When one young sibling is ill, will the other sibling get infected? This depends on the diagnosis. Recently I encountered two cases of sibling illness. One case was of two male ragdoll cats, 11 months old.
The other case was not under my care but the owner, being my wife's ex-classmate phoned me for a second opinion as she was worried that the living 6-month old Golden Retriever X, now healthy might suffer from the same disease. This would be written in Sibling Illness 3 - The Vomiting Golden Retriever X
CASE 1.
"My wife consulted Vet 1 and Vet 2 for 4 times in the past 2 weeks, but the cat continued vomiting. We told the vets that the cat was not putting on weight compared to his sibling." He consulted Dr Jason who took a blood test and gave the necessary IV drip. The cat died overnight. I saw the owner the next day. He appeared upset and so, being the Practice Manager which is equivalent to the KEO or licensee, I spoke to Dr Jason as to what was going on. Dr Jason said that the owner thanked him and was not unhappy. This is the type of emotional situation where a blood test gave clues to the cause of illness and satisfy the owner.
BLOOD TEST OF RAGDOLL 1.
Date Mar 4, 2011 (date of admission to Toa Payoh Vets).
Urea 16.9 (7.2 - 10.8)
Creatinine 83 (71-160)
SGPT/ALT 91 (<121)
SGOT/AST 214 (<67)
Haemoglobin 6.6 (8 - 15)
PCV 0.21 (0.24 - 0.45)
Platelets 152 (300 - 800)
The cat was recumbent. 2.5 ml of blood was taken from the femoral vein and put into 3 tubes for laboratory analysis. With the blood results, Dr Jason had supporting clues as to why the cat had died and the owner was satisfied and his unhappiness was "why the other vet did not take blood test".
His questions to me today, Mar 17, 2011 when I met him again while his 2nd cat had been treated by Dr Vanessa for constipation and 6 days of hospitalisation earlier for fever (very high white cell count) were as follows:
1. Why didn't the vets take a blood test? He said it could be that the cat was treated by different vets in the practice.
2. Would the first deceased cat be saved if a blood test was taken earlier?
3. What was the cause of the illness, leading to weight loss compared to his sibling? Both lived in a house, had freedom to roam, fed canned food and given dry food unrestricted.
I took out his case sheet for the Ragdoll 1 to review the case and asked him more history. This required time and so time is seldom available for most vets.
"Did your first cat prey on lizards and cockroaches?" I asked since the 2nd cat treated for a high fever had a very high white cell count.
Thursday, March 17, 2011
You can't teach an old dog new tricks?
Case study: You can't teach an old dog new tricks?
I am reminded of an English idiom I had to memorise and understand for my PSLE (Primary School Leaving Examination) exam in Primary Six in 1962 when I was 12 years old. The only dogs I saw in the Redhill area I lived (there was actually a real red hill) were stray dogs and no resident in the S.I.T (Singapore Improvement Trust) apartment keep dogs as pets. It was the 1960s and the residents were the working class. I am sure the rich families living in Cluny Road or the other areas keep dogs as pets. As for me, I had never seen dogs performing as there was probably no TV yet or at the most, a black and white one.
This idiom was: "You can't teach an old dog new tricks". What did it mean to a 12-year-old boy whose life was decades from being an old foggy.
When I encountered the real situation yesterday, March 16, 2011 during a class I had to attend at 60 years of age, I could understand the meaning of the idiom. See whether you agree with me as to whether the story explains the idiom succinctly?
On March 16, 2011, I attended a REA course which lasts 2 months with lectures 3x/week from 10am - 1 pm. A fair lady in her late 30s who is in the family of developers said: "I am too old to study. When is the examination? I have to go overseas in May."
"The exam is in May," I said. "After the end of the course, you will get a completion certificate (75% attendance needed). Then you can register for this examination conducted by Informatics. It is best to take this May exam after the lectures if you wish to have a better chance of passing."
Our lecturer, white-haired and trim in his late 60s said: "I can pass the exam and you are much younger. If you put your mind to it, you will pass. My student studies 3 hours/day and he passed."
I said: "You must have missed renewing your real estate licence with the IRAS (Inland Revenue of Singapore) before the CEA (Council of Estate Agents) takes over the regulatory functions in 2010. Otherwise, you will not need to take this course."
"Yes, for the last 3 years, I did not renew the licence with the IRAS."
All licences must be renewed but in this case, the IRAS did not provide the electronic debiting of licences unlike the CEA. The IRAS declared that all realtors had to self-renew and no reminders would be sent.
There were those who did not do so. When the CEA took over, these were the fishes trapped in the net and if they want to be the KEO (Key Executive Officers) of their realty firms, they have to take this REA examination. No mercy or compassion from the CEA even if you have the CEHA certificate. I had the CEHA but I had not renewed my licence. Bad luck to me. So that is why I am in class studying the laws of tort, contract, architecture notes and more regulations.
My class-mates appear to be over 30 years mainly and I presume we are all in the same boat as this developer.
The mind must not think "old" if one wants to live longer and be successful in examinations. Otherwise, the self-fulfilling prophecy kicks in - you think you are old and can't pass the exam or be successful. So, your mindset becomes negative and you really age soon.
The lecturer had 5 shophouses to sell at $14 million for re-development. He asked this developer firm for her name card. Then he threw his name card onto her table.* I asked for one too. One must network and think positively.
P.S. In some cultures, throwing the name card to another person may not be polite. It should be handed with two hands. You will see Japanese businessmen handing name cards with two hands as that is their way of doing things.
This lecturer was very supportive and encouraging. He is a very good lecturer. He said to me: "Just study my CD. Or you can download to your phone for reference." I was surprised that this could be done. He showed me his Nokia phone and there were the notes. According to some classmates, the notes in the CD needed to be printed in 400 pages! There are so many new technology and if one knows how to use it, one could just study from the smartphone when one is free. This may be a useful tip to veterinary undergraduates. The old lecturer had someone to download the CD for him as I asked how he did it. Always ask and you will find that people usually are kind and will answer your "stupid" question.
From this experience, write down a list of licences to be renewed on a piece of paper and display in front of your desk. Nowadays, most Singapore government departments don't do what the IRAS did to the realtors. They send e-reminders and that should be the way to serve the tax payers.
I am reminded of an English idiom I had to memorise and understand for my PSLE (Primary School Leaving Examination) exam in Primary Six in 1962 when I was 12 years old. The only dogs I saw in the Redhill area I lived (there was actually a real red hill) were stray dogs and no resident in the S.I.T (Singapore Improvement Trust) apartment keep dogs as pets. It was the 1960s and the residents were the working class. I am sure the rich families living in Cluny Road or the other areas keep dogs as pets. As for me, I had never seen dogs performing as there was probably no TV yet or at the most, a black and white one.
This idiom was: "You can't teach an old dog new tricks". What did it mean to a 12-year-old boy whose life was decades from being an old foggy.
When I encountered the real situation yesterday, March 16, 2011 during a class I had to attend at 60 years of age, I could understand the meaning of the idiom. See whether you agree with me as to whether the story explains the idiom succinctly?
On March 16, 2011, I attended a REA course which lasts 2 months with lectures 3x/week from 10am - 1 pm. A fair lady in her late 30s who is in the family of developers said: "I am too old to study. When is the examination? I have to go overseas in May."
"The exam is in May," I said. "After the end of the course, you will get a completion certificate (75% attendance needed). Then you can register for this examination conducted by Informatics. It is best to take this May exam after the lectures if you wish to have a better chance of passing."
Our lecturer, white-haired and trim in his late 60s said: "I can pass the exam and you are much younger. If you put your mind to it, you will pass. My student studies 3 hours/day and he passed."
I said: "You must have missed renewing your real estate licence with the IRAS (Inland Revenue of Singapore) before the CEA (Council of Estate Agents) takes over the regulatory functions in 2010. Otherwise, you will not need to take this course."
"Yes, for the last 3 years, I did not renew the licence with the IRAS."
All licences must be renewed but in this case, the IRAS did not provide the electronic debiting of licences unlike the CEA. The IRAS declared that all realtors had to self-renew and no reminders would be sent.
There were those who did not do so. When the CEA took over, these were the fishes trapped in the net and if they want to be the KEO (Key Executive Officers) of their realty firms, they have to take this REA examination. No mercy or compassion from the CEA even if you have the CEHA certificate. I had the CEHA but I had not renewed my licence. Bad luck to me. So that is why I am in class studying the laws of tort, contract, architecture notes and more regulations.
My class-mates appear to be over 30 years mainly and I presume we are all in the same boat as this developer.
The mind must not think "old" if one wants to live longer and be successful in examinations. Otherwise, the self-fulfilling prophecy kicks in - you think you are old and can't pass the exam or be successful. So, your mindset becomes negative and you really age soon.
The lecturer had 5 shophouses to sell at $14 million for re-development. He asked this developer firm for her name card. Then he threw his name card onto her table.* I asked for one too. One must network and think positively.
P.S. In some cultures, throwing the name card to another person may not be polite. It should be handed with two hands. You will see Japanese businessmen handing name cards with two hands as that is their way of doing things.
This lecturer was very supportive and encouraging. He is a very good lecturer. He said to me: "Just study my CD. Or you can download to your phone for reference." I was surprised that this could be done. He showed me his Nokia phone and there were the notes. According to some classmates, the notes in the CD needed to be printed in 400 pages! There are so many new technology and if one knows how to use it, one could just study from the smartphone when one is free. This may be a useful tip to veterinary undergraduates. The old lecturer had someone to download the CD for him as I asked how he did it. Always ask and you will find that people usually are kind and will answer your "stupid" question.
From this experience, write down a list of licences to be renewed on a piece of paper and display in front of your desk. Nowadays, most Singapore government departments don't do what the IRAS did to the realtors. They send e-reminders and that should be the way to serve the tax payers.
Wednesday, March 16, 2011
Sunday Mar 13, 2011's two interesting case
CASE 1. The case of pug with the swollen male private part.
The lady owner who has nursing knowledge apologised for phoning me on Saturday and said: "Remember my pug with the urinary stones? But now, my pug has a big swollen penis for some time. He could be humping. Is it serious? Will he recover with time? What is the cause? It can't be urinary tract infection as his urine is OK."
This is the type of question that is very difficult to answer. If I said yes and the pug self-mutilated his penis by further licking causing bleeding, I would get an unhappy owner who would lose confidence in my judgment. So, it was wiser to get her to bring the pug for examination and treatment to bring down the penile engorgement.
"I don't know," I said. "It is best to send the pug down for treatment."
The pug was still having the big swelling when the lady brought him to consult Dr Jason Teo who was on duty on Saturday. His injection brought down the swelling. I did advise collection of urine for analysis and hospitalisation for one day. It would be negligent not to do so.
Urine test showed no bacterial infection or urinary crystals with the pH being 6.5. However blood in the urine was 4+ (a lot) and there were protein casts.
So, what was the problem? Self-stimulation? Kidney trauma causing bleeding inside the urinary tract?
The dog developed fits during hospitalisation. So, could the dog have injured his penis when he had fits or penile engorgement due to fits? Since most fits have unknown causes, it was hard to say. I phoned the owner who had not witnessed any fits said: "So the cause was due to fits."
This was a strange case. I did advise neutering but she would not do it.
CASE 2. Left thyroid malignant tumour.
The couple had this Beagle for 15 years. When she was not eating properly, he sent to me for dental scaling last month. Then, last week, he showed me the video of the dog gulping and "snorting" after swallowing. A left throat lump, the size of a 50-cent coin
The lady owner who has nursing knowledge apologised for phoning me on Saturday and said: "Remember my pug with the urinary stones? But now, my pug has a big swollen penis for some time. He could be humping. Is it serious? Will he recover with time? What is the cause? It can't be urinary tract infection as his urine is OK."
This is the type of question that is very difficult to answer. If I said yes and the pug self-mutilated his penis by further licking causing bleeding, I would get an unhappy owner who would lose confidence in my judgment. So, it was wiser to get her to bring the pug for examination and treatment to bring down the penile engorgement.
"I don't know," I said. "It is best to send the pug down for treatment."
The pug was still having the big swelling when the lady brought him to consult Dr Jason Teo who was on duty on Saturday. His injection brought down the swelling. I did advise collection of urine for analysis and hospitalisation for one day. It would be negligent not to do so.
Urine test showed no bacterial infection or urinary crystals with the pH being 6.5. However blood in the urine was 4+ (a lot) and there were protein casts.
So, what was the problem? Self-stimulation? Kidney trauma causing bleeding inside the urinary tract?
The dog developed fits during hospitalisation. So, could the dog have injured his penis when he had fits or penile engorgement due to fits? Since most fits have unknown causes, it was hard to say. I phoned the owner who had not witnessed any fits said: "So the cause was due to fits."
This was a strange case. I did advise neutering but she would not do it.
CASE 2. Left thyroid malignant tumour.
The couple had this Beagle for 15 years. When she was not eating properly, he sent to me for dental scaling last month. Then, last week, he showed me the video of the dog gulping and "snorting" after swallowing. A left throat lump, the size of a 50-cent coin
359. Mis-treatment by a famous surgeon
This was a story related to me by a 30+ lady who had her rabbit treated by me. Her friend, also 30+ had a tumour near her heart and consulted a famous experienced surgeon in a government hospital.
"This surgeon had done many of such cases before and they were benign tumours. So he opened up the chest but the tumour was malignant," the rabbit owner said. "Worse of all, he could not remove all the tumour tissue. Imagine my friend's distress. If it is diagnosed malignant before the operation, chemotherapy could be used to shrink the tumour before operating. Now, my friend could not be given chemo-therapy and must wait 6 weeks."
"Waiting with malignant tumour inside her chest was very stressful. And the surgeon is a well known doctor in this hospital."
"Could a biopsy of the tumour be done to see whether the chest tumour is cancerous or not before proceeding to sugery?" I asked. She didn't know and neither did I.
"Did your friend seek a second opinion to get an earlier date for chemotherapy?" I asked.
"No," the owner said.
"So, what happened?"
"Well, my friend had chemotherapy 6 weeks after the operation. She is recovering in Europe."
Medicine springs some surprises to doctors and veterinarians. It is wise to do biopsies for chest tumours unless the owner does not want it done. The common practice for surgeons may be just to take out the tumour and send for histopatholgy test, rather than wait for biopsy results.
"This surgeon had done many of such cases before and they were benign tumours. So he opened up the chest but the tumour was malignant," the rabbit owner said. "Worse of all, he could not remove all the tumour tissue. Imagine my friend's distress. If it is diagnosed malignant before the operation, chemotherapy could be used to shrink the tumour before operating. Now, my friend could not be given chemo-therapy and must wait 6 weeks."
"Waiting with malignant tumour inside her chest was very stressful. And the surgeon is a well known doctor in this hospital."
"Could a biopsy of the tumour be done to see whether the chest tumour is cancerous or not before proceeding to sugery?" I asked. She didn't know and neither did I.
"Did your friend seek a second opinion to get an earlier date for chemotherapy?" I asked.
"No," the owner said.
"So, what happened?"
"Well, my friend had chemotherapy 6 weeks after the operation. She is recovering in Europe."
Medicine springs some surprises to doctors and veterinarians. It is wise to do biopsies for chest tumours unless the owner does not want it done. The common practice for surgeons may be just to take out the tumour and send for histopatholgy test, rather than wait for biopsy results.
Sunday, March 13, 2011
358. Malignant tumour left neck - disc shaped
Sunday Mar 13, 2011 Blue skies, white clouds, sunshine
2 interesting cases
CASE 1. Beagle, 16-year old.
The owners, a couple in their 40s, were kind enough to permit me to use their dog case for education of vet students.
HISTORY
In
2 interesting cases
CASE 1. Beagle, 16-year old.
The owners, a couple in their 40s, were kind enough to permit me to use their dog case for education of vet students.
HISTORY
In
Tuesday, March 8, 2011
357. Singapore's education system data
Reference: Straits Times, Mar 7, 2011 A19 "An education in mobility"
What is the actual situation of the Singapore's education system? Does one's family background - rich v. poor parents affect the child's ability to stay at the top or bottom of the social ladder respectively? This means that the rich becomes richer and the poor becomes poorer in Singapore.
MINISTRY OF EDUCATION'S STATISTICS
said that students from poor homes can still move up, giving example that the top 5% of the Primary School Leaving Examination pupils are consistently distributed among the 95% of the primary schools and not just the elite ones. In addition, >90% of each cohort goes to publicly funded post-secondary institutes and almost 50% of students who live in one- to three-room HDB flats make it to universities and polytechnics.
In my opinion, almost 80% of the population lives in HDB apartments. How many % of the HDB group goes to universities which exclude long-distance studies? Did the MOE provide such figures? Unfortunately, I don't know.
Education is a priority for Asian families. The children from disadvantaged homes cannot afford the expensive early, pre-primary education and so, will be always at a disadvantage. But is it necessary that 80% of the students go to universities when there are not sufficient places and ability?
Reference Straits Times Mar 8, 2010 frontpage
Education Minister Ng Eng Hen said:
1. One in 10 children from one- to three-room flats goes to University. 4 in 10 goes to polytechnic.
2. 1 in 6 children from the bottom third of the socio-economic ladder scored in the top third of the PSLE (Primary School Leaving Exam) cohort. 1 in 2 scores in the top two-thirds.
3. Every primary school produces at least 10 pupils who score in the top third of the PSLE.
So, better opportunities for every child, said the minister.
What is the actual situation of the Singapore's education system? Does one's family background - rich v. poor parents affect the child's ability to stay at the top or bottom of the social ladder respectively? This means that the rich becomes richer and the poor becomes poorer in Singapore.
MINISTRY OF EDUCATION'S STATISTICS
said that students from poor homes can still move up, giving example that the top 5% of the Primary School Leaving Examination pupils are consistently distributed among the 95% of the primary schools and not just the elite ones. In addition, >90% of each cohort goes to publicly funded post-secondary institutes and almost 50% of students who live in one- to three-room HDB flats make it to universities and polytechnics.
In my opinion, almost 80% of the population lives in HDB apartments. How many % of the HDB group goes to universities which exclude long-distance studies? Did the MOE provide such figures? Unfortunately, I don't know.
Education is a priority for Asian families. The children from disadvantaged homes cannot afford the expensive early, pre-primary education and so, will be always at a disadvantage. But is it necessary that 80% of the students go to universities when there are not sufficient places and ability?
Reference Straits Times Mar 8, 2010 frontpage
Education Minister Ng Eng Hen said:
1. One in 10 children from one- to three-room flats goes to University. 4 in 10 goes to polytechnic.
2. 1 in 6 children from the bottom third of the socio-economic ladder scored in the top third of the PSLE (Primary School Leaving Exam) cohort. 1 in 2 scores in the top two-thirds.
3. Every primary school produces at least 10 pupils who score in the top third of the PSLE.
So, better opportunities for every child, said the minister.
356. Monday's 10 am appointments
Two clients wanted to consult me and so made an appointment at 10 am.
CASE 1. Cairn Terrier, Female, Not spayed, 2 years.
SKIN ITCHINESS
Keeps scratching all over the body. "Why?," the pastor asked me. "Can it be due to the dog food? I buy various brands and mix them."
"It is possible," I said. "Dry dog food allergy does occur, making the dog itchy." The only area with black spots due to dried up blood from skin pustules and scratching was the inguinal area, near the vulva. The vulval lips were much swollen around 20X and the mammary glands were full.
FALSE PREGNANCY
"Your dog had heat 2 months ago," I said to the pastor. "She will be behaving strangely, like carrying an object in her mouth, loses appetite, get aggressive or withdrawn?"
"None of the behaviour you mention," the pastor said. "As you know, dogs like air-conditioned rooms but lately, she just go to the kitchen to sleep. Very strange behaviour!"
"She thinks she wants to give birth soon," I expressed minute drop of milk from her mammary gland. Too little to be seen when I asked intern Michelle and the owner to see. However, another swollen nipple produced some secretion.
"Your dog is suffering from false pregnancy," I presumed the dog was not bred as the owner did not mention about breeding and from his looks, was very astonished at seeing swollen mammary glands and a bit of milk. "Was she mated 2 months ago?"
"No, no," the pastor said. "How to prevent this from happening again?"
"The only solution is to spay her," I said. "Otherwise, the false pregnancy comes again. Did you want to breed her and get some pretty Cairn Terrier pups?"
"Yes, but I can't find any male."
I said: "Enquire from the dog breeders in Pasir Ris, your seller or the Singapore Kennel Club. You may have to pay a fee of a few hundred dollars without guarantee of success. Spaying her would be better as she is likely to get pyometra in later life. Do you know what is pyometra?"
The pastor had no clue and I explained that it was an infection of the womb with lots of pus inside. Sometimes the dog can die from toxaemia due to delays in seeking vet treatment.
As for the skin itchiness, I checked the ear canals. Dark brown ear discharge. I asked the intern to check on the microscopic examination. Nothing was seen. "The brown stuff keeps coming back after ear cleaning," the pastor said.
I advised ear irrigation and let the pastor tried. He squirted the 20 ml syringe of water and wetted me and the whole table. I did it for him and lots of brown wax flushed out from the left ear.
The ear infection and the anal sac impaction (black liquid in moderate amounts) and the hormonal imbalance of false pregnancy could cause the dog to be itchy. "Resolve the basic problems first," I advised. "Before you think of dog food allergy."
Ear ointment was given. "10 drops/ear/week." I said. "Excuse me for saying this to a man of religion - you must apply the ointment religiously for one month or two and let me know if there is still scratching. If not, then the infection has cleared."
The pastor asked me: "Are you retired?"
"No," I said. "It is better for a younger vet to continue the services of Toa Payoh Vets as I am 60 years old and if I don't plan to have a successor, all my clients will suffer in the long term. That is why I don't hang around every day as Dr Vanessa is experienced."
CASE 2.
BACK ACHE
The old Shih Tzu had seen me in March 2010 for a deep central corneal ulcer which had healed. Black pigmented central area with opaque ring. I tried taking pictures under the sunlight with my assistant holding the head and everting the eyelids of the right eye, but they may not turn out well. Need to practise how to do it.
"The dog seems to be walking lame," the mum said. Her daughter is in Melbourne studying Masters of Nutrition. I put the dog on the floor and observed. The dog walked ataxic as if drunk. The hind legs were slower in movement. This looked like a case of spinal disc prolapse. I put the dog on the examination table, pressed the T/L spinal area from the neck backwards. The dog winced in pain.
"It is not serious now, but this dog must stop jumping from the sofa," I said. The daughter had been encouraging the dog to jump from puppyhood and now, after 8 years, he has backache problems.
This seemed to be the 2nd recent case of back pain. The first one was th Chihuahua which went for extensive testing by Vet 1. So, will there be a 3rd one? Things do come in 3s.
CASE 1. Cairn Terrier, Female, Not spayed, 2 years.
SKIN ITCHINESS
Keeps scratching all over the body. "Why?," the pastor asked me. "Can it be due to the dog food? I buy various brands and mix them."
"It is possible," I said. "Dry dog food allergy does occur, making the dog itchy." The only area with black spots due to dried up blood from skin pustules and scratching was the inguinal area, near the vulva. The vulval lips were much swollen around 20X and the mammary glands were full.
FALSE PREGNANCY
"Your dog had heat 2 months ago," I said to the pastor. "She will be behaving strangely, like carrying an object in her mouth, loses appetite, get aggressive or withdrawn?"
"None of the behaviour you mention," the pastor said. "As you know, dogs like air-conditioned rooms but lately, she just go to the kitchen to sleep. Very strange behaviour!"
"She thinks she wants to give birth soon," I expressed minute drop of milk from her mammary gland. Too little to be seen when I asked intern Michelle and the owner to see. However, another swollen nipple produced some secretion.
"Your dog is suffering from false pregnancy," I presumed the dog was not bred as the owner did not mention about breeding and from his looks, was very astonished at seeing swollen mammary glands and a bit of milk. "Was she mated 2 months ago?"
"No, no," the pastor said. "How to prevent this from happening again?"
"The only solution is to spay her," I said. "Otherwise, the false pregnancy comes again. Did you want to breed her and get some pretty Cairn Terrier pups?"
"Yes, but I can't find any male."
I said: "Enquire from the dog breeders in Pasir Ris, your seller or the Singapore Kennel Club. You may have to pay a fee of a few hundred dollars without guarantee of success. Spaying her would be better as she is likely to get pyometra in later life. Do you know what is pyometra?"
The pastor had no clue and I explained that it was an infection of the womb with lots of pus inside. Sometimes the dog can die from toxaemia due to delays in seeking vet treatment.
As for the skin itchiness, I checked the ear canals. Dark brown ear discharge. I asked the intern to check on the microscopic examination. Nothing was seen. "The brown stuff keeps coming back after ear cleaning," the pastor said.
I advised ear irrigation and let the pastor tried. He squirted the 20 ml syringe of water and wetted me and the whole table. I did it for him and lots of brown wax flushed out from the left ear.
The ear infection and the anal sac impaction (black liquid in moderate amounts) and the hormonal imbalance of false pregnancy could cause the dog to be itchy. "Resolve the basic problems first," I advised. "Before you think of dog food allergy."
Ear ointment was given. "10 drops/ear/week." I said. "Excuse me for saying this to a man of religion - you must apply the ointment religiously for one month or two and let me know if there is still scratching. If not, then the infection has cleared."
The pastor asked me: "Are you retired?"
"No," I said. "It is better for a younger vet to continue the services of Toa Payoh Vets as I am 60 years old and if I don't plan to have a successor, all my clients will suffer in the long term. That is why I don't hang around every day as Dr Vanessa is experienced."
CASE 2.
BACK ACHE
The old Shih Tzu had seen me in March 2010 for a deep central corneal ulcer which had healed. Black pigmented central area with opaque ring. I tried taking pictures under the sunlight with my assistant holding the head and everting the eyelids of the right eye, but they may not turn out well. Need to practise how to do it.
"The dog seems to be walking lame," the mum said. Her daughter is in Melbourne studying Masters of Nutrition. I put the dog on the floor and observed. The dog walked ataxic as if drunk. The hind legs were slower in movement. This looked like a case of spinal disc prolapse. I put the dog on the examination table, pressed the T/L spinal area from the neck backwards. The dog winced in pain.
"It is not serious now, but this dog must stop jumping from the sofa," I said. The daughter had been encouraging the dog to jump from puppyhood and now, after 8 years, he has backache problems.
This seemed to be the 2nd recent case of back pain. The first one was th Chihuahua which went for extensive testing by Vet 1. So, will there be a 3rd one? Things do come in 3s.
Monday, March 7, 2011
355. Sunday Mar 6, 2011 interesting cases
Bright sunshine day. My assistant phoned to say I had 2 appointments at 10 am.
CASE 1. A slim mother came with a black and white rabbit and two slim pre-teen daughters. The mother said: "The rabbit has this roughness on his feet and ears. What is the cause and whether the disease will infect people?
"I felt itchiness in my elbows," the mother flexed her left arm and scratched her left elbow.
"It is scabies mite infestation," I said to the mother and took out the Hills' Vet book of illustrations to show the mites. "Rabbit scabies don't infect people. However, it is possible that the mites may try to bite you but will not be successful. Hence you felt the itchiness in your elbow."
But Hills' book has only the dog scabies. "The mites look similar to these in the pictures," I said. "Rounded bodies burrowing under the skin and causing itchiness and pain to the rabbits."
I asked my assistant to scrape the skin to get the mites after intern Michelle failed to find any. After 3 failed attempts, Mr Saw scraped deeper into one paw till the blood showed. He got ready the bottle of oil to put a drop onto the slide. I stopped him, "There is no need to use oil," I said. "Oil is recommended by professors in college but actually a drop of water will be better. Michelle, get a cover slip to put on top of the skin scraping."
As Michelle who just got 3As in her A-level results on Friday and would be eligible to study veterinary medicine in Australia looked blankly at me, I realised that she did not take Biology in her A-levels. So, I asked Mr Saw to get one. Mr Saw has the habit of putting another slide on top of the skin scrapings for some peculiar reasons. It is difficult to change his mindset sometimes.
This will also do but is not the correct way to do microscopic examination as a cover slip is much thinner and allow better viewing. I took over the viewing of the skin scrapings as the interns and assistants were taking some time and I dislike making other clients wait. There was an owner with a Beagle pacing outside.
I spotted one moving fat brown mite and asked the mum and 2 daughters to see. "You need to adjust the focus," I said to the be-spectacled elder sister who had some difficulty seeing anything. The 3 members of the family finally saw the mite and so were convinced.
"Where do I buy the Hills' book?" Mum asked me. "You can't buy it," I said. "It is given free to vets. But nowadays, the internet will give you all the pictures of rabbit scabies, and so you will get all the information." Elder daughter nodded her head vigorously.
Younger sister was afraid of seeing the rabbit being injected with ivermection 0.1 ml with saline and closed her eyes. "This daughter can't become a doctor," I told the mum. "Elder sister can as she is not afraid of such things," mum said. The thin 1-year-old rabbit squealed after injection. "It can be quite painful," I said to the mum as elder sister looked worried. "I will rub the skin to spread the injection. This rabbit is very thin and it is not good for his health. Feed more hay and pellets."
The younger rabbit at home had the same problem. I gave a Revolution syringe and advised one drop on the skin weekly for 2 weeks as the younger one would be too thin for the injection. "Usually one injection would kill all mites and skin crust will drop off in 7 days' time," I said to the mum. "As to where the rabbit got infested, it would be from another rabbit in the pet shop or breeder. It is a curable disease."
"What happens if I don't get the rabbit treated by the vet? Will the rabbit die?"
"If the rabbit is healthy, it may not die soon. The crusts on the paws, ear edges, nose and eyelids get thicker and thicker. I have seen some becoming cauliflower in shape. It is a painful condition as the rabbit can't get rid of the mites by itself and the mites keep burrowing under the skin and reproducing."
"What about the male scabies mite?" the mum noted that Hills' book stated that female mites burrow under the skin and lay eggs which hatch to become mites. "Male mites do burrow too but the Hills' book did not mention the males." Sometimes, the illustrator or writer can overlook the fact that male scabies mites still need to burrow inside the skin to survive being washed off or killed by sunlight. I have no doubt that the male scabies must burrow under the skin to mate with the female. Well, the book can't mention every aspect of the scabies mite's sexual behaviour.
CASE 2. The 15-year-old Beagle had his dental treatment more than one month ago but now, she had a problem. The man in his 50s took out his video camera and showed me what was happening in real life. He switched on the camera. The Beagle started to eat heartily. Then he made a gulping sound or movement as he tried to swallow the dry dog food. "As if he had a bone inside his throat," the owner said. "I did feed him pork knucle bones after the dental treatment. Could there be pieces of bones stuck inside the throat?"
I put the dog on the examination table, asked my assistant for a torch-light. "The beagle bites," the owner forewarned me. The Beagle refused to open his mouth. My assistant suggested that he opened the mouth while I shine the torchlight and said: "There is a swelling on the left side of the throat." I had not gone into palpation yet as I wanted to see the inside of the mouth. The Beagle didn't co-operate.
"It is unlikely to be a bone fragment or abscess inside the throat for the past 4 weeks," I said. "There is a 50-cent lump on the left side of the neck, where the thyroid gland is located," I said. "It is a painless lump but large. It may be a thyroid tumour or infection. Or possibly a traumatic wound caused by some sharp object into the side of the throat."
The owner did not want blood test or X-rays. So it was difficult to get a definitive diagnosis. "There is slight pain when I palpated the lump deeper," I said as the dog objected in mild pain. At the age of 15 years, this dog had survived anaesthesia during dental work at Toa Payoh Vets some 4 weeks ago. The owner would not want another anaesthesia or surgery as this may kill off his favourite companion. Antibiotics and an anti-inflammatory injection were given and we would wait 7-14 days to see if the lump of 10 cm x 10 cm disappears. I would think it is a thyroid tumour in view of the dog's age of 15 years which is equivalent to a person at 105 years.
CASE 3. I thought I had seen all hamster conditions thanks to various Singaporean hamster owners over the years. Yet this hamster puzzled me. His right hind foot was swollen 50X in two parts. The foot and ankle was swollen as one lump of 1 cm x 0.5 cm. Then there was a narrow normal width of tissue which spreads out to another similar big swelling of the leg muscle.
"How did my hamster get two big swollen lumps in his leg?" the young lady owner asked me. She had previous hamsters treated by me before but this one sure was puzzling.
"It looks like the hamster's leg had been strangulated by a rubber band, stopping blood flow to the foot and toe at first," I said as the lady told me that she observed a swollen right hind foot first some 2-5 days ago. Then, another swelling above the foot. "Then the blood flow above the strangulated thin area is interrupted and the area swells 10X! Now, the hamster starts licking the swollen areas to relieve its pain. The area becomes shiny and purplish."
However the lady disputed my hypothesis. In any case, there is no such small rubber band inside the hamster's crate. Therefore, what would be the cause of the strangulation?
Fortunately, there was a square piece of cloth with holes and loose threads. This was the clue. "This hamster likes to chew towels and cloth," the lady said. "He lives alone."
"It was possible that the leg got trapped inside the hole and the threads wound round the leg above the ankle when the hamster tried to get free," I postulated. "The more he struggled, the tighter the threads wound round his leg, stopping blood supply for some hours. That is why you see a normal thin strip of leg in between the two bulging masses."
The owner was not fully convinced, I think and thought she could take the hamster home. The hamster was warded for treatment and observation. He had a good appetite and even exercised on his wheel despite his handicap. Facts are stranger than fiction sometimes. However, this hamster must be treated or the swellings would be severely infected by bacteria. The swellings have become purplish and that meant gangrenous.
I told the owner that the hamster might not survive long as gangrene had set in. If the right hind was to be amputated, the hamster might die during anaesthesia and so it was not wise to suggest amputation which should be the course of action. If a hamster died during surgery, the vet costs would be higher and the outcome of death would be the same as when the hamster would be treated conservatively with drugs. In either case, the outcome would be the same. Therefore, I did not advise amputation as the risk would be very high.
Veterinary medicine throws up some challenging cases now and then. In most days, cases are routine but the Divine Powers, if you believe there are such existing, throws in a surprise to keep the vet on his toes.
CASE 1. A slim mother came with a black and white rabbit and two slim pre-teen daughters. The mother said: "The rabbit has this roughness on his feet and ears. What is the cause and whether the disease will infect people?
"I felt itchiness in my elbows," the mother flexed her left arm and scratched her left elbow.
"It is scabies mite infestation," I said to the mother and took out the Hills' Vet book of illustrations to show the mites. "Rabbit scabies don't infect people. However, it is possible that the mites may try to bite you but will not be successful. Hence you felt the itchiness in your elbow."
But Hills' book has only the dog scabies. "The mites look similar to these in the pictures," I said. "Rounded bodies burrowing under the skin and causing itchiness and pain to the rabbits."
I asked my assistant to scrape the skin to get the mites after intern Michelle failed to find any. After 3 failed attempts, Mr Saw scraped deeper into one paw till the blood showed. He got ready the bottle of oil to put a drop onto the slide. I stopped him, "There is no need to use oil," I said. "Oil is recommended by professors in college but actually a drop of water will be better. Michelle, get a cover slip to put on top of the skin scraping."
As Michelle who just got 3As in her A-level results on Friday and would be eligible to study veterinary medicine in Australia looked blankly at me, I realised that she did not take Biology in her A-levels. So, I asked Mr Saw to get one. Mr Saw has the habit of putting another slide on top of the skin scrapings for some peculiar reasons. It is difficult to change his mindset sometimes.
This will also do but is not the correct way to do microscopic examination as a cover slip is much thinner and allow better viewing. I took over the viewing of the skin scrapings as the interns and assistants were taking some time and I dislike making other clients wait. There was an owner with a Beagle pacing outside.
I spotted one moving fat brown mite and asked the mum and 2 daughters to see. "You need to adjust the focus," I said to the be-spectacled elder sister who had some difficulty seeing anything. The 3 members of the family finally saw the mite and so were convinced.
"Where do I buy the Hills' book?" Mum asked me. "You can't buy it," I said. "It is given free to vets. But nowadays, the internet will give you all the pictures of rabbit scabies, and so you will get all the information." Elder daughter nodded her head vigorously.
Younger sister was afraid of seeing the rabbit being injected with ivermection 0.1 ml with saline and closed her eyes. "This daughter can't become a doctor," I told the mum. "Elder sister can as she is not afraid of such things," mum said. The thin 1-year-old rabbit squealed after injection. "It can be quite painful," I said to the mum as elder sister looked worried. "I will rub the skin to spread the injection. This rabbit is very thin and it is not good for his health. Feed more hay and pellets."
The younger rabbit at home had the same problem. I gave a Revolution syringe and advised one drop on the skin weekly for 2 weeks as the younger one would be too thin for the injection. "Usually one injection would kill all mites and skin crust will drop off in 7 days' time," I said to the mum. "As to where the rabbit got infested, it would be from another rabbit in the pet shop or breeder. It is a curable disease."
"What happens if I don't get the rabbit treated by the vet? Will the rabbit die?"
"If the rabbit is healthy, it may not die soon. The crusts on the paws, ear edges, nose and eyelids get thicker and thicker. I have seen some becoming cauliflower in shape. It is a painful condition as the rabbit can't get rid of the mites by itself and the mites keep burrowing under the skin and reproducing."
"What about the male scabies mite?" the mum noted that Hills' book stated that female mites burrow under the skin and lay eggs which hatch to become mites. "Male mites do burrow too but the Hills' book did not mention the males." Sometimes, the illustrator or writer can overlook the fact that male scabies mites still need to burrow inside the skin to survive being washed off or killed by sunlight. I have no doubt that the male scabies must burrow under the skin to mate with the female. Well, the book can't mention every aspect of the scabies mite's sexual behaviour.
CASE 2. The 15-year-old Beagle had his dental treatment more than one month ago but now, she had a problem. The man in his 50s took out his video camera and showed me what was happening in real life. He switched on the camera. The Beagle started to eat heartily. Then he made a gulping sound or movement as he tried to swallow the dry dog food. "As if he had a bone inside his throat," the owner said. "I did feed him pork knucle bones after the dental treatment. Could there be pieces of bones stuck inside the throat?"
I put the dog on the examination table, asked my assistant for a torch-light. "The beagle bites," the owner forewarned me. The Beagle refused to open his mouth. My assistant suggested that he opened the mouth while I shine the torchlight and said: "There is a swelling on the left side of the throat." I had not gone into palpation yet as I wanted to see the inside of the mouth. The Beagle didn't co-operate.
"It is unlikely to be a bone fragment or abscess inside the throat for the past 4 weeks," I said. "There is a 50-cent lump on the left side of the neck, where the thyroid gland is located," I said. "It is a painless lump but large. It may be a thyroid tumour or infection. Or possibly a traumatic wound caused by some sharp object into the side of the throat."
The owner did not want blood test or X-rays. So it was difficult to get a definitive diagnosis. "There is slight pain when I palpated the lump deeper," I said as the dog objected in mild pain. At the age of 15 years, this dog had survived anaesthesia during dental work at Toa Payoh Vets some 4 weeks ago. The owner would not want another anaesthesia or surgery as this may kill off his favourite companion. Antibiotics and an anti-inflammatory injection were given and we would wait 7-14 days to see if the lump of 10 cm x 10 cm disappears. I would think it is a thyroid tumour in view of the dog's age of 15 years which is equivalent to a person at 105 years.
CASE 3. I thought I had seen all hamster conditions thanks to various Singaporean hamster owners over the years. Yet this hamster puzzled me. His right hind foot was swollen 50X in two parts. The foot and ankle was swollen as one lump of 1 cm x 0.5 cm. Then there was a narrow normal width of tissue which spreads out to another similar big swelling of the leg muscle.
"How did my hamster get two big swollen lumps in his leg?" the young lady owner asked me. She had previous hamsters treated by me before but this one sure was puzzling.
"It looks like the hamster's leg had been strangulated by a rubber band, stopping blood flow to the foot and toe at first," I said as the lady told me that she observed a swollen right hind foot first some 2-5 days ago. Then, another swelling above the foot. "Then the blood flow above the strangulated thin area is interrupted and the area swells 10X! Now, the hamster starts licking the swollen areas to relieve its pain. The area becomes shiny and purplish."
However the lady disputed my hypothesis. In any case, there is no such small rubber band inside the hamster's crate. Therefore, what would be the cause of the strangulation?
Fortunately, there was a square piece of cloth with holes and loose threads. This was the clue. "This hamster likes to chew towels and cloth," the lady said. "He lives alone."
"It was possible that the leg got trapped inside the hole and the threads wound round the leg above the ankle when the hamster tried to get free," I postulated. "The more he struggled, the tighter the threads wound round his leg, stopping blood supply for some hours. That is why you see a normal thin strip of leg in between the two bulging masses."
The owner was not fully convinced, I think and thought she could take the hamster home. The hamster was warded for treatment and observation. He had a good appetite and even exercised on his wheel despite his handicap. Facts are stranger than fiction sometimes. However, this hamster must be treated or the swellings would be severely infected by bacteria. The swellings have become purplish and that meant gangrenous.
I told the owner that the hamster might not survive long as gangrene had set in. If the right hind was to be amputated, the hamster might die during anaesthesia and so it was not wise to suggest amputation which should be the course of action. If a hamster died during surgery, the vet costs would be higher and the outcome of death would be the same as when the hamster would be treated conservatively with drugs. In either case, the outcome would be the same. Therefore, I did not advise amputation as the risk would be very high.
Veterinary medicine throws up some challenging cases now and then. In most days, cases are routine but the Divine Powers, if you believe there are such existing, throws in a surprise to keep the vet on his toes.
Saturday, March 5, 2011
354. Chihuahua with Acute Abdomen.- Part 2
On March 4, 2011, Dr Vanessa and I discussed the case. The dog was Ok - active, eating and had passed stools and water. I noted that this dog had more dripping of urine on the floor of the consultation room as seen on March 2 when he was admitted and I. She phoned the owner to take the dog home.
The owner was reluctant to keep the dog in Toa Payoh Vets as Vet 1 charged around $35/day for hospitalisation according to the bill of over $75 for 2 days.
"We charge $15/day," I sensed that the owner just wanted treatment and bring the dog home. He had said that he could not afford Vet 1's veterinary bills. He was told by Vet 1 who had said: "Some owners had spent $3,000 - $5,000 and still the vet cannot tell what's wrong with his dog."
This was a case which had puzzled Vet 1 and so it would be in the interest of the dog to be warded for observation and urine testing via catheter.
There was no urine in the bladder (palpation) during admission as this dog urine-marked. In any case, he had urinary incontinence and was dripping large drops of urine on the floor of the consultation room when I placed him on the floor to assess his mobility. He could walk normally but was a bit depressed due to the effects of Tramadol given by Vet 1.
One has to be observant as the dog can't talk. I asked the owner: "Does your dog dribble urine onto the floor?" He said: "All the time, since young."
Now, if you take the owner's word at face value, you would think that there was nothing wrong with this dog. What the owner meant was that the male dog urine-marks, by spraying urine onto vertical areas since young. What I meant was that the dog has urinary incontinence which is not normal. It was a clue - a urinary tract infection which persisted despite 2 days of hospitalisation and treatment by Vet 1. Vet 1 had not performed a urine analysis but he had done blood test, X-ray with barium meal, plain X-ray without barium meal and an ultra-sound.
According to the owner, Vet 1 had said that nothing abnormal could be detected in his dog. After spending nearly $1,000 for 2 visits, the owner expected an answer as to why his dog was lethargic, not eating and had difficulty standing on his hind legs. His wife had remembered my vaccination card which was recorded for the puppy vaccination in 2003 and the husband phoned me to get a second opinion about his dog having a swollen "stomach" with no definitive diagnosis from Vet 1.
I had said: "Not all cases can give answers to the owner despite many tests. Such tests are expensive and therefore the vet bills can be high. Get all the records from Vet 1 if you can and let Vet 1 know one day in advance rather than taking the dog out immediately."
So, 2 days after hospitalisation at Vet 1, the dog came to me. Seeking 2nd opinions is a common occurrence and all vets do encounter such situations. It is best to provide the records to the owner directly. That was why I asked the owner to do it with kindness rather than abruptly taking the dog out from Vet 1 to cut costs.
When the owner came, I asked about the veterinary report. He said: "It will take a week for Vet 1 to write the report." I was surprised that Vet 1 would not provide him the report as is common practice. However, the blood test result, the ultra-sound and the CD of the X-rays were available and those were good enough. After all, Vet 1 had already said that he or she was puzzled by the case and so I let sleeping dogs lie.
I introduced Dr Vanessa to the couple and was also present as the couple wanted to consult me. Usual weighing and temperature taking, history taking and general examination were done by Dr Vanessa. I palpated the dog's abdomen after she had done.
During my palpation, the dog reacted in mild pain from the liver to the bladder and prostate area despite being given Tramadol (an opiate derivative) injection and tablets by Vet 1. I remembered my Glasgow Vet Professor calling the presenting sign as "Acute Abdomen". That was nearly 40 years ago and you can see how ancient I have become.
So, what are the differential diagnosis? This was a tough nut to crack as the dog had been given pain-killers by Vet 1 and was "eating" again according to the owner. He was also walking on 4 legs now. Except that he was dribbling urine onto the floor of the consultation room.
To make diagnosis more difficult, Vet 1's blood test showed an increase above normal of neutrophils and granulocytes (which consist of neutrophils, eosinophils and basophils) but with NO increase in white cell count. Normally in bacteraemia, the white cell count would have also increased. The L/N ratio was normal too. So, what was going on inside this dog's abdomen? Due to economic reasons, I did not suggest another blood test. I tried to diagnose this cost with as low cost as possible as the owner had said he could not afford to pay the vet fees anymore.
His wife would be giving birth soon and understandably there are much more expenses. "Will she be giving birth at Mount Elizabeth Hospital?" I asked as this is said to be the top dog in private hospital services. "No, no," he said.
Back to the dog. I tried to reduce as low as possible the costs.
Back to basic. I asked the owner again: "Was your dog unable to stand on his two hind legs?" He had said something to that effect but then all sick and anorexic dogs are lethargic and would not want to stand up at all or take a long time to stand up. But he had said "hind legs." So, that is one clue. It could be presented as a case of paraparesis.
On admission, the dog was walking and standing up on his two hind legs without problems! So, there was nothing to talk about. However, this dog had been given Tramadol pain-killers and since he had no pain, he would be standing on all legs. I was suspecting intravertebral disc lesions, normally at T/L or L or L/S spinal discs at this age. I would expect this Chihuahua to leap from sofa to floor for the past 8 years of his life and now would bear the consequence. Like joggers who pound the pavement when they are young. They get knee pain in middle age. So, this dog could have suffered IV disc prolapse but not on a serious mode yet.
With the dog standing on the consultation table, I pressed the spinal area from neck to tail. Despite Tramadol, the standing dog winced slightly when my two fingers depressed the lumbar area. I repeated the action and elicited the same reaction in front of the couple and Dr Vanessa. So, there was something wrong with this dog's spinal area and he might have got a painful disc. That was why he suffered paraparesis - an inability, temporarily, to stand up on his hind legs.
Pain diffused to cause his stomach to bloat as he could not pass stools normally. He also could not pass urine well and together with gas inside the intestines, leading to bloated stomach. Pain was diffuse causing acute abdomen as the pain of a partially slightly prolapsed IV disc hurt him badly. So, he did not feel like eating and moving. The owner's mother was worried and sent him to Vet 1.
All these hypothesis needed to be confirmed. As I was under the constraint not to add more vet cost to the owner, I asked Dr Vanessa to zoom in on the disc area of the X-ray of the dog's abdomen where barium meal was given and found in the large intestine.
Dr Vanessa put in Vet 1's CD in her lap-top. Suddenly Mandarin songs and music blasted out (Part 1 of the story) to our amazement. It was as if there was a bugle call to attention to soldiers for the forth-coming commander. It was unexpected and therefore quite funny.
In any case, the zoomed area showed some cloudiness over L1/L2 and L2/L3 IV area and slight narrowing of the IV space. With financial constraint, this was my approach to viewing this X-ray instead of a proper X-ray of the spinal disc. One has to be understanding of the owner's financial wishes as vet tests can add up.
However, the urine test was compulsory. It showed ph 8.0, bacteria ++, amorphous phosphate crystals ++, indicating an INFECTION-INDUCED STRUVITE UROLITH. Now, there was protein +++ in the urine which could indicate cystitis (thick-walled bladder felt by me during palpation before the dog goes home). This was another medical problem and needed to be followed up.
The dog was OK and went home with instructions of no more jumping from the sofa at all, antibiotics and advice to neuter (to prevent prostatic hypertrophy, infection or tumour). The dog needed urine analysis review. Old dogs need more care and annual health screeing if the owner wants the dog to live to a ripe old age and not to incur expensive vet bills. But sadly, most Singapore owners do not bother.
The owner was reluctant to keep the dog in Toa Payoh Vets as Vet 1 charged around $35/day for hospitalisation according to the bill of over $75 for 2 days.
"We charge $15/day," I sensed that the owner just wanted treatment and bring the dog home. He had said that he could not afford Vet 1's veterinary bills. He was told by Vet 1 who had said: "Some owners had spent $3,000 - $5,000 and still the vet cannot tell what's wrong with his dog."
This was a case which had puzzled Vet 1 and so it would be in the interest of the dog to be warded for observation and urine testing via catheter.
There was no urine in the bladder (palpation) during admission as this dog urine-marked. In any case, he had urinary incontinence and was dripping large drops of urine on the floor of the consultation room when I placed him on the floor to assess his mobility. He could walk normally but was a bit depressed due to the effects of Tramadol given by Vet 1.
One has to be observant as the dog can't talk. I asked the owner: "Does your dog dribble urine onto the floor?" He said: "All the time, since young."
Now, if you take the owner's word at face value, you would think that there was nothing wrong with this dog. What the owner meant was that the male dog urine-marks, by spraying urine onto vertical areas since young. What I meant was that the dog has urinary incontinence which is not normal. It was a clue - a urinary tract infection which persisted despite 2 days of hospitalisation and treatment by Vet 1. Vet 1 had not performed a urine analysis but he had done blood test, X-ray with barium meal, plain X-ray without barium meal and an ultra-sound.
According to the owner, Vet 1 had said that nothing abnormal could be detected in his dog. After spending nearly $1,000 for 2 visits, the owner expected an answer as to why his dog was lethargic, not eating and had difficulty standing on his hind legs. His wife had remembered my vaccination card which was recorded for the puppy vaccination in 2003 and the husband phoned me to get a second opinion about his dog having a swollen "stomach" with no definitive diagnosis from Vet 1.
I had said: "Not all cases can give answers to the owner despite many tests. Such tests are expensive and therefore the vet bills can be high. Get all the records from Vet 1 if you can and let Vet 1 know one day in advance rather than taking the dog out immediately."
So, 2 days after hospitalisation at Vet 1, the dog came to me. Seeking 2nd opinions is a common occurrence and all vets do encounter such situations. It is best to provide the records to the owner directly. That was why I asked the owner to do it with kindness rather than abruptly taking the dog out from Vet 1 to cut costs.
When the owner came, I asked about the veterinary report. He said: "It will take a week for Vet 1 to write the report." I was surprised that Vet 1 would not provide him the report as is common practice. However, the blood test result, the ultra-sound and the CD of the X-rays were available and those were good enough. After all, Vet 1 had already said that he or she was puzzled by the case and so I let sleeping dogs lie.
I introduced Dr Vanessa to the couple and was also present as the couple wanted to consult me. Usual weighing and temperature taking, history taking and general examination were done by Dr Vanessa. I palpated the dog's abdomen after she had done.
During my palpation, the dog reacted in mild pain from the liver to the bladder and prostate area despite being given Tramadol (an opiate derivative) injection and tablets by Vet 1. I remembered my Glasgow Vet Professor calling the presenting sign as "Acute Abdomen". That was nearly 40 years ago and you can see how ancient I have become.
So, what are the differential diagnosis? This was a tough nut to crack as the dog had been given pain-killers by Vet 1 and was "eating" again according to the owner. He was also walking on 4 legs now. Except that he was dribbling urine onto the floor of the consultation room.
To make diagnosis more difficult, Vet 1's blood test showed an increase above normal of neutrophils and granulocytes (which consist of neutrophils, eosinophils and basophils) but with NO increase in white cell count. Normally in bacteraemia, the white cell count would have also increased. The L/N ratio was normal too. So, what was going on inside this dog's abdomen? Due to economic reasons, I did not suggest another blood test. I tried to diagnose this cost with as low cost as possible as the owner had said he could not afford to pay the vet fees anymore.
His wife would be giving birth soon and understandably there are much more expenses. "Will she be giving birth at Mount Elizabeth Hospital?" I asked as this is said to be the top dog in private hospital services. "No, no," he said.
Back to the dog. I tried to reduce as low as possible the costs.
Back to basic. I asked the owner again: "Was your dog unable to stand on his two hind legs?" He had said something to that effect but then all sick and anorexic dogs are lethargic and would not want to stand up at all or take a long time to stand up. But he had said "hind legs." So, that is one clue. It could be presented as a case of paraparesis.
On admission, the dog was walking and standing up on his two hind legs without problems! So, there was nothing to talk about. However, this dog had been given Tramadol pain-killers and since he had no pain, he would be standing on all legs. I was suspecting intravertebral disc lesions, normally at T/L or L or L/S spinal discs at this age. I would expect this Chihuahua to leap from sofa to floor for the past 8 years of his life and now would bear the consequence. Like joggers who pound the pavement when they are young. They get knee pain in middle age. So, this dog could have suffered IV disc prolapse but not on a serious mode yet.
With the dog standing on the consultation table, I pressed the spinal area from neck to tail. Despite Tramadol, the standing dog winced slightly when my two fingers depressed the lumbar area. I repeated the action and elicited the same reaction in front of the couple and Dr Vanessa. So, there was something wrong with this dog's spinal area and he might have got a painful disc. That was why he suffered paraparesis - an inability, temporarily, to stand up on his hind legs.
Pain diffused to cause his stomach to bloat as he could not pass stools normally. He also could not pass urine well and together with gas inside the intestines, leading to bloated stomach. Pain was diffuse causing acute abdomen as the pain of a partially slightly prolapsed IV disc hurt him badly. So, he did not feel like eating and moving. The owner's mother was worried and sent him to Vet 1.
All these hypothesis needed to be confirmed. As I was under the constraint not to add more vet cost to the owner, I asked Dr Vanessa to zoom in on the disc area of the X-ray of the dog's abdomen where barium meal was given and found in the large intestine.
Dr Vanessa put in Vet 1's CD in her lap-top. Suddenly Mandarin songs and music blasted out (Part 1 of the story) to our amazement. It was as if there was a bugle call to attention to soldiers for the forth-coming commander. It was unexpected and therefore quite funny.
In any case, the zoomed area showed some cloudiness over L1/L2 and L2/L3 IV area and slight narrowing of the IV space. With financial constraint, this was my approach to viewing this X-ray instead of a proper X-ray of the spinal disc. One has to be understanding of the owner's financial wishes as vet tests can add up.
However, the urine test was compulsory. It showed ph 8.0, bacteria ++, amorphous phosphate crystals ++, indicating an INFECTION-INDUCED STRUVITE UROLITH. Now, there was protein +++ in the urine which could indicate cystitis (thick-walled bladder felt by me during palpation before the dog goes home). This was another medical problem and needed to be followed up.
The dog was OK and went home with instructions of no more jumping from the sofa at all, antibiotics and advice to neuter (to prevent prostatic hypertrophy, infection or tumour). The dog needed urine analysis review. Old dogs need more care and annual health screeing if the owner wants the dog to live to a ripe old age and not to incur expensive vet bills. But sadly, most Singapore owners do not bother.
Thursday, March 3, 2011
352. Chihuahua with Acute Abdomen.- Part 1
It was 2003 when I vaccinated this Chihuahua puppy and 8 years later, the original owners phoned me to ask for a second opinion of not eating and a "swollen stomach".
Vet 1, during the 2nd consultation, had taken blood test, barium-meal X-ray, ultrasound. According to the owner, the Vet 1 could not find anything wrong with the Chihuahua.
"I can't afford the vet fees anymore," the husband said as he had spent around $1,000. He had kept my vaccination card of 2003 and so gave me a call to quote my fees.
"If all the tests are done and nothing can be found in the abdomen, I would propose a laparotomy to open up the abdomen. This is risky as the dog is ill. If the dog has abdominal tumours, twisted intestines or stomach, inflamed livers or spleen, then this surgery would let you know the cause of the swollen painful stomach and you can decide what to do next. However, this would be the last thing to do. The cost is around $500 but I can't say exactly.
To save money, you need to get the case reports and test results from Vet 1," I discouraged him from taking the dog out immediately as it was under I/V drip for only 2 days and he should give Vet 1 some time to close the case. I gave him an appointment at 12 noon the following day and did not expect him to turn up.
He came without the case reports saying "Vet 1 says he needs to take one week to write the report!".
"It is Ok," I said. "In one week, it will be too late for the dog if he is not eating."
The husband took out a CD from Vet 1. I would handle this case together with Dr Vanessa Lin as two heads are better than one. She put the CD into her lap top and suddenly loud Chinese songs blasted through the silence.
"Wow, your laptop can play Chinese music with this CD!" I tried to inject some humour in this serious situation and to break the ice as the couple expected only me to handle their case. Normally, no music would be heard on insertion of a CD and I was thoroughly surprised by this laptop's behaviour. I wondered whether Vanessa had a new model?
Vet 1, during the 2nd consultation, had taken blood test, barium-meal X-ray, ultrasound. According to the owner, the Vet 1 could not find anything wrong with the Chihuahua.
"I can't afford the vet fees anymore," the husband said as he had spent around $1,000. He had kept my vaccination card of 2003 and so gave me a call to quote my fees.
"If all the tests are done and nothing can be found in the abdomen, I would propose a laparotomy to open up the abdomen. This is risky as the dog is ill. If the dog has abdominal tumours, twisted intestines or stomach, inflamed livers or spleen, then this surgery would let you know the cause of the swollen painful stomach and you can decide what to do next. However, this would be the last thing to do. The cost is around $500 but I can't say exactly.
To save money, you need to get the case reports and test results from Vet 1," I discouraged him from taking the dog out immediately as it was under I/V drip for only 2 days and he should give Vet 1 some time to close the case. I gave him an appointment at 12 noon the following day and did not expect him to turn up.
He came without the case reports saying "Vet 1 says he needs to take one week to write the report!".
"It is Ok," I said. "In one week, it will be too late for the dog if he is not eating."
The husband took out a CD from Vet 1. I would handle this case together with Dr Vanessa Lin as two heads are better than one. She put the CD into her lap top and suddenly loud Chinese songs blasted through the silence.
"Wow, your laptop can play Chinese music with this CD!" I tried to inject some humour in this serious situation and to break the ice as the couple expected only me to handle their case. Normally, no music would be heard on insertion of a CD and I was thoroughly surprised by this laptop's behaviour. I wondered whether Vanessa had a new model?
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