Monday, November 28, 2011

748. Verrucca

There was a suspicious growing brown growth on my left chest. It was around 0.5 x0.5 cm x 0.2cm. As I do advise pet owners to get growths removed when they are small, esp. for older pets, I practise what I preach. So, today, Monday, Nov 28, 2011, at 7.15 am, I was at the Ambulatory Surgical Centre of the Singapore General Hospital to remove "verrucca" as stated by my surgeon. Last week, I saw a nurse from China googling when I was sent to the room to receive financial conselling. This is compulsory for all. "What are you googling?" I asked the friendly nurse who had seen me before for a synovial cyst excision on my right thumb. "Just to check the spelling of verrucca what Dr Foo wrote," she said. I was impressed with the thirst for knowledge imparted to the nurses.

On the surgical table, I asked Dr Foo whether he could remove the many red growths, as if blood vessels had burst. One young nurse told me: "In China, your many red spots on the man's skin are signs of good fortune." No wonder I am still alive.

I had a blood pressure monitoring arm band on my left forearm which expanded at regular intervals, giving readings in red.Another nurse who monitored my blood pressure asked if I have been active exercising. "Low pulse rate? Is it good or bad?" I asked the nurse. Low heart rate seems to be uncommon for senior citizens as I had been asked this question in another surgery. "I don't think Dr Sing exercises at all," Dr Foo commented correctly.

The carbon dioxide laser machine came into the room. I had multiple warts on my upper chest and so this machine would be useful. The nurse swabbed my upper chest with some liquid. Then Dr Foo got a purple marker pen to circle the verrucca or warts. "How many warts do you mark?" I asked Dr Foo. "Eleven. I am injecting local anaesthetic," he said. "It may be painful."

My eyes were covered by a piece of wet swab to prevent the bright operating lights blinding me. So I could not see what was going on as the laser buzzed. I could feel slight pain in some and none in other wart removal areas. A whiff of BBQ smoke pased my nostril. Soon, it was over. 3 samples of growths were taken for histopathology. The red one which was said to be a haemangioma and would recur when removed. A brown wart. Dr Foo said to the two young cheerful nurses from China: "Take the one rounded brown growth Dr Sing was worried about for the lab." I thanked him. "It could be an accessory nipple," he said of the brown growth near my armpit. "It is on the line," Dogs do have 5 pairs of nipples and well I knew what he was talking about.

Overall, it was a pleasant and enjoyable experience at the operating theatre. The bright yellow Crocs clogs were outstanding in two nurses. The others wore blue, green and black coloured ones. One man wore white boots. The cream0white vinyl tiled floor with red square patterns was very clean and shiny. There were 6 operating theatres. I could not understand why the large word "WASH" was pasted on the stainless steel sink where the surgeons scrubbed up and washed their hands pre-surgery. I saw one surgeon putting on a cloth glove and two more pairs of latex surgical gloves. "Some surgeons are allergic," the kind nurse explained to me.

Sunday, November 27, 2011

747. The tu tu kueh woman's dog

Yesterday was a long day at work on a Sunday. I usually work half a day and let Dr Vanessa do the rest. I asked Mr Min to take the afternoon off and so I stayed around and stayed to do some administration. A practice needs to be administered well or it will just suffocate and wither as the world is getting complex and competitive. The clients are getting sophisticated and more demanding.

For example, one client wanted me to excise a large paw haematoma without sedatives as she was afraid that her old pug would die under sedation. That is a valid fear. To do it or not? It is up to the vet. The vet can just reject her case. What if the old pug dies under sedation? And nobody can predict this. For the sake of the old pug, I incised the haematoma and let it was OK.

The tu tu kueh woman at Bishan Shopping Mall. She asked what stall I was managing as she had seen me so many times over the years buying tu tu kueh from her and asking about her work. She had cooked soup which was shared with other woman stall holders and her brother who sold cakes under the same boss. When I told her I am a vet, she said: "I cried a long time when my dog died. Just running nose. A lot of it. My friend sent it to a vet. Some injection. Hospitalised for 2 days. My dog died. Just runny nose. Goes to the vet. Injection. Died."

"There could be many reasons," I said. "It could be a drug allergy. It could be a serious infection. How old and what breed?"

"7 years old. A Pomeranian." Her eyes teared up as she remembered her dog so well.

Now this dog was a clever dog. "My dog would jump and greet me when I unlock the apartment door. He could hear my key sound. When other family members unlock the door, my door would ignore them," she said, turning her head sideways.

"When I stayed too late watching TV, my dog would lick my ears to ask me to sleep. If I did not, he would jump to obstruct the TV screen."

"That sounds like a very intelligent dog," I was surprised. "It is as if he was a very caring human being re-incarnated as a dog." Some religions believe in re-incarnation and this canine story seems to support this.

If I can find a small breed to be rehomed, I will get one for her as she cares so much for dogs.

Sunday's interesting cases - Nov 27, 2011

1. Septicaemia from gangrenous vaginal hyperplasia and prolapse
The Chihuahua passed away after heavy panting. I had a complete blood test done 2 days ago and had informed the owners that the dog had toxic blood. The total white cell count was twice as high as the higher range, the red cells were twice as low as the lower range and the platelet count was very low at 14. Urine analysis showed bacteria and blood (estrus). I noted that her tongue was purplish and that was not a good sign as it indicated some abnormality of health. The blood test was indicative of a septicaemia.

"After two days, the tip of the vagina prolapse became black," the caregiver mum told me over the phone. That was when she consulted Vet 1. The dog stopped eating and was treated but the blackness at the tip spread more. If this was a gangrenous tail tip, it could be amputated. But this was part of the vaginal mucosa. In any case, anaesthesia and surgery of a dog that is not eating and has a lower than normal rectal temperature (37.6 in the first 2 days) was highly risky. The dog was spayed and survived the operation for 4 days. The Chihuahua was 10 years old and was in good bodily condition.

It is important that a blood test is taken when necessary two days after the surgery as septicaemia is an on-going process. The earlier blood test did not show serious changes. In the event of a bad outcome, the owner and all family members will like answers as to the cause of death. Evidence-based medicine using blood test provided the answer.

2. The dog with a gangrenous tail. "It is important that the owners, you and I meet together in the consultation room to discuss about her case," I said to Dr Vanessa who had stitched up a serious profuse bleeding tail wound and had sent the dog home with an e-collar and medication 3 days after surgery. "I had spoken to the owner," Dr Vanessa said. However, I had promised the owner to have a joint meeting as it is hard for me to listen to one side of the story - her side and Dr Vanessa's side and advise. "This joint meeting in my presence is important to clear any misunderstanding," I said to Dr Vanessa. "The owners have not been happy with the dog developing a tail gangrene after surgery. This meeting is not to find blame on the vet. Such misunderstandings from the owners do happen to all vets after surgery, including myself. It is best to meet jointly and clear up all emotional unhappiness."

"I don't blame Dr Vanessa," the owner said first.

"From my experience with tail wound cases, it is usually the dog that traumatises the wound, causing it to become infected and gangrenous. That is why I normally advise tail amputation in serious wound cases as the owner does not know how to take care of it after surgery. However, some owners don't like this idea and want the tail to be saved. In your dog, the tail would be hammered by the end of the e-collar to relieve its pain and itchiness."

"The dog bites me when I try to clean the tail," the lady owner said. "Yet at Toa Payoh Vets, the dog lets the vet change bandage without biting! He uses the e-collar to scratch the tail. The wound opens up. Yellow pus is seen. I phoned Dr Vanessa but she did not answer the call. That is why I phoned you."

"I got a phone call after midnight," Dr Vanessa said.
"Was the tail gangrenous when the dog went home 3 days after surgery?" I asked.
"No," the owner said.

"Many times, the unhappiness is due to financial reasons," I shared my experiences with Dr Vanessa. "You attempted to save the severely lacerated tail by stitching and controlling the bleeding. You sent the dog home 3 days after surgery but the dog can't stand the pain and itch despite your NSAID medication. So, he bites the owner trying to change the bandage. The tail gets infected and gangrenous. Now the owner has to spend more money to get the tail amputated.

"That is why I always advise tail amputation of a seriously wounded tail as the first choice. If the owner declined and the tail becomes gangrenous, there is no unhappiness. You had done on in a cat some time ago when the owner accepted my advice. Have you seen any return of the owner?"

"No," Dr Vanessa said.
"As a vet, we try to salvage the tail. As the vast majority of owners cannot do post-op nursing, the tail becomes gangrenous and this is stressful and expensive for the owner.

Friday, November 25, 2011

745. The "hidden" pup in canine Caesarean sections

http://www.sinpets.com/F5/20111126hidden-pup-caesarean-section-dog-singapore-toapayohvets.htm
has the complete story.








744. Anaesthesia of old Chihuahua - vaginal hyperplasia and prolapse

Chihuahua, Female, 10 years
Active and eating well till 19.11.2011 when the owner noted a vaginal prolapsed. The dog became lethargic and did not eat. Vaginal or uterine prolapse diagnosed by Vet 1. Owner went back but the pushed back vaginal tissue came out again. Tip became black after 2 days. No e-collar worn.

22.11.11 A friend of the owner was worried and asked me to advise the owner to euthanase the Chihuahua if she was suffering from liver and kidney infections as deduced from abdominal ultrasound and blood test reports. I reviewed the case.

As the owner is not able to take care of the everted vaginal tissue and it had become necrotic, I advised spay the next day as this was the solution. But there was a high anaesthetic risk as the dog did not eat for the last 4 days and her tongue was purplish. Mild dehydration. Temperature below 38 deg C for the last 2 days.

22.11. 11 One day Pre-op IV drip and antibiotic
23.11. 11 37.6 deg, 3.5 kg.
10am
IV drip glucose 5 minutes, then dextrose saline. Tongue became pinker.
IV lasix 2 ml
Domitor 0.05 ml + Ketamine 0.05 ml IV
Isoflurane gas top up at 0.5 - 1%
I expected a 10-minute spay.
Dog vomited yellow liquid after intubation. Repeat.
Dog passed loose black stools. Cleaning up. This took time.
Opened abdomen, hooked out left ovary.
However, both the ovarian ligaments and bv ruptured when ligated. Bleeding seen. So, I had to make a large skin incision to locate the bleeder far inside, behind the kidneys. Two quail-egg sized blood clots on left and right sides were taken out. Bleeders located but bleeding was oozing now. Clamped and ligated one bleeder as the left one slipped off the kidney area. Checked and cleared all bleeding inside abdomen. Closed up 2/0 PDS sutures. Completion at 11.30 am.

Thursday, November 24, 2011

743. Day 3. Vaginal hyperplasia & prolapse in the female dog - Surgical option

Day 3. The Chihuahua bites me and my assistant any time we try to catch her. She does not eat but otherwise is alert and strong. "Is the vaginal prolapse the same size?" I asked my assistant Min, as part of my coaching process. I had pushed in the prolapse yesterday morning.

"Same as before," Min said. "Come out again." He could have difficulty understanding Singapore English as he is not proficient in this language.

He tried to muzzle the dog for me to examine. The dog snapped at him. I had taught him to use a towel to cover the dog's head but he did not do it this time. It needs lots of patience to train a person. I covered the dog's head with a towel. The dog moved to a corner. "Use a leash to lasso her," I said. Otherwise it is impossible to examine her. Min held the leash and lifted up the tail. The dog moved but could not bite us.

The prolapsed vagina had decreased by 60% in size. I was not surprised as spaying removed the oestrogen causing this problem. Min saw the size and that is important. I pushed it in. The dog should be able to go home soon as she is not eating here. I did advise a 20-ml syringe to feed her. A 2-ml syringe with canned food is too short.

741. Severe tail injury - the sole option -- tail amputation

"There is only one option when the dog or cat suffers serious injury to its tail," I said to my associate vet who had stitched up the slanting tail laceration wound of more than 6 cm long and sent the dog home with e-collar and medication.

"Based on my past 30 years experience, many Singaporean dog and cat owners are not able to nurse their dog's tail wounds. Even with e-collars, the dog or cat hits the injured irritating tail, causing more damage. The tail does not heal and becomes gangrenous. The owner becomes upset as she had already spent money on this first surgical treatment. It is not working and now the owner is upset."

"In all tail injury cases, the owner must be advised firmly and in writing that tail amputation is the sole option as gangrene is likely to set in, with stitching and other bandaging. There was a case of a cat with tail injury. I advised tail amputation. We don't see any complaint post-op. Now, this case comes back with lots of unhappiness as the tail becomes blackened and the tip has become cold."

As the owner was unhappy with the outcome, I advise that she and the operating vet and myself meet at the same time to discuss the matter. It is best done that way than individuals giving their points of view to me one-on-one basis.

The outcome of a case of tail injury is very important to the owner. The owner wants just one visit and not be inconvenienced by having repeat treatment. "Even with gushing blood and copious bleeding, ligate the tail blood vessel, bandage the tail and amputate the tail 2 days later."

741. Keratitis in pugs and people

Keratitis is an inflammation of the cornea. In people wearing soft contact lens, there are 3 types of keratitis:

1. Infective Keratitis. Cornea inflammation caused by micro-organisms like baceria, fungi and parasites. Can lose eye-sight if not treated early or by appropriate antibiotics. Cloudy scar on cornea when healed. A person can't see clearly. Same with pugs and other dogs. Big prolem in pugs and shih tzus. It is called ulcerative keratitis. See one picture below:




2. Epthelial Keratitis. The top layer of the cornea is inflamed. Small holes are seen in the epithelium. It is called punctate epithelial erosions and this is also commonly seen in pugs and shih tzus. For the dogs, it is due to traumatic injury. See the green spots of one pug's eye below:
The holes may get infected by bacterial.

3. Allergic Conjunctivitis. The membrane which is below the eyelids is called conjunctiva. An allergic reaction to the contact lens or its solution leads to eyelid swelling and pain.

Chemosis - swelling of eyelids.

PUGS, SHIH TZUS AND PEKINESE
Ulcerative Keratitis is commonly seen due to injury to the protruding eyeball. Early treatment saves the eye sight.

Many Singapore owners of the pug and shih tzu and related breeds have no time to maintain the facial folds or damage the cornea during cleaning of the facial fold. Hairs get trapped inside the eyelids and as you can see from the picture below, the cornea is deprived of oxygen by the turfs of hair and get irritated and infected by bacteria found in the hairs.

My advice is to get your vet to excise both facial folds, preventing the formation of ulceratitive keratitis. But many Singapore owners do not want to accept this advice and so, as the years pass by, the cornea becomes blackened or browned by pigments (chronic irritation for many years). The dog is practicallly blind but the owner is not personally affected. It is just so sad. Keeping the eyes of pugs, shih tzus and pekineses clear and transparent to old age is a heavy responsibility. I hope the younger google generation will be more enlightened and sophisticated to prevent such problems by early treatment at the vet or by getting the facial fold excision done.

Monday, November 21, 2011

740. SOP Dental scaling at Toa Payoh Vets

The following is advised before an old dog (>5 years old) gets dental work done under general anaesthesia

1. General and detailed examination
2. Complete blood test for health screening
3. Oral antibiotics for 7 days before dental work
4. Dental work with low sedation and use of isoflurane + O2 gas
5. Post-op antibiotic and pain-killer injection
6. Post-op pain-killer and antibiotics 5 days
7. Teeth extracted to be shown to owner
8. Dental record
9. Dental reminder 2 years later
P.S. X-rays of lungs and heart ECG may need to be done

Sunday, November 20, 2011

A big thank you to the young Singaporeans who produced the following videos to educate pet owners and bring veterinary medicine and surgery alive to the vet students studying hard for their exam.

As these google-generation people are very busy and have not charged me for services, I have not asked them to edit again to make a perfect production.

The following are the videos:


http://www.youtube.com/watch?v=tmTYP8T95V4 - Kennel Cough video the Sec 3 St Andrew boys produced. The "owner" of the pug was the student but the other characters are genuine. The video producer was another student and his teacher had kindly recommended him to me to help in this production. It turned out to be quite fun to watch this video, in my opinion.

For example, locking the door of the black Mercedes car is not done nowadays but we all had great fun in producing this video. The "owner" seemed to be smiling when he came for a second vet visit with a puppy that had worsened in coughing! I mean, the real owner would be very worried!

After hospitalisation in a crate, there was a scene of the puppy on the consultation table inside the vet consultation room! This should be cut! This is the first video production and no more other versions. That is why I explained the "deficiencies" in the production!

http://www.youtube.com/watch?v=FYeG9tUXp78 - Responsible Pet Ownership video - Nicole Pereira. Excellent summary of some of the main problems seen at Toa Payoh Vets. Great work.


http://www.youtube.com/watch?v=ExTT2a8eUCs - Oronasal Fistula Follow Up - Temasek Polytechnic Vet Tech students who do not wish to be credited

http://www.youtube.com/watch?v=9vKmXgAS_SA - FIV in stray cats 2 - Temasek Polytechnic Vet Tech students who do not wish to be credited

Overall, it took a lot of time. Too much time.

734. Educational videos produced by young Singaporeans for Toa Payoh Vets

E-MAIL FROM DR SING DATED NOV 21, 2011

Thank you very much for your help in producing the Responsible Pet video meant for the AVA Responsible Dog Ownership Road show. The KC video was also good thanks to your help. The voices of the narrators were distinct and clear, to my surprise and the narrative scenes were not boring unlike a power point presentation or a professor's lecture. I hope the vet students do learn a bit about complicated kennel cough.

I gave each party general guidelines as I want other views and presentation.
Each party brings in something new (ideas and presentation and music) in video production and that is why it is so interesting to watch them. Thanks again.

I am only worried about the microchip scanning pic and some other pic you put on the Responsible Pet Ownership video as they may be copyright. Pl confirm the source as we can get sued or get a legal warning to remove it! Pl look into this matter and it is best to remove them and put in original images.

On Sun, Nov 20, 2011 at 5:06 PM, Nicole Pereira wrote:

Hi Dr Sing, here's the links to the videos i uploaded to your 99pups account-
http://www.youtube.com/watch?v=tmTYP8T95V4 - Kennel Cough video the St Andrew boys produced
http://www.youtube.com/watch?v=FYeG9tUXp78 - Responsible Pet Ownership video
http://www.youtube.com/watch?v=ExTT2a8eUCs - Oronasal Fistula Follow Up
http://www.youtube.com/watch?v=9vKmXgAS_SA - FIV in stray cats 2

Sunday Nov 20, 2011 interesting cases

EYES
1. Pug with right eye perforated ulcer treated by me some months ago came in for annual vaccination. A young couple who remembered me as much as I remember them due to this serious eye injury drama as described in my case:


Ulcer healed very well but two very small green ulcers (fluorescein stain) seen to the 7 o'clock. Extraordinary amount of hairs clumped together on corneal surface when I cleaned it (see image). Dr Vanessa had applied the fluroescein strip and had flushed out the green dye. I took over while she checked another dog as the couple wanted to consult me.

Left eye - no ulcers but brown pigmentation covers 50$% of central area - friction from owner cleaning facial fold daily?

I advised facial fold excision as the hairs from the fold must have irritaed the corena (central area) and the pug must be rubbing the eye. "Alternative is to close the eyelids when cleaning the facial fold area," I said.

"Will the surgery affect the health of the pug?" the lady asked. "No," I said. Less itchiness and no more need to wipe the secretions off the facial fold. If irritation continues, the cornea will be seeded by brown black pigments over the years and the dog can't see clearly in front.

The owners would think about the surgery. Their other pug has no corneal ulceration problems. It is hard to foresee the future. "The facial fold is part of the pug's beauty but healthy is more important than beauty," I said.

2. CORNEAL DYSTROPHY
The miniature pinscher owner had texted to consult me yesterday to review the eye. She firmly believes that the circle of whiteness of the inside of the cornea had been reduced with the use of garasone eye drops daily with one small drop.

I will refer to the other picture I took some time ago and see. It seems that the circle has shrunk a bit and the edges are more firm. I need to review the old pic.


The left eye has some interesting developments when I view the images. The dog was fidgety and therefore no proper examination was possible. The owner did not want fluroescein eye stain test for the eyes and so I can't confirm whether the left eye still has ulcers in the upper half near the melanomas.
The pic traken toaday shows "crocodile skin" areound the eyelids. Must check previous pic soon.

CASE 3
A 13-year-old pug passed away after 11 pm yesterday. My assistant Min saw him alive and resting at 11 pm when he did his last checking.

"Why did you send a pug for grooming?" I asked the young couple who told me that the pug had never coughed once before going to the groomer two days ago (Friday). Then she coughed vigorously at home for a long time and so I was consulted on Saturday morning. The pug did not cough when I saw him. "The likely cause of coughing is due to kennel cough," I said as kennel cough is a common disease in places where dogs of various ages mix and it is a very contagious disease. The old dog had not been vaccinated forl many years. So, the primary diagnosis was kennel cough - a dry hacking cough.

I recommended to ward the old dog in a cage so she could rest. "Continuous coughing will result in blood vessel rupture in the lungs," I said to the young couple. Blood test was advised to check for infectious situation but the owners declined.

When the pug died, both her nostrils had red blood. Her tongue was cyanotic. So there was some respiratory damage and bleeding. "An independent post-mortem by the AVA will be needed to ascertain the cause of death," I said to the lady whom I phoned. "The dog is old and her immune system would be weak and she was not able to fight off the viruses and bacteria of kennel cough," I said. Cremation was arranged and the urn would be available in 2 days' time. It is one of the cases where old dogs without vaccination should not be exposed to other dogs. The pug was having her nails clipped and she panted at the pet shop. It was a sad Sunday for me as the pug had not shown any signs of impending death at the Surgery. In fact he had eaten some food after treatment with antibiotics and a drip. However, I had warned the owner of a possible death and the owners were understanding.

736. Health of Westie

The Westie Foundation of Amercia - health matters funded.

Atopic dermatitits (an allergice skin disease)
Bladder cancer
Idiopathic pulmonary fibrosis (lung scars)
Copper toxicity (hepatitis & liver failure)
Legg-Calve-Perthes disease (hip joint degenerative disease)
Luxating patellas (dislocating knee caps)
Addison's disease
Inflammatory bowel disease
Cataract
Dry eye (keratoconjunctivitis sicca)
Cranio-mandibular osteopathy (painful bone growths in the skull and jaw b ut usually OK by 12 months of age)
White shaker dog syndrome (entire body shakes or trembles - appear in other small white breeds - immune system disorder suspected - successfully treated with steroids).

Thursday, November 17, 2011

735. Inspirational picture

MESSAGE TO AN ENTREPRENEUR

As regards your water project, I am reminded of this martial arts movie "Dead Or Alive" which is free online and just watched by me as I do my early morning internet work. In the movie, the antagonist mentioned 3 words about the Japanese lady not up to the mark as her brother. She needs "Skills, Timing and Strength" but she has no "strength".

Somehow, these 3 words seem apt for your project in wanting to expand your business from Singapore to China and Indonesia. I was wondering what to write in a picture of flowers I just took last Saturday at Sentosa. Now, I know and I produce a picture to encourage you.

1. The timing is right (environmental health concern for clean water), the skill is there (your brother) but the strength (of the parties doing marketing) is to be established and you have got the expatriate

and others you are networking to build up a team to increase your strength.

2. Thinking of making money all the time will not make one be successful in business, in my opinion.

Wednesday, November 16, 2011

734. SOP - Lameness in a Golden Retriever

Thursday, Nov 17, 2011
9.30 am

I usually consult from 9.30 am to 11 am.
A lady owner and two friends consulted me for a 2nd opinion as regards her 9-month-old male Golden Retriever. born Feb 2011, limping on right hind for the last few weeks. Vet 1 had been consulted earlier regarding some skin disease.

Below are my Standard Operating Procedures for examination of canine lameness at Toa Payoh Vets for this case as a real case example as it is easier for reader to understand. Basically it is similar to examination of a lame horse.

1. HISTORY OF LAMENESS - Right Hind lamenss
Purchase - 3 months old from a Pasir Ris breeder
Onset - RH lame seen at 7th month
Duration - 2 months
Further questioning: The puppy does not jump up or down car and does not hop down stairs since purchase. Pain in hip and other joints likely to be present before purchase as most normal puppies will do the jumping.

2. LAMENESS EXAMINATION - Outside the Surgery. As in the racehorse lameness exam.
2.1 Walk
2.2 Trot
2.3 Turn
Limping on right hind obvious as the dog did not put weight on this leg and the left hind hip dipped on trotting.

3. PUT ON EXAMINATION TABLE - Do not examine on the floor!
3.1 Pain check of dog standing esp. spinal area. Spinal T5-L5 slightly painful.

3.2 Pain check by palpation of joints with dog lying down sideways on the table.
Slight pain on extension of right hip and right knee.

3.3 Dog recumbent on right side. Extend and flex all joints vigorously. The owners were worried about my vigorous manipulations but the dog did not react since he had no pain from the extensions and flexions. Some vets do gentle manipulations and mis-diagnose.

3.4 Dog standing on table. Compare length of right and left hind limb by extension and show to the owner the lengths of two hind limbs. In this case, the owner could see that the riight hind was noticeably shorter by 2-4 cm. Subluxation? Mild pain only. To X-ray both hip joints later.
3.5 There are other reflexes to be checked if the dog is paralysed but in this case, it is not. Refer to your neurological exam book.

4. TENTATIVE DIAGNOSIS
Right hip dysplasia likely as this condition is better shown at the 9th - 12th month than as a young pup. To X-ray hip joints at a later date.

5. ADVICES
5.1 No weight gain throughout his life, thereby avoiding surgery
5.2 No slopes or stair climbing or jumping from sofas etc

6. SKIN DISEASE. A separate case study and procedure which will not be written up here. Generalised pustular dermatitis, elbow and hock sores. Dog likes to sleep on wet floors. Anal sacculitis (pink hairless areas below anus pointed out by the owner). Rashes seen on elbows and hock area pigmentation suggested licking and early onset of elbow and hock sores. Preventive measures including moisturers for a time. The owner asked for Neoderm cream. No cream advised by me as the hair will not grow if the cream is used for a long time.

Best is daily grooming and inspection of the coat for this Golden Retriever and know where the "hot spots" will occur. Dog is clipped bald. Generally, the skin infections are due to bacteria but the vet cannot rule out ringworm and demodectic mites. Vet 1 had scraped skin and found no mites but there was no medical report given to the owner.

Monday, November 14, 2011

733. Kennel cough follow-up by text message

The young generation prefers to text but it is not good when it comes to your pug's illness as illustrated in the following case.

Nov 13, 2011 10.59 am
Good morning Dr Sing.This is ... the owner of Zorro (Pug). We visited your cllinic on 8th. My puppy was having kennel cough and runny nose. He used to eat well and was active but this morning, he is not having any food and keeps on sleeping. When he walks, he has difficulty walking due to heavy coughing. So he walks a bit and then just sits down and he is not active anymore. Antibiotic has not been finished yet but since he seems not well, should I bring him back to the clinic?

It would be much appreciated if you could reply to my sms




Nov 13, 2011 12.04 pm
Pl tel me

NO REPLY. I PHONED. NO REPONSE.


Nov 13, 2011 9.31 pm
Dr Sing, I really need your help now with my pug. For all day, he rarely moved and seems no energy with him. Is there any chance we can bring him for emergency now?

I PHONED THE OWNER. As the pug was ok, I advised giving him a teaspoonful of honey + water and bring back to the clinic at 10 am on Nov 14.

On examination, the pug had copious amounts of nasal discharge. Difficulty in breathing. Some lung sounds, but no fever. I gave treatment and cough mixture.

"It is not possible to cage him 100% at home," I had advised the couple who brought the pug to me for examination one day after purchase on Nov 8.

"Play with the pug for only 5 minutes after meals which were given twice a day," I had advised. "Kennel cough is caused by virus and bacteria. Viral diseases do not have antibiotics but resting the puppy by confinement strictly in a cage will help speed recovery. Some cases take up to 3 weeks to recover."

In this case, the pug had space to run around as all puppies take advantage of freedom at a new house. He also hated taking medicine as he fought me when I syringe him 0.05 ml of the cough mixture.

"It is difficult to give him medicine by mouth," the young man said. "My pug rests his head on a soft toy," the gentleman said.
"Puppies do that when they can't breathe properly," I said. I rolled up a towel like a small pillow. The pug rested his neck on the edge of the pillow. Eyes bright but he was tired.

"Can we visit him for 15 minutes?" the gentleman asked.
"Yes," I said. "But this pug must be inside the cage for the next 2-3 days to rest." The couple came at 7 pm on the same day. Nursing, feeding, electrolytes and observation are made every 2 hourly to ensure that the pug is OK.

Saturday, November 12, 2011

731. Animal Welfare Activists

On Mon, Sep 5, 2011 at 12:39 PM, ...@gmail.com> wrote:

Attention to the Veterinary Head of Toa Payoh Vets,

My name is ... and I am working full time for a church in Singapore.

Our church is currently in the process of getting a new animal shelter set up in Singapore. We are waiting for tenders from AVA or SLA for dog farms in Sungei Tengah. The shelter should be up and going in about 1 or 2 year's time. Our emphasis will specifically be to help stray or abandoned dogs. We are serious about this ministry and is looking forward toward setting it up as soon as possible.

The reason for writing to you is to ask if your clinic would be be interested to participate in the sterilization, vaccination and medical treatment program of our dogs.

We hope that you could partner with us in this good cause.

If so, please let us know how much you will charge us (roughly) for the following services so that we can better estimate our financial planning. We would greatly appreciate if you could give us a subsidized rate that is lower than the market.

Vaccination of a dog (regardless of size & inclusive of medication)
Sterilization of a dog (regardless of size & inclusive of medication)
Microchipping
Consultation fee
Medication discount
Essential Products such as heartguard, frontline
Medicated shampoos

Hope to hear from you soon. Thank you.

Alternatively, if any of your vets are interested to help on an individual, voluntary or private basis, please also respond to me.


God bless you,
...



On Mon, Sep 5, 2011 at 4:00 PM, Kelly Lim wrote:

Dear Dr Sing

Thank you for your prompt reply. We will contact you again when we have the latest update.

God bless you,
....


E-MAIL REPLY FROM DR SING DATED SEP 5, 2011

I am Dr Sing. As there is inflation and prices go up yearly, it is not possible to quote now and there will be misunderstandings when your shelter is built in 2-4 years' s time. Please let me know when the tender has been successful.



E-MAIL TO DR SING DATED NOV 11, 2011

On Fri, Nov 11, 2011 at 10:40 AM, ...gmail.com> wrote:

Dear Dr Sing

I am .., who have previously communicated with you over a few emails regarding our church's planned shelter for stray dogs. We have confirmed with AVA about the timing of the tender. It will probably be open only in 2013.

However, in the meanwhile, we can't just sit and wait for the land to come and ignore the terrible plight of the stray dogs. For the past 2 years, a few of us have already been feeding about 70 strays here and there, as well as actively putting up adoption for the puppies. We have our puppies screened for parvo virus, vaccinated & dewormed before giving them away for adoption. For the grown dogs, we have also got a few happily adopted. So far they are all success stories. We also sterilize the females. Many of them are sterilized except for about 10 more because they are very smart. Yet 10 females can reproduce beyond what we can cope. Still trying our best to patiently gain their trust.

Occasionally tragedies still happen. This year, we lost 2 batches of 8-9 puppies (could not catch them in time when they were about 5 weeks old and started running around in the open) that were in one night swept by the China and Thai workers for their "makan". These workers usually congregate over weekends and that is when they will notice the puppies and gang up to catch all of them.

Recently 1 black mongrel puppy was kicked to death at 3 month old and the other one blinded by the impact but a miracle happened and his eyesight is restored. Now he is in a foster home. They were the only ones left un-adopted because they were black in color.
So far I have visited ... and .... They do have 10% discount for strays but the bills still come up to an exorbitant amount for so many dogs.

Would you be able to propose a medical service package for us during these 2 years of transition before our shelter is formally up?

Looking forward to your reply.


God bless you,
...



E-MAIL REPLY DATED NOV 13, 2011
I am sorry I can't help you as my clinic is very small with 1 full-time vet, unlike ... and ... and other clinics who have many vets. In any case, I advise you to contact the newer clinics (there are over 40 clinics) in Singapore and these may be able to help you. You just need to do so personally. E-mails save time but not so good if you want to be an activist.

Wednesday, November 9, 2011

730. AVA Reponsible Pet Ownership Roadshow 2011 - Toa Payoh Vets

TOA PAYOH VETS
Block 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074
6254-3326, 9668-6469, judy@toapayohvets.com, www.toapayohvets.com

Speaker: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Founder & Practising Veterinarian, Toa Payoh Vets
Saturday, November 12, 2011

Nov 10, 2011

AVA Responsible Pet Ownership Roadshow 2011
Saturday, November 12, 2011, 1.30 pm - 2 pm, Changi Expo


"SOME COMMON DISEASES IN DOGS"

I accepted two slots on Saturday and Sunday to present a talk on dogs and hamsters respectively. However, the AVA cancelled my Sunday talk scheduled from 3.30 pm to 4 pm and offered me another slot at 1.30 pm. I am unable to take up this slot.
Therefore, I will talk about common diseases in hamsters on this Saturday as dwarf hamsters are quite popular with Singaporeans.

In short, I will be presenting some health care cases mainly in dogs. However, the responsibilities of health care and ownership in canine cases apply to the care of cats, hamsters and rabbits.

I apologise for the inconvenience caused to the audience who expect only canine matters to be presented.


As Power Point slide presentations of "Responsible Pet Ownership" can be extremely dull and sleep-inducing in my experience, I have just got videos produced and hope all of you will enjoy the stories based on some common real life cases encountered at Toa Payoh Vets. The stories cover some common cases seen at Toa Payoh Vets from the birth to old age of the pets from around 1980 to 2011.

If you have any questions about responsible pet ownership as regards health care matters or the the cases in the videos, some details are available at www.toapayohvets.com.

If not, tel me at the Surgery at 6254-3326, 9668-6469 or e-mail judy@toapayohvets.com

Tuesday, November 8, 2011

729. Right ear weeping in a Westie - an unusual case

"I have seen 3 vets. One of them said there might be a tumour inside the right ear," the young lady said to me. "The last vet advised ear surgery." From my impressions, the young couple wanted a permanent solution to this one-year problem of the Westie with the itchy right ear and they came to see me.

This dog had lots of "water" inside the ear canal. I palpated the right ear. There was some pain as the dog moved his head away. But not great pain. As I pressed the ear, more "watery" discharge come out. As I cleared the discharge with a piece of tissue and then pressed the ear, more "watery" discharge comes out. Not those thick yellow pus, but watery. Why?

It was as if the horizontal ear canal was a deep well with lots of water. "Did your father apply the commercial ear drops recently?" I asked.

"No," the young lady said. "No more ear drops left."
This was a most unusual case. It was as if there was "underground" water.
"This ear needed to be irrigated," I advised.

I collaborate with Dr Vanessa on this case as part of my mentorship and succession program for Toa Payoh Vets.

Each young vet has his or her own idea of treatment and I wanted to make sure that this dog had a treatment that I would be doing and to maintain a standard of care that would be satisfactory to dog owners who come to Toa Payoh Vets for second or more opinions.

TREATMENT
Domitor IV sedated the dog partly. Muzzled. Dr Vanessa put in the pink antiseptic solution into the ear canal, massaged it to clear the debri. That is the standard way and that would be what the other vets had been doing. Nothing wrong with that.
But it might not be effective compared to ear irrigation.

So I intervened and demonstrated how the ear irrigation ought to be done. There is a technique. I had shown this in my video at:
http://www.youtube.com/watch?v=xhZ5eGJdwnY

Dr Vanessa used the 20-ml syringe to flush the ear. "You need to exercise your thumb muscles," I said as she injected the water into the ear without much force. "The irrigation angle has to be at 45 degrees to the horizontal canal and with speed," I demonstrated. It is easier said and demonstrated than done.

White tissue pieces from the walls of the vertical canal came out. Large extensive ulcers. As I irrigated more, a small piece of brown tissue came out. Then a few more brown bits. Strange. No pus.

I left the room to talk to the couple. Then I returned to the room to continue working with Dr Vanessa. She had extracted a big amount of brownish fibres from deep inside the ear. Good work. "What are these brown stuff?" I asked her.
"It could be tumours," she said. We showed the brown fibres to the young couple who was equally as perplexed.

"Did your father use cotton buds to clean the right ear?" I asked.
"Yes," the lady said. Later she said that her father used cotton wool wrapped around a pair of forceps to clean this ear.
So, the clue was given. The father would have used lots of cotton wool over the past year to resolve the ear problem. The fibres loosened and got impacted inside the horizontal canal. The whole canal filled up. The fibres absorbed the "water" of the commercial ear drops. At the same time, the bleeding from the canal wall due to aggressive ear cleaning by the father stained the fibres into dark brown as red blood becomes brown over time. These were the fibres or "tumours" pulled out.

Is this hypothesis sound? It is an unusual case as there was no pus. No time for pus to form too as the father must be doing ear cleaning every day. Sometimes, the grown up children don't know what the father is doing in the care of the dog as they work long hours.

Dr Vanessa extracted as much as possible. Evidence shown. She showed the couple the ear canal via the auroscope.
Ear swab for bacterial culture. Blood test.

SOLUTION
My advice was to lateral canal resection to resolve the dog's problem once and for all. The impacted cotton wool is deep inside the horizontal canal and opening up the vertical canal to get the hidden wool is the best solution. Owners want one treatment not several visits. This is understandable for every one. I advise surgery one week later.

728. Scupturing dogs with veggie dyes and making them look like pandas etc - animal cruelty?

MY REPLY TO COMMENTS ON DOG DYED TO LOOK LIKE PANDAS AND OTHER ANIMALS

Thank you for your email. I have not seen one client Toa Payoh Vets with coloured/dyed dogs from 1982 to 2011. It is surprising.

If I do, I will advise the owner to check whether the dye is carcinogenic, allergic or toxic to the dog when licked and in the long term.

Nowadays, what is deemed animal cruelty in subjecting a dog to being dyed to one person is not cruel to another. As long as the quality of life of the pet is good and the pet is healthy despite "vegetable-dyed", I am not against this practice which you may consider cruel.

Older men and women dye their white or grey hairs to look younger. Young people dye their hair to look different. Such hair dyes may have long term toxic effects on the kidneys and livers as they are used for a long time to maintain youthfulness esp. in older people. This is my opinion that is not supported by scientific evidence, if any.

But most people don't bother about the safety aspects and that is why so many "herbal" and "nutritional/vitamin" pills with possible harmful effects to the liver and kidneys have great sales.

I hope my reply is satisfactory to you.

727. Dr Sing's presentation at the AVA Responsible Pet Ownership Seminar Sat Nov 12, 2011 1.30pm to 2 pm

30 minute talk. Instead of boring power point slides on how to be a responsible pet owner in Singapore, I will be showing videos


My videos on caring for your pet to permit it to live longer and have a good quality of life will likely be:

1. Oro-fistula and follow up in an old Chihuahua who had had pyometra
2. How to bathe a Roborovski hamster with generalised skin disease
3. Ear irrigations for a Golden Retriever with chronic ear infections
4. Emergency Caesarean section advices for the home-breeder
5. FIV in a stray cat
6. Blood in the urine in a dog
7. Tumours, Perineal hernias, Circum-anal tumours in older pets including hamsters, dogs, cats
8. Eye ulcers are emergencies.
9. Puppy parvoviral disease and prevention by vaccination.

Early detection of diseases and removal of tumour save lives. Be a responsible pet owner.

I hope the videos will last the 30-minute of talk and be entertaining and useful for the audience

726. Regional nerve block in vet dentistry video

I spoke to Daniel, a Murdoch 5th year vet student who wrote a research article on the above subject and said it was inexpensive and fast and therefore should be used by vets.

I do not do regional nerve block in vet dentistry as the dog still needs General Anaesthesia, unlike human beings. Maybe in very old dogs? GA using isoflurane + oxygen is safe even for very old dogs. So I believe almost 99% of vets in private practice do not bother with regional nerve blocks in vet dentistry in the dog and cat.
However, I chanced upon a video on this subject today while doing my research for the AVA Responsible Pet Ownership 2011 Seminar on this Sat Nov 12,2011 at 1.3pm0 - 2 pm at Changi Expo. I will be showing videos rather than the boring Power Point Slides presentation. Probably only 10 adults and a few children will be present at this talk, from my past observations!



There is a video at:
http://www.youtube.com/watch?v=UtWUzkHnLTk&feature=related

Monday, November 7, 2011

725. AVA Responsible Pet Ownership Roadshow 2011

AVA Responsible Pet Ownership Roadshow 2011
12 & 13 November 2011
Singapore Expo Hall 4B
Toa Payoh Vets' Talk: Be A Responsible Home-breeder - Dystocia in the Dog

Story of 2 case studies - Small breeds with large pups
Experienced home-breeder. Arrangement with a vet to standby.
Inexperienced home-breeder. Veterinary Costs. Wait and See?
Delays in seeking Emergency Caesarean Section - What happens?

Hook 1 - After midnight emergency Caesarean Section


Video Scene of undertakers around Toa Payoh Vets. Ghosts roam after midnight? White apparitions seen outside clinic. Pass the case to other vets? Duty of care?

INTRODUCTION

MIDDLE - Case study 1. Experienced breeder saves surgery time.
Case study 2. Breeder does not know how to revive pup with water-logged lungs. I had to show. Swing hard but carefully. Picture.

CONCLUSION - Vet fees are higher after office hours. From $1,500 - $3,000.
Hook 2 - Public holiday

1. TRENDS IN SINGAPORE PET OWNERSHIP BY DR SING AS A VET FROM 1974 - 2011

1.1 MANY MORE CARING YOUNG ADULT SINGAPOREANS - BEST HEALTH CARE FOR THEIR PETS
1.2 CONFLICTS WITH SENIOR CITIZENS & DEPENDENTS - THE GOOGLE GENERATION V. SENIOR CITIZENS WHO ARE PRAGMATIC - BUYING A NEW PET IS CHEAPER THAN PAYING VET FEES. What values are imparted? Don't care when pets are old and sick? Get a new one!


2. ADVICES. DO NOT BREED. EMERGENCY CAESAREAN SECTIONS ARE RELATIVELY "EXPENSIVE" - FROM $1,500 - $3,000
3. IF YOU WANT TO BREED,
3.1 READ AND RESEARCH ON DOG PREGNANCY AND DYSTOCIAS IN YOUR BREED
3.2 BUILD A GOOD RELATIONSHIP OF TRUST WITH THEIR VET
3.3 BE ABLE TO AFFORD THE VET FEES FOR EMERGENCY CAESAREAN SECTIONS
3.4 FIND A VET WHO CHARGES $200 FOR A CAESAREAN SECTION?

3. MORE CAESAREAN SECTION CASE STUDIES BY DR SING AT:
http://www.bekindtopets.com/animals/20081201PAGE2_Dog_Surgery_Anaesthesia_ToaPayohVets.htm

CREDITS

PRODUCED AND NARRATED BY:

Thursday, November 3, 2011

724. Parasites/mites from dog to person

On Fri, Nov 4, 2011 at 12:43 AM, ...@gmail.com> wrote:

hi there, i've come across your website as i've been searching on google for an answer to my question:
my dog is currently being treated for parasites/mites, and now my daughter has strange bites and itches all over her arms and legs, could it be that the dog has passed her the parasites as well? what can i do for my daughter to help her as our family doctor's itching cream has not been working to relieve her itches at all.
thank you,
Name

E-MAIL REPLY FROM DR SING DATED NOV 4, 2011

You need to know what parasites/mites are involved in your dog by asking your vet to give you a vet report. Let the doctor know the diagnosis or seek a skin specialist/2nd opinion from another doctor.

723. House-call for Golden Retriever with ear area snipped

Nov 2, 2011.

"It sounds like a surgical case," I said to the lady who googled "house-call vets singapore" and phoned me as to whether I would do a house-call in East Singapore. She volunteered to bathe this dog. Her maid and the neighbour's were cleaning the neighbour's Golden Retriever. There was a big clump of matted hair behind the ear. So, the scissors cut off the matted lump. 50% of the skin depth was cut off too. Size of 4 cm x 5 cm. So, the kind lady phoned for a house call.

I got the transport man to bring the dog down to the Surgery at 12 noon.
A bit overweight.

SEDATION
28 kg. Unknown health status.
Domitor 0.4 + Ketamine 0.5 ml IV (1/3 calculated dose for 30kg, young healthy dog).
GR sedated within 1 minute but woke up

Wednesday, November 2, 2011

722. Cracked RU PM4 in golden retriever

A young couple saw me today for a second opinion as the dog was chewing on the left side for the past 2 weeks. He was fed lamb shanks and raw diet for some years but recently cracked his RU Premolar.

A red hole 1 mm in diameter was obvious and so I thought it was the cause of the tooth ache. The owner had palpated the tooth and there was a sliding of the upper front part of the tooth and told me. Indeed, there was movement. I shone a torch.

Still it took nearly 30 minutes of review and palpation before I finally concluded that the dog actually had a V-shaped fracture sideways from the upper anterior end! At one review, red blood oozed out from the crack. A v-shaped side fracture!

That was why it was moving. The owner gave treats many times to prevent the dog biting the vet and so there was some distractions. But at least, it was not the gum.

721. Expert questions autopsy findings: liposuction death

Dr Stephen Leadbeatter, foerensic pathologist, Cardiff University, Wales Institute of Forensic Medicine told a coroner's enquiry into the liposuction death. He said that based on the available info, he could not ascertain which aspect of the operation caused the death of Mr Franklin Heng. He was the expert witness for Dr Jim Wong, a GP who carried out the procedure.


Health Sciences Authority (HSA) said the death was caused by mulltiple punctures in the intestines due to the liposuction. HSA consultant forensic pathologist said the holow steel tube used could have caused the patient to go into shock and died.

Dr leadbeatter's points for the defence are:
1. He saw images from the autopsy, but said it was unclear whether the puncture wounds had gone fully into the intestines.
2. He saw no signs of peritonitis, the thin lining of the peritoneal cavity. If there was full puncture, the intestinal contents would have spilled out of the intestines into the peritoneum.
3. Lack of info about the description of any intestinal contents in the peritoneal cavity
4. Lack of microscopy to determine peritonitis
5. Another possible cause of death could be fat emboism - fat entering the blood stream into the lungs and brain. He had seen only slides of the b rain, not other organs.
6. Mr Heng could have difficulty breathing from an allergic reaction. This issue was not addressed in the blood taken.
7. Propofol used as a sedative could have contributed to the death according to the autopsy report.
But Dr Leadbeatter said the concentration of drug in the blood after death might not correctly be the same amount at the time of death.

In my reading of the report, there was no info as to whether peritonitis was present or not present and it seemed that the intestinal punctures did not go into the full thickness of the intestines. Will follow up.

720. Tray-training a Golden Retriever puppy

On Tue, Nov 1, 2011 at 11:14 PM, ...@hotmail.com> wrote:


Hello there, came across a site where you've provided information of toilet training dogs. I current have some enquiries and I would be glad if you could help me with it. I've gotten a golden retriever pup 4 days ago and he is 2 month old. We've been crating him with a tray inside and some space left for him to lie down. So far while in the crate, when he needs to do his business he would do it on the tray and not on the empty space. However during the day, we will let him out to play and only let him in during his nap time. This has caused several accidents. However, after observing, we noticed some consistency in his pee and poo time so we bring him out when we feel he needs to release and hence the no of accident has decreased. We have another tray placed outside where I hope I can train him to do his business there. However every time we place him on the tray, he will start sniffing and will without fail walk out of the tray and do his business outside the tray. I have placed tissue soaked in his urine and poo with new newspaper on top of it and metal grill to prevent him from stepping on his pee or chewing the paper. I was wondering what should be done to train him to use the tray instead of the floor. Should I lease him so he cannot wonder off the tray or should I 'fence up' his toilet area and only let him out after he do his business. My friend recommended me to leave him in his crate for a month and not let him out at all even to play so he will get toilet trained . But I don't think it's a good idea to crate him up without letting him out as I'm afraid of complications such as too much energy not release and becoming destructive or excited once let out etc. I hope you can give me some advice on what to do. Your help will be greatly appreciated.



E-MAIL REPLY FROM DR SING DATED NOV 3, 2011
I am Dr Sing from Toa Payoh Vets. I assume you want the puppy to pee and poop on a "tray". Is the tray of sufficient size as this is a big breed? What are the dimensions?

Pl send at least 3 images of housing and layout plan as what I visualise about the tools you are using for toilet-training, based on your text description, may be incorrect. A "tray" to you can be a floor grate + pee tray below to another dog owner.

719. Update on animal activist's help of a tick fever rescue dog

Update on animal activist's help of a tick fever rescue dog

The Rescue Group's vet had said that imizole would not be effective against Babesia gibsoni and advised a triple-drug combination costing $1,000. The rescue group wanted this activist to pay $600 to top up the $600 budget from the rescue group. The activist sought my advice by text and there was some delays as the Rescue Group's vet said that Berenil would be available as a cheap alternative in a few days' time. So the activist waited. But no Berenil. The activist was pro-active and posted online for help. A donor responded and would pay for treatment by the donor's vet. It seems that this rescue dog will survive the tick fever and that is good news for her and for anyone.

The following is her reply to my follow-up on her rescue dog's status

E-MAIL TO DR SING DATED NOV 2, 2011

...@hotmail.com>

Hi,


Its been a busy few days.

The Berenil is discontinued in Singapore already, and the rescue people told me I have to pay myself or let her die. We brought her home on Saturday and on Sunday she was having difficulty breathing and could not stand up. I posted her pictures online and a very kind stranger offered to pay for her treatment on the condition that we go to her vet. ... is being treated at (Name of vet practice given) as requested by the donor.

Her red count had dropped even further, and her platelets dropped to only 12. She stayed there for 2 nights and they gave her lots of supportive fluid therapy, erythropoietin and used steroids to stop the hemolysis. She perked up very well and is now resting at home. We will repeat her blood count on Friday and give her Imizole on Saturday if all goes well. For now she is on pred, metronidazole, doxycyclin and some other supplements. I was also forcefeeding her Hill's a/d several times a day. As of this morning she was willingly eating herself! I think things are looking up and Dr ... thinks she will survive. I hope the Imizole works to cure the infection.
I'm sorry we were not able to take her to you. I have great faith in your clinic, but unfortunately the money is not mine! :(

Thank you so much for your concern, you are very kind..
Btw, she's not my dog! We are just fostering her and hopefully will find her a home.

Smile,
Name


E-MAIL REPLY FROM DR SING DATED NOV 3, 2011

I thank you for being proactive in helping the stray dog. The vet is doing a great job and I am quite sure imizole will be effective. Best wishes.

718. Follow up on Cocker Spaniel with tick fever - 14 days later

SUNDAY'S INTERESTING CASES
Oct 30, 2011

On Friday, Oct 28, 2011, I got a text message from a young lady caring for a Singapore Rescue Group's stray dog with tick fever diagnosed by Vet 1 consulted by the Group. According to her, Vet 1 said that the imizole commonly used for treatment of tick fever would be ineffective as this dog had Babesia gibsoni.

As imizole is "ineffective" against Babesia gibsoni, Vet 1 wanted to use the "3 effective" drugs atovaquone, clindamycine and azithromycin. However, it would cost the Rescue Group $1,000. Berenil was cheaper but might cause anaphylaxic shock and in any case there was no stock at that time.

The Rescue Group asked her to top up the bill but she did not have the means to do so. So, she texted me for advice and alternative options.
Below are my replies to her.

It is kind of you to do dog rescue work. There are many financial considerations.

Combination of atovaquone, clindamycine and azithromycin by (required by Vet 1) as said by you, is claimed by Vet 1 to be effective against Babesia gibsoni infections in this dog. Vet 1 had said that imizole is ineffective against Babesia gibsoni.

I will not comment further as I don't use these expensive drugs. Success rate depends on follow up, not just one injection. Blood transfusion 1.5 bags at $500/bag and hospitalisation will be more than $600 budget from the Rescue group.

Berenil is cheap but anaphylaxis according to your text. Hb at 5 is low for your affected dog, but you also need to know total RBC.

In conclusion, anti-tick fever treatment is not cheap due to prolonged treatment and follow ups.


E-MAIL TO DR SING DATED Oct 29 (2 days ago)

Thank you very much Dr Sing. I am heading out to check on the dog this morning. If the rescue doesn't want to pay for treatment, I think I will bring the dog home to die as she doesn't like the cage...


Thanks again. Will email u soon.

Name given

COMMENTS
The dog was sent home without the expensive treatment or imizole. The lady activist thought that the dog was "alone" at the vet clinic and she would take the dog home to die. Berenil would be available possibly 2 days later.

Coincidentally, I was following up on an English cocker spaniel, 11.5 kg with Babesia gibsoni and Ehrlichia tick fever 10 days ago. A Cocker Spaniel has tick fever in 2011 is the case report.




Day 1 to Day 5 of tick fever
She came today (Sunday Oct 30, 2011) for her 2nd imizole injection (0.6 ml SC today) 10 days after the first injection (0.5 ml SC). Based on her active normal behaviour and much pinker gums, the first imizole injection had worked. Otherwise she should be dead by now.

So, should Vet 1 have given imizole to that stray dog rather than wait for the cheaper Berenil to be available later? Is imizole totally ineffective against Babesia gibsoni? I related the story of the stray dog with tick fever to the cocker spaniel and she was worried that I had not given the correct treatment.
Day 1 --->





Day 4 & 5 --->


Day 4 & 5 --->


Day 4 & 5 --->


Day 10 --->



"Will you dog be active and rushing out to play and have pink gums 10 days after the first injection if imizole was ineffective?" I asked her as I gave the 2nd injection today. As the dog still had ticks attached to her head and spinal area, I asked: "Does your dog go under the bed?". She said "Yes, my dog likes to sleep under the bed." I said: "Ticks may be present on the under part of the bed and attaches to the dog. Advantix should work as this spot-on was given 10 days ago when the dog came in. Give another dose in 4 days." I wanted to prescribe the anti-tick wash but did not as I asked her to use the Advantix and the dog had not many ticks.

My thoughts on this fine Sunday morning were for that stray dog and the caregiver who was a student. The young Singaporeans prefer to text and on Saturday, Oct 29, 2011, 2.53 pm, I got the following:
"Dr Sing, I brought the dog home as they could not do anything for her. Rescue opted to try Berenil but can't get for a few days so we are waiting. She is very weak. I think she may be dying. How much is one shot of imizole? Do u think it is worth a try? If not too expensive, I don't mind trying myself. What else can we do for her in the meantime?
I phoned her on Saturday and told her to bring the dog for the imizole injection on Saturday at 9.30 am. But she said that the transport was not available. In any case, the Berenil may be available on Monday and the dog was still alive. So I hope that this dog had the Berenil treatment soon.

As for the English Cocker Spaniel, as at Nov 3, 2011, the dog is normal. "Except that she tires easily," the owner said to me. She submitted a urine sample for testing. The values were normal. The urine SG was high, at 1.041 (range should be 1.005 -1.030), pH was 7.0 and struvite crystals were present. "Could it be the high liver I am feeding?" the lady asked me. "Should I stop feeding the liver?" She was also feeding iron supplements and all the good home-cooked food. "Since your dog tires easily, she has not fully recovered her normal red cell amount," I said. "The high urine SG is unusual. It shows that the kidneys can concentrate the urine well but what causes it is hard to say." I may need to have another urine test 2 weeks later.


Nov 3, 2011, as I update this report, I had been thinking about the high urine SG. My hypothesis is that the destruction of so many red and white blood cells damaged by the Babesia and Ehrlichia organisms during the past 14 days would have contributed to a large amount of protein damage for the past few days. The kidneys are normal and have to work hard to excrete the urea. This resulted in a high urine SG. There may be a high blood urea but I did not take a blood sample when the urine sample was sent.

Since the kidneys and bladder were normal, there was no proteinuria during urinalysis. Is this hypothesis sound? These are the types of questions the professor may ask in a case study during the final exam of the 5th year vet student. I remembered my "viva" or "oral exam" on a case study during my final year by my Professor of Vet Medicine and an external examiner and I presume Murdoch vet students still get this oral test.

A reply or hypothesis may not be possible for a vet student so much burdened with 5 years of vet knowledge memorised to pass the Final examination in November 2011 if the Professor of Vet Medicine asked about the high SG during the oral test!
Earlier report: A Cocker Spaniel has tick fever in 2011 or
http://www.sinpets.com/dogs/20111039tick-fever-cocker-spaniel-singapore-toapayohvets.htm

IT IS NOT POSSIBLE FOR ME TO POST THE VARIOUS EDUCATIONAL IMAGES ON BLOGGER.COM
UPDATES AND MORE IMAGES WILL BE AT TOA PAYOH VETS
http://www.sinpets.com/dogs/20111036babesia-gibsoni-treatment-drug-imizole-success-singapore-toapayohvets.htm