Thursday, September 10, 2020

3146. A 14-year-old female Labrador Retriever passes blood with urine for over one year. Hepatitis. Chronic haematuria

    SCRIPT








 


Dogs are considered senior when they are as follows:
Small and Medium-sized breeds: Over 7 years
Large and Giant-sized breeds: Over 5 years.

 

AN OLD FEMALE LABRADOR RETRIEVER PEES BLOOD IN THE URINE MANY TIMES 


Hematuria is the presence of red blood cells in the urine. 
 

DIAGNOSIS
History and physical examination. 
Signs of dysuria (difficulty in urination) and/or pollakiuria (abnormally frequent urination) point to a lower urinary tract location

Use laboratory aids to diagnosis. Blood and urine tests. X-rays and ultrasound, IVP, CT scan and MRI.
Voided urine is usually sent for testing. Ideally, urine is collected by cystocentesis (from the bladder directly). 


  • Urinalysis is the examination of urine for various cells and chemicals. Red blood cells are found in haematuri. White blood cells a urinary tract infection. Casts, which are groups of cells molded together in the shape of the kidneys' tiny filtering tubes signal kidney disease. Excessive protein in the urine also signals kidney disease.
  • Blood tests may reveal kidney disease if the blood contains high levels of urea and creatinine. 
  • Kidney imaging studies include ultrasound, computerized tomography (CT) scan, or intravenous pyelogram (IVP). An IVP is an x ray of the urinary tract. Imaging studies may reveal a tumor, a kidney or bladder stone, an enlarged prostate (in the male dog, or other blockage to the normal flow of urine.
  • cystoscope can be used to take pictures of the inside of the bladder. It has a tiny camera at the end of a thin tube, which is inserted through the urethra. A cystoscope may provide a better view of a tumor or bladder stone than can be seen in an IVP.


DIFFERENTIAL DIAGNOSIS

1. Infections 
    Upper Urinary Tract Infections .  
     Lower Urinary Tract Infections  
    Uterine/vaginal disease e.g. pyometra in unspayed female dogs. 

2. Urolithiasis. Urinary stones in the kidneys, ureter, urethra and bladder. Bladder stones is most common. 
3. Neoplasia - Tumours or cancer of the kidneys, bladder or uterus

4. Others 
4.1 Trauma e.g. hit by a vehicle or fall into the drain. 
4.2  Coagulopathy. The blood has clotting problems/.
4.3  Hereditary in some breeds.
4.4  Drugs
4.5  Oestrus in old dogs
4.6  Idiopathic renal haematuria - cause is unknown. 
4.7 Renal disease such as Renal telangiectasia.  

Some dogs, including Welsh corgis, have a genetic predisposition to this spontaneous widening of blood vessels in the kidney, which can lead to blood in their urine.

TREATMENT depends on the cause.  Infections. Antibiotics.



PREVENTION

1.  As large breeds usually pee outdoors, the owner must be vigilant to monitor by checking whether her urine has blood. Early detection and treatment enables your dog to live to a ripe old age.

2. Yearly urine and blood test for your senior dog.

3 Prevention of urinary stone formation by feeding certain food to optimise the urine pH.  or example, struvite bladder stones develop when the urine is alkaline. A therapeutic diet from Hills or Royal Canin acidifies the urine to prevent such stones being developed. 


Taking your dog for regular veterinary checkups is the best way to prevent blood in their urine and other urinary problems. Your vet can tell you if your dog is predisposed to urinary issues. If they are, the vet can routinely test your dog's urine to make sure they're in tip-top health.







  
















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AN OLD FEMALE LABRADOR RETRIEVER PASSES BLOOD IN THE URINE AGAIN.
Dr Sing Kong Yuen, BVMS (Glasgow)

On this Thursday 10 Sep 2020, the owner of a 14 year-old female Labrador Retriever came to Toa Payoh Vets to buy Zentonil and was surprised to see me. Her dog was inside her car.




“What do you buy Zentonil today? I asked. “It is for my dog’s liver disease!”

4 days ago, on 6 Sep 2020, the owner consulted Dr Daniel Sing as her  the 14-year-old Labrador Retriever was not eating and losing weight. The dog has multiple subcutaneous "fatty" lumps over the past 3 years or  more and another vet advised to leave them alone. The dog pees blood in the urine, but recovered when the other vet prescribed antibiotics for 3 occasions.  Dr Daniel had a blood and urine test done.


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Shyan to create a table of the blood and urien  test results and show me first.

BLOOD TEST on 6 Sep 2020

1. Liver disorders.
SGPT/ ALT   788 U/L  (less than 59)
SGOT/ AST   259 U/L  (less than 81)

2.  Bacteraemia.
Total white cell count in the blood was  29.0 x 10*9/L. The normal reference range is (6-17)
Neutrophils  96.1%   (60-70%)    Absolute  27.9 x 10*9/L (3-11.5)

3.  No kidney disease. Urea and creatinine within normal units. 

URINE TEST on 6 Sep 2020
pH = 7 (5-8)
SG  1.020  (1.005-1.030)

Protein 4+ (Negative)
Ketones 2+ (Negative)
Blood  4+ (Negative)

White blood cells over 900 (/uL)
Red blood cells over 1800 (/uL)
Bacteria +
No casts or crystals.

DIAGNOSIS

1. Hepatitis
2. Urinary tract infection

Bacteraemia. No vomiting or polydipsia and polyuria.
Fever due to bacteraemia. Infections could be from the liver and urinary tract infections.



ADVICES
 
1. Chronic haematuria. Blood in the urine stopped when the vet prescribed antibiotics. This happened on 3 occasions.  What to do?

My advice will be to check for urinary tract infections due to urinary stones or neoplasia. 

“Did the other vet do an X-ray for urinary stones?” I asked. “No,” she replied. The dog was 14 years old and old age could lead to urinary neoplasia or urinary incontinence and infections. 

“My dog has many large lumps in her body,” the owner said that the other vet consulted told her to leave the lumps alone unless they cause the dog to be unwell. No biopsy was recommended to check for cancer.

“The dog is inside my car,” the owner had parked her car some distance away. I walked with her to see the dog. The dog was active and slightly thin. She was OK as she was on antibiotics prescribed by Dr Daniel for 10 days.


I advised
1. Completion of the course of antibiotics. 

2.  A therapeutic diet (Hills L/D) to help the liver to recover.

I have not recommended a therapeutic diet to prevention urinary stone formation by feeding certain food to optimise the urine pH.  For example, struvite bladder stones develop when the urine is alkaline. A therapeutic diet from Hills or Royal Canin acidifies the urine to prevent such stones being developed. 


3. X-ray of the abdomen for liver tumours, urinary stones and neoplasia of the kidneys, bladder and urethra.

4. Spaying the dog may prevent a possible womb infection bacteria going into the bladder to infect the bladder. In my experience, spaying may help to prevent urinary tract infections in the old female dogs as they may have open pyometra.  

5. Multiple large subcutaneous tumours.
The owner did not want any treatment as advised by the other vet earlier. Are they lipomas?  Or mast cell tumours or others? A biopsy will be preferred. 

3. Old dogs need more regular check ups, at least once yearly if you want them to live to a ripe old age. 
 
VIDEO

























 

Monday, September 7, 2020

3146. STEFANIE. Leg amputation in dwarf hamsters AND TWO OTHER CASE STUDIES.

1.  Use movie structure
HOOK  --- VIEWER DISCRETION Surgical procedures ---BKTP IMAGE ---TITLE

TENSION

SATISFACTION

2. Do NOT reuse the same images for Credits as you have had used for other videos before. There are many to choose from.

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1. VIDEO 1. SURGERY - LEG AMPUTATION


DIAGNOSIS

Climb wire cages. Leg got stuck or fell down from a height. Fractured

right hind leg.

Red swollen area
Limping.
Not bearing weight on fractured right hind leg.

Footages -
Video 1/6. Consultation. Owner was not in favour of proposed leg amputation. Show some footage of conversation, if possible. 

Video 2/6.  1:36 - 2;44.  Owner decided after 5 days and brought hamster down
Right hind leg being licked till it is red.  Not bearing weight on RH. Falling down.


TREATMENT


Video 3/6.  1:40 - 2:10 approximately. Clipper used to remove hairs before operation. Edit out blurred footage.

Video 4/6.  1:27 - 1:37.   Show clipped RH

Video 5/6. Use whole clip, editing out blurred images if possible. Leave my narration intact unless repetitive.



Anaesthesia - 0.01 ml of Zoletil 50 IM (2 drops).  In this case, no isoflurane gas anaesthesia is needed as the surgery was completed within the Zoletil anaesthetic effects  SHOW BOTTLE OF ZOLETIL 100.


Surgery (show the whole video footage as narrated by me. Video 6/6)

1.  Scalpel blade used.

2. Amputate two times as follows:
At the initial fractured area
Nearer to the knee joint - higher up.

If one amputation at lower tibia, there will be a dangling stump as the hamster moves. This will irritate the hamster and cause trauma and infections. Second amputation nearer the knee joint ensures no dangling stump. Also, there will be sufficient exposure to ligate the muscles and big blood vessels to prevent bleeding to death. .

3.  Control of bleeding by suturing muscle stump.

Outcome - normal life although 3-legged. No more pain and irritation from broken exposed inflamed fractured area.

What if the owner does not want to amputate?
The swollen fractured area becomes infected as the hamster continue to lick it to relieve the pain.
Bacterial infection of the broken skin due to licking for several days.
Loss of appetite and death.

REFERENCE:
https://2010vets.blogspot.com/2014/06/1371-leg-amputation-in-dwarf-hamster.htmlAnother case of fracture in a hamster FINAL VIDEO: A SYRIAN HAMSTER FRACTURES HIS RIGHT HIND LEG https://www.youtube.com/watch?v=jrMOAmLT3mo&feature=emb_logo



Stefanie.  Many interns find difficulty in creating a hook although they can create excellent videos.
A good example of a well created hamster except that the intern did NOT use the movie structure. NO HOOK.

Priapism in a Syrian hamster
https://www.youtube.com/watch?v=7kWsOXVxF1o
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HOOK. A wired hamster cage is less expensive. But it is not safe. A hamster loves to climb up the wired frame. Falls and fractures its leg.  






1. VIDEO 1. SURGERY - LEG AMPUTATION


DIAGNOSIS
Climb wire cages. Leg got stuck or fell down from a height. Fractured
right hind leg.

Red swollen area
Limping.
Not bearing weight on fractured right hind leg.

Footages -
Video 1/6. Consultation. Owner was not in favour of proposed leg amputation. Show some footage of conversation, if possible.

Video 2/6.  1:36 - 2;44.  Owner decided after 5 days and brought hamster down
Right hind leg being licked till it is red.  Not bearing weight on RH. Falling down when trying to stand upright.







TREATMENT


Video 3/6.  1:40 - 2:10 approximately. Clipper used to remove hairs before operation. Edit out blurred footage.

Video 4/6.  1:27 - 1:37.   Show clipped RH

Video 5/6. Use whole clip, editing out blurred images if possible. Leave my narration intact unless repetitive.



Anaesthesia - 0.01 ml of Zoletil 50 IM (2 drops).  In this case, no isoflurane gas anaesthesia is needed as the surgery was completed within the Zoletil anaesthetic effects  SHOW BOTTLE OF ZOLETIL 100.


Surgery (show the whole video footage as narrated by me. Video 6/6)








1.  Scalpel blade used.

2. Amputate two times as follows:
At the initial fractured area
Nearer to the knee joint - higher up.

If one amputation at lower tibia, there will be a dangling stump as the hamster moves. This will irritate the hamster and cause trauma and infections. Second amputation nearer the knee joint ensures no dangling stump. Also, there will be sufficient exposure to ligate the muscles and big blood vessels to prevent bleeding to death. .

3.  Control of bleeding by suturing muscle stump.

Outcome - normal life although 3-legged. No more pain and irritation from broken exposed inflamed fractured area.

What if the owner does not want to amputate?
The swollen fractured area becomes infected as the hamster continue to lick it to relieve the pain.
Bacterial infection of the broken skin due to licking for several days.
Loss of appetite and death.

One example is seen here:


REFERENCE:

https://2010vets.blogspot.com/2014/06/1371-leg-amputation-in-dwarf-hamster.html



















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2. VIDEO 2 AND 3. 

2. Create two videos based on images in 2 case studies at:



3145. Tick Fever in dogs - case studies. Babesiosis tick fever in a Presa dog


TICK FEVER IN DOGS - CASES

1.  Babesiosis in a Presa in 2014

3144. A stray cat has an ocular dermoid



HOOK

Video footage - show relevant footages










LIMBAL-CORNEAL DERMOID  in a cat





An OCULAR DERMOID is a fatty growth with skin parts including hairs located in the eye area.

In this case, the ocular dermoid is located at the temporal limbus, within the sclera and corneal areas.

 It is classified as a 
LIMBAL-CORNEAL DERMOID 

Ocular dermoid - limbal-corneal. (Advised but surgery was not done. Surgical excision can be done using surgical blade No. 11).
https://www.youtube.com/watch?v=5hwuWx4T83I


The cat keeps rubbing his eye as the hairs rubs onto the cornea. The cornea becomes ulcerated and painful.  Tears flow down the sides of the eyes daily, leading ro tear staining and infections.  














SURGICAL TREATMENT - COMPLETE EXCISION





For the general practitioner, the use of
1. Superficial keratectomy using scalpel blade No. 11.



1.1. In this case, pull the globe ventrally using a 5/0 nylon stay suture. To do this, put a stay suture into the dorsal bulbar conjunctiva at around 2 o'clock above the medial canthus.   

1.2  Stab and cut away the dermoid carefully from the cornea.  

2.  Start cutting from the lateral aspect of the dermoid. Undermine the dorsal bulbar conjunctiva and excise the dermoid. For the cornea, excise to a third of the corneal stroma depth and 1 mm of normal corneal tissue circumferentially. Be careful of inadvertent corneal perforation. Anti-inflam not given, if kitten or puppy.

The corneal epithelium is excised (superficial keratectomy). Third eyelid flap covers the cornea. Antibiotic eye drops. Healthy replacement cells will grow. If done well, no corneal scarring. E-collar. 






THE 2ND AND 3RD TREATMENT OPTIONS ARE: 
2. Use electro-surgery. I used the circular loop to slice out the dermoid carefully. 



For the specialist.
3. Non-penetrating lamellar keratectomy using the operating microscope and micro-surgery.























RESEARCH NOTES



What is the normal range of corneal thickness in cats?
An average cornea is between 540 µm and 560 µm. A thick cornea is 565 µm or more, with a very thick cornea being greater than 600 µm

Lamellar keratoplasty is an operation in which diseased corneal tissue is removed and replaced by lamellar corneal tissue from a donor. The procedure is performed either to improve vision (optical keratoplasty) or to provide structural support for the cornea (tectonic keratoplasty).

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A healthy cornea is important for good vision. When there is scarring or corneal disease, it can cause one not to see well. Fortunately, there are advanced corneal surgeries such as Lamellar Keratectomy, DSAEK and DALK that are available at The Eye Associates.
There are several common conditions that affect the most superficial layer of corneal cells, the epithelium. These conditions include recurrent corneal erosion (RCE), band keratopathy, Salzmann’s nodular degeneration and epithelial basement membrane dystrophy (EBMD). These conditions can interfere with vision and even cause significant pain and gritty sensation, due to a rough and irregular ocular surface.
If ocular lubricants fail to improve the pain or vision, a procedure known as Lamellar Keratectomy or LK can be beneficial. After the eye is anesthetized with drops or ointment, Dr. Foster selectively removes the diseased epithelium. A soft contact lens is placed that minimizes discomfort after the procedure. This remains in place until it is removed by Dr. Foster. In a few days, a stronger, healthier cell layer will replace that which was removed. Some scratchiness and irritation is normal for a few days after the procedure until the surface has healed.


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REFERENCE:

Dorsally located corneal dermoid in a cat


Sunday, September 6, 2020

3143. The dog had adverse drug reactions - a rare photography positioning.


Aug 20, 2020. 

 
The young lady owner had consulted two vets about the tumour near the left eye. She chose Vet 1 for the surgery. The dog had a blood test done showing low white cell count and low lymphocytes. A PCR test for Babesia was positive. So, Vet 1 prescribed a 10-day course of anti-tick medication to be followed by a 6-week course of another drug.

The dog had vomiting and diarrhoea after 3 days of the 10-day course, but Vet 1 insisted on continuation of the medication and began to hospitalise it. 

Vet 1 suspected pancreatitis. The dog was exhausted and dehydrated and had breathing difficulty. The owner's father took the dog out from Vet 1's inpatient service. The father consulted me on Aug 20, 2020. The dog was given SC drips for at least 7 days and 3 injections of baytril. No oral medications.

 





 

 

 

Aug 27, 2020

 

I did a house-call to see the dog.
The dog had stood up to see me. He pants when he moves and has no appetite. He is fussy about the water quality before he drinks it. The owner said that his teeth were chattering when he returned from an inpatient at Vet 1's practice (a toilet room was used to house him).

His inguinal area was inflamed with urine scalding (pampers by Vet 1) and his anal skin area was raw. The owner's father had pulled him out from Vet 1's inpatient treatment for tick-fever. 

The diagnosis of tick fever was based on positive PCR Babesia. He had vomiting and diarrhoea after 3 days of anti-tick medication but Vet 1 insisted on completion of a 10-day course. He was given IV drips and was an inpatient for some days till the owner's father pulled him out. 

I took a photo from inside my car, parked outside the house. My car was at a lower level than the house entrance.

The owner's car was parked on an elevated ground, hence it looks blurry (bokeh). The dog looks as if he had been photoshopped and pasted onto the photo in front of the car. eye contact iwht the dog. This is a rare shot. 

This dog is likely to recover, but it is hard to be sure as his immune system is not good. He had liver and kidney disorders prior to consulting Vet 1 on the eye tumour and his total white cell count and lymphocytes were low.

The blood test taken when I saw him at Toa Payoh Vets were high total white cell count and lymphocytes, with increases in liver and kidney enzymes. 


This photograph looks so unusual, as if the dog has been pasted onto the car. It was taken with a zoom lens, focused on the dog's eye. The dog was on elevated grounds while I was inside the car on the lower road surface. You can still see the skin tumour on the left eye area and the IV drip scars from Vet 1.
The urine scalded inguinal area and the anal area are no longer inflamed.




No skin tumour removal yet as the dog is still recuperating. Much less panting. The owner's father prefers to feed his own food. So I have not advised the therapeutic L/D or K/D diet for such cases with liver and kidney disorders.  


Sept 6, 2020.
Phone the owner's father. The dog is better but has not fully regained his appetite and zest to bark loudly when people come to the gate or when the squirrel jumps on the tree branches near the house.  The owner's father sent me a video of the squirrel that will hop on the branches daily. It is great to have Nature in his backyard. He has green fingers and have planted trees and small plants in his house. 

 


 

 

DETAILS OF THE DOG'S CASE OF ADVERSE DRUG REACTION ARE AT:


Part 1

https://www.youtube.com/watch?v=203zY0ssIYE

 

Part 2

https://www.youtube.com/watch?v=4ut5EeotEwg