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Wednesday, June 26, 2013
1477. Update - Speedy ear surgery in a very old dog
TOA
PAYOH VETS
1476. Update: 3 urinary stone cases
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Tuesday, June 25, 2013
1475. Vet Case. Jun 2012. Speedy ear tumour surgery in a 14-year-old Maltese X
"There is plenty of time," my new assistant Nia said to me. "This Maltese is 4 years old."
I had advised my assistant to be well prepared as I wanted to perform a speedy surgery to remove the large tumour outside the ear canal and more tumours inside the ear canal.
"She looks young," I showed Nia the eyes of the Maltese. "Look at his thick white cataract eyes. Four-year-old dogs do not have eye cataracts normally."
I said, "Young dogs can survive a longer anaesthetic time but she is 14 years old and had heart murmurs. Any lengthy surgery might lead to heart failure and death!"
So I was much worried about death on the operating table. The young lady
owner had consented to the operation as her Maltese kept scratching the
right ear till the skin bled and soiled the apartment and her furniture
and her bed. She had cleaned the infected ear mass for the past 3 weeks
and had given the oral antibiotics and painkillers daily. A blood test
showed the Maltese had no liver, kidney or blood disorders and was fit
for surgery.
"Doc, see, the ear tumour is present only outside
the ear now," Ms Jenny Lim declared ."So just remove this tumour outside
the ear canal would do!"
"The right ear has more hidden
tumours inside the vertical canal. You just can't see them." I said.
"Please place your fingers and feel the hard lump way down the vertical
part of the ear canal. Then compare this ear to the softness of the
vertical canal of he left ear! No lumps at all."
She was the Millineal generation of dog owners who surf the net for information about her dog's ear tumours and knew more than the baby-boomer generation.
The dog survived the anaesthesia although she had a weak heart. The owner wanted her home on the next day and would nurse her wounds. I gave an Antisedan injection IM to reverse the drowsiness of Domitor and the dog woke up within 2 minutes.
Old dogs should get up fast as
prolonged recumbency may lead to respiratory or cardiac failure.
Antisedan is a good antidote. The lady owner was happy as her dog was
alive. No histopathology was done to lower medical costs.
Speedy surgery is necessary in old dogs. However, this case still took around 50 minutes.
I am grateful that she survived the operation as old dogs are extremely high risk anaesthetic patients. Domitor + Ketamine + isoflurane + oxygen were used in this case.
UPDATES AND DETAILS
AT:
https://2010vets.blogspot.com/2013/06/1475-speedy-ear-tumour-surgery-in-14.html
ILLUSTRATION TO EDUCATE CLIENT ON FIRST CONSULTATION ON MAY 30, 2013
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1474. Judgement Day - An unusual closed pyometra in a Jack Russell
Monday June 24, 2013 6pm
"It is up to the vet to decide when to operate," I had seen the X-rays of this small-built 7-year-old female Jack Russell X who could be a cross with a Chihuahua as this was a popular breed with local breeders. "I usually give the dog an IV drip plus antibiotics to stablise the dog and operate 24 hours later. Waiting another day may lead to the dog being toxic as there is a lot of pus and bacteria inside the swollen uterus of pyometra."
Dr Daniel had palpated the Jack Russell yesterday, Sunday. She had a painful abdomen and had been on heat 2-3 weeks ago. She could pee normally. Today, her rectal temperature was 37.6 deg C. "It is more important that she be operated to remove her swollen womb today," I advised. "If the womb ruptures overnight, she will be dead tomorrow. The X-rays showed the swollen uterine bodies. There is no need to wait for the complete blood test results."
I put the dog on the table and palpated a large swollen mass in the mid-abdomen. The dog did not cry in pain but was uncomfortable. "It felt like a big swollen bladder or stomach," I said. "But it could be the swollen uterus."
"The dog can pee with no problem," my assistant Nia said. "No blood in the urine."
So, it would likely be closed pyometra rather than a gastric dilatation (stomach swollen with gas). Dr Daniel decided to operate.
I could see a large distended uterus stretching from the lower chest to the pelvic area. This was unusually long and large in a small-bodied Jack Russell X. "Make a longer incision forward to the sternum," I could see that Dr Daniel could not fish it out.
"It is a swollen stomach," Dr Daniel said after fishing out the hemispheric swollen organ. Certainly it has the structure of a stomach full of gas or fluid with a greater curvature seen initially. As Dr Daniel extricated more of the organ, there were the continuation to the left uterine body which had 10 times smaller lumps. So this was closed pyometra confirmed.
This was an abnormal presentation as usually all uterine bodies would be filled with pus and be of similar sizes. Here, there was only one gigantic swelling of part of the left uterine body, as if both ends of the lobules were cut off, resulting in one portion grossly distended. I took a video and some images of the challenges diseases present to sharpen the diagnostic skills of the veterinary surgeon.
"Use the triple forceps method," I advised Dr Daniel. Each vet has his or her own method. "No need to ligate the omental fat separated from the uterine side but just clamp and cut. Surgery has to be quick in case the dog dies. For the uterus, ligate two parts so that if one ligature slips, there is another one."
The dog was recovering when the mother and her two adult children came to visit at 7 pm. She looked dazed. "Why is her tongue sticking out? Will it be permanent?" the daughter asked me as Dr Daniel was busy clipping the long claws of a recumbent 18-year-old cat brought in by an adult son and his mother. It was his mother's cat.
"The tongue sticking out is due to anaesthesia," I said. "The tongue will be in when the dog is awake."
The dog's eyes were open wider as the owners stayed for another 20 minutes. But she could not stand. An Antisedan injection would reverse the Domitor given earlier and waken up the dog. But as each vet has his or her own ideas, I did not insist.
The dog would likely recover after the operation on Judgement Day. If there was a delay, she might be dead. Evidence-based medicine is important in the diagnosis of closed pyometra as owners want to know for sure. In the old days, I would have got a history of the dog being on heat, passing out "blood with mucus", palpated a painful abdomen and advised spaying. This would save the dog's life and the owners some medical expenses. But nowadays, evidence-based medicine is important as owners are most sophisticated and likely to sue.
BLOOD TEST RESULTS Jun 24, 2013 on admission
Total white cell count and neutrophil - normal
Total WCC 10.6 (6-17). N 69.8 Absolute 7.4-R
Monocytes 18.6 --- high
Haemoglobin 11.8 (12-18).
Platelets 135 (200-500) --- toxaemia is present.
Urea 7.2 (4.2 - 6.3)
Creatinine 59 (89-177)
X-RAYS
A swollen uterine body may be seen.
UPDATE Junw 25, 2013 9.30 am
Dog is OK, tongue colour much pinker. Not eating the A/D. Wound is OK.
"It is up to the vet to decide when to operate," I had seen the X-rays of this small-built 7-year-old female Jack Russell X who could be a cross with a Chihuahua as this was a popular breed with local breeders. "I usually give the dog an IV drip plus antibiotics to stablise the dog and operate 24 hours later. Waiting another day may lead to the dog being toxic as there is a lot of pus and bacteria inside the swollen uterus of pyometra."
Dr Daniel had palpated the Jack Russell yesterday, Sunday. She had a painful abdomen and had been on heat 2-3 weeks ago. She could pee normally. Today, her rectal temperature was 37.6 deg C. "It is more important that she be operated to remove her swollen womb today," I advised. "If the womb ruptures overnight, she will be dead tomorrow. The X-rays showed the swollen uterine bodies. There is no need to wait for the complete blood test results."
I put the dog on the table and palpated a large swollen mass in the mid-abdomen. The dog did not cry in pain but was uncomfortable. "It felt like a big swollen bladder or stomach," I said. "But it could be the swollen uterus."
"The dog can pee with no problem," my assistant Nia said. "No blood in the urine."
So, it would likely be closed pyometra rather than a gastric dilatation (stomach swollen with gas). Dr Daniel decided to operate.
I could see a large distended uterus stretching from the lower chest to the pelvic area. This was unusually long and large in a small-bodied Jack Russell X. "Make a longer incision forward to the sternum," I could see that Dr Daniel could not fish it out.
"It is a swollen stomach," Dr Daniel said after fishing out the hemispheric swollen organ. Certainly it has the structure of a stomach full of gas or fluid with a greater curvature seen initially. As Dr Daniel extricated more of the organ, there were the continuation to the left uterine body which had 10 times smaller lumps. So this was closed pyometra confirmed.
This was an abnormal presentation as usually all uterine bodies would be filled with pus and be of similar sizes. Here, there was only one gigantic swelling of part of the left uterine body, as if both ends of the lobules were cut off, resulting in one portion grossly distended. I took a video and some images of the challenges diseases present to sharpen the diagnostic skills of the veterinary surgeon.
"Use the triple forceps method," I advised Dr Daniel. Each vet has his or her own method. "No need to ligate the omental fat separated from the uterine side but just clamp and cut. Surgery has to be quick in case the dog dies. For the uterus, ligate two parts so that if one ligature slips, there is another one."
The dog was recovering when the mother and her two adult children came to visit at 7 pm. She looked dazed. "Why is her tongue sticking out? Will it be permanent?" the daughter asked me as Dr Daniel was busy clipping the long claws of a recumbent 18-year-old cat brought in by an adult son and his mother. It was his mother's cat.
"The tongue sticking out is due to anaesthesia," I said. "The tongue will be in when the dog is awake."
The dog's eyes were open wider as the owners stayed for another 20 minutes. But she could not stand. An Antisedan injection would reverse the Domitor given earlier and waken up the dog. But as each vet has his or her own ideas, I did not insist.
The dog would likely recover after the operation on Judgement Day. If there was a delay, she might be dead. Evidence-based medicine is important in the diagnosis of closed pyometra as owners want to know for sure. In the old days, I would have got a history of the dog being on heat, passing out "blood with mucus", palpated a painful abdomen and advised spaying. This would save the dog's life and the owners some medical expenses. But nowadays, evidence-based medicine is important as owners are most sophisticated and likely to sue.
BLOOD TEST RESULTS Jun 24, 2013 on admission
Total white cell count and neutrophil - normal
Total WCC 10.6 (6-17). N 69.8 Absolute 7.4-R
Monocytes 18.6 --- high
Haemoglobin 11.8 (12-18).
Platelets 135 (200-500) --- toxaemia is present.
Urea 7.2 (4.2 - 6.3)
Creatinine 59 (89-177)
X-RAYS
A swollen uterine body may be seen.
UPDATE Junw 25, 2013 9.30 am
Dog is OK, tongue colour much pinker. Not eating the A/D. Wound is OK.
Monday, June 24, 2013
1473. Sunday Jun 23, 2013's interesting cases
RECURRING URTI IN A 15-YEAR-OLD CAT
I rehearsed with my assistant Nia and intern Terrence on videoing this case. Hands-on practice makes them more engaged and interested in the patient, rather than the patient being just a patient number.
"Practice by putting the paper towel roll on the receptionist counter and use the camera to focus on it. Then walk around it, making sure no obstacles." I said to Terrence, now sunburnt brown from National Service full time, thin and crew cut hair, black framed spectacles. "Nia will bring the cat out on the counter. You have only a few seconds to video the runny nose and the cat will scratch and struggle."
We rehearsed. When Nia went to pick the cat from the crate, she hissed and so there was no filming. Instead, Terrence practised filming the cat in the crate.
Earlier the owners came complaining about the cat not eating again after being cured one month earlier. "Did she really eat?"I asked as this cat is very old and had runny nose at that time. Dr Daniel sedated her and took blood sample for analysis. The total white cell count and high neutrophils showed a bacterial infection. Use of evidence-based medicine is important for a proper diagnosis, rather than just giving antibiotic injection for this old cat, assuming a bacterial infection, as is normally done.
"Yes, she ate a lot and was OK for some weeks."
What causes this URTI to recur?
"Could it be the haze?" the owners asked.
"Yes, it is possible. The last 2 days had the city shrouded in smoke such that the outline of buildings could not be seen. The Pollutant Standards Index, an indicator of air quality, was over 400. A figure over 200 is considered hazardous. The cat did not go out but windows of the flat were opened and she did go to the balcony. So she breathed in the smoke particles and is now sneezing.
When Terrence videoed, he did not see the runny nose. "I had given injection when the cat came in." I said. "Nia was able to scruff the cat when he took out of the carrier and I injected her. However, you can video the cat's tongue licking the nose. This is like people using tissue to wipe the nose. So, the cat does have runny nose and your video should capture the evidence!"
I rehearsed with my assistant Nia and intern Terrence on videoing this case. Hands-on practice makes them more engaged and interested in the patient, rather than the patient being just a patient number.
"Practice by putting the paper towel roll on the receptionist counter and use the camera to focus on it. Then walk around it, making sure no obstacles." I said to Terrence, now sunburnt brown from National Service full time, thin and crew cut hair, black framed spectacles. "Nia will bring the cat out on the counter. You have only a few seconds to video the runny nose and the cat will scratch and struggle."
We rehearsed. When Nia went to pick the cat from the crate, she hissed and so there was no filming. Instead, Terrence practised filming the cat in the crate.
Earlier the owners came complaining about the cat not eating again after being cured one month earlier. "Did she really eat?"I asked as this cat is very old and had runny nose at that time. Dr Daniel sedated her and took blood sample for analysis. The total white cell count and high neutrophils showed a bacterial infection. Use of evidence-based medicine is important for a proper diagnosis, rather than just giving antibiotic injection for this old cat, assuming a bacterial infection, as is normally done.
"Yes, she ate a lot and was OK for some weeks."
What causes this URTI to recur?
"Could it be the haze?" the owners asked.
"Yes, it is possible. The last 2 days had the city shrouded in smoke such that the outline of buildings could not be seen. The Pollutant Standards Index, an indicator of air quality, was over 400. A figure over 200 is considered hazardous. The cat did not go out but windows of the flat were opened and she did go to the balcony. So she breathed in the smoke particles and is now sneezing.
When Terrence videoed, he did not see the runny nose. "I had given injection when the cat came in." I said. "Nia was able to scruff the cat when he took out of the carrier and I injected her. However, you can video the cat's tongue licking the nose. This is like people using tissue to wipe the nose. So, the cat does have runny nose and your video should capture the evidence!"
1472. UPDATE: Red-eared slider with loose skin folds
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