Saturday, April 28, 2012

968. Dr Sing on leave from Apr 29 to May 2, 2012

I will be on leave from April 29 to May 2, 2012 and will be in Cambodia. Any queries can be directed to Dr Daniel Sing +65 9664 0404 or text me at +65 9668-6468. Best wishes.

If the internet connections are OK, I will be blogging in Cambodia.

Friday, April 27, 2012

967. The new Yangon vet practice

On April 25, 2012, I sent James Aung and his wife off at Changi Airport to Yangon. He has been renovating his own practice in Yangon and should be opening in June 2012.

James Aung is a Myanmar qualified veterinarian but in Singapore, he is just a veterinary technician. He had worked in various practices and know much more over the last 20 years as he is hands-on in assisting in veterinary surgery and medicine. He gives values to his employers by giving more time and effort to hospitalised cases than expected of an employee. He has earned a good reputation in Singapore.

"Got to get the models to be at the opening ceremony," the wife had invited me by offering to pay for my air tickets. Her friend had the connections to the media in Yangon. Car salesroom in Yangon always show models standing around.

"No models," I advised. "Actresses and actors. Famous ones! Any lion dance like Dr Jason Teo who opened his clinic?"

"No, no," the wife said. "Lion dances are for the Chinese."
"Ok, how about horse or donkey dance?" I asked as I had seen such events during my travel to Mandalay from a resort military garrison town.

In this practice, a big pre-owned car had been bought for $60,000 cash. Renovation of the 3-storey building would be at least $40,000. Two water tanks, a well dug and sewerage pits must be planned unlike in Singapore.

Sometimes, it is penny wise pound foolish in starting up a vet clinic. James said he would buy the auroscope but not the opthalmoscope because his wife objected. I told the wife that was not the right thing to do and she gave permission. Asian wives can be quite powerful as James hand over his pay to his wife and get an allowance.

Still, there is much more to having a pretty modern veterinary clinic and an experienced vet like James. Will the clinic be able to sustain its profitability? There is the marketing part. The business development part. The technical part. If the clinic is not profitable over the years, it is a white elephant and James' wife would have lost a lot of money..

966. Sharing memories online - SingaporeMemory.sg web portal


1.  The Singapore Memory Project aims to build up the story of Singapore  through the eyes of Singaporeans was started in 2011 and aims to collect 5 million memories from Singaporeans by 2015

2. Every Singaporean has a "personal memory account" on the website. An SG Memory iPhone app will be launched in April 2012.

3.  I would like the future generation to know more about Singapore veterinary matters and learn from the mis-steps of some pet owners, therefore I have participated in this Project. However, most of my files will be at http://www.toapayohvets.com/ and http://www.bekindtopets.com/  .

4.  Sustainability of the Project. As I don't know how long the Singapore Memory Project will be around as all government policies keep changing (new Chief Executives/Board of Directors have their own pet ideas and chop and slash older projects when there is a need to cut cost and this Project is free of charge), I have copied my notes written at the Project webpage below:

PARTICIPATION IN THE SINGAPORFE MEMORY PROJECT

Saturday, April 29, 2012

I am Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS, aged 61 years, a veterinary surgeon in Singapore. I graduated in 1974 and there was around 1 small animal veterinary practice located in a commercial premises in Watten Estate.

After graduation, I had to work for the Primary Production Department for 8 years (inclusive of 2.5 years in full-time National Service), as a condition of my veterinary scholarship. Soon after graduation, I met Dr James Tan, a private dog and cat vet 5 years my senior, telling me he had to be on the look-out for Dr Giam Choo Hoo, from the Primary Production Department. He was practising from his home in Tiverton Lane and I presumed he was being hounded. I was a greenhorn and did not ask him why he had to behave that way.

Now, there are over 45 veterinary practices and the numbers keep increasing as some of the younger vets are well financed by their parents who set up the practices for them. I had no such fortune.

In 2012, the younger generation dog and cat owners are much more sophisticated owing of internet information and are much more caring compared to my baby-boomer generation when I started Toa Payoh Vets sometime in 1982.

I record my stories of so many interesting clients I encountered and their pets' conditions, at www.toapayohvets.com as part of my giving back to the small animal community and to bring veterinary medicine and surgery alive to the stressed out veterinary undergraduate. I hope the stories of practice-based research cases are of interest and use to the new generation in the years to come.

The link to the Project is at:
http://www.singaporememory.sg/contents/SMA-d847587c-eca0-41c9-b042-991b2a7ae823

I hope this Project is still around in 2015. Five million memories are not difficult to get from Singaporeans. It is the quality of the memories that is difficult to source.

Thursday, April 26, 2012

965. Food allergy?

"I guess every vet will give a different opinion about the skin infections on the lower body," the woman brought in an older Golden Retriever full of ticks and Vet 1 had prescribed anti-allergy food diet for the past 3 months. But the dog was still furiously scratching to blackness, the neck and armpits.

The pest control had fumigated the garden and house and the dog would need to be de-ticked by a vet.

"My theory is that the dog had itchy infected ears and he scratched with his hind paws, the neck to relieve the ear itch for many weeks till the skin becomes black."

As if on cue, the dog's hind leg vigorously scrubbed the neck.

A plan of treatment is given to Dr Vanessa to treat this dog. I doubt its black neck and armpits are due to dog food allergy.
"I trim the hair short," the owner said.    

964. Two old female spayed dogs

Yesterday, Thursday, April 25, 2012, I saw two old female spayed dogs from 7.20 pm to 9.30 pm.

Case 1. Lhasa Apso, 13 years. Tearing on right eye last 2 days. I used fluroescein strip and showed the lady owner that the dog had a new ulcer. A white scar above it was bigger and was a healed ulcer. The left eye cornea also had white ulcers.

"I am out of Clavulox," she was prescribed Clavulox to be given 3 times a week for many weeks as her dog had "lump" in the bladder on X-ray and had bacteria on initial urine analysis. She does regular health screening of blood and urine test with Vet 1. "No more bacteria in the urine," she said. I checked the vulval mucosa. The dog winced and withdrew. But overall, there was only inflammation at the tip.

There are some vet recommendations to give antibiotics weekly at 2-3x/week for many weeks for UTI, but I would not advise it. It would lead to drug resistance. So I did not prescribe antibiotics. For the eye ulcer, the husband requested e-collar wearing instead of surgery. So, this matter was settled by the husband.

 Case 2. Miniature Schnauzer, 15 years, panting, swollen abdomen
Vet 1 suspected liver tumours (blood test on elevated liver enzymes and X-ray of enlarge liver) and advised an ultrasound.
"Abdomen looked fully distended as if it is going to burst," I viewed the X-ray. "What did Vet 1 say about this swollen abadomen?"
"She said nothing," the lady told me. "She put a needle in and nothing came out from the needle."
Overall, this would be a case of liver disease and I gave a poor prognosis of 6 months or less to live.

The surprising findings were:
1. that the Schnauzer's teeth were still good and had little tartar despite no dental work done, according to the owner.
2. the vulval lips and lower inguinal area were jet black, as compared to the Lhasa Apso above. The vulval mucosa was bright red. All these suggested a chronic UTI.

I advised monitoring of water intake and panting as I prescribed medication. Today, April 27, 2012, I phoned up. The 66-year-old mum answered the house phone and said: "The stomach is still swollen as before. I guess it will take time for the drugs to work."
"Is the dog panting?" I asked.  
"Much less," the mother and later the daughter phoned me, gave the feedback.
"Is the dog more active?" I asked.
"Yes," the mum said. 
"Did the dog pee a lot?"
"Yes, more than 3 x last night."
My hypothesis is that the fluid accumulated in the abdomen caused pain and difficulty in breathing, leading to heavy panting.  
"Did the dog eat the L/D diet?" I asked.
"1/4 can."

963. Follow up: GME? The circling Schnauzer

Mini Sch Male 12 years
Consulted Vet 1 two weeks ago but Vet 1 said no obvious problem but would require MRI and blood test.

I saw the dog on April 24, 2012. Dog was circling anti-clockwise in smaller and small circles. Collapsed on April 24, 2012 as she couldn't circle anymore as the circle was too tight. Continuous movement, whining. Loss of bladder control. Euthanasia not accepted by the young lady owner. Her colleague referred her to me.
Warded 2 days. Treated. Could look straight when sent home on April 25, 2012 with phenobarb 30 mg bid.

Friday April 27, 2012
Follow up:  Phoned lady owner today

1. Dog has excellent appetite, could control bladder and bowel movements
2. Head tilt to the left mainly but not permanently as prior to my treatment. Walk mainly anti-clockwise but can walk straight or turn right.
3. Head tilt to the right and left, like a pendulum sometimes. Therefore left and right turning possible, instead of permanently circling anti-clockwise befoe.
4. Can see
5. Looks at owner when called.
6. Not as restless as before treatment. No obsessive need to walk anti-clockwise and whine continuously.
7. "Is he dopey and sleepy?" I asked. "Not really," she said. I asked her to monitor the times of usage of phenobarb, now given twice a day by a family member.
 
Will phenobarb work? Much depends on owner's compliance with medication dosage and timing. There needs to be follow up by the owner.

Cause of this brain disease to be GME?  Granulomatous meningo-encephalitis?
Eosinophils and monocytes were higher than normal.
962. Scratched by an angry drooling cat
On April 24, 2012, I peeped into the consultation room and saw my assistant Min holding a lasso at a hissing cat about to be treated by Dr Vanessa 1 with subcutaneous fluid and antibiotics before dental work the next day as the cat had not eaten for the past few days.


"Stop," I said. "You can't lasso the cat in an open consultation room." Actually I had thought them what to do with aggressive cats which are rather rarely encountered and I presumed they have forgotten. What happened was that this cat came in with drooling and bad breath and I had demonstrated to Dr Vanessa how I would examine the cat. I put the cat on the examination table, opened his mouth wide and shown the white torch-light inside the mouth.

The cat was rather quiet but he got quite fed up with me as I pried open his mouth again to check for oral tumours and ulcers and plaques in the fauces (back). He had pain in the mouth and here I had not respected him. The careful thing to do would be to sedate him to examine his mouth but he was sickly and had a fever. I advised treatment with fluid and antibiotics first and dental work under anaesthesia the next day.

So, in the afternoon, there was Min, with bite scars from dogs and cats, holding the lasso inside the consultation room and preparing to get the cat out of the wooden crate. I went into the room to show how I would restrain the cat by the scruff of the neck. "Take the cat cage into the room," I told Min as we need to put him into a crate. His owner had a small rattan box carrier and no angry cat would go in. Min said: "My hand is weak, can't do it."

So Min could not restrain the cat for injection by me. He had some bad luck with cats as he had not been able to read "angry cat or dog behaviour" and got some serious hand injuries in the past year and I had to get him to see the human doctor twice! This was despite the fact that he had worked in a Malaysian vet surgery the year before. As the consultation room is very small, I asked her to leave the room. I took the cat out of the crate, placed him on the consultation table. No problem so far but the cat's tail and back hairs were up. He started hissing. From the look of his eyes, I know I had no time. "Open the crate upper door," I shouted to Min. Just in time, I put the cat into the crate. He hissed and jumped up like a pole vaulter. His claws pricked in my left hand and my middle finger of my right hand. Min got some claw marks too.

It was a matter of seconds, like a lightning strike. "The best way is to sedate the cat inside the crate with Zoletil 100 IM according to weight, and commence with the dental work," I said to Dr Vanessa. "You must inform the owner of the change of plans," Dr Vanessa reminded me. So, she did the necessary and had the cat's 4 rotten back teeth extracted, did scaling and sent the cat home the next day. Not a single claw scratch for her! As a routine, I do open the mouth of all salivating cats. Maybe, I ought to do it once and not more times. But no cat would co-operate as he has oral pain and a visual examination is important to plan for treatment.

Fortunately, we don't encounter many dangerous cats at Toa Payoh Vets as Min does the front-line. In this case, if he had lassoed the cat, all hell will break loose. It is important to reinforce instructions to staff several times as different situations occur and staff are people who think in different ways.
961. An old dog pants heavily. This is a serious health problem for the old dog.

AN OLD DOG PANTS HEAVILY - AN ULTRASOUND TO CHECK FOR LIVER CANCER? E-MAIL TO DR SING DATED APRIL 26, 2012 To: judy@toapayohvets.com Dear Mdm I would like to make an enquiry about my dog (Schnauzer-cross). She is 15 years old. We brought her to the vet as she was panting heavily and her stomach swelled and keeps hiding in the room, away from the rest of the family. X-ray results shows that she has an enlarged liver. Also, the blood test shows that she has high Calcium, high platelets and white blood cells. Most likely, says the vet, my dog has cancer and recommended an ultrasound at its hospital. Meanwhile, the vet has given her some liver medication and my dog's condition has improved though the vet did share that this would be temporary. I am worried about the costs of sending my dog to their hospital as I did some research and found that the hospital tend to order several tests and cost of the treatment usually escalates. If she is found to have cancer, it's likely that we will not opt for treatment as she is old and already her quality of life is poor, with poor eyesight etc. Does your clinic offer ultrasound services and how much does it cost? Is ultrasound the best option for my dog now? My family wants to see her pass on without suffering too much. What should I do to alleviate her suffering? I would really appreciate if you could advise me. Please feel free to call me if need be. Rgds Name & Phone


E-MAIL REPLY FROM DR SING DATED APRIL 26, 2012 I am Dr Sing from Toa Payoh Vets. We spoke by phone today Apr 26, 2012, 3.31 pm and the following is my brief reply to you: In my opinion, the important health care issues in your old dog are: 1. what is the cause of "panting heavily" and "swollen stomach" 2. what is the cause of the "high platelet and white blood cell count" Is there liver cancer or not? Is there a cure? If the cause of the illness is known and treatment can be effective, it should not be "panting heavily".

Tuesday, April 24, 2012

960. Update: Feline Eosinophilia Granuloma Complex (Images)

For veterinary students studying hard on oral conditions in the cat, the updated website and more images are



at: http://www.toapayohvets.com/20120415feline-eosinophilic-mouth-ulcers-young-stray-cat-singapore-ToaPayohVets.htm

959. What to do? Carrier cover closed on the cat's tail

April 24, 2012 I saw the consultation table stained by KMnO4 today and was quite furious that there was no newspapers being used to protect this table. Vets who don't bother to take care of equipment will have to pay for the damages. The KMnO4 powder was applied to stop the bleeding from the cat's tail. Somebody had closed the lid on the longer tail of the cat and injured it.

There was hysteria and bleeding. So the vet used KMnO4 and did not bother to use the newspaper to protect the table. "KMnO4 does not work in stopping bleeding of bigger tail wound," I said.

"In such situations, treat it as an emergency and apply the following procedures:"

1. Be firm and ask the owner to wait outside the at the waiting room.
2. Bring the cat to the surgery room.
3. Sedate if necessary as the cat gets excited and worried with all the human commotion.
4. Pressure bandage will stop the bleeding.

Bandaging and cleaning the wound would be better.

PREVENTION Get the owner to put the cat in her carrier when she comes to take her cat back. I had given such instructions for owners to cage their own cats and not let the assistants do it. All of us learn from experiences.

958. Uterine prolapse in the cat - seen by Dr Sing

On Tue, Apr 24, 2012 at 3:33 AM, Sorrel J Langley-Hobbs wrote:

Dear Dr Sing Kong Yuen, I am writing a chapter on the feline genital tract and would like an image of a uterine prolapse to include in the chapter. I found yours - the website was forwarded to me by another veterinarian. If you have a higher resolution image of the uterine prolapse (attached) - needs to be 300dpi and about 10cm x 10cm then it could be publishable. I would of course acknowledge you for use of the picture. thanks very much Sorrel Langley-Hobbs -- Sorrel Langley-Hobbs MA BVetMed DSAS(O) DECVS MRCVS European Specialist in Small Animal Surgery University Surgeon Head of Small Animal Surgery, Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 OES Tel 01223 337621 / 337653 Fax +44 1223 330848 Email - SJL41@cam.ac.uk

E-MAIL REPLY FROM DR SING DATED APRIL 24, 2012
Hi I am Dr Sing. The picture was taken many years ago and at that time, the images were on poor quality as I was just starting out my digital photography. Pl feel free to use the image and I have not seen any more such cases of uterine prolapse in the cat. Best wishes

Monday, April 23, 2012

957. Eosinophils and monocytes compared in two old dogs

April 24, 2012 Blood test done by the same lab on two aged dogs. An interesting case of the circling dog to be compared to an ordinary case of maggot wounds.

Case 1.  The circling Schnauzer 12 years old, Male - Dr Sing's case
Date of test April 23, 2012
Total WCC 6.2 (6-17)
Neutrophils 71.5% 4.43 (absolute)
Lymphocytes 11.3% 0.70
Monocytes 6.5% 0.40
Eosinophils 9.6% 0.59
Basophils 1. 0% 0.06
PCV 0.47 (0.37 - 0.55)
Platelet 337 (200-500) Few giant platelets seen. No platelet clumping noted.
Glucose - specimen grossly haemolysed. Query glycolysis. Suggest repeat.

April 24, 2012. Day 2 after treatment. 10am. Dog does not cry. Sedated. Can walk with head straight but ataxic. No circling. Went home on April 25, 2012 with no head tilt. To review.


Case 2. The eye-maggot-wound Golden Retriever 14 years old, Male - Dr Vanessa's case Numerous maggots below R eyelid

Date of test April 20, 2012
Total WCC 22.5 (6-17)
Neutrophils 90.8% 20.43 (absolute)
Lymphocytes 7.6% 1.71
Monocytes 0.3% 0.07
Eosinophils 1.2% 0.27
Basophils 0% 0.0
PCV 0.39 (0.37 - 0.55)
Platelet 276 (200-500) Large platelets present. Platelet clumping noted.
Glucose 3.9 (3.9 - 6)


Conclusion:  The monocytes and eosinophils were very high in Case 1.  Case 2 would be considered to have normal ones but the total white cell count  and neutrophils were high (bacterial infection) .

Could Case 1 be suffering from a chronic illness? For example, bad rotten teeth infection - toxins and bacteria travelled via the Eustachian tube to the middle ear and the brain? This resulted in increase in monocytes and eosinophils and a possible auto-immune reaction?). Hard to confirm unless a spinal tap is also done. There is the economics additional tests to be considered.  

956. Miniature Schnauzer with head turned left

Yesterday, April 23, 2012, I was surprised to see a 12-year-old Miniature Schnauzer I had not seen since 11 years ago. A young couple in their mid 20s came with the dog whose head tilted or turned left at around 90 degrees to the neck. I recognised the name of this dog which was one of a kind and recalled the father who brought this dog specially for the young daughter who was 12 years old then.

As he lived quite far from Toa Payoh, it was understandable that I had not seen this dog. There could be other reasons but this is expected. "Was the dog walking in circles?" I asked. "Yes," the young lady said. "At first wide circles near the wall. Now, in small circles. Always circling to the right."

Sudden onset 2 weeks ago said to have fallen from the couch. Vet 1 examined and said nothing was abnormal. Soon the dog started walking in smaller circles and crying. The daughter decided to consult me. The father wanted euthanasia as the dog was whining the whole day and restless.

Yet he ate and had not lost much weight. He vomited the food recently. What's the cause of this circling? Is there a solution?

There was mild pain in the spinal area on palpation esp. T/L and inside the ears when I applied a cotton bud. Other than that, no cervical pain.

Blood tests were not taken by Vet 1 and no medication or injection was given as the dog was "normal." This was a puzzling case. Middle ear infection or trauma? Ears were quite clean. Infection from bad teeth's bacteria into the brain via the Eustachian tubes to the brain?

The dog had two dentals, the recent one being in January 2012.

TREATMENT Diazepam 1.5 ml sedated the dog for around 2 hours. The dog started to paddle. I gave Domitor+Ketamine at 20% to let him sleep. His neck was now straight due to diazepam. Will wait till blood test results come in today and see what's the problem.

No spinal fluid test is done yet. There's a big below gum upper molar tooth embedded.

Could this tooth be rotten inside the gum, causing bacteria to go up the maxillary sinuses into the frontal sinus and to the brain? Now, there is no bad breath. Ear canal had little yellow wax and grooming was done 2 weeks before the appearance of clinical signs. It is a difficult situation as the cause is still hard to find without X-rays and scans which would cost money.

UPDATE

Blood test - significant results were the high eosinophils and monocytes.

The dog was warded two nights and went home. The head had not tilted 90 degree to the left. When I called him, he could turn his head to the right. So far, he could walk straight and his head pointed normally forward. What is the cause of his circling?  He circled from larger circle to small tight circles to the right. He could circle no more in the sense that the circle had become too small. A very rare case reminding me of "scrapie" in the sheep shown by the professors when I studied at Glasgow Vet College some 40 years ago. The sheep was walking in circles and it was quite unforgettable even now. 

955. Sinusitis

Sinuses are empty air spaces in the skull bones. They have openings to drain mucus from the sinus into the nose. People have 4 pairs of sinuses in the spaces.

The frontal sinuses near the eyebrows, the maxillary sinuses inside the cheekbones, the ethmoid sinuses between the eyes and the sphenoid sinuses behind the ethmoid sinuses.

Sinusitis is an infection of the sinuses in the face. Swelling and inflammation of the sinus mucosa blocking up the sinus passages to the nose. Obstruction can also be due to nasal polyps, a deviated septum or enlarged sinus turbinates.

Follow up: Lateral ear resection poodle, cat eosinophilia

Monday April 23, 2012 report
LATERAL EAR CANAL RESECTION POST-OP COMPLICATONS

All vet surgeons will encounter post-surgical complications no matter how experienced they are. So, I got one case now. Yesterday Sunday, I re-stitched the two ears (day 5 of surgery). Took over 1 hour under isoflurane gas only. Stitch breakdown uncommon but does occur in any surgery. Phoned owner not to take the dog back as scheduled as I need to nurse it again. Why stitch breakdown? Many reasons probably.

1. I noted that the ears had oozed thick fluid on Day 2 and Day 3, unlike other dogs and took some images.
2. High tension stitching?
3. Handling of ears by my assistant Min to give oral medication painkillers and antibiotics, ear powder, cleaning surgical area, disturbing the stability of the ear sutures? Most likely. I told Min not to touch the dog. Today I used a scoop and drop water at a height to wash away the oozing fluid in one ear (left?, check images). The other ear was dry.
4. I need another 5 days.

UPDATE ON APRIL 26, 2012. Ear wounds still oozing with fluid. Unusual. Used antibiotic powder to dry wound. Owner visited yesterday.



CAT EOSINOPHILIC GRANULOMA COMPLEX Cat went home on last Saturday. Gum and palate ulcers have shrunk 30% by observation of less redness and size after the steroid injection.

Advised 4 weeks to review and cat is on medication.

Blood test results on April 17, 2012
Glucose 11 (normal 3.9 - 6)
SGPT/ALT 294 (121) SGOT/AST 121 (67)
Total WBCC 13.5 (5.5 - 19.5)
N 64.4 8.69 (absolute)
L 23.6 3.19
M 5.7% 0.77
E 6% 0.81 B 0.3% 0.04


GOLDEN RETRIEVER,  9 YEARS, MALE, TICK FEVER
PASSED AWAY YESTERDAY
Positive for Ehr +ve  Babesiosis +ve
4 weeks ago

Apr 21, 2012 haemoglobin 5.2 (10.8 -15.6)
Total RCC 2 (3.8 - 5.8)
Total WBCC 102 (5.5 - 19.5)
Dog died one day later

Extremely high total WBCC and loss of blood.
For some reasons, the owner did not follow up and delayed treatment of the tick fever.

Sunday, April 22, 2012

Sunday's interesting cases Sunday April 22, 2012

Case 1: The hot dog farted on abdominal palpation again! The two young ladies came with the hot dog for a review and blood test. "The Miniature Schnauzer bites," one young lady held the dog's head with both hands as I palpated the abdomen with my left hand. "No more vomiting. Normal now." Suddenly the dog farted as I palpated the back half of the abdomen.

This was a loud cracking sound. It was a reproduction of the same incident when I saw him on April 8, 2012. Scientific experiments are valid if others can reproduce the outcome and in this case, I was able to do it again. It is not a common occurrence and so I was much surprised with this loud puffing crack from his backside. "Something wrong with the intestines producing too much gas," I said. The dog was on LD prescription diet and some dog treats, but he still farted. I asked the owners to wait 4 weeks from the first blood test to take blood to check whether the liver has recovered.

I gave the young lady a bottle to collect the dog's urine in the morning as he pees a lot and then dribbles with difficulty (I suspect urine marking as some male non-neutered dogs will try their best even to pee nothing!). In any case, the first urine test show struvite + and spermatozoa 2+ and so we need to review again. The male dog had no more urine and so I did not bother to catherise to collect the urine.

Case 2: Two shrivelled front teeth in a 5-year-old Maltese. The marketing books say "Give what the owner wants." Well, the wife did not want the teeth to be extracted and had been to Vet 1 who did recommend that. "It is not good for the dog," I showed that the gum had receded considerably. "The dog does feel the pain and bacteria will continue to grow after antibiotics.

The teeth may then crack." After much discussion, the wife agreed one bent front tooth to be extracted. Giving what the customer wants is good marketing. I asked the couple to think about it as the dog would need another anaesthesia if the other tooth fracture due to shrivelled root and instability. "It is not stable anymore," I said. "Like tree with rotten roots. During thunderstorms, the tree topples. This root will break and part remains in."

Much time was spent in discussion. It was up to the wife. Much time would have been saved and more fees earned if the vet just do what the customer wants as there will be two anaesthesias involved. The first to do dental scaling of the two front teeth. The later one to extract. However, this cost the owner money and the dog more pain in the delay. Finally, the wife agreed to extraction of the two front teeth and dental scaling.

During anaesthesia, another right upper molar tooth was loose after tartar removal. I did not extract it, knowing the wife's preference to have teeth present in this 5-year-old Maltese. It was loose but not that unstable. Yet all the other teeth were quite strong and relatively clean. The two loose front teeth were a surprising revelation as the other teeth were solid. Veterinary dentistry can be full of surprises. Domitor + Ketamine 50% and isoflurane was safe and fast. Owner wanted a blood test which was done.

Case 3. Phone review of the Maltese with acute bacterial meningitis 10 days ago. I phoned the owner. She said the Maltese was OK and she would come for a blood test later.

Case is written in: http://www.sinpets.com/F5/20120414acute-meningitis-dog-singapore-ToaPayohVets.htm
Signficant blood test results at time of stiff neck is as follows:
April 12, 2012 Maltese, 5 years, Male

Glucose **. Specimen grossly haemolsed. Query glycolysis, suggest to repeat.
Plasma glucose = 20mg/dL Liver Profile. ALT/SGPT normal. AST/SGOT 95 (normal = 81)
Total WCC 19.3 (6-17)
Neutrophils 94% 18.16 Lymphocytes 5.4% 1.04
Monocystes 0.4% 0.08
Eosinophils 0% 0 Basophils 0% 0

Based on sudden onset clinical signs and the total tal WCC and very high Neutrophils, this would be a case of acute bacterial meningitis.

Case 4. The spayed cat caterwauling loudly for the past 4 weeks, starting from first month after being spayed by Vet 1. The young couple showed me their phone video of the cat rolling over, tail up, backside up as if ready for mating. However, no audio. "Most likely, there is a bit of ovarian tissue left behind by Vet 1," I said. "It will be very difficult to find this tissue even if there is a repeat spay." What to do?

Case 5. A 2.5-year-old dwarf hamster had a much swollen right eye. The lower eyelid was as round as a ball, around 4 mm X 4 mm. Squeezing out the pus with fingers had been done by Vet 1 but the swelling remains as solid as ever. A small hole released the pus if you press the lower eyelid. "The best way is to cut a big cut and release the pus," I said to the mother who said this was her favourite "Small White" hamster and was concerned that the hamster would die under anaesthesia. "The hamster is at the end of his lifespan," she said.

"If he dies on the operating table, there is no more." "He will die if he does not eat or drink. Within 2 weeks," I predicted."No antibiotics and eyedrops will help. This is a large conjuntival abscess that needs to be cut around 3 mm to let the thick pus out. Anaesthesia is needed. The hamster may just die during surgery."

So, the 40-year-old mother with a small boy did not know what to do. The older man who could be her father was more aware of the no chance with eye drop and antibiotic treatment. Finally, she decided. I got it done.

A big cut. The hamster survived with a much normal sized lower eyelid and went home.

UPDATE: APRIL 26, 2012. No complaint from the owner

Case 6.  The previous blog is below: 939. The hot dog growls at the vet Tuesday, April 10, 2012 "More active, no more vomiting," the lady said. "The dog has not recovered fully from hepatitis yet," I said. I prescribed some liver supplements and anitbiotics. Every family member is happy. The dog was warded 4 days for lethargy and recurring fever.

10 days ago, I had operated on him and removed a big epidermal cyst. The dog was rubbing his back area where the cyst had been removed. So, the grandpa applied bright yellow powder onto the wound. It looked like yellow sulphur, which is toxic. Saturday, April 8, 2012 The owner had brought the dog to see me last Wednesday with complaint of lethargy and fever.

I boarded him for observation and on Saturday, the whole family of 2 ladies, their husbands and grandparents came to visit this miniature schnauzer of 5 years, male. Saturday was my day off, but I went back to Toa Payoh Vets to see this dog. That was how I met the group outside. The dog growled when I approached him to palpate his abdomen to see whether it was still tense and hard. "That is a good sign of recovery to health," I said.

 "Yesterday, Dr Daniel said he stood like a statute for a few minutes when let out." "Maybe he is frightened," the young lady said. "Possibly," I asked the owner to hold his muzzle while I palpated his abdomen. Not tense as before.

So,I decided to let him go home. He would recover faster at home. Well, he did recover. As to the cause of his tense stomach area, I can only sketch this scenario as follows: 1. The wound was contaminated by the yellow powder. Toxins and bacteria entered the wound.

Blood test showed high liver enzymes. Low red cell count. The stomach was full. Impaction. I had given anti-spasmodic inj to cool him down. The tense anterior abdomen was due to his liver inflammation.

APRIL 26, 2011Urine test did not reveal any struvite crystals.
This morning, the owner phoned to say the dog had 4 partly swollen paws and red eyes. Yesterday, he had fever and was treated by me with one anti-fever injection. Eating and drinking normally this morning.  Had vomited once on going home and after eating the AD canned food.
I asked her to wait and see. Could the liver be inflamed again?

Saturday, April 21, 2012

952. Epulis in an old chihuahua

952. Epulis in an old Chihuahua APRIL 22, 2012. ||


"Wait-and-see, take antibiotics" is not the appropriate advice to give to an owner of an old Chihuahua with a gingival growth, known as Epulis. Gingival growths in old dogs may not be Epulis and a biopsy is most important to confirm the diagnosis of Epulis or malignant tumour.

Surgical excision using electro-surgery involving the periodontal ligament should be advised. Some vet text books advise the complete removal of the tooth and periodontal ligament to prevent recurrence. A "wait-and-see" advice may be considered negligent advice.
5227. In old dogs, gingival tumours or growths should be excised, not being advised to "wait-and-see" after a course of antibiotics. Electro-excision of epulis including the periodontal ligament prevents recurrence. However, this means the whole tooth or teeth must be removed and this may not be what the owner desires. An informed decision must be made by the owner The vet should advise the surgical excision of all growths in dogs especially old dogs.

Whether the owner accepts the advice or not, depends on the wishes of the owner and this response must be recorded in writing in the case record in the presence of the owner.

This "Against Medical Advice" record is very important in cases of veterinary complaint investigation or litigation when family members find that the gingival growths had grown considerably, leading to pain, bleeding and dysphagia due to "wait-and-see" advice of the vet. Youtube website has one similar case of Epulis video: http://www.youtube.com/watch?v=1KDwaAWCY1s&feature=related

951. System, processes and protocols to prevent veterinary errors

Yesterday, April 20, 2012, I met the owner of the 14-year-old Chihuahua with a reddish gum growth extending downwards and covering the front upper teeth and asked what Dr Vanessa had advised. "Give antibiotics for 2 days, wait and see," she had spotted the growth since 7 days and it had "not grown much bigger." This dog had been looked after by me for many years. She had two operations to remove breast tumours last year. Now she had this gum growth which may or may not be malignant. Growths in old dogs should be advised to be removed early, not wait and see. "Do you expect the growth to disappear or become smaller after 2 days of antibiotics and an injection?" I asked her.

She was not sure. "I trust the vet's opinion." I asked Vet 1 whether she did advise a wait-and-see. She said she had advised surgery and blood test. "Were the advices recorded?" I looked at her case sheet. "It is best to record your advices in case of litigation. Oral evidence during litigation is one person's word against the other. The world nowadays is much more complex and owners are prone to sue. So, record down as you speak. For example, yesterday I spayed a 6-month-old Shih Tzu. I advised blood test to screen the health and to prevent misunderstanding from family members should the dog die on the operating table or after surgery.

I wrote on the case sheet, in font of the owner that he did not want a blood test. That is all that is needed. An informed consent." "Will advising surgery be like being pushy?" she asked. "Professional advices to take blood tests are optional as the pet owner has to pay for them. If the owner does not want the blood test, it is up to the vet whether he or she should undertake the anaesthetic risk to operate the dog.

Unlike the Singapore General Hospital, all surgery patients have to undergo blood tests, X-rays of the chest and ECG to check the heart before the surgeon will operate. This is to prevent litigation if the patient dies on the operating table. "However failure to record the advices may lead to a possibility of negligence or a lack of duty of care. This written recording is part of the vet's professionalism and protection in a court of law."

It should not take a law suit to make a vet wiser. I have instituted a system and process to record AMA (Against Medical Advices) and vets must adopt them for their own good. It is not that my vets must do hard-sell. If the owner does not want blood tests and surgery to remove an oral growth, this is AMA (Against Medical Advice). Record this down promptly in the presence of the owner. Not later. There is no need for a vet to do hard-selling in Toa Payoh Vets. For younger vets, they must be aware of the litigious world they are operating in and the sophistication of the Singaporean clientele.

The licensee (me) must beef up the system and processes to prevent veterinary errors in consultation and treatment. Also protocols for the diagnosis of diseases. There is no other way to protect the practice and the veterinary when litigation comes. P.S. In the human medicine area, a few Singapore surgeons and doctors had been sued for "negligence" and for failure to give informed consent.

Vets in private practice must learn from the reports of such cases and beef up their system, processes and protocols.

Any update will be at: Toa Payoh Vets webpage is at: http://www.sinpets.com/F5/20120418epulis-chihuahua-14years-female-spayed-singapore-ToaPayohVets.htm

Friday, April 20, 2012

951. System, processes and protocols to prevent veterinanry errors

Yesterday, April 20, 2012, I met the owner of the 14-year-old Chihuahua with a reddish gum growth extending downwards and covering the front upper teeth and asked what Dr Vanessa had advised. "Give antibiotics for 2 days, wait and see," she had spotted the growth since 7 days and it had "not grown much bigger."

This dog had been looked after by me for many years. She had two operations to remove breast tumours last year. Now she had this gum growth which may or may not be malignant. Growths in old dogs should be advised to be removed early, not wait and see.

"Do you expect the growth to disappear or become smaller after 2 days of antibiotics and an injection?" I asked her. She was not sure. "I trust the vet's opinion."

I asked Dr Vanessa whether she did advise a wait-and-see. She said she had advised surgery and blood test.

"Were the advices recorded?" I looked at her case sheet. "It is best to record your advices in case of litigation. Oral evidence during litigation is one person's word against the other. The world nowadays is much more complex and owners are prone to sue. So, record down as you speak. For example, yesterday I spayed a 6-month-old Shih Tzu. I advised blood test to screen the health and to prevent misunderstanding from family members should the dog die on the operating table or after surgery. I wrote on the case sheet, in font of the owner that he did not want a blood test. That is all that is needed. An informed consent."

"Will advising surgery be like being pushy?" she asked.
"Professional advices to take blood tests are optional as the pet owner has to pay for them. If the owner does not want the blood test, it is up to the vet whether he or she should undertake the anaesthetic risk to operate the dog. Unlike the Singapore General Hospital, all surgery patients have to undergo blood tests, X-rays of the chest and ECG to check the heart before the surgeon will operate. This is to prevent litigation if the patient dies on the operating table.

"However failure to record the advices may lead to a possibility of negligence or a lack of duty of care. This written recording is part of the vet's professionalism and protection in a court of law."

It should not take a law suit to make a vet wiser. I have instituted a system and process to record AMA (Against Medical Advices) and vets must adopt them for their own good.

It is not that my vets must do hard-sell. If the owner does not want blood tests and surgery to remove an oral growth, this is AMA (Against Medical Advice). Record this down promptly in the presence of the owner. Not later. There is no need for a vet to do hard-selling in Toa Payoh Vets.

For younger vets, they must be aware of the litigious world they are operating in and the sophistication of the Singaporean clientele. The licensee (me) must beef up the system and processes to prevent veterinary erros in consultation and treatment. Also protocols for the diagnosis of diseases. There is no other way to protect the practice and the veterinary when litigation comes.

P.S. In the human medicine area, a few surgeons and doctors had been sued for negligence and vets should learn from such cases

950. Follow up - lateral ear resection of poodle - operated on Apr 17, 2012

April 19, 2012
Ear operation areas were wet. Took some images. Cleaned up the ears. Gave 2.5 mg pred PO. Painkillers and antibiotics. Dog was eating. No pain on touching ears. Applied trimetho powder onto wound to dry it. No chemicals like iodine or KMnO4 as the area is stitched up and such chemicals irritate and delay healing.

April 20, 2012
Review in the morning. Ear operation area much drier. Dog looks happier. It takes lots of nursing in such operations. At least 7 days to clean wound to ensure proper healing.

Thursday, April 19, 2012

949. Clinic Inspection on April 19, 2012

Yesterday, Toa Payoh Vets was inspected by the AVA before its operating licence can be renewed. It was the same AVA vet who did the inspection the previous time and I wanted Dr Daniel to be present. Somehow he was not around during the inspection of the waiting area and reception counter. Then, during inspection of the surgery room, he had to answer a phone call.

It is important that the operating vets be around at the inspection although they are not licensee as many regulatory matters are best learnt from being on the spot. Sometimes, new inspection surprises are introduced. This time, there was a check on 3 medical records. I took out the recent 3, all of which were done by Dr Vanessa. A dog and two hamster cases done.

There is a checklist for inspection but it is not available on the AVA website. Some years ago, the two AVA vets who came to inspect were behaving like the army non-commissioned officers. One Dr Lau placed his fingers on the window sill to check for the presence of dust during his inspection. Later, when I could not meet the AVA deadline to complete my clinic renovation, he decided to close me down. The reasons being that I had not installed the wall cabinets and the reception counter.

"You ought to penalise the contractor in the contract for not be able to complete on time," he said to me as he marched off. He had closed the first Vet Surgery in Singapore for the AVA. A record. The surgery had all facilities available - water, electricity, air conditioning, all regulatory rooms, drugs and medication. I got a table and chairs and mobile cabinets but he was not interested in the fact that this clinic was operational. I had to write in to appeal to the Dr Ngiam Tong Tau to state my case and was permitted to commence operations. Yet, the HDB which is my landlord offered advices on how to get contractors and expedite planning permission. Two government organisations. One tried to kill the business. The other tried to help it start fast.

There was another AVA vet, Dr Liow who referred me to the Singapore Veterinary Association for using "xylazine to induce dogs". She had asked me what drugs I used to induce dogs, like those professors doing viva for final year students. I said I used xylazine and then halothane mask. She did not come back to me for clarification but instead wrote to the SVA. I was not called up by the SVA but I was told by the President of the SVA that she had written to the SVA to lodge a complaint.

So, you can see why I am wary of the AVA vets nowadays. However, the recent AVA vet, Dr Joanna Khoo did not come to penalise but gave excellent advices on veterinary matters like controlled drugs of importance to the HSA and on a vet practice that require other vets to call him personally if they want to refer after-office hour patients. Too much business is good for this vet practice. When more referral practices are opened, this practice may be relieved.

Wednesday, April 18, 2012

948. A stray cat with bad breath and oral ulcers - not necessarily a FIV cat - Eosinophilic Granuloma Complex - .

April 17, 2012

"Nothing much can be done," Vet 1 told the stray cat care-giver and her domestic worker some 3 months ago when she adopted a skinny malnourished cat with bad breadth and a leg wound and a very bad breath. "This stray cat has FIV. Give him clindamycin one capsule per day for 15 days." Vet 1 treated the cat's leg wound and neutered him.

The cat's bad breath returned after the end of the course of antibiotics.
So she gave clindamycin for 15 days for another 15 days by sprinkling the powder from the capsule into the cat's food. The cat still ate but was not so active.

The cat looked plump and had a rectal temperature of 39.3 C. No runny nose. No bad breath or diarrhoea. Just not eating.

"Unlikely to be FIV as this cat looked so plump at 5 kg and has no upper respiratory tract infections or drooling of saliva," I gave the owner the option as to whether to test for FIV or not since she was fostering at least 5 stray cats. "Of the two, a blood test is more useful." Vet 1 assumed this stray cat has FIV but did not do the test to save the owner costs.

FIV/FeLV TESTS - Negative

MOUTH EXAMINATION
It is important that the owner actually see the inside of the mouth. I asked my assistant to shine a white torchlight into the mouth as I pried open the mouth. The cat was quiet but there was pain and objected to it. I opened the sides of the mouth - gum ulcers, tongue ulcers and two large ulcers at the back of the mouth, beside the tongue on both sides.

DIGITAL IMAGES
Best to take pictures to document the oral ulcers at presentation. I took several pictures on April 17. Today, April 19, I took some images. The cat was eating and was less hostile now.

BLOOD COLLECTION
The cat was quite fed up since I had pried opened his mouth a few times. Dr Daniel collected blood from his veins but there was insufficient. The cat started clawing in self-defence.
"It is not easy to collect sufficient amount of blood from an angry cat," I said. "I will tranquilise him and Dr Vanessa will collect the blood from the jugular vein after 10 minutes." 3 ml of blood was colllected by Dr Vanessa.

Blood Test Results - significant findings
1. Glucose elevated 11.0 (normal 3.9 - 6.0) - "stressed induced hyperglycaemia" in the cat.
2. Liver enzymes ALT & AST elevated.
3. Urea below normal.
4. Platelets low 146 (300-800). Large platelets present.

RBC and WBC are normal.
Differential count:
N 64% 8.69
L 24% 3.19
M 6% 0.77
E 6% 0.81
B 0.3% 0.04

Could the oral ulcers be due to eosinophilia? Need to review my past report at:

http://www.asiahomes.com/singaporepets/0747cat_tonsils_overwhelmed_Singapore.htm

An extract from the above webpage is as follows:

3. RODENT ULCERS IN CATS (feline eosinophilic granulomatosis). Salivation and ulcers are signs.

Eosinophilic Granuloma Complex -

Three distinct but related clinical syndromes comprise the granuloma complex:

3.1 Eosinophilic (or rodent) Ulcer. This may occur on the skin or in the mouth but usually affects the upper lips. The lesions are well-demarcated ulcers.

3.2 Eosinophilic Plaque. These are raised, moist, red eroded or ulcerated areas with a well demarcated border. Pruritus is usually severe. lesions usually occur on the underside of the cat (abdomen, brisket or inside the thighs.)

3.3 Linear Granulomata. These can occur at most sites, especially behind the hind legs and within the mouth. They are well-demarcated lesions which are raised and yellow to
yellowish-pink in colour. They are often thin, hence the name *linear* granuloma.

CONCLUSION
Could this be a case of Eosinophilic (or rodent) Ulcer? The mouth ulcers are well demarcated. The eosinophils are high. This could be a case of "rodent ulcer" and there is a treatment for it.

947. Post-op lateral ear resection, spay female shih tzu 6 months old and stray cat with "FIV"

April 18, 2012

LATERAL EAR RESECTION POODLE
I was reviewing the poodle with the lateral ear resection case operated by me 24 hours ago. The ears were still bleeding. My assistant Min had changed a new bandage and the bleeding had stopped. It was a bright sunshine morning. So, I had some pictures taken for record.

EFFECTS OF BANDAGING
1. There was some swelling below the neck seen at 9 am today. This was inevitable as the bandage had to be tight to stop the bleeding. My assistant Min had changed bandage overnight. I had the bandage removed.

2. Yesterday, I bandaged the ear 2 hours after the surgery at around 1 pm. The poodle had cyanotic tongue colour and so I loosened the bandage and re-bandage. No breathing difficulty. Why the tongue was purplish and the gums pale? This could be due to the bleeding and surgery as this was a small poodle. I gave the duphalyte and normal saline drip, Vit K1 2 ml SC and tolfedine and baytril. The dog was monitored closely and was OK.

ANAESTHESIA
1. Domitor and Ketamine at 10% IV. Normally 50% but this poodle looked weak. "Nothing wrong with the ears (to justify the ear surgery)," Dr Daniel examined the ears. He did not know the history. "You are seeing the ears after one week of medication," I said. "The dog had been scratching the ears for several months and there were vet treatments before."

2. Isoflurane gas top up via endotracheal tube. Minimal 1% anaesthesia as this dog needed >30 minutes of anaesthesia. At the last stitch, the dog woke up with some crying as the gas anaesthesia wore off fast. It is better safety as dog would be unlikely to die from isolfurane anaesthesia during and post-op, but the disadvantage is the crying at the last stitch. Tolfedine was given SC and the crying stopped.

SURGERY
Over one hour due to bleeding. If there was no bleeding, it would be faster but every case differs.

HEAVY BLEEDING
There was heavy bleeding on the right ear at the end of surgery. Ligation of the blood vessels in the region cranial to the lateral wall would be best. Some cases don't have bleeding as the main vessels were not electro-incised. In this case, I bandaged the ears overnight and the bleeding of the left ear had stopped.

EATING
The dog usually ate dry food, according to the owner. "It would be better to fed canned food as the dog could have pain in swallowing." The dog ate one can of A/D overnight.


SPAYING A 6-MONTH-OLD SHIH TZU THAT EATS STOOLS
"Do you want Dr Vanessa to operate on your dog?" I asked the young man as his dog had been vaccinated and attended to as recently as last week. He came in at 10 am and I was on duty. Dr Vanessa usually comes around 12 noon. "If not, I will do the spay and you come back at 12 noon." He opted to have me operate.

3 kg. very thin. Ate 3x/day by hand-feeding. Still hungry after feeding.

ANAESTHESIA
Domitor and Ketamine IV at 50%. Waited 5 minutes.
The dog was sufficiently sedated to intubate.
Large tonsils of around 8mm x 4mm. Normally, can't see tonsils. I took a pic to show the owner as this is abnormal. Could be due to eating stools? I had a long chat with the young man about his management of this dog (very thin and eating stools) at around 12 noon when he came for his dog.

"If you don't spend time training him not to eat stools now, she will eat stools as an adult for the rest of her life." I advised. The dog would wait till the owner goes to work before pooping and would eat the stools.

The dog is crated in a cage of around 3-foot wide. A yellow plastic pee pan (with small holes for urine to flow through but not stools) covers 50% of the grated area. The dog lies on the grated area and poops and pees on the yellow pan.

These are my recommendations to reduce poo eating:
1. Don't confine the dog inside the crate when the owner goes to work as the dog is adult and the crate is not big. So, the dog starts to eat stools due to lack of space to move about.

1.1 When the owner goes to work at 9 am, put the dog inside a bigger space e.g. bathroom. On one side, put the crate (cleaned and neutralised with white vinegar: water at 1:3), water and feed bowls. On the other end, put the pee pan. Get a baby gate.

1.2 The owner feeds the dog at 8 am, brings her down to pee and poop as a routine (except on weekends, 9 am). Bring newspapers to scoop up poo. Bring some poo in the newspaper and put on the grass to let the dog smell it as part of the training.

1.3 Feed 2X/day instead of 3. Now the owner hand-feeds the dog as she swallows all dry food within 30 seconds and begged for more.

1.4 Antibiotics to be given for the next 7 days and repeat. There is a possible urinary tract infection as the dog passed white urine (no smell) and yellow urine (very smellay) many times a day. Dogs at this age can control their bladder unless not trained or do urine marking (female dogs do urine marking but this is uncommon). Poo-marking is possible too.

1.5 Training may take more than 4 weeks. Patience and spend time doing the training.

LARGE TONSILS
See image. Both tonsils incredibily large. Bacterial infection or toxins from eating stoolsl over past 3-6 months?

SPAYING AT 6 MONTHS
Some vets believe that bones have not been fully formed. So don't spay at 6 months. I usually advise spaying 2 months after the end of the first heat. Sometimes, as in this case, the owner prefers the spaying to be done at 6 months. Singapore dog licence - $75 if not spayed at next renewal of licence. Otherwise $14 if spayed. There used to be $14 licence only if the dog is less than 5 months old but the AVA may have changed this.

Tuesday, April 17, 2012

946. Hamster nose wart enquiry from overseas

E-MAIL TO DR SING DATED APRIL 18, 2012

Dwarf Hamster Tumor or Wart

Haven for Hamsters havenforhamsters@gmail.com
12:13 AM (3 hours ago)

to judy


Hi Dr. Sing & Associates.

You helped me several years ago with a hamster who had a eye condition. I am in Albuquerque, NM and run Haven for Hamsters Rescue. Last night I discovered a large rough lump on one of our dwarf hamsters. It is blood red in color, firmly attached to her nose, does not seem to cause her any pain or discomfort. It has no hair on it and seems to be the consistence of a human wart. Do you have any suggestions on what to do. Our vet is afraid if they remove it she will bleed excessively and not survive. Can she live with this on her comfortably?

Any help you or your staff can offer would be greatly appreciated.

Thank you,


E-MAIL REPLY FROM DR SING DATED APRIL 18, 2012


Pl send two images of the nose wart if possible. Bleeding can be controlled by the vet using pressure, ligation, electro-cautery or powder depending on the size of the wart and the situation. You may need to find a vet who knows what to do.


E-MAIL TO DR SING DATED APRIL 19, 2012


I have attached some pictures of the little hamsters wart/tumor. Any information would be great. Thank you,

E-MAIL REPLY FROM DR SING DATED APRIL 19, 2012


Thank you for pictures. Surgery is the only option if you want a good clinical outcome.

Electro-surgery is preferred. General anaesthesia and stitching are required. One anaesthetic method is zoletil sedation IM + isoflurane gas and then into electro-excision and stitching.

You may need to find a vet who does hamster surgeries.

E-MAIL TO DR SING DATED APRIL 19, 2012


Do you have any idea what it is?



E-MAIL FROM DR SING DATED APRIL 19, 2012

It is a large skin tumour. How old is the dwarf hamster?


E-MAIL TO DR SING DATED APRIL 19, 2012


I'm thinking about 6 months old or so.


E-MAIL FROM DR SING DATED APRIL 19, 2012


Your vet may need to do a skin biopsy or fine needle aspirate to check whether the growth is malignant or not and whether it is inflammmatory. This may not be feasible economically. Excision seems to be the only option. If it is inflammatory, your vet may try intra-lesion injection of antibiotics and steroids but this is not a guaranteed to work treatment. It does work for cases of lick granulomas (inflammatory) in my dog cases. E-MAIL TO DR SING DATED APRIL 21, 2012

Thank you so much for all your great advice. Our vet has determined there is just not much she can do. Here vets are very nervous about treating hamsters, no one really has the skills or knowledge. We are just getting them to learn about guinea pigs and rats. For now she is doing okay, but I can see her going down hill pretty quickly. Once again, thank you for all your help and advice. It is greatly appreciated.

Sunday, April 15, 2012

945. Sunday's interesting cases - old dog with heart disease - dental

Sunday April 15, 2012

The past week had been quiet. Economic recession sets in? Yet the Certificate of Entitlement (COE) to buy new cars of 1600 cc in engine size was over $80,000 last week. The Health Science Authority had decided to charge high fees to inspect every medical equipment being imported to make sure they are of good quality. This will , lead to higher medical costs of health care. Property cooling measures means increase fees for property purchasers. So, the average pet owner has less to spend. So, less visits to the vet while more vets start up their own practices.

Case 1.
Old Maltese Cross with bad breath.
Last Sunday, this case was seen last week by Dr Daniel as the Chinese father and his daughter brought in a dog for dental work. I noted that Dr Daniel took some time in consultation and Sundays are busy days. If the dog comes for dental work, then, the dog ought to be examined within 5 minutes and sent in for the anaesthesia, not taking a lot of time in talking. It is good to have long chats with clients but the review of cases hospitalised is not done early due to insufficient time and consultations if the vet does not do time-management.

I had intervened to say that tooth brushing and diet would not resolve the tartar build up and bad breath as Dr Daniel was explaining the pros and cons of brushing. "The dog has Stage 4 periodontitis," I said and pointed to the photos of Stage 3 and 4 on the left side of the consultation table. "Tooth brushing cannot get rid of the tartar." It was frank advice but we can't afford to take too much time on Sundays to chat like old friends and charge affordable fees. Owners have to understand this.

"The father had asked about tooth brushing," Dr Daniel said to me later as I asked why he had been spending so much time talking about tooth brushing when it was clear that this "alternative" treatment would never be effective. I don't like wasting the time of clients or the vets as Sunday is a busy day and in any case, there is a lot of administrative work like reviewing cases and records that the vets ought to do daily.

The father and teenaged daughter brought in the dog for dental work. He did not want a blood test. The dog coughed when I palpated the throat. I took over the case and advised antibiotics for 7 days before dental today.

I checked the heart. A faint machinery murmur on the left side. The dog still had a sore throat but not so painful now. This would be a high risk anaesthesia case. "Does the dog cough at night or sometimes?" I asked the daughter. She nodded her head but the father said no.

ANAESTHESIA
Isoflurane gas mask directly would be best. But this dog had s sore throat and might vomit or swallow vomitus into the lungs. The owners had not fed the dog since last night.

The following was given.
Maltese, 11 years old. 6.5 kg. Blood test advised but not accepted. So, the health status is unknown. Has left sided cardiac murmurs. A history of "coughing". Anaesthesia has to be very careful. All owners expected a dog alive at the end of dental work.

Furosemide 0.6 ml IM. Waited 5 minutes
Domitor + Ketamine IV at 10% of the calculated dosage. For healthy old dogs, I usually give 50%.
Dog was very weak as 10% could sedate him heavily. At one stage, he stopped breathing when isoflurane gas was given by mask.
Top up with isoflurane gas by mask whenever the dog moved.
"Intubation" would be preferred there was some irritation of the throat and intubation might worsen this inflamed throat.
Four molar and premolar teeth were loose and extracted.

The dog woke up as the surgery took some 30 minutes. But this was a safer method. The dog went home to a happy mum. The dad was in hurry and so he did not say much. The teenaged daughter was absent, but I could see that she was most worried about the anaesthesia. She did not voice her concerns to me.

"Better move fast," I said to the mum who came with her husband around lunch-time when Mr Min, my assistant had gone for lunch on this Sunday (Myanmar new year for one week). "No more bad breath," she said to me happily.

This case was done by Dr Daniel. It was a typical dental case but because the dog was old and had heart murmurs and coughing, this case was a very high anaesthetic case and I had to intervene. A happy ending is not guaranteed as there are dog deaths during dental work if the dog is very ill or a high standard of veterinary care is not provided (e.g. vets and assistants joking during anaesthesia).

Case 2.
The kitten had swollen conjunctiva in the left eye for more than 2 weeks. The couple had consulted 2 vets and given eye drops and medication. But the conjunctiva of the left eye was still as swollen as ever since the conjunctiva had swollen so much that the upper and lower eyelids swell to prevent any view of the eyeball.

"The kitten needs to be sedated to check whether the eyeball is infected," I said. "If the eyeball is ruptured and badly infected with bacteria, the only solution is to remove the eyeball. There is no chance of the eye returning to normal in such situations."

The other two vets had not done so. In such severe cases, eye drops don't work.
The Malay couple was concerned about this type of suggestion. "We will go home and ask my mum," the husband said after asking about the fees involved in enucleation of the eye.

Case 3.
An old cat came in for 2 black pigmented spots on the backside hip skin. "Could this be fleas?" the young adult daughter asked. The Indian father and daughter loved this cat very much and as I had "retired," I seldom see this cat. Dr Daniel was collaborating me in this case. I used a razor blade to scrape the black pigment. It was superficial jet black epidermis and examined under the microscope. "No ringworm," I said. "Was there any cream applied or any rubbing?" I asked. "No cream," the daughter said. "But the cat did rub her backside now and then."

I held the cat's tail high with one hand and expressed the anal sacs with the other. Copious amounts of brown oil shot out. I had taught the daughter how to express the glands but she said the cat would not permit it. This could be a cause of itchiness in the back area and licking. I noted a fine growth of hair coming out from the back quarters instead of the usual wiry hair. This could be due to the cat excessively grooming himself. I checked the scrotal area as the daughter did not want the cat neutered. "The scrotum is very dirty," I said. "Most cats do clean this area, but not this cat." In this case, the owner must clean for him.
"Are you retired?" the daughter asked me. "No," I said. "However, many cases have to be done by the younger vets as part of succession handing over and training."

Saturday, April 14, 2012

944. An old cat with multiple seizures

"I want a house-call as I prefer my cat to be euthanased at home," the woman phoned me. I asked Dr Daniel to do the house-call. This would be his first house-call and I advised that he get an assistant and place the cat on the table for injection.

He had no problems with this house-call. The cat was having continuous fits. He gave the IV after the fits. I would have preferred sedation first. Each vet does his own way, being the vet on the spot.

943. Maltese with seizure goes home on Day 2 - acute bacterial meningitis

The owner came for the Maltese in the morning. She accepted my advice to let the 5-year-old dog stay overnight at Toa Payoh Vets for observation. No fits. As good as gold. The active dog just jumped and pawed her legs as she settled the bill. Tongue pinkish as normal.

"Most likely a bacterial infection based on increase in total white cell count and a very high neutrophil count. Neutrophils are produced in large numbers by the dog's body to fight against bacterial infection. Did the dog go outdoors last few days?"

"No," she said. "This dog stays indoors and if he goes out, is not allowed to sniff the grass."

It was a surprising finding in the blood test. Evidence-based medicine is the best way as the owner wants answers and in this case, the blood test had been taken before treatment and provided some answers.

"There is a possibility of low blood gluocse which can lead to (hypoglycaemic) fits in your Maltese," I said. "The lab report mentioned a possible glycolysis and a repeat test. A blood test 2-4 weeks later is needed."

This is one of the cases where the owner got the vet to treat the seizure dog promptly and the blood test was taken. All dogs with fits must have blood tested unless the owner objects to them. Practise evidence-based medicine.

In this case, bacterial meningitis was likely to be present in the dog. As the owner had not delayed treatment, the antibiotics given had got rid of the bacteria and the dog recovered the next day.

NOTES ON ACUTE BACTERIAL MENINGITIS

1. Bacterial meningitis is an infection of the meninges which are the membranes surrounding the brain and spinal cord.

2. Causes: viral, bacterial and fungal infections.
3. Most common bacteria in people meningitis include

3.1 Streptoocccus pneumoniae (pneumonococcus),
3.2 Neisseria meningitidis (meningococcus)- upper respiratory infection bacteria enters bloodstream
3.3 Haemophilus influenzae (haemophilus) - upper respiratory infection, ear infection (otitis media) or sinus infections.
3.4 Listeria monocytogenes (listeria) - soil, dust, contaminated food.

When I was studying vet medicine in Glasgow in 1969-1974, I still remember my lectures about listeria in British pigs causing brain diseases. Antibiotics erythromycin were very effective.

Probably this dog had got listeria (blood test - total white cell count and neutrophils increase). The inflammation and swelling of the meninges caused "headache" (collapse suddenly according to the owner and vomiting), fever (not present in this case), neck stiffness (see image of the dog looking skywards I took) and abnormal mental state (eye-staring, salivation due to fits).

SPINAL FLUID TEST will confirm what type of bacteria is involved. Due to economic reasons, this was not done.

Bacterial meningitis can occur over a few hours or in 2 to 3 days. Delays in treatment can lead to permanent brain damage (coma, fits) or death.

Prompt antibiotic treatment enabled him to recover fully. Where the dog got infected (contaminated food, sniffing soil etc) is a mystery. This dog seldom goes out and therefore may not have the resistance to the bacteria. I had treated him for an ear infection two months ago but his ears had only a bit of yellow wax.

P.S. Reference to human acute bacterial meningitis.
There is an interesting case of a woman who contacted acute bacterial meningitis while holidaying in Bangkok and became unconscious for 3 months.
(Straits Times, Apr 18, 2012, Home, Pg B3, ex-coma patient in flap over lease)

Wednesday, April 11, 2012

942. Lack of humility in the young

Yesterday I was at Khin Khin Employment Agency to advise on her business operations as she was new to the game of entrepreneurship.

"This girl is very good staff material. Very pretty. Can speak English very well as she has worked in Singapore for 2 years. She's got an Employment Pass. I would like to employ her as the other girl can't even speak good English."

She phoned the pretty woman and asked me to interview her by phone after showing me the resume. Certainly, the woman could not stop carrying on a conversation by greeting me and taling.

Of the few questions, I asked this: "What do you mean by increasing 72% of the sales since you joined the Singapore company?". Her resume also showed that she had increased 72% of the sales when she worked for a Myanmar company before joining this Singapore company. This was not possible. Exactly 72% increase in sales in both companies.

She gave an evasive answer and was quite impatient. I passed her back to Khin Khin who told me that the pretty woman said that if I was serious to employ her, she would bring her manager down from Kuala Lumpur to testify for her.

"I am not employing her," I said to Khin Khin. "You are the one interested."
"She's aggressive and much better than this other girl. I need such aggressive and able to speak good English staff for my business."
"Then, employ her," I said. "She does not have an E Pass and you, as the boss of the agency should present the facts correctly. She had an S Pass. An aggressive employee will be good for sales.

"But you can get your tail bitten off by an aggressive dog if you are not careful. You have need always to be careful. Besides she does not have the relevant experience. How do you know she will produce sales?

Khin Khin thinks that a pretty face and good English will get into the hearts of prospective Singapore employers. There is some truth in this.

However, this interview revealed an aggressiveness, lack of humility and respect and impatience to a young pretty woman looking for a good job. This is a time bomb when the interview reveals such a personality and I don't employ such a person if I was the prospective employer. Unlikely to be a team player. No respect for the boss or anyone.

Young people looking for good jobs need to be humble and respectful. The world does not owe them a living.

941. The 5-year-old Maltese "vomited" and collapsed at 10 pm - Standard Operating Procedure

"Why you did not give diazepam injection first and then take blood sample?" Dr Daniel asked me when we attended to this emergency. "Diazepam will not affect the blood test analysis."

The Maltese's neck extended skywards and he was recumbent. "His eyes are so staring and he has saliva coming out of his mouth," the mother said to me while the father and teenaged daughter were worried.

Naturally, the first thing to do is to give the diazepam to resolve the sky-looking head.

I don't know whether diazepam will affect the blood analysis but I prefer to do the basic. Take the blood before any drug is administered. That will be the basic of scientific research, in my opinion.

"We need to check for glucose level to see if there is hypoglycaemia," I said. "We can take some more blood after giving the IV drip." I had also included the glucose and multivitamin amounts to be added in the normal saline drip. The Hartmann's solution would be given soon.

"You can't take the blood to check for glucose level after administering glucose", Dr Daniel had pointed out.

After taking the blood, we gave glucose 50 ml IV, Normal saline and diazepam amongst others.

Within 1 minute, the dog's neck returned to normal position and was not rigid anymore. I asked the owners to come and see. The daughter's eyes were red.

"His eyes are closed and no more staring," the mum noted. Eyes are windows to the soul in this case. I mean, dilated pupils can indicate impending death from uncontrolled seizures and the mum must have meant "staring dilated pupils" as staring eyes.

"What's the cause of this seizure?," the mum asked me. She had consulted me earlier about this Maltese having ear infections 5 months ago but there is no more redness or ear itchiness now.

"It is hard to say. If it is sudden, it could be an injury to the brain. Is the Maltese a very active dog?" I asked.
"Yes, yes," the mum said. "He jumps up and down, to greet us, and he was doing it before dinner."

"The blood test will give us some answers," I said.
Dr Daniel said to me that the dog could be suffering from hypoglycaemia and went into fits as he was fed only once a day instead of twice a day. "Possible," I said. "Wait for the blood glucose result."

In conclusion, the standard operation procedure of taking the blood before treatment is still the best. Take blood before doing any treatment will NOT result in conflicting test results as, for example, after administering glucose and taking blood during emergency confusion will make the test for glucose invalid. There must always be a SOP in emergencies.

940. Veterinary anaesthesia to spay stray cats & multiple ovarian cysts

Yesterday, April 11, 2012, I visited a vet who had spayed thousands of stray cats. The young cat was laid on a metallic M-shaped holder (apparently commonly seen in Australian vet spays), without the need to tie up the legs. She tried to hook out the ovary but could not. She extended the skin incision to bigger than the width of her forefinger and could hook out the left uterine horn.

The cat had been pregnant and therefore the uterine horn was not easily hooked out. There seemed to be something stuck to the left ovary as she could not pull it out. I saw large veins from the uterine body to the ovary. "I have to refer to Vet 1", she said. Complicated surgical and medical cases are farmed out to Vet 1, as this is the policy.

"Just extend the skin incision by 1 to 2 cm more," I advised. "You will see what's been affecting the ovary." She used the scissors and cut further. It was a huge surprise. Around 3 big ovarian cysts of around 1 cm in diameter. had prevented the pulling out of the ovary till the incision was extended.

"I need to take a picture," I said as this type of medical condition is very rare. She had not seen it too despite many years of spaying stray cats. She said OK and I rushed to the car park to get my camera. When I returned, she had taken out the ovary but the cyst had ruptured. There was one cyst I managed to photograph for vet students to appreciate. We are taught about ovarian cysts but in the real world, they are uncommon. "Take another picture of the normal ovary to compare," she said as I had not thought of it. I got a few tips from her.

HOW TO ENSURE THAT SPAYED STRAY CATS DON'T GET STITCH BREAKDOWN
1. Suture muscle layer and linea alba with cat gut.
2. Subcutaneous suture, interrupted, at either ends of the fatty tissue with monofilament
3. Subcutaneous suture of the fatty tissues with continuous
4. Two horizontal mattress sutures of the skin, with one interrupted suture knot stitching out at one end. I can't figure this out as it is supposed to be buried.
No complaints of stitch breakdown with this method. The other knot at the other end was buried.

I just do Steps 1 and 4 in all cats and have no problems with stitch breakdown. Too many layers (Step 2) irritate the cat and dog during healing and also likely introduce pathogens. Keep spay simple is my policy.

Each vet has his own tested method and will not change his or her mindset when the method is successful. The important thing is the client's perception as many Singaporean clients appreciate excellent stitching (which may be a buried subcuticular suture, continuous i.e. Step 2 without Step 3.)

VETERINARY ANAESTHESIA FOR STRAY CATS IN THIS PRACTICE
Well tested and proven to be effective and does not involve "ketamine."
I saw two cats well anaesthesized with this procedure. The dosage is as follows:

Spay
3kg young
Zoletil 100. 0.2ml. IM. Separate syringe.
Xylazine 20. 0.2ml. IM. Separate syringe.
duration >25min
Hartmann SC post op

DOG
Eg Jack Russell
Xyla 0.3 ml first.
Zoe 100. O.3 ml. Slow IV
To effect

Each vet has his or her own method. This method works very well and the vet sees no need to change. For me, in cats, I give a one-syringe Xylazine+ketamine combination IM. So, the cat gets one injection IM instead of 2. The less the better for our patients as injections may cause irritation. It is hard to change mindsets of most vets when they are used to a successful method of anaesthesia. Younger vets want to introduce propofol and althesin but these are expensive and add to the inventory. It is best that young vets adopt what is effective in the practice unless their method is more superior as for example, diazepam and xylazine is said to be safer than domitor and xylazine IV but I am used to the latter and find it effective. Diazepam is said to be safer than domitor in anaesthesia by not "affecting blood pressure or cardiac rate" according to one vet I spoke to.

But how much safer? So, I don't also go for another type as I find my present formula very effective and safe. In other words, there are many injectable anaesthestics and the vet must focus on one combination. Peferably one injection.

939. The hot dog growls at the vet

Tuesday, April 10, 2012

"More active, no more vomiting," the lady said. "The dog has not recovered fully from hepatitis yet," I said. I prescribed some liver supplements and anitbiotics. Every family member is happy. The dog was warded 4 days for lethargy and recurring fever. 10 days ago, I had operated on him and removed a big epidermal cyst. The dog was rubbing his back area where
the cyst had been removed. So, the grandpa applied bright yellow powder onto the wound. It looked like yellow sulphur, which is toxic.

Saturday, April 8, 2012
The owner had brought the dog to see me last Wednesday with complaint of lethargy and fever. I boarded him for observation and on Saturday, the whole family of 2 ladies, their husbands and grandparents came to visit this miniature schnauzer of 5 years, male. Saturday was my day off, but I went back to Toa Payoh Vets to see this dog. That was how I met the group outside. The dog growled when I approached him to palpate his abdomen to see whether it was still tense and hard. "That is a good sign of recovery to health," I said. "Yesterday, Dr Daniel said he stood like a statute for a few minutes when let out."
"Maybe he is frightened," the young lady said.
"Possibly," I asked the owner to hold his muzzle while I palpated his abdomen. Not tense as before. So,I decided to let him go home. He would recover faster at home.

Well, he did recover. As to the cause of his tense stomach area, I can only sketch this scenario as follows:


1. The wound was contaminated by the yellow powder. Toxins and bacteria entered the wound. Blood test showed high liver enzymes. Low red cell count.

2. Stomach was full. Impaction. I had given anti-spasmodic inj to cool him down. The tense anterior abdomen was due to his liver inflammation.

Tuesday, April 10, 2012

938. Close-circuit anaesthesia is efficient and economical

Two days ago, I met a senior vet. He was reiterating the way the younger vets now use gaseous anaesthesia with a very high flow rate of oxygen, using an open circuit, thereby wasting a lot of anaesthesia and Oxygen. The younger vets would not accept his method of using closed circuit. This was also a method I used. Now I used the semi-open method.

"Take it easy," I said. "The younger vets have their mindsets so much different from us. Their vet professors have had trained them and they did it the professors' way. After all, vet professors don't have to account for the bottom-line. Neither do the younger employee vets. So, they don't worry since they don't have to pay to replace fast-consumed isoflurane which is extremely expensive.

I used oxygen flow rate of 0.5 in a closed circuit, while the younger vets used 2 litres/min. In a long surgery of 2 hours, the volume of oxygen and isoflurane gas used is considerable and costly.

"Maybe the younger vet is afraid that in a closed circuit, the isoflurane level increses and then kills the dog," I said.

"No," the senior vet said. "Just switch off the oxygen or lower the flow. The 2% maintenance isoflurane in a closed circuit may go down to 1.8% but will not increase."

"Maybe the younger vet is afraid that the carbon dioxide will accumulate inside the closed circuit, killing the patient. I know, soda lime absorbs the CO2, but the younger vet may be worried."

"Yes, the soda lime removes the CO2. So, there is no worry. I had long discussions with a human anaesthestist on the closed circuit and that's the most economical way. Don't use nitrous oxide though as some dogs do die."

"But young vets who are employees don't have to pay for any amount of isoflurane they use. So, a high oxygen flow rate (over 2 litres/min) use up a lot of isoflurane in an open circuit - so what? They don't need to pay. So, they can't be bothered," I said.

This senior vet is irked by inefficiency and unnecessary wastage but the younger vet refused to adopt the closed circuit. Maybe, they have their reasons. I have not talked to them.

Each vet has his own peculiarities. This senior vet uses electro-surgical coagulation in the castration of dogs. I don't. Seldom do other vets. "I wonder how I manage without it?" I asked one young vet as this senior vet uses it for all surgeries except spay.

Monday, April 9, 2012

937. Breathing heavily and coughing in the older dog - 3 cases

Yesterday, I saw the 3rd case, similar to the other two I wrote sometime ago. Previous vets had been consulted but the respiratory problem remains or recurs.

A young man in his 30s, accompanied by his senior citizen father, brought in his 12-year-old Shih Tzu that coughs non-stop. He had consulted my associate some 2 weeks ago.

"Can you hear the heart sounds?" I asked Dr Daniel. "Was the old dog suffering from heart disease?"
"Not possible. The lungs were crackling with loud sounds. The mouth has large ulcers, a tumour. The teeth and gums were all infected."

New graduates will quickly do the ABC. Airways, Breathing and Circulation. So, the first thing their vet professor had taught would be to give oxygen therapy. I had seen this being done by new graduates. The dog's tongue was purplish and therefore lacking in oxygen. He could not stop panting.

"He had a seizure when he fell down," the gentleman said to Dr Daniel. Later I told Dr Daniel that the owner had got the process all wrong. There is a stage just before seizure when the dog is unsteady in balance. Seizure comes, he falls down. More fits. Saliva foaming. To the owner, the fall causes the seizures!

What to do in this case? Put on oxygen mask for half an hour?
The professor's lectures of "ABC" are still vivid. The professors may also give the impression or may not, that old vets are outdated.

So, must do ABC with oxygen therapy first. Gas mask. Switch on the oxygen.

In my experience, a simple IV injection of Lasix will help the dog breathe easy and normal. A bit of dexamethasone perhaps but it is the Lasix that does the trick. So, I advised Lasix. "Give SC and IM," I said as Dr Daniel felt that the dog may be too stressed to be given IV. His tongue was cyanotic and he was about to pass away from lack of oxygen in his blood stream. This is a serious matter. Life and death is always a serious matter.

After 10 minutes, the dog's breathing was back to normal. As I expected. Then we got the dog for the X-ray as the lung fields will be clearer. I don't know whether the professor teaches this procedure or not. In academic lectures, it is probably not possible to teach this way. In real life, the most practical and efficient way in such respiratory distress cases, is the Lasix. One vial. Why Lasix? Because it is a branded product. I could use generic and they should work as well.

X-rays- small nodules in the lungs. "Engorged blood vessels seen end-to-end," the young vet would venture his opinion when I said these would be likely micro-abscesses or tumour metasized to the lung from the pedunculated one in the umbilical area and from the oral tumour. Each vet has his own opinion as only the MRI scan (too expensive) would confirm. I asked sleepy-eyed Dr Gladys for her opinion as two heads are better than one. She had attended a wake and was really tired. She said: "It could be the small tumours forming. It could be abscesses."

The dog did have a high fever but it could be due to panting. The blood test results should come in today.

CONCLUSION
Much time must be spent with the owner to educate and explain the consequences of not taking the heart drugs. Failure to do so lead to an unhappy owner who hops to another doctor. Usually the last doctor benefits from the history and well, every vet will have such clientele.

Sunday, April 8, 2012

936. Chronic Otitis Externa - Ear surgery

On Sunday, April 8, 2012, at 3 pm, I met an old client at Toa Payoh Vets. Nowadays, I seldom consult on a Sunday afternoon. But on this Sunday afternoon, I was around to do my "audit and trust" review of cases done by associate vets. This is to ensure a high standard of veterinary care to be provided by Toa Payoh Vets.

Mr Ong had come to pick up his poodle. My associate vet had told him that his poodle required a "medical bath" yesterday and somebody called him to pick up his dog at Toa Payoh Vets. The dog was at another place. When the dog arrived, I examined his dog. The sides of the ears were blackened due to continuous scratching over many years and the neck skin was bald.

"Your dog need an ear surgery," I said to him. I checked his dog's medical records and noted that he had sought itchy ear treatments since 2009. He told me about his poodle's continuous scratching since young. "You had advised an ear surgery before," he said to me. "I went to see Dr Jason enquiring about an ear surgery. He said that the ear surgery is very complicated. The cause of this poodle's ear problems could be genetic or food allergy. Therefore, he recommended a medical bath and medication."

The ear surgery is called lateral canal resection. It is described using images of an operation I did on a Miniature Schnauzer to educate dog owners.








































Any updates on the poodle to be operated by me 8 days later will be at the Website:
http://www.kongyuensing.com/folder8/20120408ear-resection-surgery-smelly-ears-chronic_ToaPayohVets.htm