Wednesday, June 30, 2010

Young poodle keeps shaking his head every day

"There is only one treatment," I said. "It is surgery to open up the vertical ear canal. Your poodle would feel better in the first 2 weeks after treatment and the problem of head shaking would come back."

"My poodle also had pimples all over the body," the lady in her 40s said.

"Most likely, the poodle had been rolling her body against the wall resulting in damaged skin and infections."

"You are correct. She has to rub her body against the floor tiles. How to cure this problem."

"The cause is due to hairy ears. Your groomer has to remove the hairs every 2-3 monthly. But you don't have time as you need to take care of your sick sister," I said. "So the head shaking comes back as the horizontal ear canals are infected and the lower ear is reddish and itchy." The poodle used her right hind paw to start scratching her neck again.

Most dog owners will just send the poodle to the groomer. But there was no real cure. Lateral ear canal resection surgery is the cure. "How is it done and will my dog be deformed?" the owner asked.

Pictures are best. Fortunately I had some pictures at www.toapayohvets.com, goto "Dogs" --- "Ear Problems" to clarify what the surgery would be. One picture is worth a thousand words.

"I have to ask the family members first," the lady said. Later she phoned and gave her consent to the surgery. "As the ears are infected, it will best to wait around 7 days before I do the surgery," I said. The owner understood.

116. The sucessful businessman and his 4 rabbits

Not all businessmen can be successful in global business. It is inspiring to meet one as they don't have much time for people who don't have any purpose in meeting them.

As my friend Khin Khin wanted some pricing info on shipping of diesel from Malaysia to Myanmar, I e-mailed him. He replied within 24 hours to say he would be back in Singapore on Jun 28, 2010 and we could talk further.

He has been in the shipping business for over 15 years and built ships. So, he was the right person to contact. On Jun 29, he messaged me apologising for the short notice, to meet at Amara Hotel to watch the soccer game between Paraguay and Japan yesterday evening and so I had to finish my dinner to go.

He introduced me to his friends as the vet who sterilised his four rabbits. "Before sterilisation, one male used to mount the female. The other female was jealous and bit the female. After sterilisation, all four became friendly and co-exist!"

It was good to know his rabbits were OK. How does one become a successful businessman globally?

1. High energy
2. Not needing many hours of sleep.
3. Able to be awake past midnight and get up to work the next morning.
4. Takes 2 hours to answer 400 - 500 e-mails.
5. Able to drink whiskey with clients. Also smoke.
6. Has a tremendous network of contacts.
7. Be a road warrior.

He loved chess and was playing a few games with his friends. One friend I would remember was a chess teacher who told me that he would be getting toe pain of gout the next day. But drinking a lot of water would alleviate the pain in his toes. He ate peanuts and fried chicken wings. He did not believe in taking anti-gout medication and so he just had to endure the toe pain the next day. I don't know whether he would get uric acid stones in his kidneys later but he was not worried.

As for me, I felt sleepy towards midnight. The businessman excused me and I left.

Saturday, June 26, 2010

114. Sunday's highlighted case. Lifestyle of dog

Jun 30, 2010
Dog: X, Male, 2.5 years old


"My dog didn't get fully cured," the couple in their early 30s said. "He had a neck bite wound some 3 weeks ago. He was treated by Dr Teo. Now the disease has spread to his left fore leg, his right fore dew claw and pad, his chin is red, there are pimples on either side of his penis. His penile sheath is swollen."


"These problems are due to the active the life-style of the male dog," I said. "It is like people. Those who drink alcohol a lot will get drunk, unlike others."

I drew illustrations to record the skin problems for ease of reference later.

1. Red inflamed chin. The dog was destroying the leather shoes of the brother
2. LF above carpus. 2 black spots due to medication and licking.
3. RF dew claw and nearby pad. Bleeding and red. Dog had bitten it. Microscopic exam showed ringworm.
4. Groin pimples and swollen penile sheath. The dog must have "humped" in the absence of the owners. There was another dog (female spayed) that might be injured.



After advising on treatment, I discovered that the young husband loved fishing. Their blog is ourfishingjourney.blogspot.com. There is a forum called fishingkaki.com.

"You need money to start a business," the young husband said and the wife noddded in agreement.

"Does it mean that if I start a travel agency business, I must own coaches, airplanes and hotels before I can start?" I asked.

"No need," the couple agreed.

"Nowadays, you have the internet. You can set up a niche deep sea fishing website and provide a service people want," I said. "Does it cost a lot of money to host this website? Will S$20/month do?"

The couple agreed that it would not need a lot of money to start a business out of a hobby.


What type of services?
1. Specialise in deep sea fishing over the next few months of years
2. Be a Singapore expert on local fishing.
3. Be able to arrange a deep sea fishing tour package.

"Anybody can search for what they want on www.fishingkaki.com," the wife said.
"What if I want to go for deep sea fishing tour package and want to know the cost. Can I find it on www.fishingkaki.com?" I asked.
"Yes," the wife said.
"No," the husband said. "You can find the boatman but not the whole package."

Thursday, June 24, 2010

112. Health screening to prevent diseases in your dog or cat

Emergency lab work includes measuring packed cell volume (PCV), total protein (Tp), blood glucose concentration, blood urea nitrogen (BUN) and serum potassium and sodium concentrations, total and differentiated white cell count (WCC), haemoglobin level.

WCC increase may indicate sepsis or inflammation. Low blood glucose may indicate sepsis, hypoadrenocorticism or hepatic disease. Electrolyte disorders may mean hypoadrenocorticism


Complete cell count, serum chemistry, urinalysis

HAEMATOLOGY
Detects infection (increased or decreased neutrophils), toxaemia or lymphoma (increased lymphocyte count). Eosinophilia may be due to eosinophilic gastritis or enteritis, parasitism, mastocytosis or hypoadrenocorticism.

SERUM CHEMISTRY ANALYSIS
Provides info about protein-losing enterpathies, azotaemia, liver disease, hypoadrenocorticism, diabetes mellius, hydration status and electrolyte concentrations. Serum amylase and lipase are not specific of canine or feline pancreatitis.

URINALYSIS
Provides info about kidney and liver diseases, ketoacidosis, glucosuria and hydration. Urine specific gravity and pH. Sediment examination for urinary crystals.

Wednesday, June 23, 2010

112. A young businessman is not patient nor respectful

"Find another agent," Khin Khin was told by the young couple who were her partners and had a prospective buyer for S$3 million of diesel oil. "We don't like this Agent X. Don't you have another one?" Agent X is a commodity agent with a vast network. It is not as if such agents are a dime a dozen unlike property agents.

So, I deduce that the young couple do not know much about the commodity trading business. The performance is closing the deal, not in having a prospective buyer or seller.

I had met Agent X some months ago and knew what he really had the knowledge and the network. He had a big scar on his left hand. "What happened to your left hand?" I asked. "Oh, the surgeon took a vein for my heart. I had quadruple by-pass."

I phoned him to find out what happened and to learn something about the oil industry as Khin Khin asked me whether there is a Malaysian quoted diesel price and that she must pay $99.90 per month to get the price.

INFORMATION

Agent X said that the couple wanted the previous price quoted but this was not possible as they had not locked in with money. The previous price was $580/metric tonne and just today, it was $660 FOB/metric tonne. So, the couple was not happy. This showed that they had did not know how business was done.

Prices are quoted in Singapore at www.bunker.com. Look for MDC (marine diesel oil) for prices.

So there is no separate Malaysian quotation. Prices had gone up as the buyer had not confirmed. At 5,000 metric tonnes, it would be around S$3.5 million and the couple had to get the LC done first. The couple wanted the price to be $500 -$600 which was not possible as at Jun 14, 2010. Agent X had quoted $583 earlier but prices had shot up. I had read in the Straits Times something about diesel prices going sky high and the impact on Singapore's economy a few days ago.

Lock In, the money must be there in the form of the LC.
To confirm, a Letter of Credit (LC) must be opened and made payable to the Seller (Petronas). This means that the Buyer had to put the money into Khin Khin's company. Once the price is agreed, the money will be paid, FOB. If the LC is in the Buyer's bank, then no commission would be likely to be paid to Khin Khin. So, it was important that Khin Khin controlled the money matters.

Commission for Agent X is paid by Khin Khin's company, based on trust. This sounds dicey to me.

Skepticism & criticism starting something

Giving Back- Connecting your business and community - Bert Berkley, Peter Economy
Matthew Flannery, cofounder of kiva.org

A business with social mission - giving people access to credit, access to financial systems, the ability to pursue their dreams -- connecting people.

When you don't have reputation or money, it is hard selling people your idea. Lots of skepticism and criticism.

Belief in yourself. Take more risks earlier, more aggressive earlier. Have a vision of a product and a service and an idea of what happens 2 to 3 years in the future. Dedicate to achieve. Build brick by brick, for years and years.

Time and web-hosting bill. Small hidden costs and cost of time.

Volunteers - if they know they make a difference, don't need to motivate them with wards, compensation.

Sustainable business. A business that make a positive impact on the world, not just making money and then giving back.

number of users, number of dollars, delinquency rate and repayment rate.

success - the financial health of the organisation, the burn rate, income, financcial sustainability and qualitative things like morale and happiness of workers

Tuesday, June 22, 2010

Cherry eye British Bulldog, Male, 4 months

"The seller said to wait till the other eye develops a cherry eye before seeking vet treatment," the gentleman owner told me. "The cherry eye gets bigger over last 2 days." The conjunctiva of upper and lower eyelids was much swollen as well.
This was a referral case from a breeder in Pasir Ris.


ANAESTHESIA
Short nosed breed - need to be careful.
Isoflurane gas by mask worked very well.

SURGERY
1. Under general anaesthesia, wash all pus off the left eye.
2. I injected 0.1 ml gentamycin and pred into swollen subconjunctiva
3. Clamped the everted gland.
4. Incise above clamp.
5. Release clamp.
6. Profuse bleeding for a few seconds. Bleeding will stop.
7. A vet ligates a central blood vessel below clamp so that there will be no bleeding after excision of the gland. I have not tried it. In any case, the bleeding soon stops.
8. Eye drops, antibiotic and painkiller injection. Goes home.

ALTERNATIVE SURGERY
Some vets claim that tacking back the swollen nictitans gland will prevent dry eye later in life as the gland is not excised. However, there is a high failure rate and the owner will not be happy to pay for recurrence. As you can see from the picture, it is good in theory to save the cherry eye but in reality, this alternative surgery is not so simple and effective. As for dogs getting dry eyes in old age when the cherry eye is removed, this is said to be a possibility. How many dog owners are patient enough to come back again for reviews and to pay again and again for a cherry eye treatment? Not many.

Monday, June 21, 2010

108. Perineal hernia repair Boston Terrier 7 years


Case: Boston Terrier, Male, Not neutered, 7 years, 12.4kg
Big swellings besides the anus, the left swelling being bigger.
Difficulty in pooping for past 3 weeks.

A knowledgeable young man who has his own views of dog care.
He presented a Boston Terrier with constipation for the past 3 weeks. He went to Vet 1 who referred him to another vet after taking a blood test as she did not want to perform the surgery. She had given him a laxative for the dog and the dog had passed loose stools instead of hard ones.

"Why don't you see the referred vet?" I asked.

"The Surgery has a bad reputation," the young man had googled the name of the practice he was referred to by Vet 1. "There is a very bad complaint about the vets from one dog owner. So I better not go there."

"All veterinary practices will have one or two nasty complaints about service," I educated this young man. "The busier the practice, the higher the chances of getting complaints. This is because the vet has no time to handle each case as thoroughly as he or she would love to. This applies to over-worked doctors in human medicine too especially in the emergency wards."

VACCINATION HISTORY MUST BE ASKED
"Has your dog been vaccinated?" I asked.
"No vaccination for the past few years. Do you have parvovirus in your Surgery?" the young man asked me.

"Fortunately for your dog, my practice does not have parvo-viral cases for many months as I seldom provide service to the dog breeders nowadays. You have taken a big risk exposing your dog the risk of parvoviral and canine distemper infections."

PRE-OP BLOOD TEST IMPORTANT FOR OLD DOGS BEFORE SURGERY
I checked Vet 1's blood test results. It is wise not to trust the blood results of other practices based on one of my experiences (see one case I had written). However, he had paid $130 for the test and I would not insist as that would increase his vet bills. Overall, the dog was examined and was healthy. So I took the chance.

ANAESTHESIA
IV saline given. Then I gave Atropine 0.4 ml IV followed by Domitor 0.2 ml IV
Waited 10 minutes. Isoflurane gas mask. Dog struggled. So, I gave Zoletil 100 @ 0.1 ml IV. This sedated the dog who was masked and given isoflurane gas at 5%. The dog slept and was intubated. Isoflurane at 1-2% maintenance was done by my experienced assistant, Mr Saw. I asked him to increase the dose when the pelvic fat kept coming out from the hernia after pushing the fat into the abdominal cavity. The dog recovered smoothly.

SURGERY
I gave him antibiotics to take and schedule perineal hernia surgery 2 days later. The surgery took nearly an hour as the hernia was large. The hernia bulge with pelvic fat is large, around 4 cm x 6 cm. An electro-incision made a big cut to the left of the anus.

It was difficult to identify the medial coccygeal and levator ani muscles in this case as there is a lot of inflammation. The internal pudendal artery and vein and the pudendal nerve on the dorsal surface of the internal obturator muscle looked compressed as I showed to my assistant Mr Saw who nodded his head. Judging from his eyes, he did not believe they were what I said.




Is there a right perineal hernia too?


Electro-incision. Big amount of pelvic fat. A retractor enabled me to have a good field of view to stitch up the defect


See the big hole through which part of the colon and pelvic fat herniated through causing a big backside swelling


Left perineal hernia repaired. Neutering in 3-4 weeks if the owner wants to do it. The right perineal hernia may need to be repaired later.
The internal obturator muscle is on the ventral aspect of the pelvic diaphragm. This was a big fatty mass horizontally covering the muscle, unlike the no-fat muscles illustrated in Small Animal Surgery, T.W. Fossum 1997, pg 354.

I used a retractor to spread open up the operating area and to see the pudendal vessels and nerve just above the obturator muscles in this case. Do not stitch these vessels or nerves.

POST-OP
Dog woke up fast. Given tolfedine painkillers.

TWO HERNIAS TO BE OPERATED AT ONE GO
I doubt that it is possible to do two hernias at one go as the muscle stitching on one side (i.e. left hernia in this case) pulled the left anal area tightly to cover the herniated hole. Therefore doing two hernia repair at the same time just is not in the interest of the dog as he will feel very uncomfortable and painful.

LOOSE STOOLS leaking out from the anus. This must be plugged. The dog had been given an oil laxative by Vet 1 for 3 days and the loose stools start to come out despite atropine injection.

CONCLUSION
The dog was OK and was warded for at least 4 days as the owner did not have a crate to prevent the dog running loose. I checked the dog every day to ensure that he had proper nursing care and pain-killers. The boy's parents came to visit the dog yesterday. The dog should be back home after 7 days. He had managed to rub his backside onto the floor of the crate despite tolfedine 60 mg at half a tablet per day for 3 days. I decided to give him 1/4 dose of a 30mg phenobarb and then Rimadryl for another 3 days to prevent pain and inflammation.

P.S
1. Yearly vaccination is important. Fortunately this dog did not get infected with parvoviral disease in the practice of Vet 1 which is a very busy practice and in my surgery. Otherwise, I end up with a dog passing blood in the stools and dying later. At the time of writing this report, it is still early at Day 5 after visiting Vet 1. Parvoviral signs come in around 10-14 days after infection.

2. "Neutering the dog when he was younger would have decreased the chances of him getting perineal hernia," I said. "Perineal hernia is more common in non-neutered dogs." The young man said: "It is cruel and that is why I don't do it." He has been advised to neuter the dog around 2-4 weeks later. As for the right perineal hernia, it is a smaller one. Wait and see. If the dog is neutered and there is
no more swelling in the backside, then there is no need to do a right perineal hernia repair.

3. High anaesthetic risks. I don't enjoy doing high anaesthetic risk surgeries as they are very stressful for me. If the dog survives, everybody is pleased. There will be deaths and the owners may be very emotional and angry. Some may post a nasty complaint in the internet. To minimise risks of deaths of old dogs on the operating table, I don't force myself to perform hernia repair and neutering at the same time. The owner has to appreciate that I don't take risks unnecessary.

Detailed report at www.toapayohvets.com

107. Lateral ear resection

Patient: English Cocker Spaniel, Male, Neutered, 5 years. Gentle dog. No Cocker Rage.
Complaint: Head shaking for several weeks. Dark red ear wax in horizontal canal. Groomer could not resolve this problem.
Solution: I advised surgery to open up the vertical ear canal so that the trapped water and debris inside the canals can flow out easily in the long term. The couple in their 40s knew what I was talking about and agreed to the surgery.

ANAESTHESIA
Jun 21, 2010. Anaesthesia and Surgery took over one hour.
Pre-anaesthetic dose Domitor 0.25 ml IV. Waited 5 minutes. Isoflurane gas. Intubate. "How about Zoletil IV?" my assistant Mr Saw asked as in the recent debarking case, I had used both.

"It is best not to give more sedation drugs than necessary. I will be using isoflurane which is safest," I advised him. "Less sedation drugs, less likely to get anaesthetic deaths. If I use Zoletil, I will need to use Atropine to prevent salivation and muscle tremors. Then I need to top up as this surgery is going to be longer than debarking as I have two ear surgeries to do. That means I still need isoflurane gas to maintain surgical anaesthesia."

Pre-anaesthetic sedation using one drug and isoflurane gas is the safest method of anaesthesia for dogs and I use this method frequently. In debarking, I had no choice but to use injectable anaesthetics and there was the hassle of topping up via the IV catheter. For gas anaesthesia, just increase the dosage and that is so convenient when the dog is intubated and given gas. For injectable anaesthetic top up, it is given by small doses via the saline drip. It is quite convenient too but nothing is as safe as the isoflurane gas.

"Any surgery consent forms to sign?" the owner had asked me earlier. "The owner can sign forms for the vet. The important thing is that the dog does not die on the operating table." Usually I assess the dog's health and the owner's personality and I seldom give them forms to sign. But I have always communicated to them the risks of anaesthetic deaths. Consent forms are common even in human anaesthesia and surgery at the Singapore hospitals.
Performance (a live dog at the end of surgery) counts a lot. I cannot be complacent as one anaesthetic death creates massive waves of emotional upheavals in the owners and the family. This English Cocker Spaniel is healthy but still no vet can guarantee the owner that the dog will not die on the operating table.

SURGICAL PROCEDURE
1. Clipped skin of ear to the base, not just partly. My assistant had to shave more, increasing the anaesthetic time. Put artery forceps to base of vertical canal to identify the location.
2. Draw the outline of the surgical area from base of vertical canal and add 50% more length (see picture).
3. Electro-incision of rectangular outline.
4. Excise subcutaneous fat to see the vertical canal.
5. Be careful of a big vein posterior to the vertical canal. If cut, ligate this vein. Elevate cut skin upwards to see the subcutaneous fat.
6. Angle forceps at 30 degrees downwards and outwards so that the drainage board is wide and clamp anterior and posterior edges of vertical canal.
7. Electro-incision on clamped groove.
8. Scissors to cut.
9. Lower the cartilage. Cut cartilage long enough to anchor it to base of skin. I stitched at the horizontal canal level first. 2/0 absorbable sutures were used.
10. Pictures to illustrate the surgical procedures are presented in:
www.asiahomes.com/singaporetpvet/dogs/0750Schnauzer_lateral_ear_resection_Singapore.htm


POST-OPERATION CARE
Tolfedine painkiller injection after surgery and orally for the next 4 days were quite effective in controlling the pain. Dosage was 4mg/kg whether by injection or oral. An e-collar was given.

I asked the owners to take the dog home on Day 4 to reduce costs for them. Ideally I would like to keep the dog for 10 days to ensure complete healing but there is always the increase in veterinary costs for the owner and this may not be in their interest.

"The left ear has a stitch breakdown on the lower right side," I said to the couple. It will close. Do not wipe the wound. The stitches will dissolve usually. I need to review in 14 days from today."

Sunday, June 20, 2010

TIPS: Socialising and 3 vaccination advices for puppies in Singapore

Vaccination Schedule at Toa Payoh Vets is as follows:

1. Most puppies to be vaccinated between 6 to 16 weeks at 3-4 weeks intervals
lst vaccination at 6 - 8 weeks
2nd vaccination at 9 - 11 weeks
3rd vaccination at 12 - 14 weeks

2. Breeder's puppies and puppies at high risk
lst vaccination at 6 weeks and then 3-4 weekly.

3. Annual vaccination advised. Although there are vaccines which require 3-yearly revaccinations, these are NOT available in Singapore. They don't cover the 3 core vaccinations (canine distemper, canine parvovirus and canine hepatitis using the CAV-2 vaccine).

4. Kennel cough (Bordetella and canine influenza) vaccines are tiven twice at 6 weeks twice. At least a week before the puppy goes to socialisation class or boarding. Breeders and pet shop puppy sellers in Singapore do NOT vaccinate against kennel cough which may cause pneumonia in puppies though it is like a common cold for adult dogs.




Socialisation classes
Unsocialised puppies can become aggressive or shy. They need to socialise before 12 -16 weeks of age.

Canine parvovirus is the main risk and they do kill puppies. The environment can infect puppies as the virus remain there.

Canine distemper and hepatitis are uncommon in Singapore. Owners have to take the risk and benefits.

Advices:
1. Take the socialisation classes when puppies are 14 weeks of age and have received at least 2 parvoviral vaccination.

2. Attend classes which are not full of puppies, e.g. animal shelters, dog park or veterinary clinic. A place with easy to clean impermeable floors. A 1-to-30 leach-water solution will kill the parvovirus. Not possible to bleach grass and soil. Staff to clear faecal deposits, not owners.

3. Small class size and less than one hour of training reduces risk for your puppy.

105. Sunday Two Highlighted Cases - Can't stand up on hind legs + backside swelling

Sunday's Highlighted Case - June 20, 2010

I was surprised to see the young couple bringing the old Miniature Schnauzer with the large cheek tumour I had excised on Jun 14, 2010 to see me on Sunday. The case is recorded in: Large cheek tumour & 15 rotten teeth.

"What happened?" I asked.
"He had been crying loudly at night for past 3 nights (Jun 17-19)," the young lady said. "The neighbours thought the dog was abused and enquired about him. He just could not stand up. Previously a vet had diagnosed hip arthritis."

PALPATION
1. T/L to L/S spinal area painful.
2. Extended right hip. Dog screamed in pain.
3. Extended left hip. Dog showed painful reaction.

CHEEK TUMOUR EXCISION EXAMINATION
"The dog will not allow me to open his mouth," the lady said when I wanted her help. I wanted to see whether the large ulcer after excision of the cheek tumour had healed well. I put the dog on the table and opened the right cheek. The stitches had broken down. The ulcer was reddish but otherwise not infected. The dog did not object to the lady opening his mouth now.

"He had painkillers called tolfedine tablets of 60 mg/day for the last 7 days," I said.

"Did he behave like a young puppy by running wild?" I asked. "Painkillers made him feel good and over-exert his muscles and joints."

"Yes," the lady said. "He was most active unlike other times when we took him outdoors. He would lift his hind leg, either left or right and pee at every vertical surface till the last drop of urine. This is his usual habit."

I explained: "The reason he cried at night and could not get up on his hind feet is that he has painful hip joints and back after the exercises. Now you have to restrain him from any activity for at least one month."

I proposed that the dog be neutered to reduce his urine-marking obsession. But the owner was not keen on the idea. The male dog lifts up mainly his right hind leg to balance weight while peeing on vertical surface. So, the extra weight puts pressure on the right hip. Therefore the right hip became very painful. However, he would switch to the left leg. So both hip joints are painful. What did he do then since he had to urine-mark at all cost? "Oh, he just squat and pee on the ground," the owner said. After enjoyment during the evening of urine-marking, the dog felt the intense pain at night for 3 nights. The neighbour was concerned and so the owner came for consultation.

I did not suggest any X-rays as the owner wanted the least cost treatment and a vet had previously diagnosed hip arthritis. X-rays are needed for more detailed examination and diagnosis of hip arthritis but economics prohibit me from further investigation.

CHANGES OF LIFE-STYLE ADVISED
1. No walking over the drainage grate from void deck to grass during outdoors exercise for the next one month or more.
2. Use of a anti-obesity dry food diet. If the dog loses 1 kg, his hip joints would bear less weight. It is easier said than done as some old dogs just love to eat and put on weight easily.

Neuter your male dog at around 6 months to prevent obsessive urine-marking. During old age and weight gain, the hip joints may be worn out due to weight bearing from the lifting of the hind leg to urine-mark.


PERINEAL HERNIAS
Boston Terrier, Male, 7 years (not neutered because it is too cruel).
Two moderate sized swellings on perineal area.


Complaint: "Squats down longer to poop than usual for past 3 weeks. Hard for stools to be passed out during the first week." Vet 1 prescribed stool softeners 3x/day yesterday. Stools loose now.

Saturday, June 19, 2010

104. Laryngotomy - Debarking

JR Male Neutered 10 years old

As last resort, the young girl had to de-bark her dog due to complaints.
I noted a plastic spiked collar (with spikes facing the neck).

1. Blood test done first on Jun 11, 2010.
Normal except that kidney shows in umol/L that urea is 3.9 (4.2 -6.3), creatinine is 61 (89 - 177). Dog was OK for surgery.

2. Jun 17, 2010 Weight
Laryngotomy





Jun 17, 2010 6.5 kg 39.2
2 pm Surgery
IV drip
Domitor 0.2 ml IV, Zoeletil 100@ 0.1 ml IV
Atropine 0.5 ml IV


Anaesthesia insufficient. Needed to top up Zoletil 100 0.1 ml IV

Friday, June 18, 2010

103. Webmaster uses asiaone.com to search "dog dental scaling"

A webmaster acts immediately to get rid of his dog's bad breath
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 19 June, 2010
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
Friday Jun 18, 2010 6.38 pm.
In the morning of Jun 18, 2010, I received an e-mail:

Hi, i have a 5 year old Bichon that is having tartar build up in his mouth. i would like to fix an appointment with you to have his tooth clean/ extract due to the bad odour coming from his mouth, please feel free to contact me at (tel and name given) so we can see to this problem ASAP
Regards
I asked my assistant Mr Saw to phone the dog owner. I was surprised that this bespectacled young man who would be in his early 30s really got his dog down to the Surgery in the afternoon for dental work. When he came for his dog at 5 pm, I sought feedback from him as to how he had tracked me down.

The young man said: "I use asiaone.com inserting "dog dental scaling" to find a vet who could do dental scaling for his dog and found your website. I then e-mail to you."

I usually "google" for webpages and had never considered asiaone. However I switched on asiaone.com to check its efficiency in search by using "dog dental scaling". The free-lance webmaster of 5 years had highly recommended this search engine as it specialises in locating local webpage searches.

I log in via Firefox but the search had problems loading. So I tried again for another 5 minutes and switched from Firefox to Internet Explorer. I had this unreliable Starhub internet USB plugged into my desktop as the Toa Payoh Industrial Park in Lorong 8 was not wired and could not receive wireless internet. So, the problem might be my internet connection. Just as I was about to give up, the search results via the "Web" search page displayed
toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm. This was the webpage the webmaster said he saw "pictures of dogs doing dental scaling." At first I could not understand what he meant till I saw pictures in this webpage.

It was a pity that asiaone takes a long time to download this evening at 6.49 pm. I google "dog dental scaling" and the search results came out within 0.23 seconds. I found
bekindtopets.com/dogs/20080828Dog_Dental_Problems_Singapore_ToaPayohVets.htm
on the 2nd page.

Many young people search for info on the internet. This webmaster research everything he needed to know about dog dental scaling, including anaesthetic risk and other worries. I had a good chat and learnt much about the pros and cons of online data base (Access recommended by him), domain hosting in Singapore v. in the U.S (he prefers Singapore) and fees for setting up a website (varies from $500 to $50,000).

The webmaster's 5-year-old Bichon Frise kept pawing him while we talked, as if the dog wanted to go home. "He is an attention-seeker," the webmaster told me as he answered a phone call saying he would be back soon. "It's my mum who wants to see the dog," he said to me. I thought it was his girlfriend or wife. The webmaster decided to microchip his dog and get a dog licence too.

Anaesthestic reactions to isoflurane
I used Domitor 0.1 ml IV via the IV drip. The dog was intubated but he just would not be fully anaesthesized after intubation. He kept moving when he should be asleep soundly as in the previous case of the Shih Tzu with cornea ulcerations and 3rd eyelid flap surgery. I had given this dog xylazine 20 @ 0.2 ml IM, masked with isoflurane gas and then intubate and maintain with the gas. The dog slept like a log as I did the 3rd eyelid flap for two eyes.

"There are a few dogs that just cannot be fully anaesthesized by isoflurane gas," I explained to my assistant Mr Saw when the Bichon Frise was still moving. "It is something like drug resistance from certain bacteria. Or an allergic reaction. You need to take out the endotracheal tube and use the mask to deliver the anaesthesia. If you continue, the dog may vomit out fluid and get inhalation pneumonia when the vomitus flows into his lungs."

I took out the endotracheal tube and use the mask. Mr Saw nodded his head. He had picked up much knowledge working in Toa Payoh Vets which is a small practice and so he could be hands on in various aspects of the practice.

He had ambitions to be his own boss and start his own veterinary practice in Myanmar and I expect him to do well. Mr Saw had told me yesterday that the anaesthestic machine was malfunctioning as a dog anaesthesized by my associate Dr Jason Teo was not fully asleep. Yet he saw the Shih Tzu sleeping very well just before the Bichon Frise and therefore the anaesthetic machine was operating normally.

As for the webmaster's Bichon, only the left upper premolar 3 had roots exposed. I had it extracted as this may be the cause of him feeling the pain and moody when the Chihuahua approached him to play. Nobody really knows but the webmaster suspected that this could be the problem.

Difficulty in brushing the back teeth
Many dog owners in Singapore have difficulty in using the finger tooth brush to clean the dog's teeth. The dog would just run away or refuse to open his mouth or bite.

TIP:
I advised him to use something the dog like, put it on the finger tooth brush as the dog had been avoiding him whenever the dog sees his finger brush and the canine tooth paste. "Use some food the dog likes e.g. cheese and put on the toothbrush. So the dog looks forward to tooth brushing every day." Human beings are devious creatures.

I told the webmaster that the tartar will build up again and bad breath will return after a year if he does not brush his dog's teeth daily or at least 3 times per week.

P.S
On Jun 19, 2010 at 1.38 am, I tried www.asiaone.com and do "dog dental scaling" search. The results were <1 second at:
rednano.sg/sfe/allsearch.action?allsearch=true&view=dir&querystring=dog+dental+scaling

I could see, on the right column, the following:

Marine Pet Image - One-Stop Pet Shop in Singapore:...
Visit PGA Website dog dental scaling before dog dental scaling after CHARGES Toy $80-$100 Med $100-$120 LG ...
www.marinepetimage.com/Dental.htm - 13k

20080816Fistula_Oronasal_Dog_ToaPayohVets v...
...of 3 year old dog having dental scaling. An annual dental...9-year-old dog having dental scaling and check up... Try to get dental scaling done when your dog is less than 5...
www.bekindtopets.com/dogs/20080828Dog_Dental_Problems_Singapore_ToaPayohVets.htm
- 35k

031208ASingapore Toa Payoh veterinary dog c...
...2005. Regular dental scaling means that the dog's teeth will...plaques as the dog grows older...than never to do dental scaling. If there is...drop off. The dog just can't...
www.toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm - 31k
You need to go to "Web" section to do your search correctly. If you go to the "News" section, you will get no satisfaction. It seems that asiaone.com is worth considering when one looks for Singapore businesses.

Updates are at www.toapayohvets.com

Wednesday, June 16, 2010

102. Dwarf Hamster has a cystic right paw

Young couple.

"The right paw shrinks and swells over the past month," the fair complexion young lady held the 15-month-old hamster in the palm of her hand for me to examine.

This is an uncommon case. The right paw had a plastic bag of light yellow fluid.
"What is the cause?" she asked.
"It is probably an embedded foreign body," I noted that the right paw was inflamed because the hamster had been trying to lick away the cyst. Whenever the cyst was broken by bites, it shrank. Then the bite wound closed and the cyst swells again.


So is there a permanent cure?

I advised the young couple: "It is difficult to know what is the exact cause. I have to cut the cyst under anaesthesia, check for abnormal tissue and and drain away the contents inside it. Hopefully, the foreign body -- probably a splinter would be removed."

I used a small sized scalpel blade to cut the cyst from toe to over the wrist for a length of 1 cm. There would be no point doing a small cut as the cyst would form again. Yellowish fluid shot out. It would be 1 ml but seemed to be 3 ml as the fluid scattered onto the operating table.
"This hamster is overweight," I was worried about the high risk of anaesthesia in plump pets. The hamster also had a red wart below the left paw. So, there would be two surgeries in one.

5% issoflurane gas anaesthesia using a plastic container enclosing the dwarf hamster was sufficient to prevent pain. "Don't wait for this hamster to close the eyelids," I said to my assistant. "By then, it would be dead." Fat hamsters are very high risk. The owner expected nothing but a hamser alive at the end of the day.

The surgical anaesthesia seen in the dog and cat cannot be observed in hamster anaesthesia. However, the pedal reflex was present in the case when the anaesthesia was lighter than needed. The hamster just pulled back its front paw as I incised. More gas for less than 5 seconds. Repeat. Incise. Cleaned up wound.

The surprising finding was a large vein from the left to the right across the carpus. Could there be an obstruction of this vein, leading to exudate from the vein into the subcutaneous tissue, causing a big cyst to form?

The wart was easily removed. Lots of bleeding but not life threatening.

The hamster seemed much more active after its right paw was back to normal size. I did not stitch up the wound. The skin was reddish and soft. "Just use a facial cotton and clean warm water to clean the wound," I advised when the gentleman asked whether he should use saline. Hamsters don't like saline or dettol onto its body.

I advised not giving the bread to reduce the weight of the hamster. Worm meals and sunflower seeds should be cut down too. 64 grams should be reduced to 54 grams for this dwarf hamster.

101. Domitor vomiting. Left eye ulcer.

Some dogs, despite fasting for over 12 hours, do vomit yellow liquid as in this case.

Old Maltese. "Keeps rubbing the left eye," the owner complained. "What's the problem?"

I showed the owner that there was a corneal ulcer at 4 o'clock by lowering the lower eyelid. It was not obvious as it was a recent injury. The ulcer was 3 mm in diameter and deep.

A 3rd eyelid flap would be the treatment of choice. No point just prescribing eye drops or e-collar to save the owner some veterinary costs as the outcome is unsatisfactory. The dog would continue rubbing his eyes and the owner would just seek another vet for help, while cursing the first vet.

However, the old dog needed to be put under anaesthesia. This would be risky for any old dog (over 5 years). Sedation and isoflurane gas is the safest form of anaesthesia for old dogs in general. This is what I used:


Bodyweight: 5 kg
Domitor 0.1 ml IV.
Waited 5 minutes
Isolfurane gas by mask
Dog started to vomit bright yellow fluid, dirtying his mouth.
Took away the mask. Clear the vomitus from the mouth.
No intubation was necessary in this situation.

The sedation was good after washing. Isoflurane gas by mask for a few seconds. The surgical anaesthesia was excellent. The 3rd eyelid flap was stitched. The dog also had several abscessces below the upper eyelid of the right eye. I used needle to puncture the abscesses.

Some vets prefer to give the Antisedan antidote to Domitor to get the dog to wake up immediately. I do not see the need to use it as the dog would need the sedation to rest after surgery. The dog woke up within 5 minutes anyway. Antisedan does work very well as the dog would wake up immediately when given at same dose, ie. 0.1 ml.

Several abscesses on the upper eyelid do occur in hamsters. This condition is uncommon in dogs.

Pictures taken for record purposes.

Monday, June 14, 2010

100. Large Cheek tumour in an old Schnauzer

June 14, 2010 4.30 pm.

Completion of a mouth tumour surgery in a fat old dog with purplish tongue.

Dog: Schnauzer X, Male, Not neutered, 11 years old. Born: 1999

Complaint: Bad breath.



June 8, 2010 Admitted
12.6 kg, 38.9 deg C.
Blood test, Grooming, Baytril and drip.
Liver SGOT/AST above normal.
Urea and Creatinine below normal.

Jun 9, 2010 Dental
Anaesthesia Domitor 0.2 ml IV. Isoflurane gas. Extracted 15 rotten teeth

Jun 14, 2010 Right cheek tumour excision - bigger than 50 cent coin size.

IV drip
For Old Dog
Domitor 0.2 ml IV
Wait
Zoletil 100 0.1 ml IV
I saw dog trembling slightly
Atropine 0.65 mg/ml given 0.5 ml IV
No tremors.

Surgical Anaesthesia last around 30 minutes
Electro-surgery
Lots of bleeding.
2/0 stitch up mucous membranes of hard palate to cheek.

Tumour is much less swollen and rounded due to antibiotics. More disc-shaped. Easier to excise now than if done on Jun 8, 2010.

Antisedan 0.2 ml IV. Dog woke up as if nothing had happened.

Sunday, June 13, 2010

99. A bi-sexual toy poodle

YOUNG PEOPLE DOING INTERNET RESEARCH AND DIAGNOSIS

Sunday's Unusual Case Highlighted:

Toy poodle, female, spayed at 6th month, 6 years old. 3.9 kg (trim).
Neck had 3 itchy patches of ringworm infestation. Very itchy.

Complaint:
For the past few weeks, she would stretch her front legs forward, lower her body and maintain this posture for several seconds.

"My poodle is suffering from pancreatitis," the young man phoned me. "Do you do blood test to check this condition?"

Sometimes the young people diagnose their own dogs.

The couple whipped out the handphone and showed me the picture of the poodle in this pose. Seeing is believing.

"Is the dog eating well?" I asked today. "Very well," the owners said. I palpated the abdomen. There was not a touch of pain. So, I advised them to wait as the dog was being treated for ringworm and the results would not be accurate.

If owners request a blood test, it should be done. How does the vet know what is occurring inside the body system but a dog with good appetite is unlikely to have any medical problems. If the vet does not do a blood test on request and the dog becomes ill some days later, he may be liable for professional misconduct. So it is wiser to do the blood test.

In this poodle, my examination discovered an unusually large clitoris. It was about 4 mm in diameter. I asked the couple to hold the poodle. The dog had been spayed in Hong Kong at 6 months of age. On further detailed examination of the vulval area, there was an unmistakeable miniature structure resembling a male organ with the body of the penile organ being 1 cm long and 5 mm in diameter. The whole mucosa was a deep red suggestive of inflammation.

It was difficult explaining to the lady in Mandarin. She could get the idea of what I was trying to explain. As for treatment of the posture, there was none. As for the large bald patches on the neck between the shoulders, anti-ringworm medication would take several weeks to work. This must be explained to the owners.

Saturday, June 12, 2010

99. Sunday's highlighted case: Oro-nasal fistula 15 years old

Date: Sunday, Jun 13, 2010

Case on a Sunday: Maltese X, Female, Not Spayed, Weight 5.5 kg. 37.9 deg C. Active and eating.

Complaint: Pus below right eye. Rubs right side of face onto bed sometimes.
3 Owners: 2 young men and a lady all around late 20s.

History: Had consulted Vet 1 who prescribed oral Baytril 50 mg antibiotics 1/2 tablet two times a day from May 16, 2010. But the owners gave the dog 1/2 tablet one time a day as they deemed that the dog would be overdosed. The pus in the facial wound disappeared after 2 days. However the medication finished after 20 days and pus re-appeared in the wound below right eye during last 2 days.

Diagnosis: Owners knew the diagnosis of oro-nasal fistula as they had researched the internet.

Prognosis: "It is very high risk and the dog may die on the operating table," I advised the owners to get a blood test done to screen her health. The vet must inform the owner and the owner is free to reject the advice. Since the owners did not want a blood test, it was hard to estimate the anaesthetic risk. In any case, such an old dog would be very high risk.

I checked the dog's heart. It was OK. The dog was in good bodily condition and had good body weight. So I gave a 50:50 chance of success. Usually the chances are less than 50%.

Pre-op:
1. Antibiotics IV with the drip or return after 5 days of antibiotics for surgery.
The owners chose the IV drip.

Anaesthesia:
1. Isoflurane gas by mask. Intubate. This dog was not able to sleep fully. When a loose tooth was extracted, he would wake up partially and moved. So, I took out the endotracheal tube, put on gas by mask and repeat the intubation. After 3 episodes, I decided just to give isoflurane by gas mask. 6 teeth extracted including the right and left premolars. Dental scaling done. If the dog had been sedated, he would have a smoother anaesthesia. However, sedation may cause low blood pressure or kill the dog and so in this case, I used isoflurane gas only as it is much safer for an old dog. This would also take a longer time to anaesthesize the dog.

Surgery:
1. IV drip with antibiotics baytril was given before surgery. The dog bit off the drip line before surgery.
2. Loose teeth were extracted. I was surprised to see thick pus actually lodged in the roots of the right upper pre-molar. Like a wallet full of cheese. I used the forceps to scrape out the light yellowish pus.

Post-Surgery :
1. Two hours later, the owners came to bring her home.
2. No solid food for the next 3 days so that the big holes from the extracted teeth would close . Just give soup, milk or honey water for 3 days.
3. Antibiotics for 20 days.

This dog should live to a ripe old age of 20 years. "No more white coat," the young man said. "As she grows older, her coat colour became brown." I asked: "Did you use yellowish shampoo?" "Yes," the owner said. "The shampoo colours the coat over the years," I explained. "If you use a "white-dog shampoo", the coat will not become stained yellowish brown for a white coated dog."

All ended well for this well loved dog. I asked the young man to sit on a chair and hold the dog and opened her mouth. The dog kept moving her head. After 15 minutes, he could open the mouth and was surprised to see a bleeding hole over 1 cm in size where the right upper premolar was extracted. "I thought the pus come from the front teeth or the fangs," the young man was indeed surprised that the source was from the root of the premolar 4. Fortunately, he could open the dog's mouth so that he could see the hole and I could snap a picture to educate readers.

This must be one of the oldest dogs in Singapore to have an oro-nasal fistula. At this age, most teeth had dropped off.

UPDATE ON JUNE 14, 2010
The owner phoned to say that the dog was coughing. "This coughing was due to the irritation of the throat during the many times of intubation, " I said. "It should clear up within 2 days. Continue giving the antibiotics." No further news from the owner after this.
VET PHARMACOLOGY FOR VET STUDENTS
Baytril 50 mg (5mg enrofloxacin/kg bodyweight) is advised by the manufacturer to be 1 tablet per 10 kg bodyweight once daily or as a divided dose twice daily for 3 to 10 days with or without food.
For this dog weighing 5.5 kg, the dosage should be 1/2 tablet once daily or 1/4 tablet 2x/day. It seems that Vet 1 advised double dosage at 1/2 tablet 2x/day.

In any case, the owners felt that the dog did not need so much antibiotics. So they gave 1/2 tablet 1x/day (which is what the manufacturer recommended) from May 16 for 20 days till Jun 4, 2010.

Baytril was effective as the pus discharge occurred only on Jun 11, 2010 (2 days ago). "What did Vet 1 advised?" I asked the owner. "Vet 1 said that the wound would not be going to heal and would come back again. She advised dental work after the antibiotics."

In this case, the owner was informed about the need for "dental work" and that the wound would return again. They were also informed about the high risk of anaesthetics and had cancelled a dental scaling one year ago. However, in the case of oro-nasal fistula, they had no choice. They were fortunate that the old fawn coloured Maltese X survived.
What is an oro-nasal fistula?
It seems that the internet had much information for the young owners, and so I did not need to elaborate. Basically, it is a wound in the face connecting the sinus to the roots of the pre-molar 4 tooth. It is also known as carnaissal tooth abscess.




A non-healing facial wound below the eye

Extraction of the carnaissal tooth is the only solution to cure the condition known as oro-nasal fistula or carnaissal tooth abscess

Friday, June 11, 2010

97. Puppy shreds papers and soiling herself

E-MAIL TO DR SING DATED JUN 11, 2010

Dear Judy,
I juz got a cockapoo for 1 wk. She is 2mths old now. Currently we
placed her in a big playpen w toys, hanging water bottle & a security
towel. There is also a corner in e pen where she pees n poops
successfully on everytime. I bring her out in short intervals abt 3
times a day, allowin her to play ard the living room. Her pen is in a
corner of the living room by the way. After playin, when I put her
back to the pen, she will pee on the papers. The problem is, she also
likes to lie on the papers, clean or soiled, when she is playin alone
w her toys, n when she starts to shred and eat the papers when bored.
I've given her toys n pushed her away when I c her on e papers. But
without supervision, she ends up on it again. When we wake up in e
morning, e soiled papers will be shredded, her toys on her urine, n
her body reeks of urine smell. What should we do? Why does she do
that? Should I expand her pen furthur? I await your kind advice. Thank
you!
Thanks & regards
Name of Owner

Sent from my iPhone

E-MAIL REPLY FROM DR SING DATED JUN 12, 2010

I am Dr Sing for Toa Payoh Vets. Thank you for your e-mail.

From your description, the puppy pees on the papers at a corner of the playpen. But she also shreds the papers. Paper shredding is a common complaint of confined puppies. As to why they do it, it is likely to be fun.

Here are some suggestions:
1. Just do not make a fuss when you see the puppy shredding papers
2. Change the soiled papers without scolding the puppy or making any comments. Your reaction makes the puppy repeat her paper shredding to get you to pay more attention.
3. Tape the 4 sides of the newspapers onto the floor (the corner of the playpen). This may not be fool-proof.
4. I saw an invention by some people at a Singapore pet shop some time ago. It is a clip-on rectangle to hold the papers tightly so that the puppy cannot shred them (in theory). This invention was not marketed well and is hard to find. Maybe you can make one with 4 pieces of wood or metal rods (which holds newspapers in the library).
5. Some owners buy the "puppy diapers or pads" which have tapes to stick it onto the floor. The puppy may or may not shred it.
6. Paper training takes a lot of time. When the owner pays a lot of vocal attention to this misdeed, it is hard to stop the puppy shredding. The puppy just loves attention and the owner keeps scolding. This is attention to the puppy. Therefore be silent.
7. Soiling herself overnight. This puppy has no "clean" instinct. Check how she was housed in the previous place (seller). Was she housed in a grate + pee pan. If that is the case, don't expect her NOT to enjoy shredding papers as she had no previous paper experience.
8. Please e-mail me 3 pictures of top views and side views of the playpen and puppy (newspapers in the corner) as sometimes, I can provide advices better after seeing the housing floor plan.

Wednesday, June 9, 2010

96. Treatment of canine perianal (circum-anal) gland tumours

INTRODUCTION
Certain breeds (e.g. Siberian Husky), old dogs and intact (not neutered) males are more prone to perianal (circum-anal) gland tumours. The majority of tumours are benign and are called perianal (circum-anal) adenomas. The malignant ones are called adenocarcinomas. They can't be differentiated by visual inspection. A histopathology of the excised tumour is needed to check whether it is cancerous.



TREATMENT - 3 OPTIONS
1. Surgical excision. Most perianal gland tumours are benign but only histopathology can determine whether they are benign adenomas or malignant adenocarcinomas. Some vets don't perform this surgery as there may be worries of the wound not being able to heal and close. The client may get very angry as the dog will keep licking the open wound. Old dogs may die under general anaesthesia on the operating table leading to highly emotional scenes and potential litigation.

These are two main reasons why some vets don't want to operate. It may be kinder to pets for such vets to ask the owner to seek a vet who will operate as the dog licks the infected tumours to relieve its pain. Blood dripping from the backside can be quite inconvenient to the owner. Owners may need to be proactive in seeking early surgical removal.

2. Neutering. Perianal gland tumours are most common in male dogs that are not neutered. Seldom occur in female dogs. In this case, a female spayed Siberian Husky had one such tumour.

3. Hormone treatment.
Tardak is an anti-androgenic hormone. Injections may be effective but need to be given regularly when tumours occur.

Tardak is for use in male dogs and cats in the following indications:

3.1 The treatment of hypersexuality (humping, wanting to stray).

3.2 The relief of prostatic hypertrophy whether benign, carcinomatous or when due to chronic inflammatory processes. In inflammation, antibiotics and anti-inflammatory drugs are used too.

3.3 For the treatment of circum-anal (perianal) gland tumours.

3.4 For the treatment of certain forms of aggressiveness, nervousness, epileptiform seizures and corticoid-resistant pruritus (developing into dermatoses and accompanied by alopecia).

4. Chemotherapy and radiation for cancerous types. This is not normally available for Singapore dogs.
INTERESTING CASE STUDY
Female spayed Siberian Husky, 11 years old suffered from blood dripping from her perianal tumour for over 4 months. Tumour ulcerates and become infected. If you see the black spot below and to the right of the anus, there were early signs of perianal gland irritation, as the black spot is due to continual licking over several weeks.

CHALLENGES
1. High anaesthetic risk as in all old dogs. The owner did not wish to have a blood test. The vet must inform the owner of the need for such a test to screen the health of the dog before anaesthesia and surgery.

2. Large tumour over 3 cm x 3 cm very close to the anus. That meant a large wound after removal of the tumour and difficulty in achieving normal closure.

3. The dog passes soft stools during surgery, resulting in possible contamination during surgery and after.

4. If the dog rubs her backside on the floor after surgery, the stitches may break down. A large e-collar prevents licking of the wound.

PLAN AHEAD
I advised the owner to get her vet who did not want to operate, to do full grooming esp. of the tail area, ensure no maggot wounds and prescribe oral Baytril antibiotics for 6 days.

PRE-ANAESTHESIA
On the 6th day, the wound was not infected. The dog's rectal temperature could not be taken as the dog struggled and leaked out urine whenever her tail was to be held up for the insertion of the thermometer into the rectum. She was in great pain in the anal area and tried to bite to defend herself. More urine leaked out as she struggled. I got her muzzled for the IV drip and the injection via the IV catheter of Domitor 0.15 ml.

ANAESTHESIA
Dog got shaved. Isoflurane gas was given by mask. I intubated the dog and isoflurane at 1-2% ensured surgical anaesthesia. I got a towel to cover the metallic operating table to prevent electrical shock when I used electro-surgery to excise the perianal tumour. A swab with saline was placed on the indifferent plate and the dog's belly for the conduct of electricity during electro-incision and cautery.

ACTUAL SURGERY, JUNE 9, 2010 FROM 2.17 PM - 3.15PM
1. I used electro-incision to cut off the tumour. The dorsal part has a dark red mass of 0.5 cm x 0.5 cm. The main mass was hard, nodular and ulcerated. It was 2.5 cm x 2.5 cm. The shorter the surgery, the better the chances of survival.

2. A small artery at the ventro-lateral area nearer and below the anus spurted out red blood. I ligated 3 times. Coagulated the bleeding point. Finally, there was not much bleeding.

3. As the elliptical gap was large and under high tension, I had to reduce the tension in order to enable good wound healing. I extended the skin incision to the left at the dorsal and ventral edges above and below the anus respectively (see illustration). The wound was stitched with 3/0 sutures.

4. During closing, this dog kept passing out the loose stools despite her rectum being plugged by a 3-ml syringe. I replaced this syringe with a 5-ml syringe but the stools kept pouring out. This was be possibly due to the minimal isoflurane gas being used and therefore the dog's defaecation reflex was present. The dog's tongue was not a healthy pink and sometimes it turned cyanotic. Since the owner did not want a health screening blood test, it would be difficult to know if this dog had anaemia, hypercalcaemia, kidney or liver disorders.

POST SURGERY
The dog woke up within 10 minutes as if she had a good nap of over 30 minutes.
I gave 2.5 ml of anti-spasmogesic IV to prevent more loose stools coming out to contaminate the wound. She wore an e-collar. I phoned the owner to take the dog home. They came to visit her in the evening.

HISTOPATHOLOGY
The vet must inform the owner that there is histopathology to verify whether the tumour is cancerous or benign. In this case, the owner did not want it.

CONCLUSION
Neutering and surgical excision are recommended. Tumours are best removed when they are very small. I advise two anti-androgenic injections post surgery at 2-weekly intervals. Neutering your male dogs when they are young and/or weekly examination of the anal area will ensure that your dog live longer. This case has a happy ending. However, vets are not Gods and there will be deaths of old dogs on the operating table. It is best that the owner gets the tumours excised when they are very small in size.


Latest info at www.toapayohvets.com

Friday, June 4, 2010

95. Perianal tumours in the dog

In the afternoon of June 3, 2010, I had taken out the files of the old Shih Tzu with gigantic perianal tumours and gave a review of this case to a new intern who was a Junior College Year 2 student from Raffles Institution.

I had driven back to the surgery with an old Shih Tzu that had large perianal tumours excised by me four months ago. However his tumours had not recurred, so the old illustrations in my case sheets would be the only way to educate her. I do illustrate my surgical cases for review and to give to my clientele to educate them and their families.




For the benefit of readers, the tumour case is described at:
Buying Time For An Old Companion - Cicum-anal (perianal) tumours in a male Shih Tzu

http://www.sinpets.com/dogs/20100533perianal_circum_anal_tumours_dogs_ToaPayohVets.htm

Jun 2009. Surgery aborted as the dog went into cardiac failure. Only the largest tumour was excised.
To continue surgery would be very foolish as no owner wants a dead dog with a completed surgery




Feb 2010. Dog came with larger tumours





Jun 2010. No recurrence of circum-anal tumours for the past 4 months after excision, neutering and an anti-androgenic injection. So is he fully cured?

Weekly monitoring of the anal area during bath-time will be ideal and any small tumours be resected or reduced by an anti-androgenic injection. But which owner would remember to do the weekly checking for perianal tumours?
"I have not seen many cases of perianal tumours as they predominantly occur in male un-neutered dogs," I said to the intern. The old Shih Tzu I drove back in my car now had a normal backside and so I could not show her the real thing. "Perianal tumours, also know as circum-anal tumours seldom present themselves in neutered male dogs or female dogs. Many Singapore dogs are sterilised as dog licence fees are much lower. This is why there are so few cases."

In the evening, I visited a veterinary surgery whose founder is an old colleague of mine during our employment by the Primary Production Department (PPD), Singapore. The PPD is now called the AVA (Agri-Food and Veterinary Authority.

 "How many cases of perianal tumours have you seen?" I asked the founder's son who was on duty. His mum had not been in good health and was not in the practice.

The son would be at least 30 years old. I could remember him as a 10-year-old running around in his mum's surgery when I was doing locum some two decades ago. Now he is a young father and have to bear the responsibilities of taking over the practice.

On this fine evening, I was shocked to see that he had both sides of his head shaved bald, leaving a central high turf of hair bleached brown. I could never imagine he would be this fashionable when he was half my height during his childhood days.

The son said: "I don't see many cases. There is one 10-year-old Alsatian in the Army having this anal problem. The Army would not send it for treatment and I donated some of my cream for the dog."

"Is the dog suffering from anal fistulas? Or circum-anal tumours? Why don't you get him treated?" I asked.

"The Army takes a long time to decide on treatment," the son said. "There are many considerations before a sick dog can be sent to the vet for treatment. The Army sends their dogs to two veterinary practices if necessary."

"Why don't you ask the Army to send the old dog to me for surgery?" I asked him. "I will charge $100 for everything to be done." The son who was doing reservist duties in the Singapore Armed Forces Provost Unit's Dog Company. I was a veterinarian in charge of the health of guard dogs and tracker dogs in this Dog Company when I was doing my National Service in the early 1970s and am concerned about the health of this old guard dog.

"It is not so easy to send a sick dog to the vet for treatment," the son said. "The Army has to be careful of expenditure and has to justify."

This is a sad state of affairs as Singapore is a developed country and a retired guard dog's painful backside does not get treatment.

One can be idealistic but in reality, any complaint from me to the Commanding Officer would likely lead to euthanasia of the old dog. For $100, a retired dog's life is terminated by the bureaucracy. But which is worse? Suffering from a painful backside daily but being alive or death by lethal injection? Has the dog any choices? Is there public funding for such cases for retired army dogs?  There must be a fund to treat retired military dogs. In the meantime, I have to store away my idealism by keeping quiet. Rocking the boat will mean death of this dog as I doubt that the Army would even organise transport to get the dog treated for free.

At the surgery, I borrowed the son's new thick cat medicine book "Problem-based Feline Medicine" by Jacquie Rand, Edition 2007. I wanted to read more about a condition in cat where the mucous membranes of the cat's fauces are swollen and edematous. This surgery had many stray cat cases and this was why I came to ask the founder and her son about one case I encountered recently. It was an immune disease as prednisolone reduced the swelling by 50% the next day.

The name of the condition is plasmacytic-lymphocytic stomatitis/faucitis. My case was severe faucitis as the cat did not have inflammation of the tongue or gums. What a name for vet students or even vets to remember.

"Where's Dr Sing?" the receptionist said in a loud voice. I was sitting on the sole chair at the waiting area to her left but she could not see me. She had phoned a young couple to come to the surgery me after asking me how much I charged for surgery to excise the circum-anal tumours.

The couple had been to another vet since this surgery did not provide this service. The fees quoted was over a $1,000 and the couple must have sought the advice of the receptionist who asked me about my fees since I was present.

"Didn't you talk to the vet about the cost of over $1,000 perianal surgery?" I asked the couple.

"No," the young-looking wife whom I estimated to be in her 30s said. "A driver sent our dog to the vet." She looked young as contrasted to her husband who has many silvery grey hairs.

"Veterinary costs are now higher as many younger vets are more careful about litigation and demand blood testing prior to surgery." I said. "My generation appears backwards as we would have simply operated. However, nowadays, in a litigious society, there is no strong defence against professional negligence if the dog dies under anaesthesia if blood tests have not been done."

I asked the wife about the size of the tumour and to illustrate on a piece of paper. It was around 2-cm in diameter and was located below the tail and above the anus. This is a very difficult area to do surgery as there will be insufficient skin to stitch up. No wonder the founder did not want to perform this challenging task.

The continuous dripping of blood from the backside of their old Husky had caused the couple much distress. "Did you talk to the vet about the breakdown costs of over $1,000 for the surgery?" I asked the couple.
"No blood test will be done for the fee quoted by Dr Sing," the receptionist interjected. "I will not send the excised tumour for histopathology to check whether it is cancerous," I said to the couple. "That would bring down a few hundred dollars of veterinary costs."
"Blood test is important to screen the health of the dog before surgery. If the dog dies under anaesthesia, the owner may complain that the blood tests ought to have been done so that they would know the risks involved before surgery. The owner may sue the vet." I explained to the couple.
Blood tests would be useful as they can tell the vet that the dog is having a serious bacterial or viral infection or a liver or kidney disorder. Treatment would be done first if the health screening showed abnormality. A complete blood test would normally cost around $200.

"Is the Husky neutered?" I asked. "She has been spayed," the wife said. I had been presumptuous. This was a female dog. Perianal tumours are rare in females dogs but this was one of them. The world of veterinary medicine and surgery is full of surprises everyday.

"Get your dog's infected backside treated at this surgery first," I advised grooming, clipping of the backside and Baytril antibiotics for 6 days. "Otherwise the wounds will not heal well." The receptionist took out the case card and recorded what needed to be done. She calculated the cost and gave a fee estimate. This was the most efficient veterinary receptionist I had met and was definitely an asset to the founder of this practice. Knowing what to do and not wasting time is rare in many young receptionists. This receptionist was able to create loyalty in the founder's clientele from the way she cared about this customer by solving their problem. She must have overheard my conversation about perianal tumours with the founder's son as the door of the consultation room was open to the reception and knew what to do.
Sometimes the chemistry between a new vet and the prospective clientele is good and this was the case after several minutes of discussion and preparation for the surgery. This is important. The wife offered to shake my hands with me before she left.

There was a young girl in pink overalls working in this surgery. Her pink apron was unusual as I seldom see veterinary receptionist in pink. A slim quiet girl who would be learning from this receptionist on how to do things. I was introduced to her after her Miniature Schnauzer's bladder stone were removed by the son at my surgery (Toa Payoh Vets) some three years ago.

The son had operated on the dog. This was his first urinary stone removal surgery and his mum had asked me for assistance. So I was his mentor. See:
Mentoring a younger vet

Now three years later, the Schnauzer is OK and has no bladder stones although he has been eating dry dog food. "Are you feeding dry dog food to your dog?" I asked the girl in pink in a serious voice. She nodded: "Dr ... said it was OK." I was surprised that this Miniature Schnauzer did not get a recurrence of urinary stones despite being fed dry dog food after surgery and for the past three years.

"It is best not to as the bladder stones may recur unless the dry food is meant for dogs with urinary stones," I said to the young graduate.

There seems to be a high staff retention rate in this surgery. "Girls who left to work in banks would come back during Saturdays to work," the receptionist announced to me with maternal pride and to say that the founder was very caring about her staff.

I was most impressed with the management of the founder. It is hard to retain staff nowadays as many Singaporeans have lots of choices and are picky.

Good service helps to retain and grow clientele too. I was most impressed with this receptionist as she knows what to do to solve a client's problem on behalf of her employer without the need of prompting and reminders. She is worth her weight in gold. Gold prices are high and she is worth at least 80 kg worth of gold.


Photos and updates at:
http://www.sinpets.com/dogs/20100533perianal_circum_anal_tumours_dogs_ToaPayohVets.htm

Blood tests and pyometra

Many owners don't want blood tests prior to dental scaling or operations to save on costs. Here is a case where blood tests must be done to prevent litigation.

Sep 8, 2008
Chihuahu, female, 8 years
Not eating past 2 weeks. Sleepy. Big blod clots fom vagina passed 2 weeks ago.

Exam
395 fever
Enlarged uterus palpated 1 cm in diameer.
abdominal pain moderate lower half.

Closed Pyometra

Haemoglobin below normal. Total WBC 72 (4.5 - 13.5).
Neutrophils 97% Absolute 70 (1.8 - 7)
Lymphocyes 2.6 % Absolute 1.84 (2 - 7,8)
Platelts 2 9 (150 - 600)
Numerous giant plateles seen.

Bacteraemia and toxaemia.

Liver SGOT/AST 53 (<41)
Kidney urea and creatinine normal

Operated. Survived. OK as at Jun 2010.

Puppy with loose stools for a long time may get intussception

It is not normal.

Silkie was active and eating well, but passes loose stools since purchase 2 weeks ago and prior to purchase. When the puppy passes red blood, the parents and grown up childen consulted me.

Why and how to cure him?

1. It is not normal for the puppy to pass loose stools every day when fed dry food.


Causes:
1. Stress
2. Vaccination by the owner
3. Licking floors and objects
4. Given variety of puppy treats

"My puppy had diarrhoea for one month," my outspoken intern said. "He was OK after that. The breeder said it was due to vaccination."

"Loose stools is not normal," I inserted a cotton bud into the rectum to take stool sample. Fresh red blood stained the cotton bud.

"Now there is red blood. It may be parvoviral attack of the intestines. I got the parvoviral test done. It was negative. In this case, it would be professional negligent not to do the test in puppies having blood in the stools," I taught my assistant Mr Saw.

"Sometimes the vet does not think it is necessary," I said. "If the puppy dies a few days later when sen home, a complaint might be lodged with the authorities. The first question would be whether the puppy had parvoviral infection?"

As an example,I told him to test the 3 puppies sent in by the breeder. All breeders want the least veterinary cost and parvoviral tests cost money and some don't want parvoviral testing. Mr Saw did the 3 tests. One of them tested positive for puppies.


Later the intestines may telescope into each other resulting in lots of bloody stools and a need to operate. The condition is rare and is called intussception."

I had seen one case. Palpation of the abodomen can reveal a telescoped lump of small intestines. This puppy may have the start of intsussception. No X-rays are taken due to economic reasons. Puppy remained active.

Warded for 3 days.
IV drip, antibiotics and dry food.

92. Hypersexuality

Cocker Spaniel, Male, 5 years, Not neutered
Blood seen in the urine today
Eats OK, No fever
Why?

History: No previous occurrence

Urine test: Not possible as bladder is not full.

Examination: Penile tip is red and inflamed.

Traumatic injury. Does the dog hump people or objects?
"Yes" the owner said. "He has been humping pillows and the other dog frequently."

The diagnosis is traumatic injury to the penile tips due to hypersexuality.
This condition can be anti-social as visitors do not welcome their legs being gripped by the male dog.

TREATMENT

1. Neuter the male dog.
2. Anti-androgenic injections regularly has been shown to reduce the libido.

Thursday, June 3, 2010

Left perineal tumour in a male intact old Shih Tzu

Case Study 1. Circum-anal tumours and Tardak injection

Jun 1, 2009
Shih Tzu, Male, Intact, 11 years old, 7.5 kg. Can't take rectal temp. painful backside
Large left perineal tumour 10 cm x 10 cm in 5 globular lumps
IV drip + antibiotics

Jun 3, 2009
Decided to operate.
No histopathology for economic reasons.

Jun 8, 2009 Went home.


Jun 3, 2010
Facial dermatitis and eye ulcerations
Owner said the tumour did not recur after 2nd surgery and neuter.
He had not wanted neuter after the first surgery








Feb 2, 2010.
Left perineal tumour 6"x5"
Shih Tzu, Male, 12 years, 7.5 kg


Treatment
Feb 2, 2010
Pre-op IV drip + baytril 24 hours.

Feb 3, 2010
Clipped bald
Blood test
1. Liver disorder. High SGPT/ALT, SGOT/AST
2. Kidney disorder. High urea 13.3 (4.2 - 6.3). Creatinine low (29 (89 - 177)
3. Total WBC 30.8 (6 - 17)
Platelets 528 (200 - 500)




Zoletil anaesthetic 0.2 ml IV
+ Isoflurane gas > 1 hour
Surgical excision
2 packets of stitching
e-collar + rimadyrl painkillers for 7 days

Feb 4, 2010
Post-op swelling. Baytril 4 days and trimaxazole syrup

Feb 7, 2010
Neuter - 2 testicles removed.
Domitor 0.5 ml IV Antisedan 0.5 ml IV & post-op painkillers and antibiotics.

Feb 9, 2010
Parts inflamed Stitch breakdown at 8 o'clock and 12 o'clock
lst Tardak 10mg/ml inj. Bodyweight 6.8 kg. Tardak given at 14 mg or 1.4 ml SC
Another one on Feb 17, 2010 advised.
Painkillers tolfedine 60 mg x 2 tab. Pred 5mg 1/4 tab/day x 20 days
Tremethoprim, medazole,
Goes home.


The owner did not return for a 2nd Tardak injection.
"What is Tardak used for?" the JC 1 intern asked.


Jun 3, 2010
7.8 kg 39 deg C. Ringworm in body spinal area and face. To shave bald.
No tumour seen



Case Study 2. Hypersexuality and Tardak injection


Tardak (delmadinone acetate) is a potent anti-androgen 17 to 40X
the potency of progesterone. It is used for 3 indications

1. To treat hypersexuality (inhibit intersitial cedll stimulating hormone -->reduced testosterone production --> decrease libido. So it will be effective for dogs that hump cushions daily. Tardak 1.9 ml SC


2. Prostrate hypertrophy - due to chronic inflammatory process, benign hypertrophy or carcinoma. In inflammations, need to give antibiotics and corticoid.



3. Circum-anal tumours
Respond favourably so long as they are small.the larger they are at first treatment, the less encouraging is the prognosis.

90. William Somerset Maugham fan

June 3, 2010 meeting at Toa Payoh Hub

I was surprised and happy to meet a Singaporean who keeps the whole set of William Somerset Maugham books. Such men are rare as Singaporeans don't read.

"The pages are yellowed," he lamented.
"Do your books face sunlight?" I asked.
"Yes," he replied.
"Sunlight has a strong effect on books. Keep them in a dehumidifier. Do











you have book

89. Reverzine S.A (yohimbine)

Reverzine injection is an "antidote" for the reversal of xylazine-induced sedation and xylazine-ketamine anaesthesia in dogs and cats.

Active constituents: Yohimbine hydrochloride 1.25mg/ml
4-aminopyridine 2mg/ml

It must be given by IV. Not to be used for animals with cardiovascular, renal or hepatic disorders

Dogs: 1 ml/10 kg bodyweight
Cats: 0.25 ml/kg bodyweight

Parnell Laboratories (Aust) Pte Ltd

Wednesday, June 2, 2010

88. An independent contractor

REPLY TO AN EXPATRIATE VETERINARIAN WANTING TO WORK IN SINGAPORE

An independent contractor as a veterinarian means he does what he wants and just uses the facilities of service providers like veterinary surgeries. I hope you understand the concept and business model. It is lots of risks for you. But you cannot have the cake and eat it!

That is why I advise you (for your own good) to be an employee first if you really want to make your fortune in Singapore. There is no short cut to success as you will know by now. My real estate company, asiahomes.com started with zero income for around one year as I had to build it up. Same applies to toapayohvets.com. Vets are not supposed to advertise their presence in newspapers etc. So, it was tough, unless the vet is proactive giving seminars and doing charity.

I find employment agreements not good once the trust is gone as the employee sabotage begins since the employee cannot get out of employment. I think you need to write a business plan first. Ensure that your financial savings to last you at least one year as you will be an independent contractor.

Other things like accommodation can be found when you are here. An HDB apartment will suit your budget for at least the first year. Rental of whole 2-bedroom HDB apartment is around $1,500 - $2,000 per month. A car is essential if you want to do big house-call vet business. Taxis are not convenient. There is the car cooperative rentals. Wessex Estate houses are usually full as Caucasian expats love them.

Please note that I do NOT get involved in car purchases for independent contractors. In life, you need to do a business plan (income and expenses especially) even if you have lots of money. Otherwise the money just goes down the drain within one year. I know of rich and influential people who want to "invest" in veterinary facilities. For example, they provide land and buildings in Myanmar and I provide the rest. But I don't know them. So, I avoid them.

As for you, you need to think and think what you want to do in Singapore as you have to leave the comfort of your home to venture overseas to sell your services.

I met a young English vet who took over a practice from a German vet in Siem Reap. After 2 years, she gave up as business was not to her expectations. I visited her when during my travel to Siem Reap in January 2010. I thought there would be expatriate vets in Siem Reap and she was the only one. She was very frank with me about the business of veterinary medicine in Siem Reap. The difficulty in getting veterinary drugs and the culture of the locals. She decided to go back to England and my visit was her last day of practice. I learnt more from her failures and my other business failures. I can tell you it is very painful. Very costly and involved loss of huge amounts of monies.


So, I don't want you to suffer in Singapore if you are not into risk taking. Costs of accommodation, cars and other matters - if you earn money and have customers through referrals and excellent service and perform correct diagnoses - they are small change.

Best wishes

Dr Sing Kong Yuen

Tuesday, June 1, 2010

87. A biting dwarf hamster

At 2.5 years old, this dwarf hamster bites when touched. His lower body is deep red and he has a bare backside. So, he must be feeling painful. He scratches his ears all the time and sometimes his body. What is the cause of his itchiness?

Contact with rough pellets and water. He prefers to stay inside his feed bowl. Mum gave him tissue paper inside a yellowish bowl. He would drag the tissues out and place them on top of the pellets near the water bottle and sleeps there. The water bottle drips water. He gets wet. Being an aged hamster, his skin is no more as good as when he was young. With friction and dampness, his lower body gets irritated and inflamed. He becomes very itch.

I gave him clean paper litter and treatment for 5 days. He was much happier and his lower body became pink and not so red and itchy. He went home to the little girl who would look after him.

"How about his big lump on his right thigh area?" the mum asked. "It is better not to operate as he may just die under anaesthesia or after surgery," I said. "He is nearing the end of his life span." Hamster lives around 2.5 - 3 years.