1082. Service Audit of Toa Payoh Vets: Recurreing urinary stones review case

DRAFT INVESTIGATION OF RECURRING UROLITHIASIS IN A SHIH TZU
A lot of time is needed to investigate this case to come to a solution for the dog.



At 9.50 am, today Saturday, I am at the Surgery and I review the case of the recurring urinary stones
in a gold/black male Shih Tzu, 4 years old. The patriarch came to see him yesterday and the day before (Thursday) and spoke to me twice, at length.

NOVEMBER 2011. TOA PAYOH VETS
"Why did you take the dog to another vet for "blocked bladder" after X-rays by my associate vet in Oct 2011?" my associate vet hadI asked. "Is there some worries about Toa Payoh Vets not being able to perform this surgery?"

"No," he said. "I was recommended a vet. After all, my dog had been to your place as a puppy earlier."  Vet 1 opened a hole in the urethra and allegedly told him that the hole would close in time and the dog would pee from the normal orifice of the penis. He was not happy that Vet 1 had to operated a 2nd time the next day without informing him. The dog's e-collar was smaller in size leading to the dog licking the urethral opeing.


APRIL 2012. VET PRACTICE X
"Was there any difficulty in urination or blood in the urine after Vet 1 operated?" I asked.
"Not for 7-8 months. My dog would lift his leg to pee a large volume of urine. However, he started having problems peeing. So, I rushed him to another practice (X). This practice has all the facilities and you can understand why I did not bring the dog to Toa Payoh Vets. Vet 2 operated on the bladder and removed the stones. The vet said he flushed the bladder several times." 


AUGUST 2012. VET PRACTICE X
The dog could not pee normally again. Less volume of urine and difficulty in urination.
"My dog's stomach was getting bloated and so I rushed him down to Vet 2. The bladder operation was done to remove the stones. However, Vet 2 told me that he need to open another hole and close the first hole as my dog could not pee. I do not want another operation and that is why I brought the dog to your Surgery."

Yesterday, Dr Daniel said there was an obstruction around the bend of the urethra. As I am not operating on this case, I will follow up.


WHAT'S THE SOLUTION?
This is a highly emotional case. The owner had spent over $2000 in Practice X recently and was assured that an X-ray post-removal of bladder stones was done. "This is good practice," I said. "So that there is proof as to whether all stones had been removed by the vet. I don't do it because of the costs involved."  But this X-ray could not be located presently.

1081. Sep 5, 2012 dog disease in Singapore with Zhao Pao newspaper

Educating the dog owners is important. The Zhao Pao reporter wanted me instead of the younger ones to talk about diseases in the dog in Singapore as I am an old vet. Some questions he asked were:

1. Commonest dog disease problems in Toa Payoh Vets.
Number 1 will be skin diseases of various causes like ringworm. Ear infections are part of skin diseases. Food allergies tests can be done but it costs money.
Vomiting and diarrhoea, coughing, urinary tract infections, tumours in skin and elsewhere in the body. Eye diseases in Shih Tzus common due to their big eyeballs. Tick infestations hard to control by some owners.
2. Bladder stones. Quite common in some breeds like Miniature Schnauzers.

3. Advices to dog owners.
3.1  Daily check up of the dog for tumours or ticks.
3.2  If dog is not eating for more than one day or not active, consult the vet promptly.
3.3  Annual vaccination is still recommended as Singapore vaccine suppliers do not sell those vaccines which last 3 yearly as reported in the internet forums. They supply combined vaccines and so important diseases like parvovirus and distemper cannot be separately vaccinated 3-yearly as in the USA dogs.
3.4  Bladder stones and eye injuries are emergencies. Do not wait and see.

1082. Blocked bladder case - urethrotomy twice

Today, Dr Daniel operated on a Shih Tzu who could not pass urine. Vet 1 and Vet 2 in another ractice had operated and made two "holes" in the lower part of the penis ie. urethrotomy. This case was referred to him by his brother as the dog could not urinate and the dog owner was his brother's friend.


I reviewed this case done by my associate vets and discovered that this 4-year-old Shih Tzu had been examined by Dr Vanessa on Oct 24, 2011. She confirmed bladder stones from X-rays and the cathether was blocked about 6 cm from tip of penis. She recorded that the owner "declined all treatment."

The infected areas were cleared. The urethral opening was stitched again and a catheter was passed through. "Pus in the penis," he said to me. "According to the book, the penile head should have been amputated." I said: "Normally I don't do it. Just open the urethra behind the os penis to let the urine flow out if the front part is completely blocked. Only in this case, there were complications of infections after surgery done by Vets 1 and 2."

As more new vet surgery text books are produced, there are new concepts. Amputation of the penile head, in my opinion, is unnecessary despite what the new vet surgery text books say. I mean, this amputation causes more pain and bleeding and I have done urethrotomy without the need to cut off the penile head and the dog was OK. "The only problem with urethrotomy is that the male dog leaks urine onto the floor and the owner does not like cleaning up," I replied to him.

In urethrotomy, the owner needs to take special nursing care as the area can close up due to infections and scarring. So Vet 2 did another urethrotomy. This gave complications as the dog could not urinate. Vet 3 proposed another opening of the urethra further back.

In conclusion, this case would be difficult to treat. In my opinion, the solution is to open up the first urethral stricture. It must be debrided and opened up to join the 2nd one. Both stitched up as one opening ventral. A catheter is to be placed for over 10-20 days for healing to take place. Not just 4 days and take out the catheter as the urethral opening will closed up and obstruct urine flow again!
       

 

1080. Retrospective study: Vaginal hyperplasia & Prolapse Type II in an old female chihuahua

"Very tired, not moving," the home-breeder said. "Not eating  1's for the past 9 days and vomit when given canned food." There was a red"tongue-like" tissue hanging from the backside of this 10-year-old female Chihuahua, fawn/white.

On Nov 18, 2011, he had consulted Vet 1 who noted "vaginal/uterine" prolapse and advised spay. She informed him there could be pyometra. She recorded that he declined blood testing. He did not want surgery as the vet warned of high anaesthetic risk. So he took some medication. However, his dog did not eat again. Four days had passed. Vet 1's Nov 19 blood test records showed elevated liver enzymes and marginal elevation of WBC (Total WCC 17.2). Her ultrasound showed mainly liver, gall bladder and kidney issues. Urine tests showed presence of glucose (3+), blood (4+), bacteria (2+), epithelial cells, WBC and RBC. However, in retrospective review today, of the differential count, neutrophils was 88% (high) and platelets 181 (200-500) was low.

The owner wanted non-surgical treatment. But there was none. Surgery was the option but highly risky as the dog had been sick for some days.

He wanted me to do the surgery which was done on Nov 27. I got a blood test done on Nov 25. This time the Total WCC was 33.2 (6-17), Neutrophils was 96%, platelets 14 (200-500).  NOW, the haemoglobin 5.3 (12-18) and red cell count 2.7 (5.5 - 8.5), Haematocrit 0.15 (0.37-0.55), MCV 55 (60-77) indicated severe anaemia too. Platelets are 14 - clotting problems exist now - dog unable to clot when the tissues are cut (see image of my report case).

CONCLUSION
1. Spaying the dog when she was young would not have caused this serious health problem.
2. Often the owner is not aware of the seriousness of the problems as the vet mentioned "high risk" and death likely.
3. The vet was not able to communicate the need for prompt surgery (1-2 days on Nov 19 , not wait longer) as delays would make survival very low.

1079. Follow up: Will my dog still have bleeding after spay?

Sunday Sep 2, 2012 was a busy day. So I did a spay of a fat SilkieXMaltese, 5 years old. This case was written earlier. Today, Tuesday, I phoned the owner to find out what happened after spay and to let them know the blood test results were OK.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.

Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
                                 Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit).  Slept sideways.

Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.

Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.

CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.

1078. Follow up: Will my dog still have bleeding after spay?

Sunday Sep 2, 2012 was a busy day. So I did a spay of a fat SilkieXMaltese, 5 years old. This case was written earlier. Today, Tuesday, I phoned the owner to find out what happened after spay and to let them know the blood test results were OK.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.

Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
                                 Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit).  Slept sideways.

Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.

Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.

CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.

1077. Email advices regarding eye tumour

Dear Dr Sing,

My pet maltese is diagnosed with malignant high grade anaplastic mast cell tumor. A first operation was performed to remove a tumor from her left thoracic flank. The histological report revealed that there is no margin of tumor-free tissue along the deepest border.


Two months after the surgery, a new lump developed on the right neck and was surgically removed. An ultrasound abdo scan also showed that the cancer has metastasized to the spleen.


She began her first chemotherapy: Prednisolone and Vinblastine (8 sessions; 4 x weekly, 4 x biweekly). Her second chemotherapy: Palladia was on for two weeks and interrupted due to a swollen right eye lid.


We seek a vet with special interest in ophthalmology today and she was definite that the swollen eyelid is a malignant tumor, without doing any biopsy. Surgically removal of the entire eye is the only option but the tumor is likely going to reappear. My pet is given a prognosis of 3 weeks.


Aside from the swollen right eyelid, she is still a very active pet and has good appetite. The tumor in the eyelid has pushed her eyeball to the side and looking very uncomfortable. She is given Prednisolone for now.


After doing some research online, most commented that eyelid tumor is benign.


Given that my pet is still in good spirits, I am not willing to put her down in any case. However, the unwelcome tumor in the eyelid seems like an time-ticking tumor. It is getting more inflamed as each day passes.


EMAIL REPLY FROM DR SING DATED AUG 24, 2012

I will be back from HK on Friday aug 24. It will be best to tel me 96686468 on Sat 10am. Most likely eye tumor is malignant.