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.

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."

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