Sunday, December 16, 2012

1218. Intern does not write post-card

Sunday Dec 16, 2012

A retiree puts a stray cat here for treatment as the cat had no appetite for over two weeks. The cat was syringed fed and given fluids and was better for a day or two. He drank a lot of water and today he was very ill despite supportive treatment for the past 5 days.

I tried to phone the owner, but his mobile phone was terminated according to the phone service provider. What to do? I asked Intern V to write a postcard in Chinese to post to him. She wrote in Chinese language covering the top right corner.

"Where do I paste the stamp?" I asked her. Young Singaporeans never send post cards nowadays and so they are not aware the position and space for a stamp!  

1217. An old female dog had difficulty peeing. Pyometra or urethra obstruction or both?


Sunday, December 9, 2012

1214. Follow-up. "Closed pyometra" case

 
Two days ago, this 11-year-old female Maltese was operated by Dr Daniel and me. This was a strange case. Total white cell count was very high in the blood test. A swollen abdomen with a globular lump. I said it was a very full bladder on first palpation but Dr Daniel said the dog had peed all urine. An X-ray showed a big globular swelling and I was quite sure it was the bladder. Or was it a large uterus filled with pus since the owner had said that the dog had passed "sticky urine".

Some owners are not very correct with their signs and symptoms of their dog and "stickiness" in urine could be pus being discharged from the infected uterus in this old dog. The owner agreed to X-rays and blood tests. No radio-dense urinary stones were seen but this just meant that the stones would not be visible in the X-rays as not all urinary stones are. The blood tests showed a severe bacterial infection with the dog being toxic.
 

BLOOD TEST ON DEC 6, 2012

Serum urea 22 (4.2 to 6.3), creatinine 188 (89-177).
RBC 4.8 (5.5-8.5), Haemoglobin 9.9 (12-18).
Total WCC  62 (6-17),  N=98%, L 1.7%, M, E, B.
Platelets 131 (200-500) was low suggestive of toxaemia
But what cause this bad infection and how to resolve the dog's problems? As the dog was old, any delay in treatment of toxaemia would result in death. Antibiotics would give a reprieve but there was more to the health of the dog than just bacterial infection. Closed pyometra was a possible diagnosis but the X-ray of a large swelling appeared to me to be that of a swollen bladder.  My abdominal palpation was that of a swollen bladder, as big as an orange. Of course, it could be a grossly swollen uterine body as well.

The next step would be surgery and after 24 hours on an IV drip and medication, the dog was operated by Dr Daniel and myself. Time was of the essence. An old dog was high anaesthetic risk but there was no option other than surgery to resolve the health problem.

SURGERY ON DEC 7, 2012

The biggest bladder ever seen. Like 3/4 of a Thai mango. The dog had been given IV drip 12 hours ago to pep her up for surgery and increase her chances of survival.  More than 15 cm long. I aspirated the urine with a sterile syringe from the apex of the bladder and sent for urine analysis. You can see that the urine is colourless from the images in this webpage.
 

Urine colour: Colourless.
Clarity: Slight turbid.
pH 5.0 (5-8).
SG 1.012 (1.005-1.030)>2250. RBC 90 (Possible haemolysis of RBC in urine).
Bacteria 2+. Crystals Nil.
"Urinary stones might not be radio-dense and so would not be seen in the X-rays," I said to Dr Daniel who was operating. "Flush out the bladder, irrigate it. Put a catheter into the bladder and pass it out through the urethra from the bladder." There was cystitis. Negative crystals in urine do not mean no urinary stones.





 




When Dr Daniel tried to pass the catheter out from the neck of the bladder, there was obstruction. "It is possible that there could be a urinary stone stuck inside the short urethra and not visible on the X-ray," I said. After a few attempts, he managed to pass the catheter out of the urethra and the vulval lips. "There could be a urethral obstruction in the female dog as well." There could be urethral spasms as well but I would bet that there was an urethral obstruction.  Most vets don't pass the urethral catheter via the vulval vestibule as they deem it difficult to do it, unlike in the dog. Dr Daniel irrigated the bladder with saline and stitched the 1-cm incision with two layers of 3/0 mono-syn sutures.

"Check the neck of the bladder for tumours," I said. "Extend the incision of the skin and linea alba caudally. As Dr Daniel pulled up the bladder, we could see a large reddish lump at the neck of the bladder on the outside. I took an image for the owner to see as it was not possible for her to be at the operation room.  This swelling of around 8 mm x 8 mm x 4 mm could be the cause of difficulty in urination.


A swollen abdomen Massive bladder Bladder incised to check for non radio-dense stones Urethra catheterised. There was an obstruction
 
Bladder sutured. A growth is seen at the neck of the tumour Pus in infected uterus removed Dog has no difficulty peeing after surgery  
DISCUSSION WITH THE OWNERS
Today was the first time I met the father and two young adult daughters as Dr Daniel was the vet in charge of the case. "Did the dog have difficulty passing urine?" I asked.
"Yes," one daughter said. "She took a long time to pee and only a few drops of urine came out."

I reviewed the record on Dec 6 when the dog was admitted. "Urine sticky. Stools red and yellow past 2 weeks. Appetite decreased. Vomited once."  Pyometra was suspected but the onset of heat was unknown. In conclusion, there was a case of pyometra and urethral obstruction caused either by a non-radio-dense urinary stone in the urethra or the neck of the bladder tumour. The "urinary stone" was not seen as the urinary catheter appeared in the vulval area as there was flushing of the urethra from inside the bladder before removing the obstruction.

Many old intact female dogs do suffer from pyometra and in this case, there was pyometra with the uterine body wall being as thin as a piece of paper, leaking out the bacteria into the blood stream as well as into the bladder, in my observation. Fortunately, the uterine bodies were removed before they ruptured. Similarly for the bladder as it would rupture if the urine could not be passed out, as you can see how thin the wall was, from the images.

More than 7 days had passed, now being Dec 16, 2012 as I edit this report. The owners were happy that the dog leads a normal life and has no difficulty in peeing. Two weeks had passed before the owners consulted the vet. Fortunately, the dog did not suffer kidney damage in the delay in seeking treatment and that the appropriate treatment was given. The old dog has a new lease of life.

Updates and images will be at:
http://www.bekindtopets.com/dogs/20121216dysuria_pyometra_toapayohvets.htm



UPDATE:
Dec 21, 2012. The dog came for stitch removal as there was a slight stitch breakdown in the last stitch nearer to the vagina. Dr Daniel removed the stitches which were absorbable.

"There is some sticky dicharge from the vagina," the lady owner said that the dog now could pee normally and was OK.

"Most likely the vestibule in the vagina still has some pus left over from the uterus," I told her. "Since the infected womb has been removed, this pus would disappear soon. There is nothing to worry and is a common occurrence in some post-op cases of dogs with pyometra spayed."

In conclusion, the surgical outcome was good and the 11-year-old dog was alive. It would be a happy Christmas for the family.    

Friday, December 14, 2012

1215. Are dwarf hamsters dumb?

Yesterday Dec 14, 2012, I spoke to the lady owner about her hamster's tumour below the right ear. Dr Daniel had done electro-excision. For such small tumours and for ear warts, he was not in favour of electro-surgery. A scalpel blade would be just as effective. "No," I told him. But it will take time and patience for me to show that electro-surgery is useful in some hamster tumour excision.

I discovered that Australian vet students don't get lectures on hamsters as nobody in Australia is allowed to keep hamsters as pets! So, a vet graduates without any hamster lectures. This happened to me as a vet student in Glasgow University in 1969-1974. My professors did not mention the "hamster" word too! But in Singapore, many dwarf hamster owners are around although I don't know how many.

I would have taught dwarf hamsters are dumb. But this Indian lady in her 40s told me that she had 3 hamsters and they were clever creatures. Hamster No. 1 was bought 2 years ago against her father's objection of keeping any pets. The older generation of Singaporeans deemed pets as a waste of money when so many people are starving i this world. Yet 2 weeks later, the retiree father was very fond of this hamster. Hamster No. 2 was bought from another place. This hamster was the most intelligent. He would not try to escape or hide under fridges. When placed on the dining table, he would inspect the dishes of the adults and then go to his own plate to eat his food. I saw her mobile phone video of this hamster on the dining table.

Presently, Hamster No. 3 with the tumour on the skin below his right ear. He would show his anger by climbing up the crate's railing and jumping down or refused to come out from his house. For example, if he was not given the correct brand of brand. "He likes only Gardenia," the lady told me. "If I give him another brand, he would go wild and climb up the railings and jump down many times."
The lady continued: "On another occasion when I used the pink colour of the cottony bedding instead of blue, he would scatter the pink ones and would not settle down. I had to go to NEX shopping mall to buy the blue ones."

"Every morning, my sister had to tell him that she is going to work as he rushes out excitedly to greet her," the lady said. "He even knows when my sister is coming back from work as if he has a clock."

"Is he the most intelligent of the 3?" I asked. "No," she said. "Hamster No. 2 was the most intelligent."
Hamster No. 3 would run to hide under the fridge if let to roam free, unlike Hamster No. 2 who harboured no thoughts of escaping under door gaps or into corners. So, I guessed that was why she considered Hamster No. 2 as most intelligent of the 3.

"Do you believe in reincarnation?" I asked.
"Sometimes I think our relatives have been re-incarnated as hamsters."
She could narrate more stories and such stories should be recorded in audio as the flavour of the actions of Hamsters 2 and 3 could not be captured in  text.

 (LATER)

1. Weight 69 g. The 2nd heaviest in the last 3 days since the black and white one we operated upon was 71 g.
2. Zoletil 50 IM not 100% effective. "Top up with isoflurane gas," I advised.
3. Electrosurgical excision was in <1 bleeding.="bleeding." nbsp="nbsp" no="no" second.="second.">4. A 3rd-year student for 2013 studies from Melbourne Univ was on internsihp for 2 weeks and I have asked her to  write about this electrosurgery in the dwarf hamster. The hamster with the ear growth was also operated using electrosurgery. 


Website and updates will be done later at www.toapayohvets.com --- goto hamsters.


   

1215. Follow up on the epulis Golden Retriever - ticks

I reviewed this case of the 12-year-old Golden Retriever who came in as he was "panting" after eating and after exercise walking for the past 3 days. No such panting before that. What was the cause?

This dog was operated in July 2012 for a large epulis which was bleeding.
See case at: http://www.sinpets.com/F5/2012072gigantic_epulis_labrador_toapayohvets.htm
He had a "gingival biopsy" of the mass in 2009 by another vet. The report stated "fibromatous epulis of periodontal origin". It said that it is generally a benign entity in the dog and complete surgical excision isusualy difficult due to indistinct boundaries between the epulis and normal gingival tissue. That was in Dec 2009. However, the lump bled a lot and so the owner came to me and I advised surgery n July 2012. 2.5 years had passed. Gum tumours are best excised when they are small.

Taking a sample for tissue biopsy is part of the process to ascertain whether it is cancerous or not.  This adds to the cost and so I usually do not advise it. Just excise the mass and send to the lab for checking of its cancerous nature or otherwise.

I checked the gums. They were OK and reddish pink.
"Has the dog been exposed to ticks recently?" I asked. The two gentleman owners had said that their dog never had ticks for many years but he had a lot of ticks just 2 weeks ago. "Every day, we pluck out the ticks," the owners said. "But now he is tick-free."
"You could have used a tick bath or dip," I said.
"Well, I bought a tablet from the internet and all the ticks died. There are various suppliers and prices vary."
It seems that this tablet worked well. The owner sms me the name: Nitenpyram. by Bob Martin. Owners nowadays do their research and experiment.  They should check out the effects and side effects of the medication.


http://www.drsfostersmith.com/Rx_Info_Sheets/rx_nitenpyram.pdf has info on Nitenpyram. Its use to kill ticks is not known. It is effective to kill adult fleas only.

So what is the cause of the panting? The dog does not have heartworms nor severe heart disease. No fever. Could it be tick fever?  The owners did not want a tick fever blood smear test. Nowadays, owners with research knowledge can be demanding. It is up to how the vet is able to communicate with such well informed owners. If the vet does not know how to communicate and if this dog comes down with tick fever later and dies, the owner will not blame himself as he had sought the vet's opinion. As at yesterday, there was no anaemia and no fever. So, it couldn't be tick fever. It is not as simple as that as tick fever could be at its first stage.   

Sunday, December 9, 2012

1214. Follow-up. "Closed pyometra" case

Two days ago, this 11-year-old female Maltese was operated by Dr Daniel and me. This was a strange case. Total white cell count was very high in the blood test.. A swollen abdomen with a globular lump. I said it was a very full bladder on first palpation but Dr Daniel said the dog had peed all urine. An X-ray showed a big globular swelling and I was quite sure it was the bladder.

BLOOD TEST ON DEC 6, 2012
Serum urea 22 (4.2 to 6.3), creatinine 188 (89-177).
RBC 4.8 (5.5-8.5), Haemoglobin 9.9 (12-18).
Total WCC  62 (6-17),  N=98%, L 1.7%, M, E, B.
Platelets 131 (200-500) was low suggestive of toxaemia


SURGERY ON DEC 7, 2012
The biggest bladder ever seen. Like 3/4 of a Thai mango. The dog had been given IV drip 12 hours ago to pep her up for surgery and increase her chances of survival.  More than 15 cm long. I aspirated the urine with a sterile syringe from the apex of the bladder and sent for urine analysis.

Urine colour: Colourless.
Clarity: Slight turbid.
pH 5.0 (5-8).
SG 1.012 (1.005-1.030)>2250. RBC 90 (Possible haemolysis of RBC in urine).
Bacteria 2+. Crystals Nil.
"Urinary stones might not be radio-dense and so would not be seen in the X-rays," I said to Dr Daniel who was operating. "Flush out the bladder, irrigate it. Put a catheter into the bladder and pass it out through the urethra from the bladder." There was cystitis. Negative crystals in urine do not mean no urinary stones.

When Dr Daniel tried to pass the catheter out from the neck of the bladder, there was obstruction. "It is possible that there could be a urinary stone stuck inside the short urethra and not visible on the X-ray," I said. After 2 minutes, he managed to pass the catheter out of the urethra and the vulval lips. "There could be a urethral obstruction in the female dog as well." Most vets don't pass the urethral catheter via the vulval vestibule as they deem it difficult to do it, unlike in the dog.

"Check the neck of the bladder for tumours," I said. "Extend the incision of the skin caudally. There was a large reddish lump at the neck of the bladder on the outside. I took an image for the owner to see.


DISCUSSION WITH THE OWNERS
Today was the first time I met the father and two young adult daugthers.
"Did the dog have difficulty passing urine?" I asked.
"Yes," one daughter said. "She took a long time to pee and only a few drops of urine came out."
I reviewed the record on Dec 6 when the dog was admitted. "Urine sticky. Stools red and yellow past 2 weeks. Appetite decreased. Vomited once."  Pyometra was suspected but the onset of heat was unknown.
 

1213. Sunday Dec 9, 2012's interesting cases

Sunday Dec 9, 2012

I seldom have expatriates as clients and was surprised to encounter 3.
Case 1Shedding Husky. Buinsessman, his wife and pre-teen son who loves tennis.
Husky, female, 1 year 4 months. Shedding hair for last 2 weeks. "Hair all over the house," mum would say. Yet I did not see any hair loss as the son combs the dog daily.

"Hair shedding is common in Huskies," I said. "Causes include hot weather, ticks, recent heat and after birth."

"Was the dog carrying a toy in her mouth and protecting it?" I checked there was no milk in the nipples nor were they enlarged.
"Yes, one month ago. She would not part with it and was very possessive."
However, the left ear was very itchy and the dog would move her head away whenever I tried to examine it. A wet dark exudate presented on the cotton tip. The right ear was also itchy. So the dog tried to relieve her itchiness by using her hind legs to scratch the flanks and causing hair loss.

The solution was to treat the ears with proper ear drops and to plan to breed the Husky on the next heat. The father wanted a pup from her just for one litter. So I advised properly timing and everybody was happy.

Case 2. "Debarking" cats.
"I have never heard of anyone asking to debark cats," I said to the Caucasian caller over the phone today at 3 pm. He said that the cat would make loud noises and this may wake up his baby, due to arrive in May 2013.

"Other than this habit of making loud noises that may wake up the baby at 3a.m, he is a sweet gentle cat. I don't want to send him to the SPCA or get rid of him. Is it possible to debark him?"

"At what times is your cat vocal?" I asked.
"Early morning and late at night."
"Just like a cock crowing at dawn?" I asked.
"Yes, like a rooster but he does it at night too. What do you propose? I have him neutered at another vet at 5 months of age. Now he is 11 months old. He has been doing that since he is a kitten."
"You are the first person to enquire about debarking cats."
"That is why they refer to debarking. It is meant for dogs," he said.
I advised boarding the cat for one month to change his behaviour or crate him and cover the crate with a big towel to give him security and changing his routine. Will this work? The expat thanked me and might let me know.


Case 3. Two macadema nuts in a dwarf hamster.The Caucasian man brought his plump hamster for a review 2 weeks after treatment from Dr Vanessa. He had been to other vets but the hamster still has complete hair loss and redness on the lower body and the legs, on the back spinal area and left ear area. This has been going on for some weeks. The lower skin and neck were not so red but hairs did not grow back.

I saw scales on the shoulder area and the Mr Min could easily pluck out the hairs for a microscopic examination for ringworm. A few hairs had ringworm but most were OK. Was it skin mites? Or management? The hamster had been eating various kinds of food and had to climb into a feed bowl which was rather sharp. "Change to a lower feed bowl with smooth edges," I advised also putting the hamster on paper towels for a month."

This could be a case of management as the hamster was free to roam in the room. There are many causes and it will take time to know. In any case, I noted that the skin below the left ear was hairless and the left cheek pouch was hard. "There could be an impacted pouch," I said. "I need to give it a little bit of anaesthesia gas and check the pouch."
"Will it be safe for my hamster?" the man had said that his hamster had been passing blood for 5 days earlier.
"Yes, it will be safe as it is gas anaesthesia and takes a few seconds."
The left cheek pouch was impacted with two large cream-coloured macadema nuts and the hamster was trying to dislodge them by scratching till the skin below the left ear was bald.
"My wife is a pastry chef," the gentleman was surprised to see two big nuts of around 6 mm in length.
"No more macadema nuts or any other food other than a good quality hamster food," I advised bathing the hamster with the anti-fungal shampoo, clipping the hair, using paper towel as bedding for 4 weeks and reviewing after 4 weeks. 
 So, this Sunday was quite interesting with 3 different types of animals posing challenging problems for me. 

1212. "Tiny" ear tumour on dwarf hamster email query



 
On Sun, Dec 9, 2012 at 8:38 AM, Z..@gmail.com> wrote:
Dear Sir/Mdm,

I have just discovered a tiny growth on the ear of my hamster. Attached are the pictures for your reference.

I would like to know if there is any treatment for my hamster and the cost of it.

If so, pls advise on an appointment date and time. Thank you.




Regards,
Z
 

EMAIL REPLY SUNDAY DEC 9, 2012  9.28 AM FROM TOA PAYOH VETS
I am Dr Sing from Toa Payoh Vets. Thank you for your email. The "tiny" ear tumour needs to be removed by surgery and under anaesthesia. The ear canals need to be examined for other growths.

The approximate cost is $150-$200 for consultation, anaethesia, surgery (+/- stitching) and medication. Appointment is by phone 6254-3326. Bring hamster at 9.30 am and it goes home by 4 pm usually. Best wishes.