1031. Sunday Jun 17, 12 interesting cases

Sunday Jun 17, 12

1. A Shih Tzu with the "decomposed corpse" smell

Yesterday was a Saturday. I came to the Surgery by bus and subway and reached at 9 am to help Mr Min and get feedback. Dr Vanessa was on duty to my surprise. A phone call came in and the owner said: "Are you Dr Sing?"

I said yes. "I want to send my Shih Tzu to the SPCA as I can't stand his decomposing smell anymore. 2 or 3 days after bathing, the odour of rotten flesh comes from his lower body. The top half of his body has no smell. I had consulted other vets and your vet (name given) 4 times but there is the same foul smell in the whole apartment. I prefer not to send him to the SPCA if you can resolve his body odour."

"Have I treated this dog before?" I asked.
"No," he said. I asked the owner to leave the dog overnight as I would be off duty. Then, on Sunday today, I had a good check up of this dog.

SIGNIFICANT FINDINGS
Shih Tzu, Male, Neutered, 8 years old, 8.2 kg.

1. Ventral part of the body has been shaved. It is inflamed and has some flakes. I smelled the ventral areea. A faint vinegar smell but no stinking rotten flesh smell.  When I told the owner about this, he said: "I had bathed the dog recently. But the whole bedroom will be full of rotten flesh smell after a few days."

2. Right anal sac was full of dark grey oily graunules. Left anal sac had some too. When I put the tissue paper with this oil, onto a table, outside the surgery for photography, at least two flies and one insect buzzed in excitely. No foul smell.

HISTORY AT TOA PAYOH VETS
Dec 09  skin problem
May 10  buy medicine for skin problem
Aug 10 buy medicine for skin problem
Oct 10  skin esp. ventral region.
Apr 11  skin, anal sac rupture
Jul 11  buy medicine for skin problem 
Jun 17, 12 Phoned Dr Sing. I told him to bring reports of another vet he saw "2 months ago" and to write what has happend to the dog during the past years.

HISTORY AT OTHER VET PRACTICE
Feb & Mar 12  Consulted another practice, according to reports presented by the owner.
Vomited and had bloody diarrhoea when he took 3 types of medication and so the owner stopped them.

LETTER FROM OWNER
The main point of the detailed letter is that the dog uses his hind legs to scratch the lower part of his body and makes some noise as if in pain. The foul smell comes after the first day of shower.

SIGNIFICANT FINDING TODAY
Ventral dermatitis with redness and scales. Ringworm +ve. Check for yeast.
Anal sac full of dark brown anal oil.



 

1030. Consistent professional advice for struvite UTI

http://www.bekindtopets.com/dogs/20120614veterinary-database-UTI_singapore-ToaPayohVets.htm






From Jun 23, 2012, all vets at Toa Payoh Vets will practise evidence-based medicine. In cases of urinary tract infection, urethral obstruction and urinary stone removal, urine test is the minimal test to be done.



Blood test, X-rays, ultrasound, urinary stone analysis (in urinary stone removal) should be advised and recorded that advices have been given. These tests (esp. urinary stone analysis) should be done, whenever relevant and possible unless the owner has economic reasons for not wanting tests done. An example is given below:

Friday, June 15, 2012

1030. Consistent professional advice for struvite UTI



I have spoken to Dr V and Dr D regarding the need to give a consistent advice on the management of struvite UTI in dogs. Many Singaporean owners check the internet and are more sophisticated than in the old days.



A case is illustrated:

Case of the female Shetland, one year old. Dr Daniel's case

Jun 10, 2012. Complaint of blood in the urine for 2-3 months.

X-ray of bladder advised but not accepted



Urine test



pH 9.0 (5-8)

SG 1.026 (1.005-1.030)

Protein +

Blood trace

WBC 30

RBC 10

Bacteria 2+

Triple phosphate occasional



Tentative diagnosis should be UTI with struvites. Dietary management, acidification of the urine and antibiotics should be the treatment, not just antibiotics.



Follow-up urine test in 4 weeks is the minimum. X-rays of the bladder will be preferred. Most owners don't bother with follow-up. It is important.



Note: Triple phosphates are "struvites".

Toa Payoh Vets' Dog Spay's Key Performance Indicators

129. Follow up: The female Schnauzer peed out 5 urinary stones

HISTORY
The female Miniature Schnauzer peed blood in the urine. Urine test showed struvite crystals. X-ray showed several bladder stones. The owners wanted spay and urinary stone removal at the same time. I did not agree to this as the anaesthetic and surgical risk would be higher. So nothing was done.  When I was in Hong Kong on May 25, 2012, I received a phone call from the husband. The dog had difficulty peeing and was lethargic. I referred him to another vet who took an X-ray and was willing to do spay and urinary stone removal at the same time. Since it was Saturday, the fees would be higher. On Sunday, the owners took the dog back. No news from them. Around June 11, 2012, the owner asked me to spay the dog first. The following is a follow-up on the spay.
E-MAIL TO DR SING 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 (Thursday). That was the day before she had difficulty to urinate and we sent her to your referred vet.

Thanks.


*2 cans of S/D diet were purchased by the owner although a 30-days' supply was advised. They felt that the dog might not eat the diet.

E-MAIL FROM DR SING DATED JUN 14, 2012
Hi

Thank you for your email and pictures.
How is XXX recovering from the spay? When she starts eating normally?

E-MAIL TO DR SING DATED Jun 16, 2012
Hi Dr. Sing
Thank you for your concern. XXX is recovering well as if nothing had happened and she is eating well, except that I noticed a red patch (about 2cm in dia) forming on her skin close to the incision point.

I am quite curious to see mytwo male dogs are getting very excited and trying persistently to climb on her these few days but she doesn't seem to be on heat. Any idea why they are behaving this way ?


E-MAIL FROM DR SING DATED JUN 16, 2012
Thank you for your email.The red patch may be due to the dog licking. Did your dog wear an e-collar? As for the male dogs being interested in her, she appeared to be on heat based on my observation of enlarged ovaries during the spay. You said her last heat was 4 months ago butit could be 5-6 months ago and so the dog came onto heat. So the male dogs would still be interested as spaying does not immediately stop the female dog from being attractive to male dogs.

You got 6 cans of S/D diet for her. Please note that the recommendation is to give S/D diet daily for 1-3 months if you wish to dissolve the struvite stones. The remaining 3 bigger stones may not dissolve even on S/D diet is given as recommended and surgical removal may be the option if there is persistent blood in the urine.

Best wishes.

1028. The rabbit keeps rubbing his right eye for 2 weeks

Today Jun 15, 2012 Friday, I was at the Surgery the whole day from 9am onwards. This is the 3rd day I took the feeder bus and subway train and feeder bus to Toa Payoh Vets as I used to drive over the past years. It is a form of exercise and an experience to appreciate life, the morning sun and the heartlanders going to work. It is humid and sweaty but that is living.

I did my trust and audit cases of the associate vets. One of these cases involved eye problems in the rabbit. Many rabbits seem to have eye problems and some vets may not be keen on treating them. I assessed how my vets treat such cases in the "trust and audit" checks. I got the dwarf rabbit into the consultation room and did the examination together with Dr Vanessa.
"You don't need to be a licensed vet if you just prescribe eye drops for "eye cases," I said to Dr Vanessa. "Any owner can buy eye drops and treat themselves if the vet just prescribe eye drops!"


The young couple came with a male 2-month-old Netherland dwarf rabbit with a red itchy right eye and a red nose. "We went to Vet 1," the fair trim lady said. "But my rabbit is still scratching his right eye."
"What did Vet 1 do?" I asked.
"He gave eye drops. We have used up the eye drops now. But the rabbit is still scratching!"
"Your rabbit may have an eye ulcer," I said.

EYE EXAMINATION
1. White light shone onto the cornea. Nothing. The cornea was as clear and transparent.
2. "Use the fluorescein eye stain," I said to Dr Vanessa. "It will stain the ulcer. This should be standard operating procedure but many vets don't do it. Just prescribe eye drops and send the rabbit home."
3. As the rabbit was frisky, I advised a gas anaesthetic by mask. Surprisingly, a green stain from 11 to 1 o'clock showed up the corneal ulcer. I asked the couple to go into the op room to see the ulcer.
CAUSE OF THE ULCERATION
The owner did not know. "Do you have hanging balls with sharp hay inside?" I asked. "The hay may have injured the eye."

"We have the ball with hay stuck inside, on the cage floor" the couple said.
TREATMENT
2 WAYS
1. Conservative. Irrigation of the 3rd eyelid. Subcon injection and e-collar. Cage rest in a dark place for around 30 days.
2. Stitching up the upper and lower eyelid. This would be my choice as the healing of the ulcer is much faster. But there is a lot of nursing.

As the young couple will be unable to do the nursing, I did the conservative way. I asked my assistant Min to give them an old carrier as they have been taking the rabbit in an open basket. The rabbit may suddenly jump up and fall and fracture his leg or back.

CONCLUSION
Solving the owner's problem should be the best practice. Otherwise the owner just go to another practice.

1027. Follow up: Acute lymphoblastic leukaemia. Whole body shivering 12-year-old Jack Russell X

Acute lymphoblastic leukaemia - low RBC, low WBC, low platelets
Prognosis is poor. Vincristine and prednisolone advised. Remission does occur.


COMPARED TO 3 MONTHS AGO. Blood in the urine. Recovered 2 days after antibiotics.

BLOOD TEST
Date 27 Mar 2012
Glucose 4.1  (3.9 - 6)
Liver ALT 6.2  (<59)
AST 56  (<81)
Urea 8.0  (4.2 - 6.3)
Creatinine 85 (89-177)

Hb 16.3 (12-18)
Red Cell Count 6.5 (5.5-8.5)
Total WCC 10.7 (6-17)
N=75%, L=10%, M=12%, E=0%, B=2.3%, Atypical Lymphocytes - None
PCV 0.45 (0.37 - 0.55)
Platelets 487 (200-500)
Platelet clumping noted. Large platelets present. Occasional nucleated RBC seen.


URINE TEST. I had discussed this in another article earlier.

TREATMENT - CHEMOTHERAPY
A bone marrow biopsy is needed. Every treatment is around $1,000 and 6 treatments

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.