Wednesday, June 11, 2014

1375. AUDIT. Owner's financial constraints. An 11-year-old Miniature Pinscher has calcium oxalate stones


Case TP 44133
The 11-year-old Miniature Pinscher was overweight at 12 kg and could not stand up yesterday. Two weeks of dribbling urine. He stopped eating for the past 2 days and had been dribbling urine for the last 2 weeks or more.

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Thursday, April 24, 2014

1358. An old Miniature Pinscher can't pee

"It is always best to get an X-ray done rather than just unblocking the bladder," I said to Dr Daniel as the owner of the overweight Miniature Doberman Pinscher dribbling urine wanted to save on medical costs and so the dog was warded for 2 days. So today, I got the dog X-rayed. Several big urinary stones obstructed the urethra at the os penis area and many more were in the bladder.

"The bladder is about to rupture," I advised an emergency surgery. "Around 10 stones in the os penis and more than 16 inside the bladder!"

The owner had delayed seeking veterinary treatment for many weeks. Blood tests showed kidney failure, thus explaining the persistence of daily vomiting by the dog.

The owner gave permission for the emergency surgery. The dog survived anaesthesia and surgery done by Dr Daniel. However, he passed away 3 days later.

Chances of survival after surgery are much lower if owners have been dragging their feet in getting their dog treated early by the vet.

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BLOOD TEST
Urea 44.6  (4.2-6.3), Creatinine 514 (89-177)
Haemoglobin and red cell count were below normal. Total white cell count at 26.1 (6-17) with Neutrophils at 95.5%. Haemocrit was low at 0.32 (0.37 - 0.55). However, the platelet count was normal. The dog was obese and very ill. This was a very high anaesthetic risk but the owner consented to the surgery.

X-RAYS
Urethral stones and bladder stones
To upload X-ray

URETHRAL OBSTRUCTION relieved by catherisation by Dr Daniel.
URINE TEST
pH 7, SG 1.011, Blood 4+ Crystals Nil, Bacteria Nil
No urine culture done

The dog passed away a day after surgery. The owner did not want any stone analysis.

I sent the stones c/o Hills to Minnesota Urolith Center Quantitative Urolith Analysis
Results: Calcium oxalate stones

1377. Territorial disputes of a dog

The 4-year-old Cross-bred bit the child who sat on the sofa. This was the 4th time he bit family members. Two years ago, he bit the owner and I had advised neutering him to reduce his aggression.

"This aggression could have been much reduced if you had neutered this dog 2 years ago," I said to him.  The dog was healthy and should not be put to sleep.
 
"I was advised not to neuter him," the man in his late 30s said to me as he brought the dog to me for euthanasia. Yesterday, he went to a bigger practice, but the vet rejected his request to put the dog to sleep and told him to come to me instead. SPCA apparently did not want the dog.

There was one option. To house him with Noah's Ark but would they accept this dog? Would this dog stop eating once he was not with this owner as it had happened before. "I am not a good owner," the man said as he spent time with the dog outside the clinic. "My dog is territorial and that was why he bit my nephew."

He would house the dog in Noah's Ark if I would be responsible for all the administrative arrangements. What if the dog bites and kill other people since he had "tasted blood" four times. I declined the heavy responsibility.

Territorial disputes happen in the canine kingdom too as between large countries. Only that the dog is the loser. He decided on euthanasia and later scattered the dog's ashes off the East Coast seas. "This is the only time I can kiss him," the wife planted a kiss on the euthanased dog. This scene reminded me of "Sleeping Beauty". Only that, the dog did not wake up when kissed by "true love",  a person who truly loved him as in the Disney movie "Maleficent" I watched recently.

1376. A 13-year-old poodle has kidney stones

The 13-year-old poodle could not stand up, leaked urine and did not eat for the past few days. She was overweight and had lost all teeth. One last upper left canine tooth remained and was as black as carbon.

"What happened?" the couple asked me when I palpated the anterior abdomen and the dog reacted with painful cries.
"I need an X-rays to check the abdomen," I said. "She might have urinary stones."

X-rays showed kidney stones in both kidneys. This explained the anterior abdominal pain. The owners did not want to spend more money for blood and urine tests. In any case, the prognosis was poor as both kidneys were affected.  They took the dog home. She died the next day and was cremated.


  

Tuesday, June 10, 2014

1374. Yangon veterinary talk to vets - July 5, 2014. Pyometra & Uroliths (treatment & prevention)

Veterinary Articles for a video production for presentation to vets in Yangon on July 5, 2014:


Treatment & Prevention

1. Calcium oxalate to struvite stones
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm



2. How to create a compelling educational video
http://www.youtube.com/watch?v=xAlGLSCFfuI&feature=youtu.be





3. How I suture the bladder in 2 layers after stone removal - Images of a case
http://www.toapayohvets.com/surgery/20080818Shih_Tzu_Urolith_Dysuria_ToaPayohVets.htm


2007 Case. Dysuria (difficulty in peeing)
Shih Tzu,
Female, 5 years. Peeing a bit here
and there many times a day for many months

Shih Tzu, Female, 7 years. Large bladder stone. Toa Payoh Vets Middle-aged and older dogs are seldom given much attention by many owners all over the world, unlike puppies. Such dogs don't live long lives if their sickness is not treated. 
After many months of painful urination, the owner consulted me. I palpated a large bladder stone and advised surgery after 10 days of antibiotics. The owner forgot about the surgery and the difficulty in urination problem recurred. Surgery was inevitable to resolve the problem. But was it too late and would the old dog survive the anaesthesia and not die on the operating table or after surgery? The owner understood the risk. The dog was alive after the surgery. The pictures of the surgery are shown below.  
Shih Tzu, Female, 7 years. Large bladder stone. Toa Payoh Vets Shih Tzu, Female, 7 years. Large bladder stone. Toa Payoh Vets 8-mm thick bladder wall. Needs 2 layers 3/0 absorbable stitching to close. Toa Payoh Vets
I prefer to incise the ventral wall of the bladder and find no problem of "the heavy weight of the internal organs pressing down on the bladder" and therefore adversely affecting the healing. Thick and reddish bladder wall of nearly 5 mm in thickness indicates that the bladder infection has gone on for many years. Some dogs die as bacterial infection spreads to the kidneys and into the blood. The submucosa of the bladder is stitched with an inverting suture pattern. 
Chronic cystitis - large bladder stone. Stitching up bladder wound with 2nd layer. Toa Payoh Vets Shih Tzu, Female, 7 years. Large bladder stone. Toa Payoh Vets Shih Tzu squatted, cried and passed urine every few minutes. One spherical bladder stone removed 6 days ago. Toa Payoh Vets
2nd layer of inverting suture is now placed. Forceps on the left anchors the knot of the first layer. No omental fat layer is sutured onto the suture line although some vets do it.




CASE 4
POOR VETERINARY WORK - Some vets, not only in Singapore but elsewhere consider urine analysis unnecessary as in this case  


2010 Case. Dysuria (difficulty in peeing)
 at the end stage of urination
Feb 26, 2010.  At 13 years of age, he just had dental scaling at another vet practice. The vet had performed 2 blood tests 3 weeks apart and this indicated excellent health. Then the owner consulted another practice (Vet 1) as the dog took a long time to pee at the end part of urination. Vet 1 advised surgery. The owner phoned me for advice after Vet 1 had been consulted. I had not seen the case and I asked "Was the dog's urine analysed?  Struvite urinary stones, if small, may be dissolved by the acidification of urine."  The young lady owner said, "No." Later, she told me that Vet 1 considered urinalysis unnecessary.     I saw the case and got the owner's permission to do a urine analysis. The urine pH was 6.5 and there were no crystals in the urine on urinalysis. So, these tests indicated that the urinary stones might not be struvites and therefore acidification of the urine would not be effective. Surgical removal, as advised by Vet 1 was my recommendation. But will the dog that growled at me,  die on the operating table as he was so old?   


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THERE ARE OWNERS WHO DO NOT WANT SURGERY TO REMOVE BLADDER STONES 
Case 1: 2010 - The Shih Tzu keeps passing blood in the urine every day
X-rays and blood tests would be best but sometimes it is not possible due to economic reasons. The vet has to be compassionate when the owner request least-cost surgery. However the diagnosis must be spot-on and the surgery must be planned to ensure survival of a dog during anaesthesia.
 

young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore "Your Shih Tzu needs an operation to remove the big bladder stone I felt," I advised the young man whose female dog passes blood in the urine for the past 2 months. I could feel the creptitus (gas-like feeling) in the bladder. But the owner did not want an X-ray nor surgery. He wanted drugs.
young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore One month later, his dog had not stopped passing red blood. He requested surgery, but no blood tests or X-rays. I was OK with this request.
young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore "It is an open-and-shut case," I thought when I saw one stone coming out. "This was the big stone I had palpated. Stitch up the bladder and go home.
Another big stone was stuck partially in the urethra as my catheter could not pass through. What to do?
The stone was stuck fast. Finally the forceps managed to grip one end and pull it out 
young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore young shih tzu fresh blood in urine daily palpation urinary bladder stones  surgery cystotomy toapayohvets singapore
Smaller stones spilled out like small bombs when the bladder was flushed. Catheter was earlier passed
out via the vagina
No more urinary stones after irrigation of the bladder
  urolithiasis, urinary stones, haematuria, blood in urine, shih tzu, toapayohvets, singapore urolithiasis, urinary stones, haematuria, blood in urine, shih tzu, toapayohvets, singapore
Day 3 after surgery. There has been difficulty in passing urine but the dog eats and has no fever. Antibiotics and pain-killers are given. I phone the owner that the dog can't go back today Sep 6, 2010 as the dog has dysuria.


REFERENCES
http://www.cvm.umn.edu/depts/minnesotaurolithcenter/
 

RECOMMENDATIONS ON TYPES OF STONES

http://www.cvm.umn.edu/depts/minnesotaurolithcenter/recommendations/home.html

                                             
Dog warded 3 days for observation. Goes home. No complaint about difficulty in urination for the next 18 months.
The gentleman owner was not interested in follow up health checks and urine testing. Urinary stone (right) is from the bladder of this Shih Tzu. The two stones (left) are from another dog.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 




 

Monday, June 9, 2014

A drooling Chinchilla - anaesthesia

June 9, 2014
Case study on the effects of an injectable anaesthesia on a chinchilla

TP 43843
Chinchilla, Female, 1 year 10 months, 350 g.

"She has wet mouth since March," the owner said. "I thought she was suckling the kid she just gave birth to. But it is now Jun 5 and the mouth is still wet!"

"Your rabbit is drooling," I said. "Usually the cause is sharp molar teeth or mis-aligned front teeth."
It is hard to check the molars as the chinchilla would run back into the cage after grabbing the food pellet given by the owner to entice her to come out.

XYLAZINE & KETAMINE SEDATION
Formula for rabbit applied to chinchilla
Xylazine 20 + Ketamine 100 at 0.25ml/kg + 0.35 ml/kg IM

At 350 g, X=0.08 ml + K=0.12 ml IM
At 50% dosage, I gave X=0.04 + K=0.06 ml IM in one syringe.

FOLLOW UP WITH OWNER on MONDAY JUNE 9, 2014

End of January- Gave birth. One kid, still alive.
Beginning of March - mouth wet. Owner thought she was producing milk and milk had overflowed onto the mouth area. The Chinchilla stopped gnawing the apple stick after giving birth.

Friday Jun 5, 2014. Injection of X + K given at 50% calculated dose IM
Lower molar spurs laterally (image and video), on both mandibles clipped. Maxillary molars worn out, no spurs. Went home recumbent with shallow chest movements. She took 2-3 hours to wake up and was very tired till Sunday Jun 7, 2014.

Saturday Jun 6, 2014. 6 pm. Ate "pellets softened with water."
Started to eat hard pellets on Sunday.

Drooling much less. "A lot better," said the owner today Monday Jun 9, 2014.

Apple stick gnawing is now not favoured by this Chinchilla. So molar spurs may return.















Thursday, June 5, 2014

1372. Optional tour - volcano & hot springs





It is up to the tour manager to market the volcano tour as the agency did not help him. In the agency brochure, there is only one sentence: "Suggested optional: Volcano boat tour".   No more information. So, some think that there are poisonous hydrogen sulphide acid and gas spurting out from the volcano, risking their health. I did not hear the manager giving a briefing and he might have done so.

The volcano is dormant. There is also the visit to the "Hot Spring" and a swim towards it.

I decided to go to this tour at the last minute and asked the manager to arrange it. Outside the booking booth, the advert said: "15 Euros".  There was some pricing exclamation from some members of the tour group.
"How much did you pay?" I asked Jamie.
"55 Euros," she said. "Are you going to pay the manager?"
It was a savings of 40 Euros apparently. As the tour manager was with us on the tour taking care of us, I should not begrudge him his commissions as he does not get much from his agency, esp. if he is a freelancer.

Monday, June 2, 2014

1371. Anaesthetic challenge. Leg amputation in a dwarf hamster


A dragging fractured hind limb is usually not tolerated by an active dwarf hamster. In this 1-year-9-month-old hamster, the right limb was fractured at the distal tibia. The fractured area became red and swollen over the last 5 days as the hamster felt the pain and the burden.




Amputation was the choice as infection and gangrene would set in. However, anaesthesia is a challenge in this case as the margin of safety is low in such small creatures. A bit more anaesthesia would kill. I gave 2 drops of Zoletil 50 IM and operated fast, within 10 minutes to remove the leg. Details are in the illustration and video.

As at 7 days after surgery, the hamster is OK and active.
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