Monday, May 23, 2011

452. Sunday May 22 2011's interesting cases

Bright sunshine blue sky Sunday

1. Case 1. 14-year-old Pom. The young lady came at 9.15 am as scheduled. "You know the high anaesthetic risk for old dogs?" I asked. "This could be the reason that the other vet did not want to operate and asked you to 'wait-and-see?".

She nodded her head: "She (the other vet) did say that it is highly risky as my dog is 14 years old."
I palpated the 3 cm x 3cm sized lump on the right chest. "There seem to be two lumps now," I said.

Case 2. Xylazine 0.1 ml IM was given at 9.20 am. I was about to commence anaesthesia when the owner of the Maltese with shivering came in to say that her dog still had a "swollen abdomen." I examined the dog. "No," I said. "But she has more back pain," I showed her the area of back pain in her dog by pressing and getting a response from the thoraco-lumbar area. "My advice is that the dog be confined inside a playpen for the next 3 months. If not, at least 1 month but very few Singaporean owners comply with my advice."

The dog was active and looked OK. What's the big deal? To prevent further damage to the spinal disc which could have prolapsed partially for now. But it is hard to make owners understand and so some vets just prescribe steroids, as in the case of the SGH Professsor's friend's Miniature Schnauzer.

"Can my dog take her daily walk and exercise?" the lady asked me. "No," I said. "Just go out to pee and poop, at least for 1 month."

Case 3. Soon another young lady with a heart-shaped fair face came. She had made an appointment for a second opinion on her 8-year-old Jack Russell, female, not spayed. "What happens to this area with bluish swelling?" she pointed to the high-energy dog's lower breast area. Two small hills from both mammary glands 4 and 5 on left and right.

"These could be due to the dog suckling her nipples here and causing the breast to swell with milk. The bluish colour is due to bruising from her suckling," I said. The young lady looked at me as if I was talking some nonsense. What did I mean?

I pressed one of the nipples in the bluish area. A missile of brownish discharge shot out onto my shirt. "Your dog has produced milk," I said. "She has false pregnancy." I showed her milk being produced by the other 2 mammary glands.

But her main purpose was to consult me about the abscess in the dog's elbows. Vet 1 had prescribed a cream. "Creams are ineffective," I said. "The dog just licks it off." She said: "I watch the dog for 2 hours. Every time she tries to lick, I will say 'no, no.'. I was impressed with her patience. "So what happens after 2 hours?" I asked. She sighed and shook her head. She could never beat time. So the dog just licked at the cream and the encapsulated abscesses on the elbow. "Surgical excision of such big abscesses is the only option," I said. She had also been advised to spay her dog to prevent pyometra (womb infection) later but she said the dog was too old.

Then she asked me about a globular growth above the carpus and the pad in the right foot. "What is this and what can be done?" I checked. "It is likely to be a tumour," I said. Again my advice was to excise it as it was now 5mm x 5 mm and would be easy to do so. The owner was not in agreement. So, I bundled some antibiotic medication and gave the injections and asked her to think about the surgery for the carpal tumour while it is still small in size. As for spay and the elbow abscesses, she had been given a second opinion. Maybe she needed a 3rd opinion?

Case 4. Just as I was going to operate on the 14-year-old Pom, another client came in with a large Samoyed said to be limping on and off in the front legs but appeared OK now. I had the Samoyed trotted outside at the side of the Surgery and told my intern Shirley to observe. Shirley wanted to study to be a vet after her graduation from the NUS and was working for the next 2 months. "Just listen, don't need to write much, " I said to her as she preoccupied herself writing the case being seen, as I wanted her to write reports to learn more, than just watching and forgetting.

After the trot which did not reveal limping, I got the dog inside the consultation room and got him on the table. Dr Vanessa had arrived and so I said she would collaborate me with this case as I would need to get operating soon. We got the dog on the table. The dog resisted being laid on her side and somehow we managed. I took the first examination and checked out the left forelimb. I extended and flexed the paws vigorously, then the carpus, the elbows, the shoulder joint. I abducted and adducted the shoulder vigorously. Not a whimper of pain from the dog. Somehow I sensed that the owners were worried about such a vigorous manipulation of the joints. However, this is necessary and normal joints, tendons and ligaments will not elicit pain. There was none.

"Now, it is your turn to check the right forelimb," I said to Dr Vanessa as we struggled to pin the dog down with her right side up. Dr Vanessa appeared to me to be gentler, picking up the paws to examine the inside for wounds. Each vet has his or her own method of limb examination. The dog could not be restrained and asserted her authority by getting up.

"So, is there lameness in the right leg or not?" the anxious wife in her 40s asked. "I can only confirm that the left front leg is OK since the dog will not permit any more examination!" I said. I left the case to Dr Vanessa as I had to operate the Chihuahua.

SURGERY. Careful and minimal isoflurane gas by endotracheal tube. It was bad news for the owner. Under the skin were a cluster of black grape-like lumps and more smaller ones spread further out, covering the subcutaneous tissue of around 6 cm x 4 cm. I tried to cut off all the grey "grapes" with the biggest being 4mmx4mm and sent them for histopathology. I suspected melanomas which have spread. I was frank with the lady owner: "It is bad news as the tumours have spread out like from the main cluster. Some are very small. It is not possible to remove 100% as some cannot be seen yet. Also, I can cut off the whole piece of affected skin as there will be a large hole on the chest."

The young lady closed her eyes and I could see that she was sad for her companion of 14 years. If only she had checked the dog daily and got the lump removed some months ago. Wait-and-see is NOT the advice of the vet for old dogs with tumours as some may be malignant. All dogs with tumours should be advised to be excised as vets are not gods and in this case, the wait-and-see advice was not good advice.

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