Friday, September 30, 2011

650. Adult Schnauzer boarded at pet shop for 20 days- vomiting and diarrhoea

The couple came with a Schnazuer boarded for 20 days. Ear infection and loose stools with blood. So, the pet shop operator asked her to consult a vet after discharge.

Know the history of the pet shop. This pet shop sells many puppies and has a history of parvoviral deaths. So I told Dr Vanessa that parvoviral tests must be done. Blood tests were taken. There was a fever.

Examination - pus in both ears.
Test - faecal parvovirus negative

Thursday, September 29, 2011

649. Old Fox Terrier with ear infections for the last 10 years

RINGWORM IN AN OLD FOX TERRIER, Male, 12 year

"Ringworm comes 2x per year for the last 10 years," the senior citizen who lived nearby had been consulting a vet for the last 10 year as his dog showed ear irritation. "The vet advises ear canal ablation," he said. The chest on both sides and the back legs were bald too.

A loud liquid swishing sound in both ears as his wife poured commercial ear drops.
"This flooding of the ear canal would never permit it to heal." The ear surface near the opening of the vertical canals were scratched black. No ear pain but full of yellow liquid, I noted in my record.
"When you started seeing the vet?" I asked.
"Since my Fox Terrier was to 2 3 years old."


I did a blood and urine test. Nothing abnormal. 10 kg was good weight. Only bad breath. Teeth looked sound. Epulis on gums.

Sedated. Irrigated the ears. Advised the owner not to flood the ear canals every day. Keep the canal dry. To review in 4 weeks.

That was Jun 2011. In Sep, the owner came saying that there were some scales on the back. "Ringworm again," he said.
"I did ask you for a review after medication for 20 days," I replied. He did not turn up.

However, he was much pleased with the hairs having re-grown on the sides of the chests. Skin diseases like ringworm are hard to treat if the owner's home hygiene is not up to the standard. Similar for ear infections. A combination of drugs and injection apparently cured 80% of his dog's problems. Otherwise, he would need to consult another vet.

RINGWORM IN AN OLD CHIHUAHUA, Female, Spayed, 12 years
"I am used to consulting you," the wife came at 9.30 am. Her husband accompanied her.
Ringworm circular patches and scales esp. around the neck. Very itchy. She was not infected.
"Ringworm again," I said. She said the ringworm came some years ago after going to a groomer. So she bought her own clipper to shave the hairs down to the skin. But still ringworm after consulting my associate vet. So she wanted to consult me.

Skin disease cases need a lot of time and patience to know the lifestyle of the dog and client. The home environment. The grooming schedule and type.

"Your clipper has lots of ringworm spores," I explained to her. "You did not disinfect it with proper anti-ringworm medication."
"I use lysol disinfectant," she said.
"Not effective.
"Did you clip the dog all bald 100%?" I asked.
"I leave some hair on the neck," she said. Later her husband told me she also left the tail unclipped.
"So the ringworm comes back because the remaining hairs are contaminated."

The couple were satisfied with my explanation about the cause and the need to be hygienic. Should have no more ringworm, I hope. "Slim her down," I said to the wife as the dog loved to eat. "Otherwise she would have heart disease."

This husband seems to me to love his wife very much and even took time off to get her dog to the vet for ringworm. Instead of self-treatment.

648. Dwarf hamster, female, 7 months, everted pouch

The young lady's vet gave a baytril 1% oral antibiotic 2 days ago. He said he would not operate as he was not able to do so. The lady surfed the net. Isoflurane gas - the assistant must focus on this. Dr Vanessa operated with me. Clamped pouch. Hamster woke up. Anaesthesia. Excised with scalpel. Anesthesia again. Stitch 6/0 absorbable x 3 interrupted.

"Don't stress the hamster," I said. "Unclamp as the hamster had woken up. Anaesthesia again."
The pouch was thus stitched.

Questions asked by owner:
1. Feed liquid food? Not need.
2. Can she store food? Not much as 80% had been cut off.
3. What if she did not get surgery done?
Pus already in pouch. Gangrene tip. Hamster will die from infections.

"Warts seen in right ear," I said. "If they grow bigger or the hamster feels itchy, they need to be excised." Presently her vet had give some anti-fungal wash to the other hamster with similar problem. Both hamsters live by themselves.

647. Parvovirus still kills puppies and young dogs


Recently I had a chat with Vet 1 regarding the importance of evidence-based medicine in the diagnosis of vomiting and diarrhoea in puppies. There was presented a case of a puppy with vomiting and diarrhoea vaccinated 5 days ago. Vet 1 did not think it was parvovirus since the puppy had been vaccinated and the recent vaccination was 5 days ago.

Vet 1 showed me two comments about parvovirus infections in a short paragraph in veterinary medicine text book edited by US vets. These comments are:

1. Parvoviral tests will provide false positive if the puppy has been vaccinated from 5 - 10 days ago.

2. Most puppies with parvoviral infections survive when given supportive treatment.


POINT NO. 1
Apparently one Singapore vet had remarked to Vet 1 that parvovirus test will show a false positive when the puppy had been vaccinated 5 days ago. Therefore, Vet 1 showed me the book which stated the same. I said: "Will Vet 1 put in writing that he or she finds that a positive parvoviral test is a false positive? I doubt it. The puppy may have got vaccinated 5 days ago but it could be incubating the parvoviral infections before that and shows positive on the test. So, it can also be a true positive."

In any case, I got this puppy which was vaccinated 5 days ago but suffering from vomiting and diarrhoea tested for parvovirus. It was positive.


POINT NO. 2

"From my experience in working with the professional dog breeders in Pasir Ris for around 2-3 years, covering almost all the breeders, I know that parvovirus kills puppies despite supportive treatment," I said. "This observation has had been reported by various breeders and vets in countries like Australia.

"Much depends on the immune status and age of the puppies, the number of vaccinations, whether the dams have had been regularly vaccinated to produce maternal antibodies, the environmental load of parvoviruses and the strains. The author of the book cannot be trusted as he wrote a generalised statement. Young puppies with one or no vaccinations rarely survive even with supportive treatment because they are very young and their immune system is not developed. Breeders sometimes miss out regular vaccinations of their dams and it is extremely difficult for breeders to isolate infected puppies owing to their management system of cleaning crates with the same brushes."

IMAGE SHOWS A CASE OF PARVOVIRUS WHERE THE PUPPY WAS VACCINATED 5 DAYS AGO AND SOLD. A DIAGNOSIS OF PARVOVIRUS ON EVIDENCE-BASED MEDICINE NEEDS A BLOOD TEST, PARVOVIRAL TEST TO CONFIRM THE CLINICAL SIGNS OF VOMITING AND DIARRHOEA.




In rare cases, expensive supportive treatment like blood transfusion, intensive care, IV drips, antibodies, long hospitalisations may save the odd puppy. But how many owners are willing to pay for such treatments which are not guaranteed to save the puppy? The puppy costs $500 - $1,000. Do you really expect the owner to shell out much more to save it without a guarantee of success? There will be owners but not many.

Two years ago, one pet shop girl told me that her staff spent $20,000 to treat her puppy with vomiting and diarrhoea at a veterinary practice when I tested it to be positive for parvovirus. The staff took the puppy to another practice for treatment since I gave a poor prognosis. I had no reason to doubt her story although it does sound incredible.

In the past years, I used to go to pet shops to vaccinate puppies even if there were only 2-3 puppies and got to know more about the practices of the pet shops and breeders. But I have stopped doing it nowadays as I need to spend more time with my private patients to build up the practice rather than being "not around" when I went to the pet shops and breeders.

Despite advances of the world's technologies, parvoviruses still kill puppies in 2011 and in some cases, young dogs that have not been vaccinated properly or not vaccinated.

website:
http://www.sinpets.com/dogs/20110926parvovirus-kills-puppies-singapore_ToaPayohVets.htm

646. Update of the massive perineal hernia in a Silkie Terrier 10 weeks later

FOLLOW UP ON CASE RECORDED AT:
http://www.sinpets.com/F5/20110714perineal_hernia
_old_Silkie_Terrier_male_dysuria_painful_backside_singapore_ToaPayohVets.htm


Yesterday, Sep 28, 2011, I neutered the Silkie Terrier that I had took 2.5 hours to operate to repair the bilateral hernias some weeks ago. I had asked the owner to return for neuter in 2 weeks' time after discharge but they did not do so.




Perineal hernias occur mainly in the older male, non-neutered dogs. Neutering removes the male hormones that favour the development of perineal hernias. I did not neuter the dog earlier as he is an old dog and anaesthesias are best kept to the shortest to ensure survival. After all, what the owner and vet want is a living dog at the end of surgery.

The dog had passed blood in the stools for the second time and that was why the owner sent the dog to me. "Why didn't you send the dog in for neutering as advised?" I asked. The left perineal hernia had recurred. The owners said they were busy travelling.

The blood in the stools was not present when the dog came in. The stools were loose. The dog looked great and had a glossy black coat and wagged his short tail whenever I see him. "It is the same Silkie," the owner assured me. "You can see the stitches in his backside hernia!"
10 weeks ago, a massive bilateral perineal hernia --->

Neutering was advised 2 weeks after recovery from the hernia repair. Neutering would reduce the male dog's frequent urine-marking behaviour (uncommon or much less urge in neutered males).

Straining the pelvic muscles is caused by urine-marking. Perineal hernias develop during old age, when the pelvic diaphragm muscles have been weakened.

10 weeks later, the dog came in for stools in the blood. The left perineal hernia had recurred bu on a smaller scale. Neutering was done.




Perineal hernia recurs 10 weeks later --->

The first approach will be to neuter the dog. Incredibly, around 12 hours after neutering, the perineal hernia had gone down by 80% in swelling when I saw him at 8 pm. He was neutered at 9.30 am on Thursday Sep 28, 2011. I could not believe it. The hernia had softened as the intestines and probably bladder had gone back into the abdomen on its own accord. I will have to wait and see.

ANAESTHESIA
6.4 kg. Domitor 0.1 + Ketamine 0.1 = 0.2 ml IV with normal saline 0.2 ml. This is much below my guideline of Domitor 0.4 + Ketamine 0.5 ml IV for a healthy 10 kg dog.

Isoflurane gas for 2 minutes
Intubated and given isoflurane gas
The dog stopped breathing and emergency measures were performed. I did cardiac massage and blowing into the endotracheal tube for around 5 minutes. The heart started beating and the dog started breathing.

Thereafter, isoflurane gas top up by mask was given in short doses of less than 30 seconds by mask. As the dog woke up from Stage 4 and vocalised, my assistant gave the isoflurane gas by mask for less than 30 seconds. As part of my mentoring, I gave a tip to my assistant Mr Min to monitor the depth of anesthesia using the eye blinking reflex. Once the blinking has ceased and the eye white rolls downwards, the dog is progressing into the Stage 4 which is surgical anaesthesia. The dog closed his eyes too.

In this case, the endotracheal tube was taken out as the dog did give a "vomiting" action earlier. Patience, focus on isoflurane effects and a longer time was needed to neuter the dog. The dog woke up immediately after surgery, therefore there was no need for Antisedan reversal of domitor. He was on the Stage 3 and Stage 4 anaesthesia and therefore woke up immediately since the dosage was slightly under.

As to what caused the cessation of breathing, it is hard to say. The dog's blood test was normal but he may have lung or other internal health problems, being an old dog. The dog had a 2.5 hour anaesthesia earlier with no problems.

Anaesthesia in old dogs is always a big risk. The left perineal hernia would need to be repaired as it was half the size of an orange. Otherwise the blood in the stools would present again as the intestines get trapped inside the hernia. If neutering stops further enlargement of the hernia, then no more repair would be done. We would wait and see as we don't want to take the anaesthetic risk in a well beloved old dog. I gave a Tardak 1.3 ml SC injection and the dog would go home on day 2 after neuter. The dog is much loved by the patriarch and he is such a happy friendly Silkie Terrier that can win the hearts of everyone. And the love of its owners.


Update and more images are at:
http://www.sinpets.com/F6/20110931perineal-hernia-recurrence-not-neutered-silkie-terrier-singapore_ToaPayohVets.htm

645. Singapore General Hospital - Pre-operation evaluation - anaesthetic risks

On Sep 28, 2011, I went to the SGH for a pre-op evaluation at 12.30 pm.

My general practitioner diagnosed a cyst behind my right thumb as part of an auto-immune disease. "This is not good news," I said. "Well, you asked me," he said and as I wanted a surgeon, he advised me to see Dr Foo. "Well, Dr Foo will refer you to a dermatologist," he said. But Prof Foo diagnosed it as a synovial cyst, drew an illustration in his case sheet and booked me for the pre-op evaluation and surgery. "You know that GA (general anaesthesia) carries risk," as I opted out of regional anaesthesia.

PRE-OP PROCEDURES ARE:
1. Blood test. A 20G needle with needle holder sucked blood from my left elbow vein into 3 tubes. No news is good news, the anaesthetist told me as not all tests were completed when she saw me at 2 pm.
2. ECG - 10 electrodes attached to me. ECG normal written in the print out.
3. X-ray - chest. Nothing abnormal.
4. Weight and height measured for BMI and Blood Pressure taken by a machine that costs $5,000 and need to be serviced half-yearly. The nurse was most cheerful.

Wednesday, September 28, 2011

Teach the young ones compassion to the disadvantaged and aged



Show our young ones how to help the disadvantaged and the poor and they will grow up to be kinder human beings

643. Recurrence of perineal hernia in the Silkie Terrier

FOLLOW UP ON CASE RECORDED AT:
http://www.sinpets.com/F5/20110714perineal_hernia
_old_Silkie_Terrier_male_dysuria_painful_backside_singapore_ToaPayohVets.htm


Yesterday, Sep 29, 2011, I neutered the Silkie Terrier that I had took 2.5 hours to operate to repair the bilateral hernias some weeks ago. I had asked the owner to return for neuter in 2 weeks' time after discharge but they did not do so.

Perineal hernias occur mainly in the older male, non-neutered dogs. Neutering removes the male hormones that favour the development of perineal hernias. I did not neuter the dog earlier as he is an old dog and anaesthesias are best kept to the shortest to ensure survival. After all, what the owner and vet want is a living dog at the end of surgery.

The dog had passed blood in the stools for the second time and that was why the owner sent the dog to me. "Why didn't you send the dog in for neutering as advised?" I asked. The left perineal hernia had recurred. The owners said they were busy travelling.

The blood in the stools was not present when the dog came in. The stools were loose. The dog looked great and had a glossy black coat and wagged his short tail whenever I see him. "It is the same Silkie," the owner assured me. "You can see the stitches in his backside hernia!"

The first approach will be to neuter the dog. Incredibly, around 12 hours after neutering, the perineal hernia had gone down by 80% in swelling when I saw him at 8 pm. He was neutered at 9.30 am on Thursday Sep 28, 2011. I could not believe it. The hernia had softened as the intestines and probably bladder had gone back into the abdomen on its own accord. I will have to wait and see.

ANAESTHESIA
6.4 kg. Domitor 0.1 + Ketamine 0.1 = 0.2 ml IV with normal saline 0.2 ml. This is much below my guideline of Domitor 0.4 + Ketamine 0.5 ml IV for a healthy 10 kg dog.

Isoflurane gas for 2 minutes
Intubated and given isoflurane gas
The dog stopped breathing and emergency measures were performed. I did cardiac massage and blowing into the endotracheal tube for around 5 minutes. The heart started beating and the dog started breathing.

Thereafter, isoflurane gas top up by mask was given in short doses of less than 30 seconds by mask. As the dog woke up from Stage 4 and vocalised, my assistant gave the isoflurane gas by mask for less than 30 seconds. As part of my mentoring, I gave a tip to my assistant Mr Min to monitor the depth of anesthesia using the eye blinking reflex. Once the blinking has ceased and the eye white rolls downwards, the dog is progressing into the Stage 4 which is surgical anaesthesia. The dog closed his eyes too.

In this case, the endotracheal tube was taken out as the dog did give a "vomiting" action earlier. Patience, focus on isoflurane effects and a longer time was needed to neuter the dog. The dog woke up immediately after surgery, therefore there was no need for Antisedan reversal of domitor. He was on the Stage 3 and Stage 4 anaesthesia and therefore woke up immediately since the dosage was slightly under.

As to what caused the cessation of breathing, it is hard to say. The dog's blood test was normal but he may have lung or other internal health problems, being an old dog. The dog had a 2.5 hour anaesthesia earlier with no problems.

Anaesthesia in old dogs is always a big risk. The left perineal hernia would need to be repaired as it was half the size of an orange. Otherwise the blood in the stools would present again as the intestines get trapped inside the hernia. If neutering stops further enlargement of the hernia, then no more repair would be done. We would wait and see as we don't want to take the anaesthetic risk in a well beloved old dog. I gave a Tardak 1.3 ml SC injection and the dog would go home on day 2 after neuter. The dog is much loved by the patriarch and he is such a happy friendly Silkie Terrier that can win the hearts of everyone. And the love of its owners.

FIRST PRESENTATION IN JULY 2011

AFTER THE PERINEAL HERNIA REPAIR



PERINEAL HERNIA RECURS. NEUTERING DONE.
http://www.sinpets.com/F6/20110931perineal-hernia-recurrence-not-neutered-silkie-terrier-singapore_ToaPayohVets.htm
Case report to be updated with pictures later

642. Clinical Research Project into normal blood values of Singapore's dogs and cats

E-MAIL FROM DR SING DATED SEP 29, 2011

Dear Dr ....

Thank you for taking the time to email to me. The following is my clinical research proposal which is of practical value for the health of dogs and cats in Singapore.

Presently, each vet practice in Singapore has its own blood testing machines or send the blood samples to Quest Lab which focuses on human medicine. The normal range of blood values vary greatly and are provided by the commercial people selling the machines or from some values published in veterinary books usually in the U.S.

For Quest Lab, the normal range given in their report is said to be for dogs and cats but since it is not a laboratory focused on veterinary medicine, I have not been able to find out from its staff where its reference values are sourced from.

Therefore I have had proposed a research project with Mr ... of .... Poly Veterinary to get a statistically significant sample of normal dogs and cats in Singapore to produce the blood values. This means working together with the bio-statistics department or a department that does clinical research to set up the research protocols to produce a scientific paper and statistically significant blood values for the normal Singapore dogs and cats.

Please let me know when you will be free to meet to discuss further.

641. Eye injuries are emergencies. Do not wait.

E-MAIL TO DR SING DATED THURSDAY SEP 29, 2011

Attn: Dr Sing - Regarding XXX's condition

show details 10:35 PM (6 hours ago)

Dear Dr Sing,

I visited your practice on the 16th of September, Sunday due to an ulcer recurrence in my dog, XXX's right eye. I first came in because he was squinting in his right eye for a few days and there was discharge. Dr Vanessa and yourself checked both his eyes with fluorescein stain and diagnosed it to be an ulcer and some scratches in the right eye, while his left eye was clear with no problems. Surgery was done to stitch up his eyelids and i was to come back in a week's time for review and another time in 14 days(02/09) for removal of stitches.

I came back on the following Sunday for Dr Vanessa to take a look at XXX and told her a problem that XXX had a few days after surgery - his left eye seemed problematic, there was a lot of discharge and he couldn't open his eye properly. She said to apply eyedrops and that another fluorescein stain test would be done next week again to see if there is an actual problem (it was not done that day because she said it is not good to do the test so many times in a short period).

Til today(23/09), i have been doing as told and his left eye does not seem to be getting better. He can barely open it, and there is still alot of discharge. Even after flushing it with saline, the discharge appears again in a few seconds. Today, i noticed that his right eye opened and i guessed it is because the stitches are dissolving, though the stitches are still on his eyelid. His right eyelids are swollen, and he still has trouble opening his right eye. I am not sure how much it has healed as it seems like how it was before surgery.

On the 10th of March this year, he had the same surgery done to his right eye, and right after removing the stitches 14 days later, you commented that the cloudiness has cleared by 50 percent. Thereafter, recovery was very good and both eyes were big, bright and clear. This time, the process is very different. His right eye does not seem to be healing well. He seems weak, lifeless and appetite has not been as good as it was before surgery.

I am certain that i have done the same things and have taken care of him the same way I did back in March. E-collar is put on 24 hours every day, medication is given daily, and i took extra care to separate him from the other dog at home. Because of his condition, i am constantly distressed and worried.

The purpose of writing to you is to let you know what has been going on with XXX. I hope that you can help. I will be at your practice this Sunday morning. Thanks for your time in reading my email.

Regards,
Name


E-MAIL REPLY FROM DR SING DATED THURSDAY SEP 29, 2011 4.42 AM

Thank you for your e-mail and excellent report of XXX's health. Eye injuries are emergencies and ulcers are best treated within 24 hours of injury.

1. Pl bring your dog to see me today, Thursday Sep 29, 2011, not Sunday, as what you described in your email is serious eye injuries in Russell. .

2. Separation of your dog from the other dog. By separation, I mean 100% total separation as advised and not even one minute of meeting each other at any one time. This is because the other dog would have licked Russell's eyes. The other eye could have been injured and become ulcerated. This would be likely what had had happened, in my opinion. I recalled that you had agreed to isolate Russell in the bedroom all at least 14 days. Did Russell "escape" out to play with the other dog or did the other dog enter the bedroom?

3. Please bring your dog in immediately today Thursday Sep 29, 2011 for me to assess urgently.



I checked my records. The case done earlier is at:
http://www.sinpets.com/dogs/20110317corneal-ulcers-dog-tarsorrhapy-3rd-eyelid-flap-toapayohvets.htm

Tuesday, September 27, 2011

640. Referrals from high-quality clientele

I witnessed an unusual style of management and advised my friend according to the e-mail as follows:

Yesterday, I was at your office and saw your style of leadership. It reminded me of a newspaper report in which the boss (father) of a big company has a habit of scolding his staff. His son was made managing director and could not get along well with some senior staff who resigned. From what I read in the newspapers, I assumed that the father must have had scolded and shouted at the son in front of the staff, as this is his usual management practice. The son who is well qualified and experienced in working for other big companies had returned to his father's business. The son resigned immediately. "Scolding and shouting at staff" is an old management practice which is not well accepted by the younger generation in Singapore and in other countries, from what I know.

It is not going to help you be successful in business if you continue with a similar style of management I described above. I saw you intervening during your Operations Manager's interview with an applicant, "scolding" the applicant in front of everybody saying you prefer not to accept her as she would cause trouble later to the agency.

For that particular "too smart" applicant asking a lot of questions, I will consider her a good prospective employee. It is best for a prospective employee to ask many questions from the employment agent before getting a suitable employer. This means she will not want to keep changing employers and that is good for the employment agency too.

It is common for an applicant to ask for the highest salary especially when they have Master's degree and a few years of work experience. So they become time-consuming pests, taking up much of the employment agency's time during the interview qualification.

As to whether the "too smart" applicant will cause trouble to the agency later, I don't agree with you as we cannot foresee the future. If you do a good job and follow the laws of the Ministry Of Manpower, knowing what to do in the processes, there will be little trouble. I will say that a "too-smart" applicant, if well serviced will provide more good quality referrals to you as that is her circle of friends.

Referrals are what most business survive on in the long term. And what a business want is high quality clientele. As a vet, I will wish to have high quality clientele who ask me a lot of questions about her pet rather than one who wants the lowest price in town and a service that cause me to lose money.

As a start up, if you keep on "scolding" applicants and staff, you will find that your business will not grow as staff do not stay long and applicants prefer not to do business with your company. You can blame every staff who resigns as not good staff. But in the end, it is the quality of leadership that makes or breaks a business. And that means retaining experienced staff.

I hope this e-mail will not make you angry. Staff management is a big headache for all companies but you can't do a business without staff.

Best wishes.

Sunday, September 25, 2011

639. Why 10-12 o'clock ulcer in the left eye of this Miniature Pinscher?

639. Why 10-12 o'clock ulcer in the left eye of this Miniature Pinscher?

Monday, Sep 26, 2011

I review around 50 images of the eyes of the fidgeting Miniature Pinscher whose owner reject injections and anaesthetics as a matter of personal preferences.

The green dye had stained the left eye 10-12 o'clock cornea a zigzagging green. I saw it. The owner saw it. But my camera techniques are lacking in that I can't capture the ulcer clearly in the operating room after application of the dye and doing hand-held. I had one respectable image. What I needed was a reflector but then Sunday was a busy day and I have not organised myself.

This morning at 8.30 am, I went through the 50 images again. Miniature Pinschers don't suffer from eye ulcers unlike the Shih Tzus and the Pekineses. She did have a small central eye ulcer scar of 3mm in diameter in 2006 when the owner first saw me and that was the only time I was consulted.

In retrospect, I must have not made a good impression to retain her services but this is expected for all vets as she lived nearby but went to another practice much further away. In any case, life is like that. Clients will doctor hop whether it is human or veterinary medicine but the vet must do his best in the diagnosis and bedside manners as well as in his receptionist services and other renovations. There are many factors involved in retaining a client's loyalty. A research subject and a book.

In any case, I was surprised that I had not seen the 3 melanomas on the upper eyelid at the 11-1 o'clock position. That is the cause of the ulcer which appeared just below these "melanomas." The 9-year-old spayed female dog felt irritated by these 3x3 mm lumps and must have tried to scratch them off. So, there was the zig zag upper corneal ulcer stained green. Vet 1 and I had not noted these melanomas. For me, the right eye was the main complaint and that was corneal degeneration/dystrophy. But the left eye was not normal as revealed by the green stain of ulcers.

The dog was moving. The owner did not want any sedation nor did I ask since she was not in favour of any injections or anaesthetics. She held the dog tightly. I muzzled the dog. Focus was on the right eye. The green ulcers in the left eye was picked up by the fluorescein dye. But what was the cause? I did say eye rubbing by the dog. The owner said: "I don't see my dog rubbing her eyes. Is the green dye poisonous?" Much of the time had been spent trying to flush away the green dye while the dog avoided by moving her head sideways. The owner tried to syringe the normal saline and said: "I wetted myself". The owner had wanted a male vet to check her dog out. Was it Dr Jason Teo or myself she could not say. It was me 5 years ago and so it was OK with her as she did not want to go to the "referred vet" named in the letter given by Vet 1. She did not believe that there are veterinary eye specialists in Singapore and this is correct.

The "melanomas" were small but could be seen clearly in the image. This shows that visual aids are good for reviews and help to diagnose. Will post the image later. It is time to go to work at 8.54 now and close the computer.

638. Sunday Sep 25, 2011 - A kitten's generalised ringworm infected the owner

The kitten has generalised ringworm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
STORY 1
The pet transport man came to get the address to pick up two kittens from The Sails condo at Marina Bay. "Today is F1 day. The road to this condo will be closed," I said. Dr Vanessa will phone the owner to inform her.

The owner who had connections with my old school known to produce "nerds" according to her, had e-mailed to me for a house-call which was done by Dr Vanessa. She brought back a kitten full of ringworm on the skin. As I was around when the owner came, I had a word with her on ringworm. Sometimes it is fun to help the owner know more about their pet's treatment, reinforcing Dr Vanessa's advices and this communication from two vets instead of one makes the owner's visit much more interesting. Most times, I don't introduce myself and am mistaken for the receptionist or vet assistant. This owner had a lot of tattoos which surprised me as she was a young fair lady. She had ringworm lesions on her throat, her thighs and her belly and showed the anatomy to Dr Vanessa and I. Well, this is a modern world and I lifting the blouse to show ringworm lesions in the belly is not immodest.

She showed me a tube of cream to apply to her various ringworm lesions. "I feel so itchy," she said or that was what I heard. Well, she had so many infected skin spots shaped like a ring and ringworm is a very itchy disease. I am surprised that her finger nails have not been infected.

"Normally, the doctor will prescribe a tube of cream. You should ask your doctor to prescribe oral medication if it is widespread," I advised and told her that ringworm is common in Singapore's dogs and cats when she asked. "We are treating your kitten with medication and ringworm washes, but no cream as kittens lick away the cream and poison themselves in the long run."

"Long ago, I had ringworm in my hair when I was an undergraduate in Glasgow University. It was very itchy and took several weeks to be cured. I had to take tablets and de-contaminate my clothing as well. You need to de-contaminate your apartment, brushes and sleeping areas!"

"Can I have some of the tablets you prescribe for the kitten?" she asked.
"No, no," I said. "We are licensed to treat animals, not people. You can speak nicely to your general practitioner and ask for the oral tablets. I am sure he will give them to you." I don't know whether I had heard clearly whether she said she had ringworm in her back. It would be difficult to apply cream there herself. Fortunately, her hair was clear of ringworm.



"I have engaged a pest controller for my apartment," she said.
"They are a waste of money," I said. "You need to personally clean up the apartment daily while the controller comes once. You need to vacuum the corners, wash the brushes and clothing and bed sheets and other. You need to get your other two kittens clipped bald as well as ringworm is contagious. Put your kittens in a carrier and bring them down to the Surgery quickly."

Dr Vanessa said: "I am getting Martin to transport the two kittens to be clipped." But the day chosen was F1 Sunday and so Martin came for nothing. Martin is our pet taxi man.

This reinforcement of Dr Vanessa's advices about ringworm is good for the lady as ringworm is a zoonosis. It may help to retain clientele and that is how a vet practice sustains its profitability. It is not about the individual veterinary ego although most owners prefer the vet that treats their dogs and in this department, Dr Vanessa is dealing with most of them and is the hot favourite.


STORY 2
From the receptionist's counter, I learnt much more about the owner's needs than as a vet. There was one interesting owner, a business man who kept asking me for the bill as he came to get his daughter's dog home from an overnight stay for treatment.

However, Dr Vanessa was in her consultation room discussing another dog treatment with some owners. This took more than 15 minutes and he was getting restless. So I talked to him as I did my work.

"How did you locate Dr Vanessa?" I asked.
"The counter girl at her old practice told me," he said.
"I thought the practice would never reveal as this means a loss of customers." Nowadays, don't expect your staff to be loyal to the employer anymore. It is now more like biting the hand that feeds you as times have changed. It is up to the employer to create loyalty amongst the staff but that is not easy as the younger generation goes to another place for a few dollars more.

"Well," he said. "Dr Vanessa must have been nice to the counter girls."
I agreed with him and asked what occupation he was in as a part of conversation.

"I am retired," he said. "What were you doing before you retired?" I asked. He was a food and beverage man.

"Did you read about the case of the supplier bribing the Chinese restaurant chefs with millions of dollars?" I asked.

"It is still a common practice," he said. "Only that this supplier was caught by the anti-corruption agents. Unlike big hotels that have a purchasing department, Chinese restaurant chefs are in charge of purchasing. So, they ask for money. Otherwise they will reject the seafood as not fresh. If they are bribed, they don't bother with the freshness or the correct weight of the food received. The supplier just increase the price or decrease the weight of the seafood to pay for the bribes!"

It is hard to eradicate corruption even in Singapore with the anti-corruption agency. We talked more about his excellent achievements of his two daughters and property investments during our era of the 1980s when bank loan qualifications were not so stringently controlled by the MAS (Monetary Authority of Singapore), the bureaucrats, the academics and the politicians.

I got a first-hand view of how he did his overseas development business which books will never be able to explain. He was around my generation. Then he asked what I did before becoming a receptionist since I was at the reception counter. "Well," I said. "You can say that I am the original vet as I started this practice."

Finally Dr Vanessa was free for him. "You have kept our friend waiting for a long time," I said to Dr Vanessa. "No, no problem at all," he said and gave Dr Vanessa the name of his business that is very good for her. A Victoria Secrets type of business. Women's business are the best in this world of business, besides property development.


Webpage at:
http://www.sinpets.com/dogs/20110927kitten-generalised-ringworm-shih-tzu-singapore_ToaPayohVets.htm

637. Pemphigus follow up on Sunday Sep 26, 2011

I thank you for your photos emailed on Sep 24, 2011. We met at the Surgery on Sunday Sep 25, 2011. I have had discussed with you further the management of pemphigus in your dog.

An auto-immune disease has no cure and control is by medication that has to be given according to response. There is no fixed formula for medication in auto-immune diseases as dosage depends on response and this can only be known through weekly or regular assessment. Too high a dosage results in kidney damage. Too low a dosage and it does not work.

On Sun, Sep 25, 2011 at 9:24 AM, ...@yahoo.com> wrote:

Dear Dr Sing,

here is an update since the review on last sunday.
the lumps on the paws are getting bigger and started to be smelly for the past few weeks; even the small lump at the mouth is also getting visible and seems growing.

i have attached some photos taken for the mouth, ears & paws.
pls advise.


E-MAIL REPLY FROM DR SING AFTER DISCUSSION WITH THE OWNER

From your feedback of the paws and the right gum swelling, the disease needs a higher dosage of medication for the next 7 days. This dosage depends on response for the next 7 days and frequent monitoring and discussion with the vet.

MANAGEMENT
Washing of the ear flaps and each paws in a bowl of warm water + anti-fungal solution, keeping them very clean and dry, wearing of pad stockings, applying anti-fungal cream to blisters, wearing an e-collar at all times and taking medication of the two immuno-suppressive drugs and antibioics are part of the management of this disease for the next 7 days and beyond.

Best wishes.

Two toilet training advices - a Sheltie puppy and 7-month-old adopted Golden Retriever

Young Sheltie.
Playpen with newspapers occupying 1/3 of the playpen space. The lady owner said this was successful. A couple with the wife being an accountant and the husband being a financial professional. At the reception, I had good discussions about accounting, purchase of an HDB flat and not being allowed to invest in private property for 5 years, the good prospects of accountants, the shortage of auditors, secretarial fees of $600 being said to be amongst the lowest in Singapore, financial leverage in property asset accumulation and property rental investments which the wife is keen on. Vets are encouraged to read financial and property news to be able to carry on such a conversation with some clients like accountants.

An accountant can open his own shop and sign documents if he has been certified by CPA Singapore. "A finance and banking graduate can do insurance," the wife said to me. "But he can't open his own shop," I said. "Insurance professionals setting up a shop requires the person to be qualified as an actuary." An actuary is a professional who deals with the financial impact of risk and uncertainty.


Adopted Golden Retriever

"I used to think that it is cruel to confine the dog," the young lady said to me as this was what Dr Vanessa advised her. She adopted the dog as the other friend did not want him. He peed and pooped all over the kitchen floor and apartment.

"The best is to confine him inside the common bathroom for 2-4 weeks," I advised. "Put feed and water bowls in front. Observe where he sleeps (clean area) and put newspapers to cover his toilet area. Put up a fencing barrier at the door entrance so that the dog can see everybody.

"Or bring the dog out to the garden spot after he wakes up and after breakfast and dinner. Give a routine to this dog and he will eliminate outdoors."

A 16-year-old Golden Retriever with thyroid tumour and a 10-year-old Shih Tzu with oral tumours.

CASE 1

"It is best to ask the family to wait outside," I said to Dr Vanessa who wanted to catetherise the vein to euthanase the old Golden Retriever in the presence of a family of around 8 sad members inside the consultation room.

Earlier, a lady had phoned about the cost of euthanasia and subsequent preparations for cremation. As Dr Vanessa was very busy on this Sunday Sep 26, 2011 such that she had no time for lunch, I spoke to the lady. If Dr Vanessa answered every phone query, her cases would be delayed and it would be past 7 pm before anybody can go home on this fine Sunday. We close at 5 pm on weekends and from Min, I was told that last Sunday's cases were completed at 7 pm. I was not around and so did not know why but this would have to do with the vet's management of case flow, answering of client queries and surgeries being done on a Sunday.

Anaesthesia and surgeries do take up some time and there were two (dental extraction of a foul-smelly old Jack Russell Cross and skin wart removal of a Shih Tzu) on this Sunday. In between consultations, the vet may have to answer phone calls and if this can be done by an experienced receptionist, it would be fine but sometimes the technical questions may be best answered by the vet.

In this case of the Golden Retriever, it would be much kinder to euthanase as he was not eating and had lost weight. The dog did not want to get up to walk to the consultation room but was finally persuaded to do so. I could see that it was very emotional situation especially for one lady who had spoken to me earlier.

The best way to handle such a case is not to euthanase the dog in front of all grieving members of the family. Some dogs react to the lethal injection by screaming and some lose control of their bladder and bowels or vomit. Such a scene is not pleasant for the owners. So I advised the family members to leave the consultation room and go outside as the old dog could sense their grief, in my observation and might be more stressed.

In this case, the owners said good bye to the dog and waited outside the Surgery. I advised a Domitor+Ketamine IM sedation first and euthanasia injection after 10 minutes. The dog passed away peacefully. The lady who cared most for this dog came to say good bye.

CASE 2.
I was at the reception area when somebody inside the consultation room bashed his fist at the wall separating the reception area and the consultation room. A dog had been euthanased by Dr Vanessa and the family members of parents and adult children were inside.

"What's happening to your clients inside the consultation room?" I searched for Dr Vanessa who was inside the Surgery to do the dental scaling and extraction. "I just heard a loud bang against the gypsum board wall." This wall is not solid brick wall and I can't afford to let clients bang till it collapses.

Dr Vanessa did not hear the loud bang. She said: "They are waiting for the cremation man and are preparing prayers for the euthanased dog." I had not seen this case. The father brought in some leaves and I thought a pineapple. The cremation man came and I quickly got him into the consultation room. Dr Vanessa came soon. Later the father told me that the dog had oral tumours which could not be cured.

Regular dental care and scaling usually prevents oral tumours but few Singaporean dog owners bother with dental health of their dogs. More are getting dental check up and scaling done on old dogs. The best is to get dental check up yearly but older dogs are generally left alone after the initial burst of attention when they are puppies.

634. Circum-anal tumours in a 14-year-old Shih Tzu

A young couple who came on Sunday Sep 25, 2011 as their vet (Vet 1) had at first said that their dog was too old for surgery to remove growths around the anus. When the growths spilled discharge, Vet 1 decided that surgery was necessary. A flip flop decision can cause a loss of confidence in a dog owner.

"Your dog has circum-anal tumours," I said while Dr Vanessa examined the dog with a stethoscope. "It usually occurs in a old dog, not neutered, old age. In some cases, on a busy day, I do get into the consultation room to do joint consultations with Dr Vanessa.

The young lady smiled. I was right on 3 counts. "Do you know what is the meaning of circumference?"

The couple nodded as they would have studied this during secondary school in Singapore. "Vet 1 is correct in saying that your dog is 'too old' for surgery - meaning that it is highly risky to operate on your dog as he may die from general anaesthesia. He is already 14 years old and is very old." I told the couple of a 16-year-old Fox Terrier whose circum-anal tumours grew to large sizes such that they cause a lot of bleeding and infection set in. This would be what happen if the dog lives up to a very ripe old age.

A blood test had been taken. This is a very high risk anaesthesia. I spoke to the couple and Dr Vanessa. If the anaesthesia is less than 15 minutes, the old dog seldom dies from anaesthesia. "That means doing the operation in 3 or 4 stages," I said to the couple. "Neuter first to remove the male hormones stimulating the growth of the circum-anal tumours. After 3 weeks, remove the larger tumours within 15 minutes and repeat with the remainder some 4 weeks later."

The tumours had spread under the anal skin from 9-3 o'clock in the upper side. Then at 5 o'clock a large tumour protruded with another small one. I did not take a picture. But this would be a protracted surgery and highly risky. If neutering and Tardak injection shrinks the tumours, then there may be less operating time. But owners and vets need to be patient in the treatment of circum-anal tumours in a very old dog.

633. Cost to spay a cat at Toa Payoh Vets

Just picked up a stray.
Please tell me what the cost is to spay.

Thanks
Owner



E-MAIL REPLY FROM DR SING DATED SEP 26, 2011
For a cat, the spay is $100. The estimated cost will be around $150 including anaesthestic, spay surgery and post-op antibiotic and pain-killer injection and tablets. E-collar is excluded.
- Show quoted text -

632. Corneal degeneration in an old Miniature Pinscher, FS, 9 years

SUNDAY'S INTERESTING CASE

The owner wanted a diagnosis from me. She went to Vet 1 who referred her to Vet 1, but she said she still had to pay Vet 1 for a non-diagnosis. I showed her that Vet 1 did diagnose "lipid" deposits in the right eye and referred her to Vet 2.

"It must have been a long time since I usually keep older records stored outside the Surgery," I said. She showed me my 2006 Toa Payoh Vets receipt with my pen illustration of "left eye white central scarred ulcer - 3mm diameter". I was impressed that she kept records. That was 5 years ago! "It was the left eye affected," she said. "The spot disappeared after a while."

"Did you use the eye ointment?" I asked.
"No," she said. "My dog disliked it".

EXAMINATION
1. To check whether the right eye had corneal ulcers or not in addition to the lipid deposits.
I showed my assistant Min how I used the fluorets paper strip. I placed it onto the lower fornix and closed the eyelid. The dog blinked many times. Green dye gathered below the lower conjunctiva.
"Is it dangerous to my dog's eye?" the owner asked. "No," I showed her the seller was Bausch and Lomb which she had instant knowledge but said that there was a lawsuit against this company for the contact lens solution.

Results: No green ulcers in the right eye but there were 11 to 1 o'clock ulcers in the left eye!

2. Digital photography useful esp. side views of corneal degeneration. Axial central corneal degeneration 4x3 mmx3mm. It looks like it is going to bulge out and ulcerate. Owner had said the swelling suddenly appeared in the last month.

3. Blood tests for thyroid and cholesterol not done yet due to financial considerations. Hypothryoid and high cholesterol are said to be important in this degeneration where aqueous fluid enters the endothelium, causing edema and whiteness and swelling (side view of image).

DIAGNOSIS
Right eye - corneal endothelial dystrophy. No definite cure as this is due to aging. Blood tests for thyroid hormones and cholesterol levels advised.
Left eye - corneal ulcers due to eye rubbing of the 3 upper eyelid "melanomas". Excision of the melanomas will prevent ulcerations.






TREATMENT
Usually not curative. Low fat diet 8% fat? Check thyroid hormones and cholesterol levels.
Prevent further corneal degeneration? What drug?
E-collar and antibiotics to prevent left eye rubbing although the owner said she never saw actual rubbing.


Website with more photos
http://www.sinpets.com/F5/20110928corneal-ulcer-eyelid-melanoma-miniature-pinscher-singapore_ToaPayohVets.htm

Saturday, September 24, 2011

Parvovirus kills puppies

Recently I had a chat with Vet 1 regarding the importance of evidence-based medicine in the diagnosis of vomiting and diarrhoea in puppies. There was presented a case of a puppy with vomiting and diarrhoea vaccinated 5 days ago. Vet 1 did not think it was parvovirus since the puppy had been vaccinated and the recent vaccination was 5 days ago.

Vet 1 showed me two comments about parvovirus infections in a short paragraph in veterinary medicine text book edited by US vets. These comments are:

1. Parvoviral tests will provide false positive if the puppy has been vaccinated from 5 - 10 days ago.

2. Most puppies with parvoviral infections survive when given supportive treatment.


POINT NO. 1
Apparently one Singapore vet had remarked to Vet 1 that parvovirus test will show a false positive when the puppy had been vaccinated 5 days ago. Therefore, Vet 1 showed me the book which stated the same. I said: "Will Vet 1 put in writing that he or she finds that a positive parvoviral test is a false positive? I doubt it. The puppy may have got vaccinated 5 days ago but it could be incubating the parvoviral infections before that and shows positive on the test. So, it can also be a true positive."

In any case, I got this puppy which was vaccinated 5 days ago but suffering from vomiting and diarrhoea tested for parvovirus. It was positive.


POINT NO. 2

"From my experience in working with the professional dog breeders in Pasir Ris for around 2-3 years, covering almost all the breeders, I know that parvovirus kills puppies despite supportive treatment," I said. "This observation has had been reported by various breeders and vets in countries like Australia.

"Much depends on the immune status and age of the puppies, the number of vaccinations, whether the dams have had been regularly vaccinated to produce maternal antibodies, the environmental load of parvoviruses and the strains. The author of the book cannot be trusted as he wrote a generalised statement. Young puppies with one or no vaccinations rarely survive even with supportive treatment because they are very young and their immune system is not developed. Breeders sometimes miss out regular vaccinations of their dams and it is extremely difficult for breeders to isolate infected puppies owing to their management system of cleaning crates with the same brushes."

IMAGE SHOWS A CASE OF PARVOVIRUS WHERE THE PUPPY WAS VACCINATED 5 DAYS AGO AND SOLD. A DIAGNOSIS OF PARVOVIRUS ON EVIDENCE-BASED MEDICINE NEEDS A BLOOD TEST, PARVOVIRAL TEST TO CONFIRM THE CLINICAL SIGNS OF VOMITING AND DIARRHOEA.

In rare cases, expensive supportive treatment like blood transfusion, intensive care, IV drips, antibodies, long hospitalisations may save the odd puppy. But how many owners are willing to pay for such treatments which are not guaranteed to save the puppy? The puppy costs $500 - $1,000. Do you really expect the owner to shell out much more to save it without a guarantee of success? There will be owners but not many.

Two years ago, one pet shop girl told me that her staff spent $20,000 to treat her puppy with vomiting and diarrhoea at a veterinary practice when I tested it to be positive for parvovirus. The staff took the puppy to another practice for treatment since I gave a poor prognosis. I had no reason to doubt her story although it does sound incredible.

In the past years, I used to go to pet shops to vaccinate puppies even if there were only 2-3 puppies and got to know more about the practices of the pet shops and breeders. But I have stopped doing it nowadays as I need to spend more time with my private patients to build up the practice rather than being "not around" when I went to the pet shops and breeders.




Website:
http://www.sinpets.com/dogs/20110926parvovirus-kills-puppies-singapore_ToaPayohVets.htm

630. Inguinal hernia in a Shih Tzu puppy in Hawaii

On Sat, Sep 24, 2011 at 10:31 AM, ...@gmail.com> wrote:

My friend gave us a sweet loving 4 month old Shih Tzu who had an inguinal hernia. No one wanted her so I took her and planned to get her surgery taken care of. Well, my husband lost his job and we don't have the $1,000+ Hawaii charges for the 45 min. surgery. When she stands it feels like a golf ball and the other side ain't so bad. It hasn't grown. Can I monitor it? When do I know we're in trouble? Hope you can help.
Much mahalo for your kokua.
Name of owner


E-MAIL REPLY FROM DR SING DATED SUNDAY SEP 25, 2011


I am Dr Sing from Toa Payoh Vets, www.toapayohvets.com. Thank you for your email.

Inguinal hernias in Shih Tzus or other puppies vary in size. Small-sized hernias of less than 1 cm in diameter may not cause problems to the Shih Tzu and have been left alone without any health issues. Two health issues are as follows:

1. Since your Shih Tzu's hernia is the size of a golf ball (according to your email), it is best to get it repaired as soon as possible. This is because the intestines get trapped inside the hernia and may get twisted over time.

When the intestines get twisted, the blood supply to the intestines get strangulated and so the intestines cannot receive blood supply. The intestines become gangrenous. The puppy's inguinal hernial area will be painful to the touch.

2. Some puppies keep licking the skin of the hernia till it becomes thin and rupture as they try to relieve themselves of the pain and irritation under the skin of the hernia. When the skin ruptures, the intestines and fat spill out, leading to the imminent death of the puppy unless the vet repairs the defect immediately.

I presume the puppy has no pain in the herniated area presently. Therefore you can still continue to monitor it. The hernia may get bigger with time as the puppy grows bigger. Therefore, it is best for the puppy to get such a large hernia repaired.

Explain to the vet your financial situation (discuss instalment payments) or look for another vet who may be able to help your puppy.

Pl email to me 2 pictures of the hernia (side view left side and right side standing) if possible. Best wishes.

Friday, September 23, 2011

Email about puppy toilet training - should the owner take it out to pee and poo?

On Fri, Sep 23, 2011 at 2:07 PM,

Hi Judy,
I read this article http://www.toapayohvets.com/sinpets/050620play_pen_toilet_training.htm and find it very useful. I am currently actively looking for a family pet and would be very thankful if you could help to answer my following query.
I am interested to use the crate + pee pan method or play pen + pee pan method. With one of these method, does it mean that they are trained to pee/poo inside the crate/play pen and I do not have to bring him/her out to pee/poo? How about at night? Do I still have to wake up and bring it to pee/poo or should I leave him/her in the crate/play pen? Your kind advise would be greatly appreciated.

Rgds,
Name of owner



E-MAIL REPLY FROM DR SING DATED SEP 24, 2011

I am Dr Sing from Toa Payoh Vets, http://www.toapayohvets.com.
Thank you for your email.

1. The objective of the two methods you mention in your email above is to confine the puppy for 2-4 weeks so that they will pee and poop within that confined area. However, the owner must clean up the soiled area immediately after the puppy has had eliminated. The puppy is naturally a clean animal and if the owner does not remove the stools or wash the soiled area, the chances of early sucess (ie. within 4 weeks) are slim.

1.1 Therefore, you do not have to bring the puppy out to pee and poop using the above methods. However, after midnight, in some situations where there is no distraction from many family members, (e.g. a couple living alone), some new puppies do make a lot of noise asking the owner to change/wash the soiled area. Owners who sleep near the puppies will do it. But most owners don't know and think that the puppy needs company.

2. If you wish to take the puppy out to pee and poop, you can do it but do it as a routine (i.e. at certain times e.g. after each meal) but you sabotage your objective as stated in Para 1. You just need to be consistent in your routine in toilet training.

I hope the above answers your questions.

628. Puppy health check-up

E-MAIL TO DR SING DATED SEP 24, 2011

My name is ... and I'd like to take my two family pets (a Jack Russell and a mongrel) for a routine checkup, just to make sure that they're in good health! How much would this cost in total, GST and other surcharges included?

Do get back to me at this email address. Thank you!

Sincerely,
Name

E-MAIL FROM DR SING DATED SEP 24, 2011

1. A general health check up including consultation & general eye examination as prescribed in our form will be $65.00/dog.

2. Blood test $150. Urine test $50.

A new ultrasonic dental scaler and anaesthetic machine

I have installed a new ultrasonic dental scaler as I had given the older one to my ex-Vet technician Mr Saw who brought it back to Yangon. He had decided to open his own practice and I hope this scaler would help a bit to lower his cost of start up.

As to the new anaesthetic machine and the piping system, I discovered that in the past 3 months, the oxygen and isoflurane used were much more than necessary. My assistant asked me to order a 250-ml of isoflurane within a month. It was not that we had done a hundred general anaesthetics.

So, I got Mr Goh to check. He said that the lever on the vaporiser was not "locked", thereby permitting leaks of isoflurane. In the old vaporisers, there was no such lever.

He got me a new set. More fanciful gadget. There is an "alarm" gauge when the pressure of the system is below normal.

As to the dental scaler, I am chasing him to install an extra switch for the water inlet so that the switch can be turned off and the machine kept in the cabinet. This is because I note that my assistants of past and present don't really bother to treat the machines well. After all, they don't pay for it.

A culture of responsibility and care for the tools of the trade is either in an assistant or not. I think the vet schools do not bother to teach them the need to take care of vet machines which are expensive things and not disposable toys.

Thursday, September 22, 2011

626. Vulval leiomyoma

Today, Sep 23, 2011, I was reviewing some medical records today as part of my performance assessment of myself and my associates. What went wrong and what could be improved? Reviews improve operational efficiency and productivity as much can be learnt from the past case experiences. Such reviews add up, providing real life experiences as the vet ages.

In a histopathology report dated May 12, 2011, the age of a Jack Russell's nodule at the dorsal vulval lips was stated to be 5 years old. It had a leiomyoma, 2x1.3x1.2 cm.

The histopathology report:
Dermal circumscribed nodule. Whorled fascicles of bland smooth muscle cells. No necrosis, cytological atypia or increased mitotic activity. No evidence of malignancy.

Why did the lab report state the dog as 5 years old? I checked my records. In 2006, 3 Jack Russell pups came in for tail docking. The dam did not come till 2009 when I excised 3 breast tumours. She was said to be 14 years old then. The owner did not want to spay the dog in her younger days as he believed that she would become fat when spayed.


With this big growing vulval tumour, he agreed to the dog being operated to excise the tumour and spayed in May 2011. This was done by my associate vet. The vulval tumour was sent to the laboratory for histopathology by my assistant who wrote 5 years as the age.

So, I phoned the gentleman who is in his mid 60s today. He said the dog would be more than 14 years old. Definitely not 5 years old. This dog could not be 5 years old and I informed my assistant and the vet to check with the owner every time. In the Singapore General Hospital, the nurse will ask the patient going for surgery, several times his name and what operation he or she would be going for on the way to the operating room. I know this because I went for an operation. Sometimes, they even took a picture of the area to be operated.
"Is she OK after the surgery (to spay and remove leiomyoma)?" I asked. "Yes," he said. If the dog is more than 14 years old, it still had false pregnancy before the spay. How old should a female dog be before they go into "menopause"? Do dogs go into menopause?

Sometimes clients cannot remember the exact age of their dogs or they may have more than one of the same breed. It is best practice for the vet to ask the client at EVERY consultation what is the age of the dog patient. Some practices take one facial image of the dog patient. In my opinion, there needs to be front and two side views in order to identify the dog. If there are markings and the dog is of one colour, it will be wise to ask the owner to identify the dog.




Website:
http://www.sinpets.com/dogs/20110924leiomyoma-old-female-not-spayed-jack-russell-singapore_ToaPayohVets.htm

625. Follow up on the dwarf hamster with foul-smelly right ear

This dwarf hamster is a tough cookie as she had survived 4 operations. Details are at case report:
http://www.sinpets.com/hamsters/20110922rotten-smelly-right-ear-abscesses-dwarf-hamster-singapore_ToaPayohVets.htm




E-MAIL FROM DR SING DATED SEP 22, 2011

How's the hamster now, Sep 22, 2011?


E-MAIL REPLY FROM OWNER DATED SEP 22, 2011
Thanks for checking in. XXX is active. Her wound is dark and dry around the edges but moist in the centre. (will try to take a photo) Sometimes, the wound has that odour, even after swabbing. She grooms and rubs the area quite often.

She is being given water from a syringe (0.05ml every 3h or so) and seems to urinate fairly regularly. Her stool count is still under 10/day but the consistency of the stools appears to have returned to normal.

She nibbled on the mashed up food pellets once, but on subsequent occasions, did not want any. She is willing eat (perhaps two or three) sunflower seeds that have been shelled for her and also seems to like this triangular black seed (can't identify) from the mix. Will mash up some peanuts and see if she will eat that. Will also try to find a proper weighing scale.


E-MAIL REPLY FROM DR SING DATED SEP 23, 2011
I did smell this rotten bad smell when I operated recently on your dwarf hamster. It was a faint foul smell from the wound and did not persist. The smell is from the bacteria deep inside the wound. It could be an anaerobic type of bacteria.

Buy a bottle of 6% hydrogen peroxide from the pharmacy. Put some on the cotton tip and try to swab deep inside the wound once or twice per day. If the smell persists, the hamster needs the antibiotics. This will be given, if necessary, after she has produced normal stools.

Wednesday, September 21, 2011

624. Ear infections in an old German Shepherd

Although German Shepherd dogs have erect years, some do suffer from ear infections but most don't. I have a case where the dog keeps rubbing his infected years for several years. The condition becomes chronic otitis externa. The owner pours in ear drops, ear oil, ear powder and anything as can be purchased from the pet shop. But the condition does not improve because the owner had not got rid of the dirt, hairs and dead cells inside the horizontal ear canal. Vets have had been consulted but the problem persists. So the owner tried another vet.

What to do in such cases?

Ear irrigation under sedation by your vet and medication. Follow up in one month's time but few Singapore owners bother to do so.

Usually such dogs are old but they need not suffer if the owner gets a vet who treats the dog with ear irrigation and follow up rather than some injections, medications and ear drops. The following is an example of a case I treated.

GERMAN SHEPHERD, MALE, 11 YEARS, 37.2 kg
Right ear full of smell and blood. Scratching all the time.
The owner was in a hurry. "No quick solution," I said. "The ear canal needs to be irrigated thoroughly and that means the dog has to be sedated. There are anaesthetic risks involved."

SEDATION
The owner was aware of the risk. I gave the following.
37.2 KG

CALCULATED DOSAGE/10 KG HEALTHY YOUNG DOG IS:
Domitor 0.4 ml + Ketamine 0.5 ml IV = 0.9 ml IV
For 37 kg, the dosage should be 3.7X but not for old dogs.

FOR THIS DOG, 37.2 KG, OLD
Domitor 0.8 ml + Ketamine 1.4 ml IV = 2.2 ml IV
Good sedation.
Atropine 1.5 ml IM

Both ears were irrigated more than 30 times with 20-ml syringe with the dog in dorsal recumbency (on his chest).

After that I gave Antisedan 1.0 ml IV to reverse the effects of Domitor. The dog took 10 minutes to wake up but was very weak. We carried him to the owner's car. Medication, ear ointment. I doubt I will see him again. A follow up one month later will be necessary but almost 100% of the owners don't bother.

My brother had a German Shepherd with the same problem. Usually he consulted other vets for some reasons I did not ask. However, he would order Hills' anti-allergy dry dog food for this dog through my practice.

One day, I told him that his dog's chronic ear infections would be likely due to an infection and not just due to "dog food allergy". He brought his dog in for treatment of ear irrigation under sedation to flush out all debri and dead cells, some 5 months ago. I must ask what happened now as I did not see him recently and forgot to follow up. No news is good news?

Case 2. FOX TERRIER, MALE, 12 YEARS
The complaint is that the skin disease does not cure despite spending lots of money seeing the vets. The sides of the chest become bald. This was generalised ringworm. I advised clipping and gave medication for 20 days. I asked for review 4 weeks later. The owner did not turn up. The dog also had difficulty peeing and I detected an enlarged prostate and advised neuter if it is enlarged. The ear flaps were black due to continued scratching over the years of suffering.

2 months later, he turned up to say that the dog still has scales but the hairs had grown back on both sides of the chest. Ringworm was detected. The dog's ears were full of liquid sounds. The wife poured pet shop ear drops almost daily. No ear pain. Much improved ear flap in that the black colour was gone by 80%.

Reviews are necessary in skin diseases. Otherwise, the owner keeps vet hopping and spends a lot of money. Who to blame? But the vet! It is best to communicate repeatedly to the owner that not all skin diseases may not be cured with one visit. However, a vet who fails to perform (by producing a cure in one treatment) will lose the client and this has happened to me too. No second chances from some owners in private practice. Cure or no cure.

P.S. In xylazine + ketamine IV sedation, the guideline is less ketamine proportion for dogs. More ketamine proportion for cats. Does it apply to domitor + ketamine sedation? I need to do some research on this. In cats, I give xylazine 0.1 ml + ketamine 0.4 ml IM for less than 5 kg spay. I have not used the combination in dogs.

623. Follow up on dwarf hamster with rotten-smelly right ear

PARTIAL REPORT
WILL SUMMARISE LATER


E-MAIL FROM OWNER DATED SEP 4, 2011 REGARDING RED AREA IN HAMSTER EAR ABOVE AND BEHIND THE RIGHT EYE

Thanks for the follow-up, Dr Sing.

On Sep 5, 2011, at 15:28, Kong Yuen Sing <99pups@gmail.com> wrote:

> Thanks for 2 pictures. There may be some growing internal abscess/cyst in the reddish area to the upper right quadrant of the ear canal opening. That is why the hamster is scratching it as in the previous time.
>
> See if the medication can work.





BACK TO THE BEGINNING, THE FIRST CONSULTATION PICTURE - Stinky smelly right ear complaint. A simple case of necrotic otitis externa? No.


Case recorded at:
http://www.sinpets.com/hamsters/20110808dwarf-hamster-break-a-leg-a-ear-Singapore-ToaPayohVets.htm

2ND CONSULTATION AND SURGERY - EAR CANAL ABLATION FOLLOW UP. RIGHT EAR WAS STILL ITCHY. IRRIGATE WOUND - MORE YELLOW PUS AND GRANULES FLUSHED OUT

3RD CONSULTATION AND SURGERY - BIG CYST AND TWO BIG ABSCESSES



Case recorded at:
http://www.sinpets.com/F6/20110906dwarf-hamster-cyst-abscesses-ear-canal-ablation-singapore_ToaPayohVets.htm

4TH CONSULTATION AND SURGERY - RIGHT UPPER QUADRANT SWOLLEN WITH PUS - TRACKED DOWNWARDS TO BEHIND THE MOUTH
LATEST STATUS AS AT SEP 22, 2011




http://www.sinpets.com/F6/20110906dwarf-hamster-cyst-abscesses-ear-canal-ablation-singapore_ToaPayohVets.htm



As at Sep 22, 2011, the hamster is recovering. Had passed loose stools. Stopped the vegetables. I have advised small amounts of mashed pelleted food and water, hand-feeding 10X/day as the hamster ate little and drank less. Continue the melon seeds. Very nervous when the owner handled her as well as when I did it prior to surgery. This was to be expected as she is in pain. Surprisingly, no major facial nerves appear to have been damaged by the large vertical incision to flush out the yellow purulent granules.
It is a long story. I hope readers can follow the four serials

Tuesday, September 20, 2011

622. Dwarf hamster lost 3 g after 4th anaesthesia and surgery

The 2-year-old female hamster with the stinking right ear still had infection, this time, at another place. The lady owner had red eyes as I explained to her that the risks are higher everytime her dwarf hamster undergoes anaesthesia and surgery. I guessed she delayed as long as possible and now the hamster kept scratching her right ear tip. I noted that the tip was blackened. So, she came to me.

I gave isoflurane gas. Cut a big vertical cut and dug out all the yellowish granules of pus deep inside. I irrigated the holes as big as 1.5 cm and that is big if you are a hamster. The rotting smell (like bad breath) came back slightly. Now, the incision extended into the right cheek and into mouth.

The hamster was still alive 4 days after surgery when I phoned her.
"Not eating much," the owner said. "One melon seed and soft food."
"This is a tough cookie. She survived 4 anaesthesia though she is quite old. It must be very painful to eat. Can you weigh her? She had lost 3 g during surgery" I asked.

She had no appropriate small weighing machine. "You can count the number of faecal pellets," I said.

"My hamster is now having soft stools. Shall I stop the vegetables?" she asked.
"Yes," I said. "Otherwise we will get a serious 'wet tail' problem"

What to advise now?
"Feed her by syringe, a drop at a time," I advised. "10 times a day. For example, mash up the pellet and feed her. Give her water by syringe as she does not drink much. This will prevent dehydration. Hand feeding is very important for recovery. I had a case of a gentleman who nursed his severely dehydrated hamster back to health through feeding many times a day. I didn't expect him (as a man) to have the patience to do it but he proved me wrong."

I hope this hamster survives. As to what causes this evil smelling infection, it is hard to say since no bacterial culture has been done. The lower the vet cost, the better for the owner. There seemed to be a deep infection. It could be the inner ear but since hamsters are so small, no X-ray is practical unlike in dogs. The infection could be from the mouth to the Eustachian tube to the inner ear. Hard to verify. This is one of those unusual cases where the lady owner did not give up caring for a dwarf hamster. A new dwarf hamster costs around $15.00 if one is calculating and this is the way the older generation thinks.

621. Health screening for your older dog - update

Health Screening For the Older Dogs
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 21 September, 2011 toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
Most pet owners in Singapore live hectic lives. There is just too many distractions and too much work.

After an intense care for their puppies, the senior dogs are just left alone as there is no time for them after their puppyhood. It is usually too late for many dogs when they are sent to the veterinarian for some chronic disease problems. Veterinary costs become high as the dog is in poor health and need more intensive care.

Senior dogs are:
Small and Medium-sized breeds: Over 7 years
Large and Giant-sized breeds: Over 5 years.

For those who may want their senior dogs to live longer, here are the following recommendations available at Toa Payoh Vets:

1. Veterinary examination every 6-12 months including examination for tumours and growths, ear infections, eye diseases, skin diseases
2. Blood tests to check for blood disorders, diabetes, liver and kidney diseases.
3. Urine tests to check on bladder and kidney infections and presence of urinary stones.
4. X-rays for arthritic hip joints (can't stand up easily), spinal column, heart and lungs.
5. Dental check up and scaling every year.
6. Heart check for murmurs and heart diseases.
7. Stool test for blood, parasites
8. A report and discussion about the delay in senility, obesity, behavioural problems, skin problems and any questions related to each individual dog. Tumours detected early can be excised saving the dog's life and reducing veterinary costs.

An example of the investigation tests and surgeries done for one older dog with heart disease and another with gum tumour is shown below

Case 1: Heart disease confirmed in an old companion
Cardiac Tamponade in a Labrador Retriever - Pt 1 Cardiac Tamponade in a Labrador Retriever - Pt 2
subcutaneous swelling - edema - cardiac tamponade - heart base tumour likely - toapayohvets, singapore Cardiac tamponade, 13 days after pericardiocentesis, lab retriever, toapayohvets, singapore Labrador Retriever, Male, 8 years, short of breath, transthoracic echocardiography, toapayohvets, singapore
labrador retriever, male, 8 years, skin swellings, cardiac tamponade, toapayohvets, singapore labrador retriever, male, 8 years, skin swellings, cardiac tamponade, toapayohvets, singapore Labrador Retriever, Male, 8 years, short of breath, transthoracic echocardiography, toapayohvets, singapore

Case 2: Get tumours excised by your vet when they are smaller
Large cancerous gum and hard palate tumour. Jack Russell, 10 years. Toa Payoh Vets Isoflurane Gas Anaesthesia. Electro-cutting removed gum tumour first. Note hard palate tumour. Toa Payoh Vets
Large cancerous gum and hard palate tumour. Jack Russell, 10 years. Toa Payoh Vets Large cancerous gum and hard palate tumour. Jack Russell, 10 years. Toa Payoh Vets
Electrosurgery stops profuse bleeding during gum & hard palate tumour removal. Toa Payoh Vets Gum and hard palate tumours in old dogs can be prevented with good dental hygiene and health. Toa Payoh Vets.
Large cancerous gum and hard palate tumou excised. Jack Russell, 10 years. Toa Payoh Vets Jack Russell, Gum & Hard Palate Tumour excised. Vet Intern. Toa Payoh Vets.
Old dogs are very high anaesthetic risks as they are seldom in the best of health unlike younger ones. Everyone is happy when the old dog does not die on the operating table after surgery. But every vet will have cases of old dogs dying on the operating table as it is impossible to get good clinical outcomes when the vets undertake high-risk16 years old fox terrier, not neutered, male, circum-anal, tail gland tumours, toapayohvets, singapore anaesthetics. This is one main reason why some vets discourage or reject old dog surgeries. "The old dog will pass away before the circum-anal tumours grow much bigger," one vet said to the owner. But the dog lived longer, splattering the apartment with blood from the bleeding tumour and requiring frequent cleaning up.

When a dog dies on the operating table, it is just too emotional for everyone including the operating veterinary surgeon. Such deaths may be bad-mouthed by the owner or the family members to friends and recorded on the internet forum. The bad news adversely affect a vet's reputation that takes so much time and effort to build. So it is understandable if a vet does not want to operate on high-risk cases. I do avoid such cases if possible as deaths on the operating table means a beloved family member that has been growing up with the family children who have become adults is lost forever.

The average life-span of a big breed dog is 12 years. Oldest small breeds in Singapore can live up to 20 years. However, many die before they are 10 years of age due to bad health and other preventable causes such as bacterial infection of the heart valves due to severe gum diseases (preventable by regular 2-yearly dental scaling and checks), pyometra (preventable by early detection or spaying), kidney diseases, diabetes and tumours like breast, gum and circum-anal tumours. Many diseases such as circum-anal tumours rarely occur in male dogs that have been neutered. If you don't wish to neuter your dog, please check his backside monthly as small circum-anal tumours are easily removed and cost you less too.

Tumours are best removed when they are small.

Make an appointment with your pet shop groomer if you have a close working relationship with them and needs pet transport to the vet of your choice. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements.

Website with images are at:
http://www.toapayohvets.com/surgery/20080807Senior_Dogs_Health_Checks_ToaPayohVets.htm

Monday, September 19, 2011

619. Two weeks after surgery & treatment - pemphigus in a Shih Tzu - Part 4

Sunday Sep 18, 2011

The Shih Tzu is now so energetic and inquisitive that it was so hard to believe that she was causing so much distress to her caring lady owner for many weeks before treatment. She had literally a mouthful of "tumours" as you can see from the picture as follows:




The long history of this case is at:
1. http://www.sinpets.com/F6/201108031Five-oral-tumours-old-shih-tzu-singapore_ToaPayohVets.htm

2. http://www.sinpets.com/F6/20110902pemphigus-foliaceus-vulgaris-shih-tzu-singapore_ToaPayohVets.htm

"This is an auto-immune disease that will return if not treated with drugs," I explained to the owner that the dog's bodies produce antibodies to attack her skin cells.

At this review 2 weeks after surgery, it was sunshine as this old companion looked almost normal. What's more, she could eat and run, like a "reborn" dog.





"Is there another tumour inside the mouth?" the young lady asked me. The Shih Tzu objected to me opening her mouth. She twisted her head here and there. So, I took a picture when she yawned. "It is hard to say if she has another tumour inside the mouth," I replied. "Wait another two weeks."

I asked her to take the two types of auto-immune drugs and will review 2 weeks later. The dog had put on weight and the hair in the body had grown more. She looked so much prettier now that the hideouos lower lip and other mouth tumours had been excised by me using electro-surgery 2 weeks ago.

The drugs must be given at the lowest safest dose and this is why reviews and 3-6 monthly blood tests are necessary. In most cases, I don't see the owners coming for reviews after the first time. This is the culture of city living in Singapore and that is the way it is.

619. House-call in Singapore

Toa Payoh Vets do make house-calls. The e-mail to Dr Sing is probably a case of a cat ringworm.

E-MAIL TO DR SING DATED SEP 20, 2011
Dear Vet Team ,

I have 3 Munchkin Kittens . At least one of them is growing a dermal fungus since yesterday .
As I m working trough the day I would like to take your service of home-visits .
I haven't been your client before so here my particularis :

Owner's particulars and address given
HP :

Patients : M1 (Blue Bi -Col , 4 Month , male ) , P1 (Gray Lepard Tabby , 4 Month , male ) , S1 (Ginger Bi-Col ,4 Month ,male )

It would be great if you would have time to visit me tomorrow evening after 7pm .

Thank you and best regards ,

Sunday, September 18, 2011

618. Urethral Obstruction in the Dog: Retrograde urohydropropulsion

Each vet has his own way of handling a case of urethral obstruction in the dog. The outcome may be similar in that the dog can pass urine normally but the post-operation complications and implications vary.

In the following case, the Miniature Schnauzer dribbled urine. X-ray showed the urethra blocked by more than 10 small stones 3x5 mm in diameter. The catheter was obstructed and could not pass into the bladder.




SURGICAL APPROACHES
1. Cystotomy and retrograde urohydropropulsion of the stones into the bladder.
2. Cystotomy and urethrostomy.

When there are too many stones, I usually take the second surgical approach. There will be less trauma to the glans penis and urethra as the urohydropropulsion (syringing 20-35 ml of water to push back the stones into the bladder). I will make a 0.5 mm cut behind the os penis, take out the stones with a forceps, close the urethra and skin. Then I take out the 3 stones from the bladder. In my experience, the urethral wound heals well if proper post-op care is given.

However, in some cases, the dog is sent home within 2 days after surgery. There is a lack of care by the owner due to inexperience in animal nursing. The wound breaks down and the urine leaks from the wound perpetually. This is because some owners do not bother to refer to the vet on seeing the wound breakdown, owing to various reasons. So, the first approach eliminates this post-op complication of an unnatural urethral gap as the penile urethra is not incised. All stones are taken out via the bladder in the first approach.

In this case, Vet 1 preferred the first approach. There are more than one surgical approaches in treating urethral obstruction and each has its own pros and cons.

However, on Saturday (my day off and 24 hours after surgery by Vet 1), I visited Toa Payoh Vets to check on this Miniature Schnauzer in the afternoon. I noted the glans penis was much swollen and so did the owner.

In this case, the dog was scheduled to go home 48 hours after surgery. The owner was concerned about this swollen glans penis - reddish and not able to get back inside the prepuce. This swelling is a post-op complication of retrograde urohydropropulsion in some cases. What makes it occur? It is due to the traumatic pressure of gripping the glans in the process of retrograde urohydropropulsion via a catheter.





Numerous small urinary stones inside the os penis (penile bone) can be removed via a urethrostomy or via flushing back into the bladder and removed via cystostomy



The Miniature Schnauzer dribbles urine for the past 2 weeks. Partial urethral obstruction with >10 small stones is seen in the X-ray. Cystostomy and urohydropropulsion removed the stones via the bladder. The owner and I see dog peeing normally as seen 2 days after the surgery before going home.
he catheter has not been able to pass through more than 10 cm inside the penis as its passage is obstructed by the numerous stones inside the penile urethra. To prevent it being dislodged as water is pumped into the catheter to push the stones back into the bladder for removal, the glans penis has been gripped as an anchor point, resulting in swelling. Gripping the penile bone may not be practical but will be preferred. In any case, the outcome was excellent in the sense that after 3 irrigations, the stones were pumped back into the bladder where they were removed. So, the penile urethra is not cut open.

In this case, there was a problem. I had to intervene to resolve this problem. I decided to give an anti-inflammatory pred injection which is not normally used after surgery. Leaving the glans penis to shrink will take many days and any traumatic injury to it will lead to much unhappiness for the owner as it will cost her money.

Although the dog has a big size 20 e-collar, the owner disagreed with me that the dog can can't reach his surgical area to bruise it. There was a small bruised area near his sutures (see picture). The lady owner told me that there was no way her dog could have licked that area since he had the collar. I said it was possible but there was no point arguing with an owner as she had not seen incidents in other cases.

Within 24 hours of the injection, the glans penis had shrunk by 50% and was much less inflamed (see picture). He peed normally, had a good appetite and an excellent caregiver. He was sent home on Sunday.

For dogs with swollen glans penis, it is best not to send home till the dog has recovered but that would take many days and trauma could still occur in the Surgery. NSAID does not work very well in such cases if they are given as the "first line of defence." NSAID was prescribed for the home stay.

More pictures are at:
http://www.sinpets.com/F6/20110920retrograde-hydrouropropulsion-singapore_ToaPayohVets.htm