2911. Strangulated uterine horns inside an inguinal hernia of 4 years in a MIniature Schnauzer

Jan 10, 2016

Miniature Schnauzer, Female, 7 years, not spayed

The owner had shifted to North East Singapore where there are many veterinary clinics. So I was surprised to see the dog with this gigantic mango-sized swelling.

"Around 4 years ago, the swelling was soft, but in the last 14 days, it became hard. There is a wound on it as my dog licked it," the mother said.

"Did the swelling go inside the body or become smaller?" I asked.
"We never observe it and so do not know," the mother and young adult daughter with the tattooed hands said.

Based on the medical history and location, I diagnosed an inguinal hernia. I prescribed antibiotics for 10 days before operation as the dog was still active and eating.

The owners took to another vet for a second opinion on Jan 4, 2016. The vet confirmed inguinal hernia with pyometra and bladder stone from the X-rays and ultrasound scan.   

So, today, Sunday, Jan 10, 2016, the owners were free to get the operation done. The dog was still standing.
"She was eating after the course of antibiotics," the mother reported happily.

Surgery.
Strangulated 90% of the swollen, reddish-brown uterine horns surprised me. The dog was still alive. The strangulation had occurred less than 4 days ago and the good antibiotics had eliminated the bacteria inside the uterus. A strong smell of rotting flesh pervaded the op room on opening up the herniated sac.

CONCLUSION
I have not seen strangulated swollen uterine horns in a dog that is still alive and standing. The other vet told the owner that the Miniature Schnauzer was one hardy dog. And he is. 

2910. INTERN CLARA. CASE 1. A 14-year-old cat pees frequently outside the litter box. CASE 2. A 7-year-old cat has kidney failure

Jan 7, 2016

A rough script is written below. The intern has to edit,  integrate and present a compelling narrative with text and images first. Then the video to further enhance the veterinary education.


CASE 1

HOOK

(Video of consultation)

BKTP




In Singapore, most cats live in high rise apartments (3 images below) as around 80% of the population is resident in apartments. The cats have been adopted and are much loved as family members. 

INTRODUCTION
 
A 14-year-old female cat would not pee inside the litter box. She would pee drops of bloody urine outside the litter box. This was the first time this cat had pollakiuria and haematuria and the lady owner quickly brought her to Toa Payoh Vets for examination.

"Do you have another other cat in the apartment?" I asked as the cat could be stressed by other cats, leading to the urinary tract condition known as FUS (Feline Urological Syndrome) or FLUTD (Feline Lower Urinary Tract Disease).

"I have only one cat," she said.

I examined the cat (video).
The cat's nose and gums were pinker than normal indicating dehydration. I palpated her kidneys and bladder. She did not show pain. A few drops of blood-tinged urine scattered onto the examination table.

"I can feel a hard bladder the size of a fish-ball or 50% the size of a golfball," I told the lady who probably do not play golf.. "It can be either a bladder stone or tumour. An X-ray is needed to confirm the stones."

PRACTISE EVIDENCE-BASED MEDICINE
There are several laboratory tests needed to gather the evidence to confirm the tentative diagnosis of urolithiasis and to differentiate it from bladder tumours which are rare in cats in Singapore.

1.  The X-rays showed an empty bladder packed with small stones. The bladder walls are thickened.  The kidneys have a few small stones.

Such an old cat. High anaesthetic risk. Not to operate will mean kidney failure later.

2. Ultrasound to check out the abdomen and bladder. I did not advise this to lower medical cost. 

3.  Blood test - Abnormal findings were low platelets, slightly high blood urea and creatinine indicating acute renal failure.

I advised operation the next day before the cat gets acute kidney failure. She was not eating much but had not vomited yet.

I gave the cat a subcutaneous drip, antibiotics and painkillers on the day of consultation.

4. Urine test. There were a few drops of urine available. The crystals appeared to be urate.

5. Stone analysis.  The stones removed from the surgery have been analysed for its chemical composition.  Positive for magnesium, phosphate, calcium and oxalate. But not for ammonia.
Most likely calcium oxalate stones.  

VIDEO. blood collection and X-ray

RISKY ANAESTHESIA
A very old sick cat. High risk of anaesthetic death. The owner was informed of the risks. She consented and the cat came in the next day for  cystotomy by Dr Daniel.





He needed time to clear the bladder of small smooth brown stones. The surgery took around 50 minutes.

CONCLUSION
The lady owner consulted the vet promptly when her old cat had abnormal urination. Surgery to remove the bladder stones was done early. The cat survived the anaesthesia and surgery and is at home recuperating.  Everyone is very happy especially the lady owner.

Early detection and surgery save lives. If there was a delay, the old cat would have got kidney failure and a successful outcome of surgery would not be possible.

Follow up on Jan 16, 206
Cat likes to eat wet food nowadays. No more peeing outside the litter box like before the operation. This is what concerned the lady owner. Drinks normally. Stools normal. Overall normal.

In the past 5 years, ate commercial food -  Science Canned Diet Mature Indoor Cat  7 years and above canned food
Royal Canine dry for older cat 7 years and above indoor cat.

5 years ago, went to Toa Payoh Vets for constipation. Fussy cat. Does not eat other types of food.
Now feeding old canned Royal Canine and dry Royal Canine S/O.

------------------------------------------------------------------------------------------

 CASE 2
A vomiting cat that cried when I palpated the kidney area. 
X rays show kidney stones. Blood test showed kidney failure (high urea and creatinine).
I advised home dialysis for 7 days, SC drips of 200 ml per day, after having done one in the surgery.

The owner did not believe my diagnosis and went to another vet who made the same diagnosis.

The cat went to ICU of the other vet and passed away 3 days later.

2909. A dog passes fishy urine for the 3rd time after medication given by 2 vets

Jan 7, 2016

"I did not go back to Vet 1 because my dog passed fishy urine before the completion of the medication as compared to Dr Daniel's" the lady said to me today when I followed up on her dog, a 7-year-old female, not spayed Maltipoo treated by me 7 days ago.

I was Vet 3 and since the dog was having medication, she could not comment on my failure or success after consultation dated Dec 31, 2015 (video).

"At least Dr Daniel (who was Vet 2) had medication which stopped the fishy urine smell during the course of treatment," the lady laughed.  Dr Daniel had done a urine test on Dec 8 and had recommended Urinary S/O to acidify the urinary pH which was 9. Blood was 3+.  However  the owner claimed that she was not told not to feed the dog with other kinds of food.

So, the urinary S/O still gave a urine pH of 9.0, nitrite +, protein 2+, blood 4+, bacteria +. There were amorphous  phosphate+ and triple phosphate + on the urine sample tested on Dec 31, 2015.

This time, I needed an X-ray done as the dog had a very painful anterior abdomen. She had dysuria, haematuria, vulval swelling but no vomiting. Fishy urine again.

X-rays show a ureter stone. That accounted for the acute painful cries when I palpated the anterior abdomen. After pain-killers, the dog was OK and as Jan 7, 2016, he was not passing any fishy urine. I advised feeding S/D for 1-3 months to be followed by dry C/D to acidify the urine.  As for urinary S/O fed on the recommendation of Dr Daniel, the owner claimed that he was not told to feed solely the S/O and had fed various other food. Hence the urinary pH was still 9 when I tested the urine on Dec 31, 2015.

Time will tell whether the dog will be passing fishy urine after this consultation. Now he is still on medication. 







 

2908. INTERN - ENUCLEATION

HOOK





BKTP image

MEDICAL HISTORY

Right eye ulcerated. Vet 1 prescribed eye drops and reviewed for 2 times.
2 images from the owner

2015 case
TREATMENT BY VET 3
Conjunctival flap

NARRATE THE 2 IMAGES OF MEDICAL HISTORY

WHATSAPP IMAGES TO DR SING K Y ON DEC 29, 2015
for advice and query on how much it costs to get an artificial eye ball.  The owner had paid for Conjuctival flap surgery by Vet 3.     

The owner has to decide
on enucleation (removal of eyeball). An artificial eyeball add to medical and surgical cost.

CONCLUSION

No vet can guarantee successful eye surgeries as there are many factors involved, including post-op care by the owner. Some owners want the dog back home on the same day of surgery
but do not know how to nurse the patient. In many of such cases, the surgical outcome can be poor.

In this pug, the owner considered that the surgery had a poor outcome.
The eyeball had popped out and become bigger.  This is one side of the story. The other side from the vet has not been asked
  .
An image of a successful conjunctival flap surgery





FOR MORE INFORMATION

--------------------------------------------------------------

EARLY TREATMENT OF ONE PUG WITH DEEP CORNEAL ULCER IN 2011

Medical history

Some vets advised enucleation (removal of the eyeball) as in the 2015 case above

Illustration of my surgery - 3rd eyelid flap and tarsorrhaphy on Mar 24, 2011
This surgery had been performed in a 14-year-old Silkie Terrier in 2015. The video is at toapayohvets.com.videos.htm

The pug's eyelids are sewn up after the 3rd eyelid flap surgery. In-patient for 3 days.
Eye ointment is given daily via the gap in the medial canthus

14 days - stitch removal. Scar bridges over the ulcer

42 days after eye surgery

42 days after 3rd eyelid flap. The ulcer is healing slowly as it is deep and extensive. On the 42nd day, the owner came for a review as the dog's eyes were reddish. However, the vertical ulcer has healed but not fully while the 6-8 o'clock corneal ulcer has changed to a white spot.
 
No more visits from the owner as the pug's eye injury has healed.

2907. PAINTINGS FOR SALE

Contact:
David Sing   +65 9668-6468, 99pups@gmail.com

2906. INTERN. Saving the eye of a 14-year-old Silkie - 3rd eyelid flap and tarsorrhaphy

Jan 5, 2016 (10th day of surgery)

Dogs suffer from injuries to the eye. In this dog, he had a deep corneal ulcer (deep ulcerative keratitis).

All vets have their own techniques and ways to treat deep ulcerative keratitis in the dog. In this case, the vet advised total removal of the eyeball (enucleation) as the dog had been suffering for around one month of eye injury and pain.  The owners sought me for a second opinion and to perform the enucleation.  I advised a 3rd eyelid flap and tarsorrhaphy to save the dog's eye. As eye injuries are emergencies, this operation will have been most successful if performed within 24 hours.

But the corneal ulcer was deep and had extended for the past month.

Day 1. The dog was present as in this image. I gave the dog an injection of antibiotics and anti-inflammatory.

Day 2. The dog's eye before surgery (3rd eyelid flap and tarsorrhaphy). You can see much inflammation of blood vessels radiating into and surrounding the corneal ulcer.

Video of surgery

https://www.youtube.com/edit?o=U&video_id=NVXJzauUUNQ


Day 14.  The eyelid stitches are taken out.

The dog is at home after 10 days of in-patient. The son wanted the dog home on the 3rd day but finally decided not to as the stitches will breakdown due to rubbing. The dog will be rubbing his eye against the bed and table legs when at home moving around. In the surgery, the dog's eye is checked twice a day, eye drops are applied, antibiotics and painkillers Rimadyl tablets are given for 4 days.

Unless the owner is skilful in nursing, an excellent outcome can only be achieved by in-patient treatment for 10-14 days. 

2905. INTERN. Can you be a millionaire breeder vet? KPI for C-sections

Videos:

Breeder's Caesarean Sections done in late 2015 and early 2016


1.  C-section Dr Sing Kong Yuen.  Corgi survived. 7 pups not moving on delivery. Very thin Corgi.  Milk. Breeder fosters 2 pups to a poodle and other pups to maltese . 

Follow up one month later. All 7 pups thriving.



2. C-section byDr Daniel Sing.
Toa Payoh Vets. Anorexic very thin Corgi and 5 pups. No milk. Pups died by 5th day, fostered out. 


3.  Breeder complained of a C-section by another vet clinic. 8 pups died. Breeder lost $40,000. Said they were alive before C-section.  Breeder alleged that the young vet was inexperienced and he was not permitted to see the surgery. He suspected IV sedation leading to death of all 8 pups, an image of which he showed in his smartphone. Old vets can do it, but young vets cause death of pups. One side of story as the other vet's side was unknown.

4.  C-section by Dr Daniel Sing.
Dam died after surgery. Breeder was not happy as usual.  3 Corgis puppies were fostered out. OK at 6 weeks seen.

Conclusion
C-sections for breeders cannot be a 100% guaranteed successful outcome as much depends on the breeder's judgment to opt for timely C-Sections. Younger vets do get the blame when the outcome is not to the breeder's expectations and perception of experience.  Very few vets in Singapore have access to professional dog breeders who get $500 C-sections from certain vets, a very cheap rate which may include X-rays too.

2904. A 7-year-old Miniature Schnauzer has an "orange" lump

Jan 3, 2015

"My dog can't sit down on hard floors," the young lady with tattooed arms and her mother said. "She pees here and there by not going to the toilet."

"Can she poop normally?" I asked.
"She poops little amount and she eat less now," the mother said. "The lump used to be soft but is now hard as an orange!".

"This looks very much like an inguinal hernia or a breast tumour at Left Mammary Gland 5," I fel the lump. "There is no pain and no spreading of any breast tumours to other breasts."

"The lump used to be soft and yielding," the mum said. "So we did not bother to see the vet."
"Did you push the lump into the body last time when it was small?" I asked.
"We don't do this," mum said. "A vet told us my dog has pyometra."
"It is difficult to diagnose without seeing the dog. She may have pyometra. When was her last heat?"

"Last week," mum said. "That is why she has this brownish vaginal discharge."  I checked but found no discharge.

"Can you ensure that the dog will survive surgery?" mum asked.
"Not possible," I replied.

3 - 7 days later, after medication, I will operate. The dog is in good bodily condition but has bad breath.   
 

2903. A 7-year-old female cat has kidney stones in 2 kidneys. Why?

Jan 2, 2016

The gentleman wanted to vaccinate this 7-year-old female spayed cat.
"She had no appetite for some time," he said.
"We must find out what's wrong as vaccination of sick cats is not recommended."

I palpated the anterior abdomen behind the rib cage.The cat reacted and arched her back.
"Most likely kidney disease," I said. "Blood tests and X-rays needed. A urine test is needed but she has no urine now."

What is the solution?

Dialysis and K/d diet first 2 weeks. Need to review whether the kidneys can still function.

2902. INTERN. PREVENTION OF DISEASES IN GUINEA PIGS IN SINGAPORE

HOOK - I leave it to the interns

Around 80% of Singaporeans live in high rise buildings (goto youtube, search apartments + toa payoh vets etc ) of  HDB or condos

Their pets are mainly dogs and cats. Very few Singaporeans keep guinea pigs as pets and have little experience of how to care for them. There are very few groomers of guinea pigs unlike those specialising in dog and cats and many times, guinea pigs fall ill, owing to lack of grooming, poor diet quality and unhygienic conditions in housing.  


 CASE STUDIES.   FOUR SICK GUINEA PIGS
Images will be in toapayohvets.com. You need to look for them or equivalent. 

Case 1.  Video 1180.
Jan 1, 2016

G.P. F. 1 yr 3 months. No fever. Head tilted stiffly to the left of the neck this morning. She could not turn her head to the right. In Aug 15, 2015, she had a left head tilt but recovered after my treatment. The owner had not cleaned the ears thoroughly and regularly as the guinea pig dislikes ear cleaning.

ADVICES:
Put the guinea pig on the table. An assistant restrains the guinea pig. The owner puts in the veterinary ear drops and massage the vertical canals.

Case 2.  Video 1203.
Jan 1, 2016
G.P. M. 5 yrs.  Lethargic and fever. Very thin. "Chipping sounds" heard by the owner.
Overgrown lower front teeth. Black scales and hair loss. Dirty ears and body. Pus in the right nostril. Upper respiratory tract infection. Clipping bald and bathing. Ear cleaning.

Video: 1203
After clipping, the guinea pig will go home on Jan 4, 2016. His owner needs to groom him and feed him medication.

ADVICES: Regular grooming, medication, good food and Vitamin C. Review in 2 weeks' time.

Case 3. Video 1181.
Jan 2, 2016
G.P. F. 5 yrs.  No fever.  Anorexia 2 days. Had green watery diarrhea 4 days ago.  Palpation. Abdominal pain. Gastroenteritis due to a change of pellet brand around 4 days ago. A new diet upsets the gastrointestinal bacterial population.

ADVICES: No sudden change of diet. Revert to the old brand. Medication.


Case 4. Video 1182.
Jan 2, 2016
G.P. F. 1 yr.  No fever.  Anorexia 1 day. Cough, eye discharge. Harsh lung sounds.                      Bronchitis and gastroenteritis.

ADVICES: Medication and regular grooming. Review in 2 weeks.



CONCLUSION
Daily inspection and grooming of the guinea pig prevents diseases



Use another image, not the one below.  Check out  latest image.