Sunday, December 4, 2011

755. Sunday's interesting cases. The male cat bit the mother is neutered

Sunday's interesting cases of two male cats that got neutered

CAT NEUTER NO. 1
I was on duty in the morning of Dec 4, 2011. Bright sunshine although showers come in the afternoon. My first case was a Malay family bringing in a muscular male yellow cat with brown dots of 10 months for neuter. "I phoned yesterday for appointment at 10 am," she said. "This cat bit my mother and so I want him neutered!"

"Cats in Singapore apartments don't bite people, unlike dogs," I said. "Why would he bite your mother?"

"He was chasing away a stray cat that came to our apartment door," the lady said. "My mother grabbed him to stop him. He bit my mother's hand!"

Never interfere in fighting cats or dogs - that is the morale of the story.

NEUTER
5.5 kg. My formula is xylazine 0.1 ml + ketamine 0.4 ml IM for cats <4 kg for a female cat spay. In this male cat, the above dosage was given. It was effective even after a delay of 15 minutes as I had to vaccinate the Chihuahua who had bitten me when I visited the apartment some years ago. He was neutered and adopted by Theresa and daughter, a Myanmar family in Toa Payoh, that loves him very much. This dog was given up by another family in Mandarin Gardens as he was a handful, peeing and pooping everywhere. "Does he pee all over the apartment?" I asked. "No," the mother and daughter said. "He just goes to the toilet." This was a good ending for this naughty male dog who had put on considerable weight. As I had injected the above-mentioned cat, I informed Theresa that I had to rush and it was OK with her as she had to go to the market. She had started her employment agency business. "How's your business?" I asked her. "Not good," she said. "The MOM (Ministry of Manpower) keeps rejecting every application nowadays." There is a political shift of not granting work visas for foreigners as liberally as before since the locals are not too happy as these foreigners affected their salaries. CAT NEUTER NO. 2
A woman with a son with dark blue pierced ear studs on his left ear came with 2 cats that had been neutered and spayed 9 days ago by Vet 1. "The female cat is OK," I said. "The stitches will dissolve soon. There is one small hole due to stitch coming out but it is not a problem." She asked: "Can I bathe her? She is so smelly!". "Yes," I said. "Just put a plaster onto the wound and bathe her."

As for the male cat, there was an open hole in the right scrotal area with reddish discharge coming out. "This is very rare," I said. "I have not encountered such a case in my more than 30 years of practice." Vet surgery is always full of surprises. I said: "It could be something stuck inside the wound and that is why it is not closing. There is no pain at all when I press it. Still the cat must be sedated and the open wound examined."

"I have asked my friends and they say that cat neuter wounds usually close within a few days."

All surgeries do give rise to complications of one kind or another in some cases for all vets including some of my cases. Like infection, bleeding, pain. In this case, there was yellowish nodules coming out as I pressed the 5 mm vertical hole in the right scrotal area.

I gave the cat a very low dosage of xylazine 0.05 ml + ketamine 0.2 ml combined IM and collaborated with
Dr Vanessa to handle this case as part of my coaching program. "Put the artery forcep into the gap at 12, 3, 6 and 9 o'clock and pull out any strands of tissues." Systematically. She flushed with normal saline. I wanted the cat to go home as the owner mentioned about loose stools in both cases, since the two cats was given Clavulox for the past 9 days and I am worried that the cat would develop full diarrhoea in the Surgery. But Dr Vanessa advised keeping the cat in for observation and I was OK with it. From my experience, this wound would close after removal of debris inside. But it is wise to listen to other vets.

I phoned the owner who was at the back coffee-shop that the male cat remained in for observation. "This is my first cat," she said. "It is like first love," I said. "It is always remembered. Usually it is puppy love as we usually don't marry our first love! Have you got a first love, young man?"

The pre-teen boy who love jazz music seemed to nod his head. "But mum, you are a doggy person," the pre-teen son said to the hard-working mum who had much conferences to organise. I had more time to talk to them as Dr Vanessa handle the majority of Sunday's cases after 12 noon. It was good to see mother and the music son being close.

EYE ULCER IN THE SHIH TZU AGAIN
"The previous Shih Tzu had no eye problem," the lady in her late 30s brought back a young Shih Tzu with the right eye white red and tearing. The left eye had a central white scar but the eye white was not reddish.

I had not seen the other Shih Tzu but from what I had seen from other owners, the Shih Tzu could have less protruding eyeballs and its corneas would be pigmented and black due to irritation over time. "It is hard to say that your old Shih Tzu had no problem," I said. "Many Singapore Shih Tzu owners, in the old days, just ignored the eye problems as the Shih Tzu scratches to relieve its eye itch and pain. I would expect your Shih Tzu to have black or brown corneas unless its eyeballs were less protruding."

"You did stitch up the eyelids of both eyes some weeks ago," the lady told me. "Yes," I referred to my medical record where I illustrated two eyes. The left eye had a central ulcer which is now healed white spot of 3 mm with some blood vessels. The right eye cornea was written as "cloudy," but not ulcerated and would have healed.

Dr Vanessa put in the fluorescein strip and flushed off the green dye with a syringe of saline. There were 3 corneal opacities seen. At 3 o'clock, central and 9 o'clock but they were not stained green at all after flushing off the green dye by Dr Vanessa. "It is surprising," I said. "These ulcers are over 3 mm in diameter and yet they don't stain green as expected." The dog had been rubbing his right eye despite an e-collar of size 12. I recommended size 15 and eyelid stitching up again for 14 days. The owner wanted the dog home on the same day although I advised retaining him for a day or two.

"The solution to this case is to get the facial fold cut off by the vet," I advised. I took out the Canine Opthalmology book and showed her the operation and the illustratons in this old book.

"Your dog goes to the groomer regularly to get the fold hairs snipped but the hairs grow fast and irritate the cornea causing ulcerations. You also snip the hairs but it is not easy to do it frequently. The hair grows and the water and liquid is trapped in between the facial fold and the lower eyelid leading to itchiness."

The owner was not in favour of surgical resection of the facial fold as it cost money. It is important that the vet informs the owner of a long-term solution to the problem for Shih Tzus and Pekineses as many owners are not aware of such a solution.

Friday, December 2, 2011

755. Ten ivermectin injections for a hamster with skin disease

Many lady hamster owners in Singapore are sophisticated and well educated. A lady asked if I had ivermectin for her hamster who has hair loss on the back and has been "cured" by Vet 1 near her residence with injections. Ten injections over the past few months but the problem came back. I had just performed a haemangiosarcoma surgery on her old white dwarf hamster which did not survive the surgery. The tumours were large and the cells were breaking down. Full of blood. The spinal area was invaded by the tumours. The dwarf hamster could not survive the surgery. The lady was understanding as I showed her the tumour cells and pieces taken out.

"It is ivermectin," she had the info from Vet 1. "A small drop". I don't give ivermectin by 10 injections to dwarf hamsters as I believe it is harmful as hamsters are so small. She said she would revert to her vet and asked for her hamster to be cremated.

754. SOP - Old cocker spaniel with skin disease

Cocker Spaniel. Head wounds, whole body skin infected. Saw the vet many times. Recovered, then skin disease again. Now over 12 years old. Eye pus.

SOP
1. History. Ear canals full of pus.
2. Blood test - Total WBC high.
3. Skin checked for ringworm, mites
4. Advise ear canal surgery when the dog has recovered. But the owner usually forgets about it.

In this case, I told the owner that the originating problem was the chronic ear infections and that an ear surgery when the dog was young would have resolved much of the scratching of the neck and flanks. Floppy ears. Covered up ear canal. No ventilation. Dampness. Bacterial growth. Pus form. Ulcers inside ear canal. Very painful. Head shaking. Hind leg scratching. But no hope from medication and groomer as problem recurs.

It is hard to persuade the Singapore Cocker Spaniel owner to do ear surgery.

753. SOP - Gangrene in an old dog's tail

The dog cut his tail spirally with a wound of 10 cm long. There was a lot of bleeding. Vet 1 stitched up and the dog went home after 4 days of being warded and cared for at Toa Payoh Vets. Gangrene developed lower down the tail. The dog had fever. The owner phoned me. What to do?



1. General examination
2. Complete blood test
3. At least 2 days of antibiotics and NSAID
4. Observe dog's appetite
5. Blood test before surgery is advised to check total WBC.
6. Isoflurane gas + O2 only at 1-2% intubated. IV drip.
7. Use electro-surgery
8. Amputate higher up to avoid gangrenous toxic tissues.
9. Post-op to stay in Toa Payoh Vets unless the owner insists on going home.

TIP. Many Singaporean dog owners have no time or are bitten when they try to clean the wound post-stitching. The e-collar worn did not prevent the dog from traumatising the tail due to pain. A long black area of the tail of more than 10 cm long developed. Gangrene. Dog had high total WBC when I admitted it. Best advice is to amputate the tail at the first instance as the owners just can't manage to nurse. Pain-killers with NSAID are not very effective in tail wound injuries for some reasons. So, I do advise tail amputation and have never received any unhappiness. In private practice, a good clinical outcome is what the owner wants. No repeat visits as this means spending more money at the vet.

752. SOP for hind lameness for an adult dog

Yesterday, Dec 1, 2011 at 7 pm, a lady in her late 20s came with a 13-year-old Jack Russell. "He is better today," she said to me as I was at the reception counter. I could see the unique make up of a certain airline cabin crew and enquired whether she was from the airline. I said: "Hair in a bun and clipped, as slim as can be, a gait with confidence and a type of facial make up that never fails to attract attention."

"It is called ghost make-up," she was surprised that I could guess correctly her profession. Well, I do to see these slim and pale-looking ladies with blue eye shadows at the Singapore Changi Airport going to work or coming home. I did not realise that they look like "ghosts" until she told me.

In the consultation room, I did the examination with Dr Vanessa. A right hind lameness was the presenting sign. The dog's right paw was barely touching the floor. "This lameness has been going on for many years," she said. Other vets had examined it. I asked Dr Vanessa to do first and then I demonstrated my approach.

The Standard Operating Procedure.
1. History of lameness & general examination including teeth.
2. Observation of gait on the floor
3. Put the dog on the examination table. Muzzle the dog.
4. Palpation of spinal column. No pain/painful? Where?
5. Manipulations - dog standing (extend both hind legs and compare the length*). Put dog on side (left, right, upside down).

This is where I have to demonstrate. Basically, it is palpation, extension, flexion, abduction and adduction. Check patellar luxation.

*Put thumb on hip joint, extend hip, and knee of both limb while the dog stands on front legs. Show the owner the unequal length of the hind limb (if there is subluxation).

6. X-rays (2 views) if necessary. Arthritis, Legg-Perthe Disease, Subluxation, luxation of the right hind compared to the left hind hip.

7. Complete blood test to check for liver or kidney disease is recommended as lameness in 13-year-old Jack Russells may be caused by other reasons.

8. Costs to be made known to the owner.

750. SOP - Post-purchase exam of a mini-Maltese

Yesterday, Dec 1, 2011, a mother and young daughter came specifically to see me with a newly purchased mini-Maltese. She was given 24 hours for vet examination of this Maltese which cost $1,500.

I did the case with Dr Vanessa as I want to standardise the procedures in the post-purchase examination at Toa Payoh Vets to ensure a high standard of care and medical recording. Basically to be able to defend the practice in the event of litigation and complaint investigation.

As in the medical profession, each doctor has his or her own approach to post-purchase exam of a puppy. I want to make sure that Toa Payoh Vets' approach cover the bases and be able to be defended in the event of litigation and this is where I have to implement the Standard Operating Procedures (SOP). In equine medicine pre-purchase examination, the SOP is quite well defined but I don't find them commonly available in canine medicine.

The SOP is as follows:

1. Use the General Examination form and fill up the details of examination of the major body systems. Dates of the 3 vaccinations to be recorded. The vet is to be meticulous in doing the examination and recording all questions asked in the form and write remarks/comments. He or she is to sign and date the form. One copy for the owner and one copy to be kept at Toa Payoh Vets in the medical case file.

2. Do a Parvoviral test. This is mandatory for Toa Payoh Vets as parvoviral infections are common in breeders and pet shops.

3. Other tests are optional and must be explained to the owner. This includes complete blood tests, urine test, faecal test, ultrasound and X-rays whenever necessary.

4. Record house-training technique of new puppy - paper-training or grate training. The vet is to advise if he or she is able to do so. Most first-time owners appreciate this advice but not all vets can advise as it is a more complicated subject and needs reading up first.

5. Inform the owner that the Seller may have given medication to the puppy to suppress coughing (Kennel cough) and it will take at least 7 days to know if the puppy has viral and bacterial infections acquired at the Seller's premises.

749. Cataract surgery in undeveloped countries

This is the operation performed by Dr Sanduk Ruit.
http://www.youtube.com/watch?v=5nnQDscK7SI


Can this be done on dogs as presently it costs over S$3000 to do a cataract removal in an aged dog in Singapore?