tested again to check for bacterial infection. Bacteria ++ were present. No more amorphous phosphate crystals. I advised oral antibiotics again for 3 days first. The guinea pig was eating normally now.

5153 - 5159. It is good practice to follow up on guinea pigs with urinary tract infections (UTI) as bladder stones could be the cause. Also some owners don't comply with the 7-day instruction to give antibiotics.

Weigh the guinea pig during veterinary consultation. In Singapore, in 2012, the plain-looking guinea pigs are no longer so popular with pet owners!

Bladder stones in a guinea pig - follow-up

Early treatment may or may not save its life. It is hard to guarantee. At this stage, it was unfit for anaesthesia and surgery. I asked the owner to nurse it to good health first. It died the next day, at home.

924. Follow-up: The Guinea Pig that passed fresh blood in the urine

Yesterday, Mar 29, 2012, the lady brought her guinea pig to Dr Daniel at 1pm for consultation as he had passed blood. This guinea pig had been to other vets and we at Toa Payoh Vets was seeing him for the 3rd time today.

First time, I had collected urine for analysis and X-rays.
See case at:
http://www.sinpets.com/F6/20120238guinea-pig-haematuria-singapore_ToaPayohVets.htm

"But no blood in the urine was seen," Dr Daniel told me in the evening when I asked him.
"Did you collect urine and send for analysis?" I asked.
"Yes," he said. "The urine is clear. Collected 6 times."
"What could be the cause of this blood in the urine?" I asked.
"5 possibilities," Dr Daniel said. "Trauma, infection, tumour, coagulopathy and toxins. The owner realised that the guinea pig had been given a shower a day before and blood came out in the urine. As in previous times."
"Was the guinea pig bathed before this, in the past 2 weeks since the last complaint?" I asked.
"No," he said.

So, was it the shampoo? The guinea pig started eating hungrily yesterday but was off food 2 days ago.

"Has he lost weight?" I asked.
"50 grams," he said.

"Tumour was diagnosed by one vet," Dr Daniel said. "Since he is one year old, it is unlikely."
"But it is possible," I said. However, the last 2 times the GP came, no blood was present in the urine. So, it is a mystery.

So, we wait for the urine test result. It is a puzzling case.

Sunday's Mar 25, 2012 interesting cases

Today is Thursday. Before I forget, I record Sunday's interesting cases.

1. ADOPTED YOUNG FEMALE CAT. The couple had decided to spay their cat adopted from the Cat Welfare Society on Sunday. However, I found that this cat was small in size and advised waiting one month since she was not caterwauling and had just stayed with the couple for 2 weeks. She looked healthy and her full set of permanent teeth had some plaque.

I estimated her age to be around 6-7 months. In the interest of the cat, spay should not be done. However, some owners do go to other vets later and so there is this need to do what the customer wants.

In spaying young cats less than 6 months, the uterine tubes are usually very thin since the cat has not matured, as narrow as 3 mm in diameter. Spaying can still be done as some humane shelters overseas do it even at <5 months of age. Since this is a well cared for cat, spaying is best done at an older age of 7-8 months. Case written at: http://www.sinpets.com/cats/20120328adopted-young-cat-kitten-singapore_ToaPayohVets.htm 2. RUPTURED EPIDERMAL CYST IN AN OLDER MINATURE SCHNAUZER "What to do now with the big hole," I asked Dr Daniel who was assisting me with this surgery. A big hole after excision using electro-surgery of a skin lump 1.5 X 2 cm x 1 cm above the neck, behind and between the shoulders. "Just stitch up?" I asked. Actually, the best way is to use Z-plasty. This is described in http://www.sinpets.com/F6/20120247z-plasty-pyometra-cat-singapore_ToaPayohVets.htm

CASE 3. Beagle with itchy lower body.
"Did you express the anal sacs?" I asked Dr Daniel who disagreed that itchy lower body would be related to any anal sac. The dog's backside was not itchy, so no anal sac problem.

"It is not as clear cut as that," I said to him. Sometimes, the itchiness is not related directly to the itchy area.

He expressed the anal sacs from the older Beagle put on the table in the waiting room. The whole waiting room filled with a pungent smell for several mintues while his hands were full of >20 ml of dark brown oil. This was really revolting. I had to open the door. The other vets had not been able to resolve the skin problem and so the owners brought it to Toa Payoh Vets. This was a case of ventral contact dermatitis with infection. A blood test would be useful. The owner had said: "The other vets did everything, so no need to do it."

"If you let the owner dictate to what you can or cannot do," I told Dr Daniel and Vanessa in the meeting on chronic skin diseases, how are you going to diagnose the problem? What had been done by other vets would not be linked to what is present now although it is still skin disease. You need to educate the owner. At least, you have to record AMD (against medical advice).

Got to rush off now.

Standard Operating Procedures at Toa Payoh Vets: Chronic skin diseases in dogs

I had a meeting with Dr Vanessa and Dr Daniel to discuss standard operating procedures in the treatment of skin diseases in dogs yesterday, Mar 29, 2012.

"In many cases, the owner had gone to at least one vet or two when they come to Toa Payoh Vets," I said. "Steroids and all medication had not worked. They had spent a lot of money. Yet their dog still scratches and bleed. If the vet at Toa Payoh Vets can't solve their problem, then there will be no referral from them. Successful outcome bring referrals. Steroids is only a short-term answer to the dog scratching."

THE STANDARD OPERATING PROCEDURES:

1. A detailed history and record of past treatments at various vets. Onset of skin diseasse. Get an overall summary if history is given orally. Pay attention and listen carefully. This takes a lot of time. Food types eaten. Treats given, shampoos used etc.

2. General and detailed examination. Location of all skin disease areas to be mapped out and written down. No general statement of "generalised dermatitis".
3. Blood test is mandatory
4. Skin test including 5 scrapings of skin for mites (not just one) and microscopic examinations. These must be recorded in writing meticulously.
5. Bacterial, fungal and yeast cultures to be advised. Sensistivity tests for bacteria.
6. Clipping of coat and bathing in an anti-mite wash is mandatory.
7. Cleaning of ears and expression of anal sacs. If otitis externa is chronic, advise ear ablation surgery.
8. Treatment may need hospitalisation for 3-7 days. Anti-mite treatments, no steroids to be given. Monitor progress of skin healing.
9. AMD. Against Medical Advices to be written down.
10. Food allergy test for 3 months. No treats or other food. This is usually not complied with.
11. Follow up by phone 2-weekly.

I will audit all chronic skin cases done by the vets.

920. Pyometra in a one-year-old cat

Yesterday I was at Toa Payoh Vets in the evening. Usually I am not present as Dr Vanessa is the vet on duty. Interns Jed and Mr Lim and my assistant Min were working hard helping Dr Vanessa. Jed was bathing the Golden Retriever with the right knee tumour wound. Mr Lim was changing to a new e-collar for him before the dog goes home. This dog had a big wound defect after excision of the large knee tumour. The high-tension area of the knee area led to stitch breakdown. The wife wanted the dog back after surgery and had slapped purple solution onto the wound which had started to break down 3 days after surgery. I asked her to bring the dog back and saw that the stitches were not holding.

When I informed the husband, he threatened to report me to CASE (consumer body) and then legal action. "If you can't do the surgery, you should not have accepted the surgery."

His opinion was that there should be no wound breakdown and if there was, I should rectify and ensure that the wound healed without charging him any money for further surgery.

"I am suing one vet as my dog had died under his treatment. My dog better not die in your Surgery." The dog was hospitalised for over 20 days to get the wound dressed daily. Stitching was not possible in this high-tension area. The dog tended to lick the wound if the e-collar was not worn. The wound had closed 20% but would need another month to granulate. It was time for the dog to go home with medication and I phoned the husband who said he would come.

CASE 1. Big tumour behind neck

Suddenly at around 6.30 pm, three young ladies came with a growling Miniature Schnauzer and I was at the reception doing some administration work and answering the phone calls while the others were doing kennel work. Dr Vanessa was consulting with another owner.

"What's happened to your dog?" I asked one lady. This was a 7-year-old male Schnauzer who warned vets off. "Are you waiting to consult Dr Vanessa?"

"I want to consult you," the lady pointed to a hard lump of 3 cm x 3 cm in the neck skin, midline, between and slightly behind the ears. "It could be a microchip inflamed lump," I said. "When did you microchip the dog?"

"He was microchipped when young."
"Did any vet inject him in this shoulder area?"
"No," she said.
I pointed the microchip scanner at this lump and it beeped showing the microchip number.

"It could also be a fast growing tumour," I said since the young lady mentioned that she only discovered the lump recently. She held the dog firmly while I examined the hard lump again.

"Tumours are what I am worried about," she said. Nowadays, many young ones read about their dog healthcare in the internet unlike the old days when many were quite ignorant.

"If it is a tumour, I would need to make a big cut to take out as much of the mass as possible and send the tumour to the laboratory for histopathology to check whether it is cancerous."
She made an appointment for this Sunday morning operation. Not all lumps are due to microchip or injections and if the vet thinks only these two possibilities, he might be in for a rude shock if the lump was cancerous.

So, it was best to excise it as early as possible and certify that the microchip had been excised, so that the owner had proof in case the regulatory AVA made a surprise check for microchip.


CASE 2. The one-year-old female cat passes pus copiously.
Another lady phone call was answered by me. "My cat passes white yellow thick discharge from her vagina non-stop. Drip, drip, drip everywhere for one month. At first, it was a little bit. Now, the cat is not eating. When do you close?"

"We close at 8 pm. It is better you get the cat treated early as it is a womb infection. It is called pyometra."

After asking about the cost of surgery, the lady came with the cat.
"Can you feel the swollen uterus?" I asked Dr Vanessa. I could feel a swollen lump like a bladder swelling of a golf-ball size and two long tubes around 1 cm in diameter. No specific hard uterine bodies. Dr Vanessa shook her had. "However, it is pyometra," I said as more yellowish-white vaginal discharge fell in patches on the consultation table.

"Now, what anaesthetic to sedate?" I asked Min. "This cat is not in good health."
"Xylazine and ketamine IM," Min said.
"That is what we usually do. Zoletil is safer."
We rarely use Zoletil on cats and so Min did not mention this.

I weighed the cat. She was 3 kg.
Zoletil 100 = 100 mg/ml. The dosage for IM was 10-15mg/kg and I decided on 12mg/ml.

I asked intern Jed to calculate so as to give him some hands-on experience. His calculator showed 2.7 ml.

"Cannot be so much," I said.
The correct calculation was 0.36 ml of Zoletil 100.
I gave 0.3 ml IM. Then I gave 0.4 ml atropine IM to prevent salivation and head twisting - side effects of Zoletil.

Dr Vanessa operated. Isoflurane at 5% for a short while by mask and then minimal 0.5%. The large womb was taken out. Dr Vanessa decided on using horizontal mattress this time as she was set in her ways, always using simple interrupted. I had advised her to practise on using horizontal mattress which is a stronger suture but she would always do her own thing. Each young vet has his or her own mindset and so I do not bother as long as the stiches heal the wound.

Dr Vanessa believed in subcutaneous sutures despite my advice not to do it as it would irritate the cat or dog during healing. Well, each young vet has his or her own mindset that would take time to change, with adverse side effect experience encountered. All vet professors lecture on the need to close up dead space using subcuticular sutures and all young vets graduate with this concept that they must do it after a simple spay. Till they realise from intense itching in a few cases of wound breakdown and unhappy owners that they need not do it for spays and Caesarean sections. It is hard to change a young vet's mindset since they believe that their professors of surgery had to be a better teacher than an old vet like me.

"For aesthetics, all sutures should be horizontal mattresses", I believed in presenting a neat surgical stitching pattern. Owners do peruse the
wound as the pet is a young family member and some do compare the competence of the vet by comparing his stitching (read one story later).
Dr Vanessa had put in two horizontal mattresses at one cm in length but felt that there was a small gap of 0.5 cm at the end of the skin. She wanted to put in a simple interrupted. "If you have to stitch that area, use a shorter horizontal mattress," I said. In total she had 4 horizontal mattresses done. Actually two would do. But it takes time to change mindsets of young vets as most have a mind of their own as regards suture patterns.

921. The vet's suture protruded the skin - Good stitching patterns count.

921. The vet's suture protruded the skin - Good stitching patterns count.

Two days ago, two ladies and their father brought a 17-year-old cat to the Surgery. The cat had been pawing her neck trying to get rid of a nodule 1 cm x 1 cm. Dr Daniel handled the case. The over 70-year-old slim built father was at the waiting room and I was at the reception and since he was chatty, I had an interesting conversation with him.

"Why do you not go to the vet nearby your house?" the father mentioned that he lived near a vet. However, his daughter did not want to consult this vet.

"The vet spayed this cat. But the cut was very long," he said. "The skin protruded from the stitches. So my daughter did not want to go there."

"Standard spay wounds are around 2 cm long," I said. "Unless there are complications of bleeding or other reasons such as pyometra."

In this case, I did not know what had happened. This is one of the times that a neat and good stitching pattern does impress and count in retaining client loyalty. And this was 17 years ago when the daughter would be in her teens. This daughter-in-charge looked to be in her earlier 30s and was in the IT field, according to the father. So, the internet brought her to Toa Payoh Vets, according to the father. The internet is a double-edged sword and could drive clients away when there are bad reviews from one or two vocal unhappy owners or competitors.

Well, the 17-year-old cat had this irritating neck nodule (1 cm x 1 cm) that she scratched. Dr Daniel's advice of a blood test prior to surgery was accepted by the IT daughter. Serum urea and creatinine levels were above normal and though the cat was normal, the daughter was not in favour of surgery.

"This cat has white strong teeth," Dr Daniel told me. "Can this cat be younger?"
"Very rare for a 17-year-old cat to have good teeth," I said. "But many cat owners do know the age of their cats."

As the father was complaining about a specialist earlier, I asked him what was the problem. "The specialist told me what was the big fuss I was making about my health since the brain scan showed no brain tumours? Why would I pay for a brain scan?"

Sometimes, it is best for a doctor or vet not to comment on personal behaviour but stick to the medical facts.

"What's exactly happened to your father's eye?" I asked the IT daughter later as her father did not speak English but the Hokkien dialect. The daughter put her fore-finger on the lateral side of her left eye and pulled up the eyelid at 45 degrees. "His eyelid flicked sideways and upwards now and then."

"The specialist said he had no problem in the brain MRI," I said. "That may be because the problem could be somewhere between the eyeball and the brain!"

"We are not refined cultured people like the specialist," the father was still mad about the poor bedside manners of this specialist.

Yet he does have a real medical problem. Earlier he had a hard lump below his left eye but this lump had disappeared.

So, what was he suffering from? He had no diabetes, no hypertension and was not obese.

"He does have a medical problem," I told the IT daughter to do an internet search of nerve pathways between the eyeball and the brain. "It is likely that a small tumour had impinged onto the nerve in this pathway. It irritates the nerve and the left eye's upper eyelid twitches suddenly, pulling up the eyelid."

It must be embarrassing for the father when that happened.

"It is best to consult a good neurologist or eye specialist." I said. "The problem is to find that particular one in Singapore. It is extremely hard to find one with the experience with this problem."

I had a similar sudden flicking up of my middle finger of my left hand two years ago. It would flick up now and then. Finally I had a non-malignant nerve tumour behind my wrist excised and the problem disappeared. So, I could empathise with this senior citizen. It was no laughing matter for him. And he does have a medical problem. "Only that the particular specialist he consulted could not diagnose this problem!"

Life is hard for senior citizens when twitches and spasms of eyelids are not diagnosed and removed. A trigger finger is not so obvious to outsiders but a twitching upper eyelid could be most embarrassing when it occurs during a conversation with somebody. I hope this IT daughter will find the correct specialist - neurologist or Ear Nose and Throat surgeon probably, I advised her. If anybody can do it, it will be this IT daughter, but would she have the time to do it? I had pointed the direction to her. It is up to her to be diligent to find out the correct specialist to pin-point the tumour affecting the father's eyelid before it grows immensely.

919. Follow up on 48-hour panting dog

Visited Clare in her new grooming shop today with Dr Daniel. Just started 2 days on her own. "How's the dog?" I asked. "No serious panting yesterday," she said.
"That's good," I said as it is bad for the dog to die while being boarded in a groomer's apartment. Some do die, from heart failures.

"This dog would have died if you had delayed vet treatment," I was told that the owner would only be back from overseas on Wednesday (today being Friday). "The blood was bluish. Her tongue was cyanotic."

So, it was good news. She started her own shop and already had clients as she had been in the grooming business for over 15 years. "This Shih Tzu was groomed by me when she was a puppy," she showed me a black and white Shih Tzu with white scars on the left eyeball protruding. "Dr Jason Teo stitched up the eyelid one time when it was bleeding."

"You can remember every dog?" I asked. "Yes," she said. "I remember all my grooming dogs." In grooming, the owner sees the groomer often. "Contact is by telephone,"Clare told me. "So, shifting to new address will not be a problem." This is unlike a vet who moved out from old positions to start up a new place. Unless the vet sends cards; if not, it is hard to find them unless the owner is persevering.

Went to see a run down building near Singapore Zoo for the pet trade today with another groomer. "It is to be tendered for the pet-trade," he said. I told Dr Daniel that the government authorities have all their nonsenses rules and regulations and by the time this dilapidated building is fixed up, at least $200,000 will be spent and unless one is in contact with contractors, the amount will be astronomical to do "pet trade."

"Only a casket company came to see this month," the officer told us.

The dog died after the operation by the vet

This is quite a typical remark from 3rd parties and from owners.
This 50-year-old lady told me about a 12-year-old dog that no vets would want to operate

917. Follow up on 48-hour panting dog 7 years old

Today Mar 22, 2012, I follow up with care-giver groomer.


19.3.12 Emergency 11 pm came in with panting non-stop. Case written earlier.

20.3.12 Groomer came to pick up dog at 7pm from Toa Payoh Vets. Dog was OK then. At 11 pm, was the worst. At 11 pm, panted and tongue came out like shortage of breath. Gave medicine fortekor half tab. Dog OK after 1 am.
Not panting badly. In morning, still pant but not badly.

21.3.12 Groomer gave the following:
9am Fortekor first, 1/2 tab
9.10 am Lasix 1/2 tab
9.20 am Vetmedin cap

Came home. 8 pm. Only gave Lasix 1/2.


21.3.12 Last night 11 pm , did not pant. Heavy breathing. Does not put out tongue

22.3.12 Repeat the same as morning of 21.3.12. The dog was normal. Appetite OK, eat Caesar canned food at 1/2 can. Normally 1/2 can 2X/day as instructed by owner. Urinated a lot.
11.31 am I spoke to groomer. Dog OK now.

INTERESTING ASPECT OF THIS CASE - In my observations and findings.
1. Heart sounds muffled on ausculation compared to normal dogs with heart disease or CCF (congestive cardiac failure). A case of hydro-pericardium?
(X-ray showed enlarged heart).

2. Heart murmurs - slight or absent
3. Tongue cyanotic during emergency admission on 19.3.12 and blood collected were bluish
4. Blood test - ALT high, serum urea and creatinine very low. Yet WBC and RBC within normal limits.
5. Heartworm test not done.

A "sudden onset" and persistent panting case. So what is the actual cause? Congestive cardiac failure? Overweight? Heat stress? Bacterial or viral infections starting? Dog eats well and is active. Puzzling?