3041. A 20-year-old female red-eared slider is lethargic, not eating, not moving for over 10 days

Red eared slider, F, 20 yrs

egg binding

Egg binding is most probable cause of lethargy and not eating for over 10 days.
Owner took home and provided a sand box for egg laying for the next 6 days, but no eggs were laid.
The slider usually laid eggs in batches of 3 in the water in a tank shared with a male slider, during the past years, but this year, she had not laid any eggs.

X rays show around 13 eggs.
The vet advised oxytocin injections for the next few days but the owner wanted the slider home.
Feeding orally the Critical Care from Ox bow 6 times a day. "She was able to walk a while, after
eating, but soon became lethargic," the lady owner told me yesterday, Mar 7, 2017.

I advised warm water and putting her back to the tank in which she used to lay eggs in the water durng the previous years.

As at March 8, 2017, the slider had not laid any eggs in the sand box. So

3040. A 3-year-old cat is diabetic

The complaint was a big lump in the hind leg of this 3-year-old cat that was limping. Blood test showed high blood glucose. Urine test showed glucose. The lump would be due to hind limb neuropathy which is a symptom in diabetes mellitus in cat.

On further questioning, the owner said that the cat was always looking for food, drank and peed a lot.

After insulin injections, the cat's lump disappeared and she was no longer ravenous, thirsty or urinating a lot.

  

3039. A 9-year-old Westie fell and broke his right hind leg - tibia and fibula. Skin disease

Feb 26, 2017

Chronic skin disease
Old dog with poor immune status
Under new drug for skin disease for the past 2 weeks

Seen by Vet 1 on Feb 26, 2017
X-rays  Spiral fracture of tibia and fracture of fibula - Right hind.

Seen by Toa Payoh Vets on Feb 28, 2017.
Proximal tibial fracture from fall
Closed fracture

TIBIAL SHAFT FRACTURES
Haematoma
Blood supply to diaphysis.

Open fractures are surgical emergencies.
Debridement of necrotic tissues and irrigation to remove bacteria and prophylactic IV antibiotics to be done within 6 hours of open fractures to decrease infection rates.


1.  Cast treatment is non-operative method. Most closed tibial fractures can be treated without surgery with good results. Wait 3 days to let swelling go down. 6 weeks. X-rays.  Non-displaced fractured tibial shaft ideal.

2.  Surgery.  Open reduction and internal fixation (ORIF) e.g. intramedullary nailing, external fixation, plating
and in some cases, amputation.
3. Intramedullary rod therapy.

Cast treatment has fewer infections than ORIF
ORIF has a higher union rate as there is more fracture stability.

Fracture stability and infection risk must be considered..

Surgical fixation is required when fractures are unstable.
Cast treatment isbest in a young patient with a non-displaced fracture.


OPEN FRACTURES
Outcome
No union
Mal union

Intramedullary nailing is generally used to treat many types of tibial shaft fractures.
Infections


IN THIS CASE
This Westie has chronic dermatitis for many years with no resolution when given steroids and coconut oil. However, in the last 2 weeks, he was given Oclacitinib (Apoquel by Zoetis) 16 mg divided into 4 parts. For the first 2 weeks, he took 1/4 tablet twice a day. He will be taking 1/4 tablet once per week for the next 2 weeks.

The owner was happy that the Westie responded very well with no itchy scratching just within the 2 weeks of Oclaitinib.

Oclacitinib, an immune suppressant drug is used for the control of pruritus associated with allergic dermatitis. The healing of the fractured tibial shaft fractures will be adversely affected if this drug is to be used  as it suppresses the immune system.

Owner warned that open reduction will result in bacteria from skin infections getting into the fractured bones resulting in osteomyelitis, pain and possible loss of leg via amputation. Also the
 high financial costs and worries if infections occur after open reduction using intramedullary nailing surgery.

The dog is old and his immune system is poorer than a young one. He had been on Oclacitinib for the past 2 weeks and this further depress his immune system.

Cast treatment is advised as the proximal tibial shaft fractures are minimally displaced and look stable on X-rays. Wait another 2 days for the swelling to go down. Antibiotics are given. No more Oclacitinib for the next 6 weeks when on cast. The dog may feel itchy and scratch again, including the right hind leg skin!    


UPDATE ON JAN 22, 2019
The Westie came in as he had a gigantic lick wound above his right elbow. Pus and raw flesh and fat were seen. Blood test showed high total white cell count indicating bacteraemia. The dog is an inpatient for 7 days to get the infection under control and cleaning of the wound. He was clipped bald and given anti-inflammatory injection of pred. He need apoquel 3.6 mg two times per day for 14 days and then 1 time per day for another 28 days, together with antibiotics. Not possible to close the wound.

3038. A 12-year-old Miniature Schnauzer scratches and licks for the past 12 months

Feb 26, 2017

"I tried changing diets and shampoos for the past 1 year," the young man could not resolve the continuous scratching and itchiness of the old dog. "Bad body odour," he told Dr Daniel. The skin is full of pustules, rashes and ringworm-like lesions. Paws are licked red and limbs are pigmented from constant licking.

Generalised dermatitis with ringworm, bacteria and yeast are the main cause. Whether there is food allergy or not, is another possiblity. Neck alopecia and inflammation. Anal sac area hyperpigmented.
Otitis externa and anal sacculitis compounded the severity of the skin disease.

After clipping bald and around 10-16 days later, the owner came back for a review. He was relieved that the dog's skin had improved.

10-16 days after treatment

The owner is satisfied with the outcome. It will take at least 2 months to know whether the Schnauzer has fully recovered. Monthly reviews with the vet are important.

3037. A 5-year-old Guinea Pig has a golf-ball sized swelling (cyst).

Sat Feb 25, 2017

A young couple visited Vet 1 near their home. Vet 1 inserted a needle into the soft golf-ball sized swelling behind the left ear and above the left shoulder. Clear fluid was aspirated. "It is a salivary cyst," Vet 1 said.

The swelling did not disappear. The couple surfed the internet and came to Toa Payoh Vets. "We saw a Youtube of a guinea pig with a swelling done by Toa Payoh Vets," the gentleman said.

"This looks more like an ordinary cyst rather than a salivary cyst," I noted that the location of this large swelling is distant from the sublingual and submandibular salivary glands. "It is possible to be a salivary cyst but unlikely. Fluid need to be sent for laboratory examination to check for cells," I advised.

Dr Daniel operated. The cyst was large (see picture) but ruptured, spilling clear fluid.

 

3036. A 6-month-old stunted red-eared slider has 2 ear abscesses - self treatment by owner.

Feb 23, 2017

A young couple went to Vet 1 to get the terrapin treated for ear abscesses. Vet 1 gave an "injection"
into the area between the neck and shoulders. The owners did not know what injection it was.
"Anyway, the abscesses still remain!", the lady said.

"There's a red bruise in the swollen left ear," I asked the lady whether she did it herself treatment.
"I pricked the swelling and a bit of pus came out," she said.
"The pus is cheesy in a terrapin's swollen ear," I said. "Pricking it will not rupture the abscess."

Under some gas anaesthesia, I had the swollen ears lanced by a scalpel, used a curette to
excavate the thick pus thoroughly. There was bleeding. The wound was irrigated and drained.

"Why did he get ear infections?" the lady had 2 siblings. The smaller one is now twice the size of this patient.
"Most likely, this terrapin hides inside the water most of the time to avoid the big bully," I said. "So, bacteria get inside the ears over time."
"Yes, he does spend most time inside the water," the lady confirmed. "I change the water every day and sometimes more than once daily."

"The older big-sized sibling is OK eating as many pellets as given, more than 16 pellets per day.
"You need to house this one separately and give plenty of space to bask," I advised. "The terrapin will be in for 3 days to ensure no residual bacteria."

Ear abscesses are a common surgical condition in terrapins in Singapore.   

3035. What to do with a large liver cyst?

Feb 21, 2017

Routine blood test. Liver enzymes slightly elevated.
Ultrasound & MRI. One large liver cyst of around 12 cm across and smaller ones.

3 Gastro-enterologists in private practice.

SPECIALIST 1.
Liver cysts are common. Computer screen shows graphic of liver.
Liver cysts are mostly benign. 3 options.
1. No treatment.  MRI 6 months later to say whether enlarged.
2. Keyhole surgery for histopathology. Not advised as not 100% of cyst wall can be sampled.
    If benign, does not mean no malignancy.
3. Surgery.
3.1 Usual risk of anaesthesia, bleeding, infection. Also pneumonia as painful to breathe post-op, phelgm accumulates. Exercise before surgery. Breathing tools. Patient may regret surgery done if cyst is benign 100% and be able to accept this possibility.
3.2  Will not take out the smaller liver cyst
3.3 Needs 2 surgeons and an anaesthesist for liver surgery.
3.4 I should have sufficient liver tissues to lead a normal life. The liver "regenerates" by enlargement, not really growing new liver cells!

4. Cost $30,000 - $40,000.
5. Need more cancer marker tests and ECG.

SPECIALIST 2.
1. Classmate of Dr Chua Seng Chew, my GP who referred me to him. He does not perform surgery. 
2. Reviewed ultrasound and MRI. 
3. Reviewed colonscopy and gastro-duodenal scopy done by Dr Eu Kong Weng. Advised
stools pre-scope to flush out residual stools affecting scope. 2-yearly scope will do. 
4. Physical exam of right upper abdomen. No pain. Took weight.
5. Refers to Specialist 3 who is a surgeon for another opinion.

SPECIALIST 3.
1. Specialist 3 who is a surgeon.
2. Only 2% of liver cysts become cancerous as most are benign.
The largest liver cyst he operated had filled up the rib cage and causing breathing distress in a patient.   
3. Inserted ultrasound CD into computer and and showed me the "echogenic" materials floating inside the
large cyst. This material and walled cyst could develop into cancerous cells. I was surprised as he had seen the MRI. "Ultrasound provides more information than MRI," he explained patiently.
4. Not Echinococcal cyst as there will be many daughter cysts. As a vet, I might have been exposed
to Echinococcal parasites.  
5. Surgery takes 2-3 hours.
6. Usual risk of anaesthesia, bleeding, infection. Also bile leakage despite closing all major bile ducts during surgery. Need to insert a "drain." I did not ask how this drain will resolve bile leakage. Enquired whether I had hepatitis vaccination or hepatitis in addition to health issues.
7. Will take out the other liver cyst too although I did not ask him.
8. Cost $30,000 - $40,000

CONCLUSION
I requested a routine blood test to screen my cholesterol levels and end up with discovery of
liver cysts from increased liver enzymes. What is the next step?