Monday, March 28, 2011

376. Sunday case. No ringworm on post-purchase health check 3 weeks ago

INTERESTING CASES ON A SUNDAY
Sunday Mar 27, 2011

"My Jack Russell runs into chairs. He can't see today," I answered a phone call from a young lady on this unusually busy Sunday afternoon. "I wish to make an appointment." I usually don't work on Sunday afternoons and this was a bright sunshine day for photography. I have an associate vet on duty and that gives me time to smell the roses.

For some reasons, I decided to work this Sunday afternoon. The appointment system does not work in practice when patients bunch up their visits on Sunday afternoons. Some cases take longer (e.g minor surgery) and some patients don't come on time. The delays make several Singapore pet owners who come on time for their appointment very unhappy. The human medical hospitals have the same problem too. It is just not possible for the vet to see every patient punctually at the appointment time.

The best is no appointment. First come first served. But I prefer the appointment system as Toa Payoh Vets do perform surgeries even on Sundays.

So, on this particular Sunday afternoon, I skipped lunch and manned the reception counter to get a feel of the front-line phone calls and assess the waiting times. If my associate vet has to take some time in a case, I would step in. Otherwise, she would handle the cases as part of her working hours.

I usually arrive at 9.30 am on Sunday and weekday mornings to handle some cases while my associate comes at around 11 am. Sunday mornings seem to be quieter and I presume most Singaporeans are sleeping late or doing their own things.

At 10 am, a Caucasian couple in their late 30s came in with a cat. "My cat has ringworm and I also had ringworm," the lady said that she had her newly purchased cat examined 3 weeks ago by Vet 1 and was given a clear bill of health. Now she had ringworm and she diagnosed her cat with having ringworm.

I reviewed the medical record of Vet 1. I said: "There was a microscopic examination of the hairs and nothing abnormal was seen. It is possible that the ringworm takes time to develop and now 3 weeks later, the signs can be seen. The armpit and groin are big red circular patches of ringworm measuring at least 1 cm in diameter."

This is one of those post-purchase health-check for situations all vets will encounter. The animal is healthy at the time of examination to be free from signs and symptoms of contagious and infectious diseases. This must be stated in the form. In addition, I always draw the locations of the skin disease areas in the dog illustration in my case sheet and this is good practice so that the clients do not dispute that I have not checked the area and in cases of litigation.

As for Vet 1, the owner had complained to her about a small scab in the right armpit during her post-purchase examination 3 weeks ago. Vet 1 had checked it out by doing a microscopic examination of the hairs. No ringworm was reported by her.

Now, this is obviously a case of ringworm in the right armpit and groin area. The owner had now done her own diagnosis and she was spot on. "Ringworm can be transmitted from people to cats," I said. "It is not possible. I don't have ringworm before I purchased this cat 3 weeks ago. My kitten had a scab in the right armpit 3 weeks ago when I bought the cat to Vet 1."

The complainant was a lawyer by profession and it seemed she had evidence in her favour if this case goes to court. After all, she was a lawyer in a high flying firm and she can sue for failure to diagnose ringworm. The case for the defendant vet would be that she had done a competent job as what had been reasonably expected from a vet. This was the microscopic examination of the scab in the right armpit.

As Vet 1 did not record the location of the hairs she had taken for microscopic examination, I asked the lady owner.

When I asked the lady where the vet had plucked hairs for microscopic examination, she lifted the hairs from the spinal area indicating this area. This area was free from any skin disease!

Yet she told me she had complained about the scab in the right armpit area to Vet 1. So this would naturally be the area the vet had checked.

It is important for the vet to record in writing or by illustration or both locations of skin diseases.

As for this case, the treatment was the standard. I advised clipping of all hairs from the cat as there seems to be a generalised ringworm of the ventral part.

The lady did not want it and this was OK with me. If I had not advised and ringworm grows in the upper part of the body later (due to vigorous brushing and contamination of the upper body), I would suffer the same unhappiness of the owner.

"It is not nice to see a bald cat. I advise that the lower body of the cat be clipped bald so that you can apply the anti-fungal wash directly and then rinse off that infected skin area. The cat dislikes the whole body shampooing of the anti-fungal wash as there is a strong medicine smell."

The lady agreed to the lower body clipping and bathing and I advised her how to give the oral anti-fungal medication and to let me know if the cat had reactions to the drug.

One consultation would make an owner very happy as owners don't like repeat visits for ringworm! Happy owners usually are loyal clients. Therefore, be vigilant of a small scab in the armpit of the kitten, cat, puppy or dog during post-purchase examinations!

TIPS
POST-PURCHASE HEALTH CHECK
Ringworm may appear as a scab of 2 mm. I would advise that the area be thoroughly clipped and exposed. Then give it a wash and prescribe anti-ringworm wash. A microscopic examination negative for ringworm does NOT mean there is no ringworm. Veterinary medicine is always full of surprises.

PS
As for the Jack Russell that suddenly can't see, I will write the story in another report as it is 6.31 am on this Tuesday morning and I need to do other things.

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