452. Sunday May 22 2011's interesting cases

Bright sunshine blue sky Sunday

1. Case 1. 14-year-old Pom. The young lady came at 9.15 am as scheduled. "You know the high anaesthetic risk for old dogs?" I asked. "This could be the reason that the other vet did not want to operate and asked you to 'wait-and-see?".

She nodded her head: "She (the other vet) did say that it is highly risky as my dog is 14 years old."
I palpated the 3 cm x 3cm sized lump on the right chest. "There seem to be two lumps now," I said.

Case 2. Xylazine 0.1 ml IM was given at 9.20 am. I was about to commence anaesthesia when the owner of the Maltese with shivering came in to say that her dog still had a "swollen abdomen." I examined the dog. "No," I said. "But she has more back pain," 

I showed her the area of back pain in her dog by pressing and getting a response from the thoraco-lumbar area. "My advice is that the dog be confined inside a playpen for the next 3 months. If not, at least 1 month but very few Singaporean owners comply with my advice."

The dog was active and looked OK. What's the big deal? To prevent further damage to the spinal disc which could have prolapsed partially for now. But it is hard to make owners understand and so some vets just prescribe steroids, as in the case of the SGH Professsor's friend's Miniature Schnauzer.

"Can my dog take her daily walk and exercise?" the lady asked me. "No," I said. "Just go out to pee and poop, at least for 1 month."

Case 3. Soon another young lady with a heart-shaped fair face came. She had made an appointment for a second opinion on her 8-year-old Jack Russell, female, not spayed. "What happens to this area with bluish swelling?" she pointed to the high-energy dog's lower breast area. Two small hills from both mammary glands 4 and 5 on left and right.

"These could be due to the dog suckling her nipples here and causing the breast to swell with milk. The bluish colour is due to bruising from her suckling," I said. The young lady looked at me as if I was talking some nonsense. What did I mean?

I pressed one of the nipples in the bluish area. A missile of brownish discharge shot out onto my shirt. "Your dog has produced milk," I said. "She has false pregnancy." I showed her milk being produced by the other 2 mammary glands.

But her main purpose was to consult me about the abscess in the dog's elbows. Vet 1 had prescribed a cream. "Creams are ineffective," I said. "The dog just licks it off." She said: "I watch the dog for 2 hours. Every time she tries to lick, I will say 'no, no.'. I was impressed with her patience. "So what happens after 2 hours?" I asked. She sighed and shook her head. She could never beat time. So the dog just licked at the cream and the encapsulated abscesses on the elbow. "Surgical excision of such big abscesses is the only option," I said. She had also been advised to spay her dog to prevent pyometra (womb infection) later but she said the dog was too old.

Then she asked me about a globular growth above the carpus and the pad in the right foot. "What is this and what can be done?" I checked. "It is likely to be a tumour," I said. Again my advice was to excise it as it was now 5mm x 5 mm and would be easy to do so. The owner was not in agreement. So, I bundled some antibiotic medication and gave the injections and asked her to think about the surgery for the carpal tumour while it is still small in size. As for spay and the elbow abscesses, she had been given a second opinion. Maybe she needed a 3rd opinion?

Case 4. Just as I was going to operate on the 14-year-old Pom, another client came in with a large Samoyed said to be limping on and off in the front legs but appeared OK now. I had the Samoyed trotted outside at the side of the Surgery and told my intern Shirley to observe. 

Shirley wanted to study to be a vet after her graduation from the NUS and was working for the next 2 months. "Just listen, don't need to write much, " I said to her as she preoccupied herself writing the case being seen, as I wanted her to write reports to learn more, than just watching and forgetting.

After the trot which did not reveal limping, I got the dog inside the consultation room and got him on the table. Dr V had arrived and so I said she would collaborate me with this case as I would need to get operating soon. We got the dog on the table. The dog resisted being laid on her side and somehow we managed. I took the first examination and checked out the left forelimb. I extended and flexed the paws vigorously, then the carpus, the elbows, the shoulder joint. I abducted and adducted the shoulder vigorously. Not a whimper of pain from the dog. Somehow I sensed that the owners were worried about such a vigorous manipulation of the joints. However, this is necessary and normal joints, tendons and ligaments will not elicit pain. There was no pain exhibited during manipulations.

"Now, it is your turn to check the right forelimb," I said to Dr V as we struggled to pin the dog down with her right side up. Dr V appeared to me to be gentler, picking up the paws to examine the inside for wounds. Each vet has his or her own method of limb examination. The dog could not be restrained and asserted her authority by getting up.

"So, is there lameness in the right leg or not?" the anxious wife in her 40s asked. "I can only confirm that the left front leg is OK since the dog would not permit any more examination!" I said. I left the case to Dr V as I had to operate the Chihuahua.

SURGERY. Careful and minimal isoflurane gas by endotracheal tube. It was bad news for the owner. Under the skin were a cluster of black grape-like lumps and more smaller ones spread further out, covering the subcutaneous tissue of around 6 cm x 4 cm. I tried to cut off all the grey "grapes" with the biggest being 4mmx4mm and sent them for histopathology. I suspected melanomas which have spread. I was frank with the lady owner: "It is bad news as the tumours have spread out like from the main cluster. Some are very small. It is not possible to remove 100% as some cannot be seen yet. Also, I can cut off the whole piece of affected skin as there will be a large hole on the chest."

The young lady closed her eyes and I could see that she was sad for her companion of 14 years. If only she had checked the dog daily and got the lump removed some months ago. Wait-and-see is NOT the advice of the vet for old dogs with tumours as some may be malignant. All dogs with tumours should be advised to be excised as vets are not gods and in this case, the wait-and-see advice was not good advice.

451. Hamster's everted cheek pouch e-mail

... to judy

show details 10:56 PM (3 hours ago)

Dear Doctor,
I have a hamster that has an everted cheek pouch. Since yesterday, her cheek pouch has been hanging outside her mouth. She seems to be in pain. Does she have to go to surgery? How much does it cost and how long does it take? I would also like to make an appointment on Wednesday, 25th May 2011 between 3 to 5 pm. Can you confirm if you are available? Please reply as soon as possible. Thank you.

Regards,
Name

E-MAIL REPLY FROM DR SING

Tuesday, May 22, 2011 2.04 am

I am Dr Sing from Toa Payoh Vets. Thank you for your email.

In reply, your hamster may need surgery if the everted cheek pouch cannot be put back inside the cheek, e.g. if it is infected and damaged badly. Cost is capped at the maximum of $150 for consultation, anaesthesia and surgery (longer duration as likely to be in your case). It takes around 10 minutes for surgery but with preparation and gas anaesthesia to effect, it will be around 25 minutes . I will only be available at 9.30 am on May 25, 26, 27 which are respectively Wed, Thu and Friday to operate as I will be studying and taking examinations for these 3 evenings.

Therefore, if we can't meet, you may consult Dr Vanessa Lin or Dr Teo by phoning 6254-3326 for appointment. Or you can leave the hamster with my assistant on Tuesday with instructions for my assistant that I will be attending to this hamster. I will operate at around 9.15 am on Wed, Thur or Friday for emergency cases such as yours. If you need to see me, it will be at 9.15 am for the above-mentioned dates or you can consult and get surgery done by the two associate vets.

Best wishes.

450. An e-mail survey or a scam e-mail?

On Sun, May 22, 2011 at 5:22 PM, ...@gmail.com> wrote:

Dear Dr Sing

I am a student of Anglo-Chinese School (Independent) and as part of an Economics research essay, I am required to conduct interviews with veterinarians practicing in the local veterinary scene in order to successfully complete the report. Having done the necessary ground work, I am impressed with the work of Toa Payoh Vets and have therefore specially chosen to include your clinic in this research essay. However, if necessary, your business name may be kept anonymous.

I would greatly appreciate your time and effort in completing the attached. The survey would take no longer than 10 minutes to complete.

Thank you and looking forward to hearing from you soon.

Yours sincerely

Name Given


E-MAIL REPLY FROM DR SING DATED SUNDAY MAY 22, 2011

I presume you are really who you claim you are - a student of ACS (I) and not one of the hundreds of scam e-mails I receive daily. I am not able to help you in answering the economic questions you ask as the financial data is private and confidential. However, you are welcome to interview me for other questions at a time convenient to both parties.

Conducting a thorough realistic research means really being hands-on, getting outdoors, seeing the place and spending time and money to meet the person rather than sending an e-mail survey.

Usually, I discard such e-mail surveys as they need to be downloaded and uploaded as in your format. There is an error in your survey form. There is no such practice called Toa Payoh Veterinary Centre in Singapore.

Best wishes.

449. Show, don't tell - Maltese shivers and has bloated "stomach"

On Saturday, May 21, 2011, I returned to the Surgery to discharge the shivering Maltese that had been hospitalised and treated for the past 2 days and is now OK. An earlier report is at:  The Maltese dog with a bloated abdomen keeps shivering. Why?
 

"Did the dog pass stools?" I asked my assistant Min. "No," he said. I expected this answer as I had given the dog an anti-spasmodic injection on day 1.

The dog had not I palpated the abdomen. It was not bloated but felt full and rounded. The concerned lady owner would be flying back from Hongkong today. Her mum and her brother came to get the dog home and to be briefed on what's the problem.

SHOW, DON'T TELL

1. INTERPRET THE X-RAY TO THE OWNER
X-ray of distended bladder had been shown to the mum and e-mailed to the owner in Hong Kong with explanation of a urinary tract infection. The owner was far away and was worried.


2. DEMONSTRATE THE BACK PAIN.
"Since the dog was boarded with a family that has small children, it is possible that the dog had been injured on her back," I told the mother and son. I put the dog on the table and pressed the length of the spinal area from the neck to the tail. "Can you hear the 'cough sound' when I pressed this area (thoraco-lumbar)?" I asked. "That is the area of pain. Something could have been dropped onto her back but I cannot say this is the case. The dog could have fallen on her back. The pain would cause the shivering."

They did not hear anything. I repeated three times and reproduced that very soft sound reaction in that area. The son lowered his head nearer to the dog standing on the table. I repeated the procedure. He heard the sound.

3. DEMONSTRATE NO BACK PAIN IN A NORMAL DOG
I got a normal Shih Tzu and repeated the spinal area pressing. Not a single sound came from this dog. "A normal dog will not 'cough' in reaction to my pressing of the spinal area as he has no pain there," I convinced the mother and son.

The dog went home. She had a nasty neck skin infection (yellow flakes on red skin, right eyelid infection and both elbow skin inflamed). "My daughter had seen many vets - yeast infection but no cure after many visits to the vets. She researched the internet and does her own treatment," the mum said. The rest of the coat was thick and normal. A small amount of dandruff fell off the dog's body. I said: "The neck skin infection should be cured as the dog keeps scratching. I will say that the neck skin should be normal if treated properly." Unfortunately, some owners give up when their vet or vets failed to produce results for the skin infections and do self-treatment instead.

4. SHOW THE URINE RESULTS. Dipstick indicated bacterial infection of the urinary tract infection. The change of colour was shown to the mother earlier. Laboratory results are not in yet. Blood test report with no abnormal findings were given on discharge of the dog.

In conclusion, this dog's shivering could be due to more than one cause. The pain in the spinal area, the pain in the neck skin area and the pain in peeing from an infected bladder. If only dogs can talk.


PICTURES AND UPDATES ARE AT:

http://www.sinpets.com/F5/201006237shivering-bloated-abdomen-female-maltese-ToaPayohVets.htm

448. An ethical and moral dilemma when clients demanded an injection only

I had two cases in the last 2 days of clients instructing me to give an injection and some medication.

Case 1. The woman brought her dog that was not eating and passing smelly vaginal discharge for more than two weeks. I palpated the swollen abdomen and the female Spitz gave up being gentle and started to curl up her lips to warn me not to do it any more. "Just give an injection and some drugs," the woman whose son was my son's classmate instructed me. I suspected closed pyometra which is a life-threatening disease - an infection of the womb.

I still remembered a recent case of the "Vets Who Don't Spay Big Breeds" where the cross bred was euthanased due to poor prognosis. The owners were referred by their vet to a brand-name veterinary practice and could not afford the fees. Much time had been wasted and the dog was no longer standing. Kidneys became infected. As the prognosis was poor, around 40% of survival, the owner decided not to operate and instructed euthanasia. This case quite upset me for this was really a dog that could have been saved if the family vet had tried not to be a one-tracked mind, always referring big breeds to an expensive surgery when his clientele comes from a neighbourhood not in the upper-middle class of Singapore.

Now, this woman demanded an injection. I did not do it as I advised X-rays and blood tests first to aid in the diagnosis of pyometra. She phoned her husband first she said. The husband and I exchanged words over the phone. He then asked his wife to go to another vet.

Case 2. In this case, the 14-year old Shih Tzu had passed a lot of blood in the urine and had difficulty peeing. "This is usually urethral obstruction, with stones blocking the urine flow," I said. But the owner insisted on an injection and medicine and wait-and-see. Now, give what the customer wants? If not, the customer goes to the competitor.

This is the type of ethical or moral dilemma. One could milk the client by doing what she wants. Revenue generated. The dog would have to come back again as the drugs will not work. This is obvious to the vet but the client wants to save money. I know the medicine will not work and refused to obey her wishes. The woman wanted it to save on costs. So there was an impasse.

She left the Surgery to consult somebody, probably her family or husband carrying the dog with her. I had asked Dr Vanessa to handle this case, under my lead management. This was going to be a hot potato if not handled professionally. I mean, if the vet gives the injection and medication as requested, the dog will not recover. The other family members start to curse the vet for incompetence especially if the dog were to die from renal failure and infection when sent to the competitor and treated belatedly. The competitor would cover for himself or herself by saying that I should have had done the blood test and the X-ray and give proper treatment early and the dog would have been alive. Not just give an injection and some antibiotics. What an incompetent vet!

Well, to make a long story short, the owner agreed to the X-ray which I told her was not necessary if she wanted to save costs on veterinary surgery. She did not believe my diagosis of urethral obstruction and so she agreed to the X-ray. A surgery by opening the bladder and getting out the urinary stones and pushing back the stones in the penile urethra into the bladder would save some money for the cash-strapped owner.

"Suck out all urine," I said to Dr Vanessa. "Pump air into the bladder and the stones would be seen clearly." She said: "The cathether cannot be passed into the bladder, so there is a urethra obstruction." Later she told me that another catheter could pass into the bladder and she got around 10 ml of bloodied urine which would be sent for urine analysis.

The X-ray came back with around 5 stones below the os penis and more stones in the urinary bladder. "How you manage this case is up to you," I passed the case to Dr Vanessa as we work well together.

My diagnosis was correct without the need for the X-ray but X-rays would be better as it is part of evidence-based medicine. Now, what to do next in view of the old age of the dog (14 years old) and the financial situation of the owner.

447. A dog with a bloated abdomen shivers a lot

E-MAIL REPLY FROM DR SING DATED MAY 20, 2011
2:39 AM

Thank you for your email to Judy. I am Dr Sing in charge of your case.


PATIENT'S HISTORY
Maltese, Female, Not Spayed, 5 years old.
Last estrus was reported by you to me from our tele-conversation from Hong Kong as to be around December. Your dog was boarded in a friend's place for the last 2 weeks. "Shivering" and not active were the complaints from your mum.

At around 10 am on May 19, 2011, your mum and brother brought XXX to consult me. Your mum complained that the dog was still shivering and not her usual self as she would normally "bite and tug at her pants" on seeing her.

The presenting sign was an acute abdomen. Your mum and I could see that your dog had a rounded "bloated" abdomen. The day before, a vet had treated the dog. I had phoned him and he had kindly told me about his clinical findings of abdominal pain and treatment. He had advised blood test and X-ray. According to your mum, he had advised surgery but she could not say what type of surgery was advised. She said that if surgery was needed, she would want it to be done by me.

EXAMINATION
The dog did not have a fever as she had been treated by Vet 1 the previous day. The pulse was normal but the dog was panting. The presenting sign was an acute abdomen. The abdomen was swollen. I could feel a large firm swelling of around 5 cm x 3 cm indicative of a swollen bladder. A swollen womb due to infection and pus (closed pyometra) could be present. The dog had a swollen inflamed vagina. She felt uncomfortable on abdominal palpation and started panting. Intestinal sounds were present on auscultation.

BLOOD TESTS
A complete blood test done today showed nothing abnormal. No increase in white cell count which might indicate pyometra. However Vet 1 had given antibiotic injection and so I would not eliminate the beginning of a pyometra.

X-RAY
Lateral view. A large distended bladder pushing all intestines to the front of the abdomen. The small and large intestines had several opaque lumps of around 1 cm and this would not be a problem if it was some foreign bodies as they would be passed out once the dog could urinate.

An ENEMA
was given by Dr Vanessa at around 6 pm. At around 10 am, I had injected the dog with antibiotic and an anti-spasmodic to relax the bladder muscles. However, the dog did not urinate till after 6 pm (see below).

URINE TEST
1. A dipstick showed a moderate amount of white blood cells present indicating a bacterial infection of the bladder. This would lead to painful urination and so the dog did not pee normally. More urine got retained and the bladder became distended causing pain and abdominal swelling.

2. As your mum came in the evening, I asked her whether the dog would run away if let free on the grass patch outside the surgery. She said no. So, I got the dog out under her supervision and gave her a urine collection bottle.

The dog peed at around 6 pm onto the grass outside the Surgery. Your mum kindly collected a full bottle of turbid urine which would be sent to a laboratory for urinalysis including a check for blood, bacteria and urinary crystals. Results will be known later today (Friday). The dog passed out some dark brown stools with oil from the enema.

ABDOMINAL PALPATION AFTER URINATION ON MAY 19, 2011.
The abdomen was normal. No more abdominal swelling. The dog started to paw your mum who was most happy. I spoke to you over the phone that the dog could go home. However, your mum was worried and so the dog would go home today on May 20, 2011.

DIAGNOSIS
A urinary tract infection based on dipstick results of white cells found in the urine and X-ray of urinary retention and clinical examination. The laboratory would confirm if urinary crystals were present as well and I would follow up with your brother soon as to what to do. The dog would go home on antibiotics and a follow up 7 days later is recommended.

ADVICE
I advise spaying of the dog around 4 weeks later as it is possible that a pyometra had started to develop.

UPDATE ON SATURDAY MAY 21, 2011
Dog normal. No abdominal distension. Will go home on Sunday.

446. Urine-marking female dog?

E-MAIL REPLY BY DR SING

Thank you for your email. As every puppy is unique, it will be most difficult for an outsider like me to know why the puppy's behaviour and reaction to your management is not what you expected. It is like parenting. Some parents produce scholars without bribery or threats, others suffer from dishonest and cheating offsprings. I will try to give you my point of view in your queries in CAPITAL LETTERS below.


2011/5/18 XXX <...@hotmail.com>

Dear Dr Sing,

I have been reading your blog entries and answers to many puppy owners and pretty much almost all of the available puppy training websites that are worth reading on the internet. I have also tried to use all the (positive reinforcement) methods and to look out for signs of my puppy needing to pee etc, but I still have a problem I need your help with. I really hope you can help me.

Please bear with me as my email is quite lengthy. I figured it'll be good to give you a clearer picture of what life is like for my Moomoo.

MM is 4+ months now, and is a cross between a Japanese Spitz and Papillon. We got her when she was only 1.5 months old and for the last 2+ months I have been trying to train her relentlessly, even watching her for hours straight just to catch her in the act.

For the first month that we brought her back, we put her in a 1x1 playpen and used a divider to partition off a part of her playpen such that 50% of the space was occupied with her pee tray, and 50% was her feeding/sleeping area (as per your advice to one of the shih tzu owners who wrote to you.) I used those house breaking aid spray to scent mark the newspapers inside the peetray as well. I would sit by her playpen and "accompany" her while waiting for her to pee.

Initially my puppy pooped correctly all the time, and peed outside of her pee tray. Within the first 2 weeks of bringing her back, she seemed to pee and poop on the pee tray 80% of the time. Some days, she even does it correctly 100%. Thereafter, as the weeks passed, instead of getting better, she seemed to pee wrongly all the time again.


AT THE END OF 2-4 WEEKS, YOUR PUPPY NEEDED MORE CLEAN AREAS BUT YOU DID NOT EXTEND HIS 'GROSS FLOOR AREA' (GFA). I am using a real estate term. It means that the living space in the playpen ought to have increased by 100% (by buying more fencing panels, so that the puppy can lie down on clean areas further away from its toilet area. This GFA gets increased so that by 8 WEEKS, there IS NO NEED TO CONFINE THE PUPPY 100%. A door or opened end of the playpen directs the puppy to the toilet area.




And the last straw came when one day she even pooped outside the pee tray, something that she almost never does.

I eventually realized, after reading through many many MANY websites, that the cause of her confusion and inability to learn the correct place to pee/poop is due to the fact that her playpen was situated on marble flooring in my living room. Marble, being porous, is like a hard sponge that absorbs the pee. So even though I cleaned the area with enzymatic cleansers, she still seemed to pee wrongly all the time. This was probably due to the fact that her pee has already seeped under the surface and hence her entire playpen area was filled with her urine smell, thus confusing her.




MAY NEED TO TRY WHITE VINEGAR:WATER AT 1 PART TO 3 PARTS to neutralise the urine smell of put NEWSPAPERS OR WHITE PAPERS AT THE BEGINNING. Some enzymatic cleansers don't work.

After 1 month+ of trying to train her to pee/poop on her peetray, to no avail, I decided to move her entire peetray into the kitchen, where the floor is tiled (making it easier to clean, and doesnt absorb urine smell as much as marble.) By now she had grown slightly bigger and I was worried that her pee tray might be too small for her, hence causing the misaims.

Hence, I bought a new & slightly bigger pee tray with raised sides and decided to start retraining her again from scratch, hoping that the new peetray with raised sides would help as she would have to STEP INTO the peetray to do her business. Attached is the picture of her playpen now, after moving it to the kitchen.

PEE TRAY LOOKS SMALL TO ME.


PROBLEM:
1) My puppy mostly poops inside the peetray now (and I always pick up the poop and wash the grate immediately after she poops). But her peeing still drives me mad. I need to understand why my puppy does not pee inside her pee tray? To be fair, she pees correctly mostly during the first 1-2 times after I change the peepad/newspapers inside the peetray. Thereafter she would pee outside of the peetray. I change her peepad/newspapers once to twice daily, as soon as it is too soiled.


THIS MAY BE A CASE OF URINE MARKING. IT DOES OCCUR IN FEMALE DOGS TOO.



2) In the first 1 month of potty training, whenever I catch her in the act of peeing outside of her pee tray, I would clap or make a loud "NO!" to startle her, before carrying her to the right place. Whenever I do not catch her in the act, I just say bad girl and clean up the mess. Somehow, I think it might have led to her thinking that she shouldnt pee infront of me. Nowadays, even though I watch her for 2 hours waiting for her to pee, she would hold it in. Sometimes she walks onto her pee tray and sniffs around, and I will say "Potty!" but she wouldnt do it. The moment I leave her for 30 secs, for a pee/coffee break or something, she would pee. And most of the time, it would be in the wrong place. *sigh* What should I do about this?

URINE MARKING BEHAVIOUR HAS BEEN INHIBITED OR PROHIBITED BY YOU. SO THE DOG DARES NOT PEE (TO MARK HER TERRITORY) WHEN YOU ARE AROUND.

TO GIVE YOU A REAL EXAMPLE, MY ASSOCIATE VET BRINGS HER ADULT DOG TO THE SURGERY. THIS IS AN ADULT NEUTERED DOG. HE STILL URINE MARKS ON THE FLOOR OF THE ANIMAL HOLDING ROOM WHEN NOBODY IS AROUND. A LARGE POOL OF URINE.

Whenever she pees correctly I will praise and treat her, make a fuss and she seems to understand, as she becomes excited and jumps around. I also let her out for about 15 minutes of supervised playtime if she pees correctly. This is aside from the 45min-1hour playtime she gets to run around in the garden.


URINE MARKING IS PART OF THE NATURAL BEHAVIOUR OF DOGS AND SOME GET NEVER BE TRAINED NOT TO URINE MARK.


3) From the many websites and case studies I read, dogs tend to not want to poop where they eat, and vice versa. However, I realised whenever I give Moomoo a nice treat like a bone which takes an hour to finish chewing on, she liked to bring her food/toy onto her peetray, and she will chew on it and play with it inside her pee tray. This seems to be an unlikely behavior for dogs. Why would she want to eat and play on her peetray?

PROBABLE REASONS ARE:
1. INSUFFICIENT SPACE TO LIE DOWN TO ENJOY A GOOD CHEW BONE AS YOU HAVE NOT EXTENDED THE GFA WITH TIME.

2. THE GRATE OF THE PEE TRAY IS QUITE CLEAN SINCE YOU USE A LOT OF CHEMICALS TO MASK ITS SMELLS (I presume you clean thoroughly many times).

3. THE DOG'S NOSE IS DESENSITISED TO HER OWN URINE SMALLS SINCE SHE HAS SUCH A SMALL AREA TO LIE UPON.


Especially when its a new exciting treat/toy. She seems to like to bring it to her peetray, lie in it and explore the treat/toy slowly. It seems a little unhygenic. I try carrying her out of her peetray but she always runs back there. She can even eat on her peetray that she has just peed on (soiled). Why does she use her peetray for the wrong reasons, after so many months?

Actually I feel that she is a very smart dog because within 4 months she has already learnt: sit, down, paw, high5, spin, bang!, rollover, leave it, stay and walk. I would think that she would learn to pee correctly by now. But she hasnt.

URINE MARKING IS OFTEN MISTAKEN BY OWNERS AS A FAILURE IN TOILET TRAINING. MANY OWNERS ASSUME FEMALE DOGS DON'T URINE MARK.

Is there something I am doing wrongly? If so, what? How can I help Moomoo learn that she should pee in the peetray and not elsewhere within her playpen? I am confining her within the playpen except for the 45min-1hr playtime she gets daily, and her 15 min "reward" playtimes. I am waiting for the day she is 95-100% spot-on peeing on her pee tray and I can be confident that she will be able to know where to pee/poop, before I allow her to roam freely around the kitchen/living room area, unsupervised.

It has been almost three months since I brought her home. Most puppies would have been trained in 2 weeks. Whats wrong??


FROM YOUR DETAILED DESCRIPTION OF THE PUPPY'S BEHAVIOUR, SHE HAS BEEN TRAINED ON THE PEE TRAY. HOWEVER SHE GETS A LOT OF ATTENTION FROM YOU IF SHE 'MISBEHAVES' SOMETIMES.

AT OTHER TIMES, SHE NEEDS TO URINE MARK.

Please help.

Thank you, your reply and assistance is very very much appreciated. I swear. Really hope to hear from you soon.


IN CONCLUSION, YOU MAY WISH TO TRY ANOTHER METHOD.
1. TWO AREAS - SEPARATE AND FAR FROM EACH OTHER. ONE IS FOR SLEEPING, EATING, AND DRINKING. ONE IS THE TOILET AREA.

2. THE PUPPY IN THIS NEW CLEAN AREA IS CONFINED AND/OR LEASED TO YOU OR UNDER SUPERVISION.

3. USE THE FORMULA N-1 WHERE N=AGE OF PUPPY IN MONTHS.

4. FOR EXAMPLE, AT 4 MONTHS OF AGE, N-1=3. BRING HER OUT FROM THE NEW CLEAN CONFINED AREA EVERY 3 HOURS TO THE PEE TRAY TO PEE. THEN PUT HER BACK TO HER NEW LIVING AREA. AT 5TH MONTH, THIS SHOULD BE AROUND 4-HOURLY. TRIAL AND ERROR AS SHE MAY NOT PEE EXACTLY ON TIME. REWARDS AND PRAISES ON SUCCESS.


Cheers
XXX

P.S ALL BETS ARE OFF IF SHE URINE MARKS. YOU ARE BETTER OFF GOING TO THE CASINOS AS THE N-1 METHOD WILL NOT WORK!

LET ME KNOW IF YOU CAN ADOPT THIS METHOD. BEST WISHES.

445. Two old dogs can't stand on their hind legs

Case 1. The Shih Tzu has back ache
"I was told to come at 9 am if I want to consult you," the lady with a Shih Tzu was waiting on this fine Vesak Day. I do morning consultations and surgeries daily except Saturdays and usually I require appointments to be made.

It was 70 days ago and I was surprised to see the owner's mother. The owner was actually the daughter who is studying overseas and was diligently ensuring that her mother take good care of this old Shih Tzu. I guess the daughter grew up with this dog and loved her very much.

I took out the case card and there was a note saying that I had phoned the owner's mother to come to collect the medication for the dog with back ache problems. The dog was hunched and could not stand on her hind legs 70 days ago. I had given medication and injection and advised strict cage confinement for at least 3 months. Also, a follow up one month after the injury to the back.

"Why didn't you come to pick up the medicine to bring down inflammation for the dog for another 4 weeks?" I asked as Mr Min took out the bag of medicine from the cabinet. I checked the T/L spinal area by pressure using my forefinger and middle finger to press directly and firmly from the neck to the tail. At the spinal area around vertebra T10 to L3, the dog reacted with a soft "ha" and did so when I repeated the palpation. It was a quiet "cough" but the mother confirmed she could hear it. There was no painful whimpering on spinal palpation now. When I placed the dog's hind legs onto the edge of the table, the dog could not put her hind feet forward instantly. I showed the owner that the dog could do so with the front feet. So, the placing reflex was still absent in this dog and she has not fully recovered.

"I have put the dog inside the cage for the last 2 and a half months," the mother said. "She would like to run all over the apartment like a bullet train but I did not allow her to do so."

"The news is good," I said. "Strict cage confinement for the last 2 and a half months helps the injured disc area to heal." I did not dwell more on her missing out on the NSAID medication as she had already said she was busy working. I decide that I must implement a system of putting such reminder info on a notice board so as to give a second reminder in the interest of the dog.

"I have been busy working," the mum said. "What are the two lumps on the dog's back?"

"The two cauliflower lumps are warts," I said. "Older dogs do get warts and the cause is said to be a virus."

"What is your advice?" the mother asked me whether a 3rd small swelling nearer to the tail was the 3rd wart.

"I will advise clipping of the coat and see how many warts there are. Get all warts excised when they are small. Nobody knows exactly why warts appear. Warts appear in very young and old dogs. I had a case where the dog had over 50 warts because the vet advised that there was no need to do anything. The warts got infected and bleed and so I had removed all of them. Some do return but most had gone in this old dog."

Spinal disc injury cases need monthly follow-up by the owner for the first 3 months. Unfortunately many don't if they see the dog as improving.

There is a grey line crossed if vets phone up the owner to get the follow up done as the owner may ignore or mis-construe that the vet is soliciting for business.

CASE 2. The Miniature Schnauzer can stand up only when given steroids.

Recently, my specialist in the Singapore General Hospital phoned me about his friend's dog, a 9-year-old Miniature Schnauzer who could stand up and walk if he takes the steroidal drugs. Without the drug, the Schnauzer could not stand up.

The doctor said: "The Schnauzer could have 'mini-strokes' earlier as his head tilted to one side. Vet 1 gave the steroids and the dog improved. Then he could not get up to walk on his hind legs and Vet 1 gave steroids. The dog could walk only when he takes the drugs. What is your diagnosis?"

"Didn't Vet 1 provide the diagnosis?" I asked.
"She said there was nothing wrong with the dog," the specialist said.
I found this hard to believe and advised him to get the medical records as Vet 1 is an experienced battle-hardened vet. The dog owner was very distressed and so the specialist phoned me for a short consultation out of the blue.

"Is there any cure if the dog has spinal disc injury?" he asked.
"There is the surgical treatment," I said. "But in most cases, there is no permanent cure and the surgical treatment needs to be expertly done by an experienced vet."

I advised tapering off the steroid and stopping all steroids if the specialist's friend wanted me to examine the dog. Pain-killers mask pain and therefore there was no point in being consulted as I would not be able to locate the injured spinal area by palpation. X-rays may help. In any case, a telephone diagnosis is very risky and unprofessional and I tried not to give any diagnosis as things don't appear to be what they are on the ground as compared to telephone imaginations and conversations.

P.S. Dogs with head tilted to the side would appear to suffer from "mini-strokes" to the human medicine doctors as they equate hemi-paralysis of the face and body with strokes or mini-strokes. In dogs, the most common cause would be otitis media!

444. Wait-and-see Veterinary Advices

"Have you retired?" the mother and adult daughter had been consulting me regarding their dog over the past few years but now was attended to by Dr Vanessa. "No," I said. "I do consultations in the mornings by appointment but most of my cases will be handled by Dr Vanessa. It is good for my clients to have a younger vet to consult as I am 60 years old."

The mother looked at me with incredulous eyes as if she expected 60-year-olds to be half hunched and said: "It is good to retire as older people get diseases. Where's your son? Is he graduating and will he be helping you?"

"Yes," I said. "He will be graduating in December this year." Five years had flown by and my golden years have melted away.

I said to the pretty and tall Indian daughter with thick black eyebrows and a sharp face and probably in her late 20s. "Why are you so well dressed today on Vesak Day? In the finest silk sari and a red sash over your left shoulder?" I asked the daughter.

Mum said: "I am also dressed in new clothes. We are Hindus but we celebrate Vesak Day." I should have complimented the mum first. She was wearing a light grey dress, silky and shiny but the bright maroon red sash of the daughter attracted my attention.

"So, what happened to your dog?" I asked them as they had consulted Dr Vanessa without bringing the dog.

"We came for medication," the mum said. "Our dog had a lump on the rib cage area but Dr Vanessa advised us to wait and see. If the lump gets bigger, she will consider operation."

"Is the lump under the skin?" I asked.
"Yes,"
"Well, is it a small lump?"
"It is quite big. We can bring him to you to see."
I said: "Every vet has his own opinion as regards lumps and bumps in old dogs. How old is your dog?"
"He is 14 years old."

I said: "Many vets do advise a wait-and-see. Unfortunately, many owners waited but don't see. They don't examine the lumps daily or weekly. After a few weeks, if the lump is cancerous, it will have exploded to a big size and that is when they see the vet for surgery. So, my advice to all owners with old dogs especially. Don't wait and see.

"Just get the vet to remove the lump when it is small. If it is cancerous, it could be removed with a wide margin including normal cells around it. If you wait and see, the cancerous cells have invaded the surrounding tissues, it would be very difficult to excise all and the cancerous lump recurs."

The mother and daughter were worried and they ought to be. A 14-year-old dog with a lump is likely but not guaranteed to have a cancerous tumour. There is the high risk of anaesthetic risk for dogs over 8 years of age. So, this could be the reason why some vets adopt a "wait-and-see" attitude.

The duty of care of a vet in such circumstances should be to advise surgical excision for old dogs and provide an informed consent. Not wait and see as, in my experience, most Singaporean owners of old dogs seldom "see" their dog's tumour daily till several weeks later, they discover that the tumour is much larger. By then, it is too late to save the dog as the cancerous growth has spread to the sides and will recur again after surgery.

P.S May 17, 2011 is Vesak Day and is a public holiday. A bright sunshine day when most Singaporeans would be relaxing.

I was at the reception counter, still trying to teach my new replacement vet assistant Mr Min how to work efficiently and faster and how to answer the many telephone queries.

For example, I taught him to put all the necessary stationery (ink pad, namecard of Dr Vanessa, stapler, date chop inside one plastic cup) so that he would not waste time looking for each one after Dr Vanessa signed the vaccination certificate. In a busy time, this saving of a few seconds counted as the Singapore clients dislike long waiting times. In addition, Mr Min had a habit of holding the dog while Dr Vanessa spoke to the client about the diagnosis. "Let the client hold his or her dog," I said to him. "You do the other work like preparing for the next case." This was what my old assistant Mr Saw would do. Mr Saw would weigh the dog and take the temperature of the next case for me. Here, Mr Min would be holding the little dog on the consultation table and waited. There was why the waiting times stretched.
So, I had to step in to speed the work flow.

Sometimes we would be busy on a public holiday but this Vesak Day was rather quiet. So I had time to talk to the mother and daughter and know more about their pet problems.

Referring to a brand name veterinary surgery so as not to lose clientele

"Very smelly flow of blood and pus from the below for over 2 weeks," the man in his late 30s told me. "I sent it to my vet (Vet 1) I trust, but he did not want to operate. He referred me to XXX (a brand-name vet surgery) but the vet fees would cost me more --- two thousand dollars. So, I checked out the internet and came to you."

The 9-year-old dog was no longer able to stand as there was at least 2 weeks of delay and the dog was not eating. Blood tests showed kidney disorder as well as high white cell count.

"How much is your operation fee?" the father asked me as I reviewed the dog's case with him and his son.

"$500," I do give discount to pet owners who are in need of lower vet fees for a pyometra surgery. Usually it would be nearer to $800 for the anaesthesia and surgery, excluding IV drips, medication and hospitalisation. There is no means testing in Singapore but this case appears to have been delayed considerably due to financial reasons.

"Can you reduce it?" the father asked me.
"It is as low as I can give to you," I replied. "This is not the normal cost. It would be around $800 - $1,000."

"However, you must know that the dog has around 40% chances of survival since she is very ill due to delays in seeking veterinary surgery." I had to be frank with the owners.

As I am responsible for the reputation Toa Payoh Vets, it is my duty to make sure that my associate vet handling this case do provide this risk assessment to the owner and not just to operate. If the dog dies, the owner will still be angry as he has to pay the bills when the outcome is not good. So I told my associate vet that I had given the 40% chances of survival to the owner and that the owner must be informed accordingly.

Any other options? I did not suggest euthanasia. The father said: "Since it is not 50:50, I will want the dog to be put to sleep."

If the dog had been operated 2 weeks ago by Vet 1, the chances of survival are very good. Unfortunately, the family vet did not want to operate on big dogs. I know Vet 1 always refers difficult cases to a brand-name veterinary surgery as a routine over the past century, without considering that his clients may not be able to afford the "Mount Elizabeth Hospital" type of fees. So some of his clients seek other practices.

Vets must understand their clients' financial situation and do what is good for them and their pets. A dog's life that could be saved was lost due to Vet 1's one-track mind to refer all cases to this brand-name veterinary surgery, on the erroneous assumption that he or she would not lose their clients as this brand-name surgery would not poach his clients.

In my opinion, once you refer to other vets, it is likely that you lose your client. Maybe, the client can't afford the brand-name veterinary surgery the second time and so you presume the client will return to you.

Why not find out what is the financial situation of your client, network with some vets who can perform the surgery competently but at "affordable" cost, get the quotations for your client. In this way, your service will be considered excellent. You will gain the gratitude and retain the loyalty of the client who has had used your services for many years? It is most likely your client will come back to you as he has had been doing for years.