928. Sunday Apr 1, 2012's interesting case

Sunday Apr 1, 2012

1. NO SECOND CHANCE
I had a few cases where the owner had been to a vet practice but their dog's problem still persist. There seems to be no 2nd chance nowadays.

In this case of the "dog with frothy vomitus and persistent coughing," X-rays were done by Vet 1 and Vet 2 of the same practice but the dog continued to cough. Cough medication and other tablets were prescribed and apparently the X-rays of the chest were normal. Why? is the dog still coughing ferociously?

"Bring me the X-rays for my review and 2nd opinion. Also, the medical records of Vets 1 and 2. This will save you some money," I said to the busy lady owner who wanted to do so immediately. In the meantime, I will check the blood test first.

The heart sounds were hard to hear as the lung sounds were harsh as the dog kept coughing. Ausculation of the throat and lungs revealed harsh long continuous coughing sounds. I told the owner that I would need to stop the coughing and follow up. It would be hard to diagnose immediately.


HOUSE-CALL - A 5-year-old male Golden Retriever slipped and his hips were very painful. He could not move and so could not come to the Surgery.

I could do the house-call but it was better to let Dr Vanessa do it to gain the operational experience. A systematic approach and efficiency are important in doing house-calls. Otherwise, the whole process will take 2-3 hours. I came to the Surgery to help clear one case of a Westie with black ears, black neck, black front paws and black scrotal inguinal area. The older woman diagnosed Westie skin disease and said: "I ought to get him treated by the vet earlier."

"Yes," I said. "Westie is well known for this skin disease."

I phoned Min at 7.10 pm. He had reached Bedok house with Dr Vanessa. "The dog is walking and the owner wants to walk him to the park to pee. It will take 20 minutes."

"The dog had a severe injury and should not walk," I said to Dr Vanessa. "In the middle of the night, he would whine with pain and it will cost the owner lots of worries and money to get the vet. Dogs have a high tolerance to pain. Educate the owner and deal as you deem fit."

Earlier, the owner had said that the dog could not move an inch and now, the dog wanted to walk to the park to pee. The dog ought to be sedated to rest - that was my plan.

ABANDONMENT OF DOGS
The owners of an old cocker spaniel and a Golden Retriever did not bring the dogs home despite phone calls. Could this be considered abandonment and what to do with the dogs?

927. E-mail from Kuala Lumpur hamster owner

Claire ...@gmail.com

April 1, 2012 12:23 AM (7 hours ago)


Hi Dr Sing,

I do not know if you will get this mail 'in time' or that I may be too late already.
Either way I feel that I would try anything right now to save my beloved hamster.
I am in Kuala Lumpur, Malaysia.

Ham is 25 months old, very ripe old age.
Started in Nov last year (he was about 18-19 months old), his health started to decline, I presumed due to old age. He suffered some fur loss, his skin had some small black spots and definitely a decline in activities. I did bring him to our local vet here, who did a skin scraping on the black spots to determine if mites or not, and nothing came about. Ham was then diagnosed with a mild Cushing disease, but was advise to just leave him as he is, since he had no problems living his life.

Fast forward to couple of weeks ago, I noticed Ham had some sores/wound on his belly. Large gaping sores, I brought him to a vet again, and was given an antiseptic cleaning lotion and antibiotics. I faithfully cleaned his wounds twice a day and fed him the antibiotics once a day as instructed by the vet. I noticed the sores healed, but not long after, another one popped up.

Early this week, his health took a rapid decline. I thought things were better since the antibiotics was working. But then I noticed he started to sleep daily, did not eat much and lost his eyesight. He became very weak, and frail, and when picked up, he weight very light and was very limp. He does not eat much and I feed him baby food as it is easy to swallow. He still pees, but have not seen him poo. I thought it was his time to come, as he is an old hamster.
What I did not know, I found out today. And I don;t know if I am too late already. I found he had a lump at his neck (throat area)

The thing was when he started to grow older, he developed loose skins around his neck. It was nothing alarming as it was expected when the hamster gets older, but it might have been these loose skin 'masking' the lump until it is affecting him.
The lump us not very large but visible.

My Q is - is it possible for operations? I am asking because I have been googling and found this site: http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm

But I am in KL Malaysia, my Ham is weak and not as alert as this ham in the picture.
Please can you advise if surgery is even something to attempt in Ham especially in his condition right now. So far I have yet to properly find any vet here reliable and as caring as I have read in that article above..

If you have advise please help, I am willing to take opportunity if there is, to save him. Many thanks!

E-MAIL REPLY FROM DR SING
I am Dr Sing from Toa Payoh Vets. Thank you for your e-mail. It is very difficult to diagnose by e-mail as NOT all hamster lumps are the same.

In reply, from your description, your hamster is lethargic, not eating and has several skin infected areas (most likely owing to a poor immune system). He unfit for anaesthesia and is very likely to die on the operating table. Definitely he is much older than the Syrian hamster with the neck tumour operated by me.

In conclusion, hamster owners do need to check their hamster for skin lumps daily, even under loose skin or hairless skin. Weigh the hamster weekly to ensure no weight loss. Tumours that are small are easily excised.

However, you may need to find a vet who does operations on hamsters as some vets do NOT perform surgeries, but simply prescribe some medications in the hope that the "lumps" will disappear. Some hamster owners consult the pet shop operators who will sell a "cream" to "shrink" the tumours. Both practices usually do not work unless the lump is a small skin abscess.

Best wishes.


MOST OLDER HAMSTER TUMOURS CAN BE EASILY EXCISED IF THEY ARE SMALL BUT MOST HAMSTER OWNERS WAIT AND SEE OR USE PET SHOP MEDICATION.

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.