Wednesday, January 13, 2016

2915. INTERN Rectal Prolapse in Turtles: 2 Cases - a Chinese Soft-Shelled Turtle and Terrapin

Case 1.  Jan 12, 2016

"I surfed the internet. My Chinese soft-shelled turtle has rectal prolapse," the young man's turtle had bloody tissues present in the tank and an "arrow-head" appendage hanging out from the backside of the turtle.  From afar, it looks like rectal prolapse with injury. Yet it is not the typical rectal prolapse as in the second case.

HOOK
Consultation Video part as hook.
Anaesthesia and slides first to explain.
Then go to video (merge all videos).



















Chinese soft-shelled turtles are rarely kept as pets in Singapore. This is a case of penile traumatic injury and not rectal prolapse. As this turtle is not used to handling, the vet has to be careful not to stress it and cause it to die of stress.

Terrapins or red-eared sliders are most popoular and the second case is a true case of rectal prolapse.



Case 2. Mar 14, 2013

RECTAL PROLAPSE IN A TERRAPIN
Narrate from slides and make a video out of the slides. No actual video footage in 2013.







Tuesday, January 12, 2016

2914. A 13-year-old male, not neutered Silkie has a gigantic circum-anal tumours

Jan 12, 2016.

Male dogs not neutered do develop circum-anal tumours sometimes.
This 13-year-old Silkie, male, not neutered has a gigantic tumour above and left of his rectum.







The dog wanted to bite me when I palpated the abdomen. X-rays show lots of chicken bone fragments fed by the father.

As regards the circum-anal tumour, the dog is very thin and old. So Tardak injections 2 weekly are advised to shrink the tumour a bit as it is uclerated. E-collar and antibiotics and to review in 2 weeks.







There is a group of dog owners who are against neutering the male dog. However, when circum-anal tumours develop and are small, get them removed by your vet. In such situations, the dog is old and so the owner may worry about death from anaethesia. In this case, the tumour is gigantic and bleeding. There is a stench from the dog's body as the tumour had ulcerated. 

2913. INTERN. Caesarean Section according to the vet text book

Jan 11, 2015



WARNING

BKTP




The 80-year-old breeder saw the 3-year-old Maltese hunched and strained for 2 days, but did not give birth. He decided on Caesarean section as the Maltese was 58th day pregnant. From his experience, he knew the puppies of Maltese and Chihuahuas would be well formed at 58th day.

He phoned me. I had my afternoon off and was watching the Suffragette movie. Dr Daniel would be operating. The breeder requested my presence and as we had known each other for over 30 years, I returned to Toa Payoh Vets. 

It was a rare opportunity for 2 interns to see a Caesarean Section as I do not service the dog breeders in Singapore nowadays.

MEDICAL HISTORY
Maltese, 3 years old, 58th day. Uterine Inertia. 5 pups.

ANAESTHESIA
Toa Payoh Vets use only isoflurane gas and oxygen. No i njecti


SURGERY IN THIS CASE WAS PERFORMED
ACCORDING TO THE VET SURGERY TEXT BOOK
1. A longer skin incision is needed to take out the whole uterus
2. Exteriorise the whole uterus
3. Incise near the uterine bifurcation
4. Milk out the puppies

SURGERY DONE BY DR SING KONG YUEN AND SOME VETS
1. A skin incision around the size of the pup's head is made.
2. The whole uterus is not exteriorised (taken out of the abdomen).
3. The vet palpates for the uterine bifurcation
4. Incise near the uterine bifurcation
5. Milk out the puppies
6. Advantage of a much shorter skin incision 1/3 of the other procedure


















Follow up visit to the breeder on Jan 14, 2016
Dam and pups were OK. The breeder was most happy. He said the selling prices of the Maltese puppies are now depressed owing to puppy smuggling from Malaysia and Thailand. The government had taken blood samples from some breeders and had asked them to show the dams to support the
existence of the puppies for sale. Possibly a DNA matching is being done.

The dam and 4 puppies look good. The smallest one or runt is struggling to suckle as the 3 bigger siblings were actively suckling and occupying the area.







CONCLUSION

A successful outcome for an elective Caesarean section depends much on the timing. That is the judgment of the dog breeder. Deaths of the dam and puppies do occur but are rarely encountered.
Isoflurane gas and oxygen provides safe anaesthesia

     

INTERN Inguinal hernia with strangulated uterine horns - Miniature Schnauzer

Miniature Schnauzer, Female, Not spayed, 7 years



HOOK







MEDICAL HISTORY
The owners were busy and delayed the scheduled operation. Within a week, the swelling became bigger. The black patch of skin became gangrenous. The dog was given antibiotics for 7 days before the operation.










PRACTISE EVIDENCE-BASED MEDICINE
1. Blood test was not done to reduce medical costs. However, I prescribed 7 days of spiramycin and metronidazole antibiotics (Stomorgyl) before surgery.

2. X-rays and ultrasound.
The owner went to another vet for a second opinion. The vet performed X-rays and ultrasound and confirmed inguinal hernia with pyometra and a bladder stone. X-ray is shown below:




SURGERY - OVARIOHYSTERECTOMY BY Dr Daniel Sing. Domitor and ketamine IV at 0.33 ml and 0.4 ml for an 8.5 kg old dog. This was  followed by isoflurane and oxygen gas. Antisedan IM was given to reverse the domitor effects. IV drip was given during and after surgery. Methone pain killer injection was given SC. The dog was not in pain post-operation. 




Gangrenous skin seen as black patch before surgery. This indicated blood supply to this area of skin was compromised, leading to death of skin cells. 



A foul rotting smell was present in the operating room as the gangrenous uterine horns were taken out.  





The time taken between first skin incision (12.59pm) and completion of skin stitching (2.12 pm) was
73 minutes. 2 packets of Monosyn were used.

The owner was WhatsApp the gangrenous uterus and omental tissues that packed the inguinal hernia. This would update her on how serious the dog's medical condition was. Gangrene can kill a dog after surgery as the toxins cause multiple organ failure. .




CONCLUSION


Surprisingly, this dog survived the operation and anaesthetic.






Hernias are best repaired when they are small. It will be much less costly and worrying about anaesthetic death on the operating table as in this case of a sick dog being operated upon.

If the dog had been spayed when she was young, she would not have got pyometra (pus in the uterus).

This is a very rare case of strangulated uterus being herniated through the inguinal ring and becoming a gigantic inguinal hernia. It is also a rare case with a happy ending. Much depends on the state of health of the patient, when to do surgery and the skills and experience of the veterinary surgeon and his or her team.














Sunday, January 10, 2016

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. 

Friday, January 8, 2016

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.