April 12, 2011
9.30am. 1-year-old JackRussellXDachshund spayed dog was itchy all over. She arrived from US one month ago, quarantined at Sembawang for 10 days and had been boarded at a Pasir Ris boarding place where there were numerous rescued dogs.
"My dog is itchy all over the body and scoots her backside," the slim European lady said. She had consulted another surgery and the vet did press some tissue around the anal area. She was not shown what was expressed from the anal area.
I put the dog on he exam table and pressed the anal sacs. I showed her the greyish particles in the anal sacs to the owner. "The normal colour is like cooking oil - light yellow," I said and explained what the anal sac oil was used for by the dog. She was quite happy.
As for the ears, I palpated the ears. The dog yelped in pain at the horizontal and vertical canal junction. I scoped the ear but found no mites. A cotton bud tip showed light brown discharge. No smell. So what was the pain? "I am no ear-person," the woman in her 40s said to me when I asked if she knows the structure of the dog's ears. I remained professional by not cracking jokes about anatomy which may be offensive since I met her the first time. Some men are said to be attracted by certain anatomy of the female and therefore, cracking such jokes as a "butt" person may not be welcome unless the client has a sense of humour.
As for the itchy body, the lady said: "My friends asked me to examine the body for skin infections but there are none. Yet the dog keeps losing hairs eve1y day. What is the problem? Also she chews her 4 paws "
I examined the dog's skin. Good coat. Strands of brown hair fall out. The lady said: "She is also developing those long harder coarse hairs. Could it be the weather in Singapore being so hot?"
"There is no skin problem," I confirmed. "Those coarse hairs could be the result of the dog's parents being wire-haired Jack Russell. Now she is one year old, her adult coat is being formed."
It sounded logical to her. As for the cause of generalised body itch, it was hard to tell what was the cause. "It is most likely allergy from the food or environment. A skin patch test may not give you the answers but costs you some money." I advised her to get the ears and paws cleaned regularly and to go on a low-allergic prescription diet for 3 months. "No treats or other foods", I said. "After 3 months, you can test her with dog treats or your food and see whether the dog itches."
I said: "It is extremely difficult to let you know what is the exact cause of the dog itching all over and so we do the food trial first. In some cases, it could be due to the loss of hormones due to spaying but these are rare cases. Hot weather and stress can cause the dog to shed hairs too as the dog came from the US."
This dog has no skin or ear problems and so a dog food or human shampoo allergy is suspected at this stage. The dog uses her human shampoo. There are so many factors and so it is best to take time to explain and illustrations of the ear canal and anal sacs to show the anatomy.
In this dog, the owner even remarked that I could have gone deeper to express the anal sacs than Vet 1 who did not show her any oil (probably).
Nowadays, it is hard to be a vet. See the following case 2.
Case 2. "Has my dog got CCD?"
This was the 2nd case in the last 3 days that a client who had researched the internet asked me about the dog having CCD.
"My dog could not recognise me and knocked onto furniture," the man in his late 50s said to me. His dog had been examined by a vet and had blood and urine tests done. "Nothing wrong with the blood and urine tests, the vet said. Can you prescribe a drug so that my dog can be alert and active?"
I was on counter receptionist duty and so got this feedback. I was surprised that another dog owner had researched the internet and diagnosed CCD again and asked for the drug.
I said: "Nowadays, owners research the internet. Sometimes, they are better informed than the vet. There is a drug but are you sure that the dog has no other health problems?"
I continued: "Many cases, the old dog has painful mouth due to teeth decay. Poison from the bacteria goes to the surrounding areas including the eyes and brain. So, the owner diagnoses CCD and asks for the drug. In the end, the dog is still suffering from pain."
"My dog eats the same amount of food every day," the man said when I asked why the dog had dropped 1.5kg in weight when it had the same appetite and was less active, esp. for the last 2 weeks. He was positive that his dog ate the same amount and had no vomiting or diarrhoea.
So I asked to check the blood and urine test results. The significant finding was a high blood urea (12 instead of the maximun value of 6). So, there was an abnormality but his vet said it was normal as the creatinine was low, meaning the dog does not have kidney disease.
It is not normal to have high blood urea, I said to the owner. As to the cause, the vet said it could be due to disorders in the muscles and internal organs and possibly cancer but since an X-ray would be useless, an ultrasound was proposed. Multivitamins were prescribed for the time being.
As the owner stated that he was referred to me by his friend, I handled his case and asked the dog to be admitted for an examination as he did not bring his dog when he came to see me.
Old dogs that have not been given dental checkup for the last 5 years (his vet did not want to do it since the dog was 8 years old) would have bad breath and oral infections. These problems needed dentistry and not a drug for CCD. Then there is the ear problems as many of the old dogs are neglected. They just get fed.
Much will depend on what I find but dentistry under general anaesthesia is needed. I strongly advised the high risks and he ought to tell his wife. His wife phoned me and I explained the possibility that her dog could just die on the operating table. That is the reason why most vets don't want to do the dentistry. "How about half dose?" the man asked me. "I use gas only and it should be quite safe if given over a short time of less than 15 minutes, but no guarantees."
"How about no anaesthetic?" the man asked. I said: "It is extremely painful to extract decayed teeth. I had only done once in dental extraction of a 16-year-old Pomeranian. It survived. However, some dogs may die of fright. Did you read the Straits Times forum letter where the writer's dog was lost and found by the AVA? The AVA micro-chipped the dog but it died. What did it die of? The AVA is doing an autopsy to ascertain the cause of death." From this incident, I prefer not to do any dentistry without anaesthesia.
Case 3.
A Chinese National sought my advice about her Silkie puppy that had fractured his right fore leg. "What can be done?" she asked me as I was on counter duty. The dog's legs were cast by Plaster of Paris and the dog had come in for a change of the Plaster. I asked Dr Vanessa what was the outcome. She showed me the X-rays before and after the cast. The tranverse fractures of the radius and ulna had closed and the fragments were aligned. So, there was good news. I told the lady that the progress was good. She had phoned me earlier wanting no invasive surgery for the fracture as proposed by another vet and Dr Vanessa had done a good job. A second opinion would be better service for the client and I was glad that she appeared satisfied.
She was from Yunnan. I had seen paintings by Chinese painters of Yunnan and read about the refugee problems from Myanmar to Yunnan which is part of China. I would like to visit this place as it appeared to be the equivalent "wild wild West" of the USA after reading about drug lords and other news.
"The travel agent in Yunnan cannot be trusted. Contact your travel agent. Many Singaporean businessmen go to Yunnan for gold," she said to me.
I asked her about the presence of elephants in the Yunnan mountains after hearing a story of a Myanmar businessman whose truck driver impatiently sound the horn to quicken the mother elephant and baby to walk past faster along the mountain road. The dam rushed onto the truck and this businesman was flung deep into the ravine. A tree broke his fall and he was hospitalised for 3 months. When he went home after that, he said to me: "My family members sprinted fast and ran away as they thought I was a ghost." In the old days before the mobile phone, he could not inform his family and they thought the elephant had killed him.
So I asked this Yuannan lady about the wandering wild elephants which I could not imagine, being a frog in the well in the small island of Singapore.
It is just too expensive to travel and I prefer the off-the-tourist places which can be more expensive and dangerous.
"There are wild elephants in the mountains. Tourists can view the mountains from the tree top."
"How do I do it?" I asked. "Just sit on the tree?"
The young lady in the IT field said: "I will not advise you to watch the wild elephants. It is very dangerous. The elephants may bang the tree and knock you down!"
Wednesday, April 13, 2011
Monday, April 11, 2011
400. Plug the leaking aqueous from deep inside the eye.
Sunday April 11, 2011
14 days ago, the young couple was referred by Vet 1 to another "dog's eye expert" at another vet surgery. However the "dog's eye expert" had no time for them. So my associate wanted to refer them to another vet as this was a highly charged emotional case. Some vets refer away the difficult and emotional cases to preserve their reputations. Others do their best as the vets being referred to are no better qualified in many cases, depending on their track record. It is hard to know the track record of other vets as we are all generalists and we don't publicise our clinical experiences.
Eye injuries are emergencies and should be treated within 4 hours of injury. The dog had been injured at the pet shop. Aqueous humour was licking out daily but it was hard for a layman to know what's happening. Under general anaesthesia, I could see the outflow. Like a damaged oil disaster in the Gulf Of Mexico. Instead of from deep inside the earth, the leaking was from deep inside the anterior chamber.
I took out the two stitches. The leak was sealed with a larger piece of white tissue. The eye, at 14th day, always looks horrible to the owner. A big white piece of tissue plugging the perforated cornea (I will show the image later). This case was a successful case.
However, the couple still has lots of nursing to do for the next 30 days. E-collar 24 hours/day. Medication & Eye drops and clean eyes as advised. No freedom to run around - restricted area. No sunlight and breezes and dusts. Follow up after 2 weeks. "The mass will shrink to a white spot some weeks later, if this eye is well cared for," I said. "The oil well has been plugged." I guessed the couple must be well read as they could relate this case to the Gulf Of Mexico oil spill which took several weeks or months to plug and caused environmental disaster!
It is just a pity that many Singapore pet owners of breeds with protruding eye balls do not know that eye injuries are emergencies.
14 days ago, the young couple was referred by Vet 1 to another "dog's eye expert" at another vet surgery. However the "dog's eye expert" had no time for them. So my associate wanted to refer them to another vet as this was a highly charged emotional case. Some vets refer away the difficult and emotional cases to preserve their reputations. Others do their best as the vets being referred to are no better qualified in many cases, depending on their track record. It is hard to know the track record of other vets as we are all generalists and we don't publicise our clinical experiences.
Eye injuries are emergencies and should be treated within 4 hours of injury. The dog had been injured at the pet shop. Aqueous humour was licking out daily but it was hard for a layman to know what's happening. Under general anaesthesia, I could see the outflow. Like a damaged oil disaster in the Gulf Of Mexico. Instead of from deep inside the earth, the leaking was from deep inside the anterior chamber.
I took out the two stitches. The leak was sealed with a larger piece of white tissue. The eye, at 14th day, always looks horrible to the owner. A big white piece of tissue plugging the perforated cornea (I will show the image later). This case was a successful case.
However, the couple still has lots of nursing to do for the next 30 days. E-collar 24 hours/day. Medication & Eye drops and clean eyes as advised. No freedom to run around - restricted area. No sunlight and breezes and dusts. Follow up after 2 weeks. "The mass will shrink to a white spot some weeks later, if this eye is well cared for," I said. "The oil well has been plugged." I guessed the couple must be well read as they could relate this case to the Gulf Of Mexico oil spill which took several weeks or months to plug and caused environmental disaster!
It is just a pity that many Singapore pet owners of breeds with protruding eye balls do not know that eye injuries are emergencies.
Injectable Anaesthetics For Cats
Below are guidelines for vets who don't have gas anaesthetic machines
e.g. animal shelter work in the field and cost considerations. Zoletil, Domitor and isoflurane are costly.
CATS
1. XYLAZINE + ZOLETIL ANAESTHESIA
5 kg
Xylazine 0.1 ml + Zoletil 100 0.1 ml in one syringe IM
If insufficient, top up with Zoletil 0.01 ml IV to effect.
In one case of a 5kg male
cat, I topped up with Zoletil 100 at 0.05 ml + 0.1 ml saline IV after 10 minutes of the xylazine 0.1 ml + Zoletil 0.1 ml IM combination. Effective analgesia for neuter.
2. XYLAZINE + KETAMINE
3-4 kg
Xylazine 0.1 ml + Ketamine 0.4 ml in one syringe IM. If insufficient, top up with Zoletil 0.01 ml IV to effect.
For cats 4-6 kg, double the above dosage IM.
I use this formula frequently for spay and neuter of cats without problems.
Duration of anaesthesia is half an hour.
3. DOMITOR + XYLAZINE
Domitor 0.1 ml + Xylazine 0.1 ml in one syringe IM.
If insufficient, top up with Zoletil 0.01 ml IV to effect. Domitor is expensive for stray cat spays.
I have not used this before.
4. IF USED ALONE, adverse effects are as follows:
1. Insufficient analgesia. Needs to top up IV.
2. Salivation and legs rigid (ketamine IM)
3. Wakes up fast
Combined with xylazine will make the cat sleep longer.
e.g. animal shelter work in the field and cost considerations. Zoletil, Domitor and isoflurane are costly.
CATS
1. XYLAZINE + ZOLETIL ANAESTHESIA
5 kg
Xylazine 0.1 ml + Zoletil 100 0.1 ml in one syringe IM
If insufficient, top up with Zoletil 0.01 ml IV to effect.
In one case of a 5kg male
cat, I topped up with Zoletil 100 at 0.05 ml + 0.1 ml saline IV after 10 minutes of the xylazine 0.1 ml + Zoletil 0.1 ml IM combination. Effective analgesia for neuter.
2. XYLAZINE + KETAMINE
3-4 kg
Xylazine 0.1 ml + Ketamine 0.4 ml in one syringe IM. If insufficient, top up with Zoletil 0.01 ml IV to effect.
For cats 4-6 kg, double the above dosage IM.
I use this formula frequently for spay and neuter of cats without problems.
Duration of anaesthesia is half an hour.
3. DOMITOR + XYLAZINE
Domitor 0.1 ml + Xylazine 0.1 ml in one syringe IM.
If insufficient, top up with Zoletil 0.01 ml IV to effect. Domitor is expensive for stray cat spays.
I have not used this before.
4. IF USED ALONE, adverse effects are as follows:
1. Insufficient analgesia. Needs to top up IV.
2. Salivation and legs rigid (ketamine IM)
3. Wakes up fast
Combined with xylazine will make the cat sleep longer.
Myanmar stories - Air Bagan flight stewardesses are the prettiest
I met a tall and slim fair Myanmar lady who speaks good English and is working in Singapore on an S Pass. I asked her about "Save The Children" organisation in Myanmar as I had seen some poster of this organisation at pre-schools built by the NGO. She said she had a friend working there and would provide me with some info.
"Do you know about Air Bagan, Myanmar Airways, Yangon Airways and a new airline with red black colours?" I asked. "I flew by Air Bagan from Yangon to Heho Airport recently to tour Inle Lake. In some Western-printed tourist guide books on Myanmar like some editions of The Lonely Planet, some airlines are mentioned not to be supported by the tourists. I find this strange as tourism benefits the ordinary people by providing jobs."
She said: "I was working for MAI and yes, I know about the airlines. Air Bagan employs the prettiest air stewardesses!"
"Why?" I asked.
"Air Bagan does not employ relatives unlike ...."
Well, this was a surprise comment to me as I did not expect a lady to comment on the external appearances of stewardess. Beauty in a female still matters a lot in this commercial world.
In any case, the travel agent books Air Bagan for me on the two times I visited Lake Inle and so I cannot confirm whether the other airlines have less pretty stewardess.
"Do you know about Air Bagan, Myanmar Airways, Yangon Airways and a new airline with red black colours?" I asked. "I flew by Air Bagan from Yangon to Heho Airport recently to tour Inle Lake. In some Western-printed tourist guide books on Myanmar like some editions of The Lonely Planet, some airlines are mentioned not to be supported by the tourists. I find this strange as tourism benefits the ordinary people by providing jobs."
She said: "I was working for MAI and yes, I know about the airlines. Air Bagan employs the prettiest air stewardesses!"
"Why?" I asked.
"Air Bagan does not employ relatives unlike ...."
Well, this was a surprise comment to me as I did not expect a lady to comment on the external appearances of stewardess. Beauty in a female still matters a lot in this commercial world.
In any case, the travel agent books Air Bagan for me on the two times I visited Lake Inle and so I cannot confirm whether the other airlines have less pretty stewardess.
NGOs in Myanmar
I had lunch on last Thursday with my accountant who had opened a new office in Peninsula Plaza. His friend, a businessman came for lunch. He is quite a jovial man and I always asked him about Myanmar as I employ Myanmar Vet Technicians and it would be good to understand more about their culture and way of life.
I asked him about "Save The Children" organisation whose notice board I saw in Inle Lake Primary schools and in pre-schools.
"It is an NGO," he said. "I want to start an NGO as it makes money and I have the connections. The sponsors give the NGOs money for the work done during earthquakes and typhoons. The NGOs take around 40-50% of the donation. One of the founders of the NGO has 3 cars and a house now!"
I said: "Nobody works for free. NGO members are not paid a salary and they do take risks going into disaster areas. Will you prefer the money to go the government? In Singapore, the money goes to an organisation too but for that NGO, the money did go to the affected people. Not 100% but at least 50%. What NGO you want to start?"
"Some environment. You know Lake Inle now is not so deep due to the chopping down of trees. The soil fills up the lake and it become shallow in certain areas. Last time, it took 2 hours to travel up and down the lake. Now, it takes half an hour!"
"Save the trees?" I asked. "Or clean water for the villages?"
He said: "Clean water will be very useful for the villages."
I said: "You just start an NGO and think sponsors will give you the money. It is not so simple. Sponsors from Europe are not stupid people. You need a team and credentials and track record. Those NGOs whom you said are waiting for disasters to strike Myanmar and to send in lorries of rice and food are experienced and have been trusted by the sponsors to benefit the affected people!"
I asked him about one of my clients who wanted to sell halal pancreatic enzymes made from bovine, not porcine pancreas and wanted to know how to get a halal licence to export his product. He said: "Your friend has to pay $10,000 and wait 6 months for approval. Nowadays, the government prevents unauthorised drug import. Some years ago, the poor people bought "Pannadol" from China as it was very cheap. They die and it was found out that what they bought was chalk tablets. So, the government now is very strict on this import of drugs. Give me a sample and I will ask my doctor friends to try. In Myanmar, it is the lowest price and not the halal process that counts."
Sick and poor people still buy medicine as they need to get cure. Many businessmen just peddle the fake medicine to them as in all countries, not just Myanmar.
I asked him about "Save The Children" organisation whose notice board I saw in Inle Lake Primary schools and in pre-schools.
"It is an NGO," he said. "I want to start an NGO as it makes money and I have the connections. The sponsors give the NGOs money for the work done during earthquakes and typhoons. The NGOs take around 40-50% of the donation. One of the founders of the NGO has 3 cars and a house now!"
I said: "Nobody works for free. NGO members are not paid a salary and they do take risks going into disaster areas. Will you prefer the money to go the government? In Singapore, the money goes to an organisation too but for that NGO, the money did go to the affected people. Not 100% but at least 50%. What NGO you want to start?"
"Some environment. You know Lake Inle now is not so deep due to the chopping down of trees. The soil fills up the lake and it become shallow in certain areas. Last time, it took 2 hours to travel up and down the lake. Now, it takes half an hour!"
"Save the trees?" I asked. "Or clean water for the villages?"
He said: "Clean water will be very useful for the villages."
I said: "You just start an NGO and think sponsors will give you the money. It is not so simple. Sponsors from Europe are not stupid people. You need a team and credentials and track record. Those NGOs whom you said are waiting for disasters to strike Myanmar and to send in lorries of rice and food are experienced and have been trusted by the sponsors to benefit the affected people!"
I asked him about one of my clients who wanted to sell halal pancreatic enzymes made from bovine, not porcine pancreas and wanted to know how to get a halal licence to export his product. He said: "Your friend has to pay $10,000 and wait 6 months for approval. Nowadays, the government prevents unauthorised drug import. Some years ago, the poor people bought "Pannadol" from China as it was very cheap. They die and it was found out that what they bought was chalk tablets. So, the government now is very strict on this import of drugs. Give me a sample and I will ask my doctor friends to try. In Myanmar, it is the lowest price and not the halal process that counts."
Sick and poor people still buy medicine as they need to get cure. Many businessmen just peddle the fake medicine to them as in all countries, not just Myanmar.
396. Sunday Apr 10, 2011 - Interesting cases
396. Sunday Apr 10, 2011 - Interesting cases
April 10, 2011. Sunny in the morning. Downpour in the afternoon. Steady stream of clients from 9.30 am to 6.30pm. I did not break for lunch. However, I insisted that my new assistant, Mr Min who replaced Mr Saw recently, to go out for lunch at 3 pm. It is best to pack a lunch box on weekends as it may be too disruptive to close for lunch as cases don't complete on schedule.
CASE 1. Cat Neuter
For example, a mother and her adult son wanted me to neuter the cat. I could not do it till 4 pm when they came for the cat. The cat was said to be fierce and so he was injected IM inside the carrying trolley cage. I tilted the cage downwards waved a piece of paper in front of him while Dr Vanessa injected him IM back muscles.
"He looks OK," Dr Vanessa said to me. The cat certainly did not show claws or aggressive behaviour. He just sat still and looked serene. "Well, the owner had already forewarned me about his aggression when handled. Looks can be deceiving. I had a cat who was taken out of the cage to be injected on the table. Before I could complete the injection, it sprung up, climbed up the vertical pipe and into a gap in the false ceiling. Fortunately, it was half sedated and I could get it down from high up in the false ceiling. You don't want to suffer this type of experience! It will even be worse if that cat had not got the tranquiliser IM and hides up the false ceiling forever." Dr Vanessa looked at the false ceiling I had pointed. "The false ceiling gap in which the vertical pipe from the 2nd floor passed down to my unit had been covered up." Wisdom can only be learnt from experience and I was not taking any chances. "Once the cat is angry and frightened, it is extremely hard to catch it."
Cat, Male, 4.9 kg.
I used xylazine 0.1 ml + zoletil 100 0.1 ml in one syringe IM. The cat looked calmly and was not on the side after 15 minutes. I asked Mr Min to get him out and gave Zoletil 0.05 ml in 0.1 ml saline IV, femoral vein. The cephalic vein just could not be seen due to probably hypotension of the earlier injection. The cat was sufficiently sedated and did not experience any pain in neutering. See guidelines: Injectable anaesthetics in dogs & cats
CASE 2. Cat with urethral obstruction goes home in a cat carrier bag.
A young lady in her 20s came with a small fabric carrier bag. The type used for holding books. She was taking the cat back after 2 days of hospitalisation. Dr Vanessa had successfully cleared his urethral obstruction and flushed out the bright red blood in the bladder 2 days ago. The cat could not urinate for the past 2 weeks. Vet 1 had prescribed antibiotics but the lady said to me: "The cat became worse. He drips urine all over the apartment!"
So, Dr Vanessa had to clear the obstruction once and for all and to ask the young lady to switch to canned food.
Now, she was here to get the cat home. I was helping out as Dr Vanessa was very busy consulting. The lady was to put the cat inside her small bag, walk out to get a taxi to go back to Bishan. The cat resisted being put inside the bag. I could see the problem as the bag was small. The lady insisted she could do it. "The cat has some pain in the penile area now," I said. "He is not fully cured. Go buy a cat carrier bag as once he escapes, he will be lost forever in most cases." However, the young lady did not believe this would happen. I went to the back and found her a carrier bag with a zip and got the cat in backside in. It was more comfortable and most important secure as I zipped 90% of the bag. This cat would not escape.
CASE 3. Tumours in old Dachshunds
An Indonesian family brought 2 Dachshunds and a terrapin for treatment. One of the two old male Dachshund had 3 subcutaneous tumours and 1 small skin tumours. The owner was worried about one SC tumour to the right and below the anal sac as it was around 3 cm x1 cm. "It is possible to operate on a Sunday," I said. "However, it is best not to ask any vet to operate on a Sunday as it is a busy day." The Dachshunds will be operated on Tuesday and will be starved on Monday night after 10 pm. For old dogs, a short anaesthesia of less than 15 minutes will be safer and one Dachshund may need two short anaesthesia rather than be a hero and excise all 4 tumours for expediency. But with a dead dog on the operating table.
CASE 4. Cocker Spaniel with an ear flap tumour
Dr Vanessa had a case of an ear wart of around 1 cm x 0.5 cm on the inside of the ear pinnae. It looked very much like a wart with no stalk and 2 nodules. However the owner did not want laboratory histopathology and had phoned. I told Dr Vanessa her request as it was not possible for Dr Vanessa to answer phone queries during a busy consultation Sunday. It would be best for her to focus and shorten the waiting time to around 15 minutes/normal case, otherwise there will be unhappiness. Case management is important on a Sunday and I had to train Mr Min who is not experienced in small animal practice yet. This was a simple surgical case but I provided some inputs to my surgical approach to this case. There is more than one surgical approach to remove a wart in the medial aspect of the ear flap.
CASE 5. Lymphoma with blood clotted inside the eye in a Jack Russell.
The mother wanted the blood clots inside the eye to be removed. 14 days ago, she came with her daughter and son-in-law to consult me because the Jack Russell suddenly could not see and bumped into furniture. He had swirling blood inside both eyes as bleeding had just started. So I sedated him and the next day, he was able to see. I advised chemotherapy but the mother was against it as she knew the bad side effects in other people undergoing chemotherapy. "Ok, I respect the mother's wishes," I said to the daughter. "Eye bleeding will return again and again till the dog becomes blind as this occurs in around 25% of canine lymphoma cases. The cause is internal bleeding due to lowered platelet count." The dog's eye whites or scleras were very red and inside both eyes, I showed that the lower 20% of the eye had a red crescent of clotted blood. "This is hyphaema," I said but I doubted the owners understood. What to do now? An ultrasound had been done by the owner to find out if the tumour had spread. "The dog is in Stage 5a which means the dog's condition had spread to other systems and is still eating," I had told the daughter before. "Chemotherapy is not a guarantee of complete cure but would buy time. In some cases, the tumours become smaller."
The tumours esp. the prescapular lymph nodes had shrunk a bit and was not so hard due to my initial treatment with dexamethasone and NSAID but it was not a cure. "The dog eats a lot and is very active," the mother had said. This is "a false dawn". It was the eye bleeding and intense eye pain that would cause the problem as well. "The dog never rubbed his eyes," the daughter said. I don't want to argue further as the dog would seldom rub his eyes in front of the owners and in any case, no owner can monitor the dog 24 hours a day. If only the dog could talk.
Now, the mother decided to have chemotherapy. Dr Vanessa and I worked together on this case. "According to some reports, chemotherapy can be effective even at late stages unlike other cancer cases," I said. "Lymphoma does not mean cancer." The laboratory report from a biopsy by Vet 1 some 3 weeks ago was inconclusive and the owner had not wanted a piece of tumour to be excised for histopathology as advised by me. Get a piece of the lymph node for histopathology instead of syringing for the cells for the lab to check, as done earlier by Vet 1.
It required anaesthesia and was too risky in case the dog dies. So, the owner had an ultrasound which indicated that the tumours had spread internally but there was no veterinary report from another vet who did the ultrasound. This is a highly emotional case to be handled with care and requires follow up. The dog had this eye bleeding for the past 7 days before the mother decided that the sedative and other injections which I did 2 weeks ago would do the trick. I told them it would not work now as the blood had clotted.
But I sedated the hyperactive dog with domitor 0.1 ml IM and after 15 minutes diazepam 0.6 ml IM to let the dog have a long rest. It was hope against hope that the clots would be removed by the body when the dog is sedated and the owners had been told of the prognosis. I will have to wait and see if the clot goes off with some sedation medication and chemotherapy. There is a need to follow up weekly but it is difficult to get the owners to comply.
CASE 6. Duty of Care.
"Dr Teo gave the cat an enema," the man in his 30s said to me at the counter. "I wish to have one as the cat can't poop." I took out his case record. There was no mention of treatment by Dr Teo who could not be contacted by phone. "Well, he referred the cat to the hospital. The cat is better but my other two cats cannot poop. Is it due to sympathy with the sick cat?" I said: "It is hard to tell. It could be the litter box and its contents or change of brand." The owner said: "I have placed more litter boxes but the contents and food remain the same." I said: "I can't really say. Try the hair ball paste commonly available in the pet shop. In any case, I can't prescribe as I have not seen the cat. Should it die due to my prescription without a proper examination, I could be subject to legal action." He understood and left amicably.
These are some cases and situations I encountered at the receptionist table. I took phone calls and appointments on this Sunday. It gave me a pulse on the standard of care provided by Toa Payoh Vets. There is no other way as in the past years, I was always inside the consultation room. Being a licensee of Toa Payoh Vets, I have to be very careful that the standard of care is up to what a "reasonable man" expects. A practice can wither away instead of flourishing if the management is very poor. It does not mean that the vet opens a clinic and people will come to make the business sustainable over the years.
CASE 7. Leaking eye plugged 14 days later. The young couple came for the stitch removal and was asking me about a red spot by phone earlier. It is hard to know what the wife was talking about. After the stitches are removed, I could show her the plugged perforated corneal spot which she referred to as a red spot. This case is recorded separately.
PERFORMANCE COUNTS IN THE FINAL ANALYSIS
An older couple came with a 13-year old Silkie that could not recognise her yesterday but could do so today. She asked whether it was a CCD as she had read somewhere in the internet. A canine cognitive disorder? In other words, an old dog's brain malfunction.
She said to me: "My friend refers you to me. Her cat could not eat despite treatment from a vet. You said it was tooth decay. After your removal of the tooth, the cat ate." I said: "It must be 10 years ago. Is the cat still alive?" She said: "The cat is much alive and well. It was around 3 years ago." Veterinary medicine and surgery is a diverse complex subject as vets are expected to know from head to toe. It is a mission impossible and needs many years to encounter the various cases. A systematic approach to medicine and surgery will help but in the end, performance counts as you can see in this case. As this owner knew Dr Vanessa from some common friends, I did not participate in this case.
April 10, 2011. Sunny in the morning. Downpour in the afternoon. Steady stream of clients from 9.30 am to 6.30pm. I did not break for lunch. However, I insisted that my new assistant, Mr Min who replaced Mr Saw recently, to go out for lunch at 3 pm. It is best to pack a lunch box on weekends as it may be too disruptive to close for lunch as cases don't complete on schedule.
CASE 1. Cat Neuter
For example, a mother and her adult son wanted me to neuter the cat. I could not do it till 4 pm when they came for the cat. The cat was said to be fierce and so he was injected IM inside the carrying trolley cage. I tilted the cage downwards waved a piece of paper in front of him while Dr Vanessa injected him IM back muscles.
"He looks OK," Dr Vanessa said to me. The cat certainly did not show claws or aggressive behaviour. He just sat still and looked serene. "Well, the owner had already forewarned me about his aggression when handled. Looks can be deceiving. I had a cat who was taken out of the cage to be injected on the table. Before I could complete the injection, it sprung up, climbed up the vertical pipe and into a gap in the false ceiling. Fortunately, it was half sedated and I could get it down from high up in the false ceiling. You don't want to suffer this type of experience! It will even be worse if that cat had not got the tranquiliser IM and hides up the false ceiling forever." Dr Vanessa looked at the false ceiling I had pointed. "The false ceiling gap in which the vertical pipe from the 2nd floor passed down to my unit had been covered up." Wisdom can only be learnt from experience and I was not taking any chances. "Once the cat is angry and frightened, it is extremely hard to catch it."
Cat, Male, 4.9 kg.
I used xylazine 0.1 ml + zoletil 100 0.1 ml in one syringe IM. The cat looked calmly and was not on the side after 15 minutes. I asked Mr Min to get him out and gave Zoletil 0.05 ml in 0.1 ml saline IV, femoral vein. The cephalic vein just could not be seen due to probably hypotension of the earlier injection. The cat was sufficiently sedated and did not experience any pain in neutering. See guidelines: Injectable anaesthetics in dogs & cats
CASE 2. Cat with urethral obstruction goes home in a cat carrier bag.
A young lady in her 20s came with a small fabric carrier bag. The type used for holding books. She was taking the cat back after 2 days of hospitalisation. Dr Vanessa had successfully cleared his urethral obstruction and flushed out the bright red blood in the bladder 2 days ago. The cat could not urinate for the past 2 weeks. Vet 1 had prescribed antibiotics but the lady said to me: "The cat became worse. He drips urine all over the apartment!"
So, Dr Vanessa had to clear the obstruction once and for all and to ask the young lady to switch to canned food.
Now, she was here to get the cat home. I was helping out as Dr Vanessa was very busy consulting. The lady was to put the cat inside her small bag, walk out to get a taxi to go back to Bishan. The cat resisted being put inside the bag. I could see the problem as the bag was small. The lady insisted she could do it. "The cat has some pain in the penile area now," I said. "He is not fully cured. Go buy a cat carrier bag as once he escapes, he will be lost forever in most cases." However, the young lady did not believe this would happen. I went to the back and found her a carrier bag with a zip and got the cat in backside in. It was more comfortable and most important secure as I zipped 90% of the bag. This cat would not escape.
CASE 3. Tumours in old Dachshunds
An Indonesian family brought 2 Dachshunds and a terrapin for treatment. One of the two old male Dachshund had 3 subcutaneous tumours and 1 small skin tumours. The owner was worried about one SC tumour to the right and below the anal sac as it was around 3 cm x1 cm. "It is possible to operate on a Sunday," I said. "However, it is best not to ask any vet to operate on a Sunday as it is a busy day." The Dachshunds will be operated on Tuesday and will be starved on Monday night after 10 pm. For old dogs, a short anaesthesia of less than 15 minutes will be safer and one Dachshund may need two short anaesthesia rather than be a hero and excise all 4 tumours for expediency. But with a dead dog on the operating table.
CASE 4. Cocker Spaniel with an ear flap tumour
Dr Vanessa had a case of an ear wart of around 1 cm x 0.5 cm on the inside of the ear pinnae. It looked very much like a wart with no stalk and 2 nodules. However the owner did not want laboratory histopathology and had phoned. I told Dr Vanessa her request as it was not possible for Dr Vanessa to answer phone queries during a busy consultation Sunday. It would be best for her to focus and shorten the waiting time to around 15 minutes/normal case, otherwise there will be unhappiness. Case management is important on a Sunday and I had to train Mr Min who is not experienced in small animal practice yet. This was a simple surgical case but I provided some inputs to my surgical approach to this case. There is more than one surgical approach to remove a wart in the medial aspect of the ear flap.
CASE 5. Lymphoma with blood clotted inside the eye in a Jack Russell.
The mother wanted the blood clots inside the eye to be removed. 14 days ago, she came with her daughter and son-in-law to consult me because the Jack Russell suddenly could not see and bumped into furniture. He had swirling blood inside both eyes as bleeding had just started. So I sedated him and the next day, he was able to see. I advised chemotherapy but the mother was against it as she knew the bad side effects in other people undergoing chemotherapy. "Ok, I respect the mother's wishes," I said to the daughter. "Eye bleeding will return again and again till the dog becomes blind as this occurs in around 25% of canine lymphoma cases. The cause is internal bleeding due to lowered platelet count." The dog's eye whites or scleras were very red and inside both eyes, I showed that the lower 20% of the eye had a red crescent of clotted blood. "This is hyphaema," I said but I doubted the owners understood. What to do now? An ultrasound had been done by the owner to find out if the tumour had spread. "The dog is in Stage 5a which means the dog's condition had spread to other systems and is still eating," I had told the daughter before. "Chemotherapy is not a guarantee of complete cure but would buy time. In some cases, the tumours become smaller."
The tumours esp. the prescapular lymph nodes had shrunk a bit and was not so hard due to my initial treatment with dexamethasone and NSAID but it was not a cure. "The dog eats a lot and is very active," the mother had said. This is "a false dawn". It was the eye bleeding and intense eye pain that would cause the problem as well. "The dog never rubbed his eyes," the daughter said. I don't want to argue further as the dog would seldom rub his eyes in front of the owners and in any case, no owner can monitor the dog 24 hours a day. If only the dog could talk.
Now, the mother decided to have chemotherapy. Dr Vanessa and I worked together on this case. "According to some reports, chemotherapy can be effective even at late stages unlike other cancer cases," I said. "Lymphoma does not mean cancer." The laboratory report from a biopsy by Vet 1 some 3 weeks ago was inconclusive and the owner had not wanted a piece of tumour to be excised for histopathology as advised by me. Get a piece of the lymph node for histopathology instead of syringing for the cells for the lab to check, as done earlier by Vet 1.
It required anaesthesia and was too risky in case the dog dies. So, the owner had an ultrasound which indicated that the tumours had spread internally but there was no veterinary report from another vet who did the ultrasound. This is a highly emotional case to be handled with care and requires follow up. The dog had this eye bleeding for the past 7 days before the mother decided that the sedative and other injections which I did 2 weeks ago would do the trick. I told them it would not work now as the blood had clotted.
But I sedated the hyperactive dog with domitor 0.1 ml IM and after 15 minutes diazepam 0.6 ml IM to let the dog have a long rest. It was hope against hope that the clots would be removed by the body when the dog is sedated and the owners had been told of the prognosis. I will have to wait and see if the clot goes off with some sedation medication and chemotherapy. There is a need to follow up weekly but it is difficult to get the owners to comply.
CASE 6. Duty of Care.
"Dr Teo gave the cat an enema," the man in his 30s said to me at the counter. "I wish to have one as the cat can't poop." I took out his case record. There was no mention of treatment by Dr Teo who could not be contacted by phone. "Well, he referred the cat to the hospital. The cat is better but my other two cats cannot poop. Is it due to sympathy with the sick cat?" I said: "It is hard to tell. It could be the litter box and its contents or change of brand." The owner said: "I have placed more litter boxes but the contents and food remain the same." I said: "I can't really say. Try the hair ball paste commonly available in the pet shop. In any case, I can't prescribe as I have not seen the cat. Should it die due to my prescription without a proper examination, I could be subject to legal action." He understood and left amicably.
These are some cases and situations I encountered at the receptionist table. I took phone calls and appointments on this Sunday. It gave me a pulse on the standard of care provided by Toa Payoh Vets. There is no other way as in the past years, I was always inside the consultation room. Being a licensee of Toa Payoh Vets, I have to be very careful that the standard of care is up to what a "reasonable man" expects. A practice can wither away instead of flourishing if the management is very poor. It does not mean that the vet opens a clinic and people will come to make the business sustainable over the years.
CASE 7. Leaking eye plugged 14 days later. The young couple came for the stitch removal and was asking me about a red spot by phone earlier. It is hard to know what the wife was talking about. After the stitches are removed, I could show her the plugged perforated corneal spot which she referred to as a red spot. This case is recorded separately.
PERFORMANCE COUNTS IN THE FINAL ANALYSIS
An older couple came with a 13-year old Silkie that could not recognise her yesterday but could do so today. She asked whether it was a CCD as she had read somewhere in the internet. A canine cognitive disorder? In other words, an old dog's brain malfunction.
She said to me: "My friend refers you to me. Her cat could not eat despite treatment from a vet. You said it was tooth decay. After your removal of the tooth, the cat ate." I said: "It must be 10 years ago. Is the cat still alive?" She said: "The cat is much alive and well. It was around 3 years ago." Veterinary medicine and surgery is a diverse complex subject as vets are expected to know from head to toe. It is a mission impossible and needs many years to encounter the various cases. A systematic approach to medicine and surgery will help but in the end, performance counts as you can see in this case. As this owner knew Dr Vanessa from some common friends, I did not participate in this case.
Friday, April 8, 2011
395. Do Skin Warts recur after excision? A case is reviewed 8 months later
Do Skin Warts recur after excision? A case is reviewed 8 months later
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 09 April, 2011
http://www.kongyuensing.com/folder5/20110330generalised-infected-warts-old-shih-tzu-singapore-toapayohvets.htm
has the pictures and updates.
April 8, 2011
"My uncle was so surprised and said: 'Your dog is so young and active," the wife said to me over the phone today when I asked what happened since 76 warts were excised by me 8 months ago. See: http://www.asiahomes.com/real_estate_tips/0816bluff.htm
"He is like a brand new dog a few days after the surgery. He behaved as if he was 6 years younger. Full of energy! It was not just my uncle who commented. Many friends were so surprised that my dog had become energised after the wart surgery!"
Today, the husband made an appointment specifically to consult me about the dog's right ear.
His first remark was that the 13-year-old male neutered Shih Tzu was a new dog after the warts were removed. I expected a half-dead lethargic old Shih Tzu but I was also surprised at the full coat and alertness.
The old Shih Tzu has been stressed by the painful eyes and right ear canal (filled with stinking pus) for at least 8 months. 10 viral skin warts came back and were frozen.
The couple will need to be diligent and educated to eliminate the stresses if his old companion is to live to a ripe old age in comfort and free from pain and itchiness. Follow up with the vet is advised after one month and subsequently.
The dog came in for a smelly right ear. I put a cotton bud and got a smear of dark brown pus at one end. The Shih Tzu winced in pain when the cotton bud touched the junction of the horizontal and vertical canal. He did not bite me. I smelt the brownish-yellow tip to check what type of bacteria or yeast infection it could be. This is not scientific as an ear discharge smear to check for yeast and bacteria would be done soon.
The smell was like some rotten flesh kept for some time. I asked my assistant and the owner to smell the tip as I waved it in front of their nose. The left ear was perfectly normal. "I ran out of your ear drops," the husband said.
There were 10 warts on the back spinal area (after I had the dog clipped bald. We thought it was 3 warts before clipping). 10/76 warts. Yet Vet 1 had told the owner: "The dog is old already. The warts are not serious. No point removing the warts. They will return back." I did say there is a possibility of recurrence too. The dog was 12 years old and a very high anaesthetic risk.
WHY DID THE OWNER SEEK A SECOND OPINION?
I asked the wife over the phone as Vet 1 had been their regular vet and they were a loyal client. "The dog was bleeding every day," the wife said. "A lot of blood. The dog was in pain. He was sleepy most of the day. I had to do something." In other words, the wife was very concerned and went into the internet to do research. Then the couple came to consult me.
WHAT DID I DO 8 MONTHS AGO?
Admitted: August 8, 2011, 2011, 9.3 kg, 38.1 C.
76 warts from head to toe literally.
R ear - rotten smelly skin. L eye - dry eye.
8 months ago, 76 warts were electro-excised under general anaesthesia
HIGH ANAESTHETIC RISK
It is not surprising that the family vet (Vet 1) did not want to perform surgery to excise the warts. He probably did not relish the blame and hassles if the old dog died on the operating table. So, over the 5- 6 years, the warts multiplied to number 76! The dog was lethargic most of the day. "What do you expect?" you would say. "He is an old dog!"
Anaesthesia & Surgery on Day 1 - August 11, 2011 and goes home on Day 2.
IV saline drip with Baytril 0.5 ml and Tolfedine 0.5 ml IV
Domitor 0.1 ml IV. Isoflurane gas maintenance. Electro-surgery. Excised 76 warts (a packet of warts given to the owner is still remembered).
2/0 absorbable stitches.
Baytril x 3 tablets, Trimethoprim and multivitamin for home.
The owner came 2 weeks later for antibiotics and no more news from the owner till today to consult about the smelly right ear. The wife was knowledgeable and had agreed that it was too risky to get the lateral ear canal resection surgery done. This surgery would have eliminated this recurring right ear infection (since 8 months ago, if you referred to my notes dated August 2010 (image below).
Procedures used to excise 76 warts
BLOOD TEST ON AUGUST 11, 2011
Liver enzymes high, urea high, creatinine low.
White Cell Count 19.8 (6-17)
Neutrophils 88% Abs 17.55
Lymphocytes 9.6% 1.90
Monocytes 1.1% 0.22
Eosinophils 0.71% 0.14
Basophils 0% 0
PCV, platelets, haemoglobin and RC etc - normal.
URINE TEST ON AUGUST 11, 2011
pH 6.5 (5-8)
SG 1.038 (1.005-1.030)
Protein trace
Blood negative
White blood cells 8
Bacteria Occasional
Crystal Calcium oxalate+
TODAY'S TREATMENT
Clipped bald. 10 warts. 2 most prominent between eyes and behind midline of eyes.
1. Right ear discharge sample. Stained exudate (fixative, air dry, S1, air dry, S2, air dry) to check for yeast and bacteria. Bacteria present. The owner had been giving his own ear drops for the past 8 months from some sources.
2. Irrigated the ear and bathed the dog after clipping the coat.
3. Froze 10 warts seen after clipping coat, 1 minute. Prominent one between eye. biggest cauliflower shaped at 4 mm x 4 mm. Others were much smaller appearing as small lumps under the skin. No need for sedative or anaesthesia.
PERFORMANCE COUNTS
This is a rare case of generalised warts in Singapore. The warts multiplied and spread over a period of 5-6 years. Why?
Food fed - home-cooked chicken and dog treats and canned Caesar. Sometimes diarrhoea, the wife said.
Given k/d canned and dry (last 2 months). Stools well formed and no diarrhoea.
OVERALL
Need to treat right ear infection and dry eyes if the dog is going to live longer with no pain and discomfort. Warts must be frozen when they are small. 10 very small warts were frozen without the need for anaesthetic and sedative as this dog was OK with the freezing. The biggest one was around 4mm x 5 mm between and above the eyes in the midline as shown below.
8 months ago. Under general anaesthesia and for around one hour, the 76 warts were excised by electro-surgery!
8 months later. The wart above and between the eye has recurred but was hidden by the hairs. Clipping exposed this wart. This was deep frozen.
Small warts <4mm x 4mm can be frozen and usually they will disappear 7-14 days later. Note that the large wart above the left ear (as in 8 months ago) has not recurred! So, the owner was happy with the outcome. But the war can be lost if one battle is won if the owner is not vigilant to get small warts excised.
PHONE ADVICE TO THE WIFE - REDUCE STRESS AS WARTS ARE SAID TO BE VIRAL AND GROW WHEN IMMUNE SYSTEM IS DONE.
A very busy working couple. I told them I do consult on Sundays and other days by appointment only. Fortunately, the dog's 10 warts discovered early - can be frozen. Only 10 small ones. The husband did not want a blood test as advised. Here are instructions given for this dog:
1. EYE CARE TO BE DONE DAILY (2 types of eye drops and Atopica) to prevent dog going blind with dry eyes 2 years later. Put dog on table. Teach mum how to do it if couple goes overseas for 2 weeks.
2. NO DIRECT WIPING OF EYEBALL by husband to clear pus around eyelids. Close the eyelids first after applying eye drops, I advised.
3. RIGHT EAR INFECTION MUST BE DILIGENTLY CONTROLLED AND FOLLOWED UP WITH THE VET. Rotten flesh smelly pus. Should be able to cure this one soon. Should review with the vet (me) 4 weeks later.
Warts do come back and can be frozen if detected early. Warts had caused pain and infection if left for several years (WCC high in Day 1). Owners are happy with the outcome. If the dog had died under anaesthesia, it would be bad for the vet. So, it is understandable that Vet 1 was reluctant to do surgery. Too many large warts, deep freezing is impractical.
A rare case in Singapore. Many older dogs have a few skin warts but this old Shih Tzu had 76 warts. The warts started with a few over the back area some 5 years ago, according to the wife. Then more and more appeared. The family vet would not want to excise them saying that the warts would come back again. So, no point removing them. The dog started rubbing his infected warts onto the floor and bloodied the apartment. "The Shih Tzu just could not stop scratching the large wart above his left ear. I have to do something," the wife checked the internet and contacted me.
What causes these warts? They are believed to be caused by papilloma viruses. Poor immune system in very young and old dogs lead to wart formation. What is the cure? Reduce the stresses.
PERFORMANCE counts in the veterinary practice. This case needs the owner to take care and follow up with the vet monthly or regularly. It had been 8 months since I saw the dog. I said diplomatically to the wife that an old dog needs more care than a young one and that stress due to pain and infection must be reduced considerably to prevent wart formation in old age. Also, good nutrition and no dry feed (urine crystals). The dog has a very good coat and skin and I presume k/d diet and some home-cooked food were sufficient.
RETROSPECTIVE REVIEW. In hindsight, I should have operated the dog after 24 hours as he was lethargic. Sometimes I want to save the owner some money by doing a same-day operation as in closed pyometra and urinary stone cases. It may not be wise to take such a risk as many dog owners never really forgive and never forget if the dog passes away on the operating table. Deaths of pets on the operating table are very highly emotional events even for the vet and his or her staff.
GET YOUR DOG WARTS EXCISED BY YOUR VET WHEN THE WARTS ARE SMALLER.
This case has a happy ending but owners are advised that skin warts in their dogs are best removed when they are few in number and are smaller. Happy endings are not always the case in high anaesthetic risky old and sick dogs with warts!
A YOUNG MAN WITH FOOT WARTS
Skin warts occur mainly in very young and old dogs as both groups have a much lower immune system. What about young people?
Do people get the cauliflower skin warts? I remember this young man in his early 20s in National Service. His shoes were damp from military training.
At first he had one and then more foot warts presented below his feet as he had to wear his boots for military service. Moe warts kept appearing on his hand as well. I can't remember how many he had. I advised him to see the doctor who made him an appointment with the surgeon as these warts seem to thrive and spread.
Like many young Singaporean males hooked onto the online gaming, he did not have sufficient rest. He would go online gaming till past 3 am every day.
He ate noodles most of the time. He saw the doctor who removed some warts. He reduced his online gaming of WOW II and other games. Slept more hours and earlier. I got him a freezing solution. He applied on the remaining two warts. Now he has no warts recurring. It seems that the warts are best excised early as they seem to spread to nearby skin areas. How he got the skin warts, I don't know. Now he has no warts at all and that is a relief for him as such warts can be quite painful.
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 09 April, 2011
http://www.kongyuensing.com/folder5/20110330generalised-infected-warts-old-shih-tzu-singapore-toapayohvets.htm
has the pictures and updates.
April 8, 2011
"My uncle was so surprised and said: 'Your dog is so young and active," the wife said to me over the phone today when I asked what happened since 76 warts were excised by me 8 months ago. See: http://www.asiahomes.com/real_estate_tips/0816bluff.htm
"He is like a brand new dog a few days after the surgery. He behaved as if he was 6 years younger. Full of energy! It was not just my uncle who commented. Many friends were so surprised that my dog had become energised after the wart surgery!"
Today, the husband made an appointment specifically to consult me about the dog's right ear.
His first remark was that the 13-year-old male neutered Shih Tzu was a new dog after the warts were removed. I expected a half-dead lethargic old Shih Tzu but I was also surprised at the full coat and alertness.
The old Shih Tzu has been stressed by the painful eyes and right ear canal (filled with stinking pus) for at least 8 months. 10 viral skin warts came back and were frozen.
The couple will need to be diligent and educated to eliminate the stresses if his old companion is to live to a ripe old age in comfort and free from pain and itchiness. Follow up with the vet is advised after one month and subsequently.
The dog came in for a smelly right ear. I put a cotton bud and got a smear of dark brown pus at one end. The Shih Tzu winced in pain when the cotton bud touched the junction of the horizontal and vertical canal. He did not bite me. I smelt the brownish-yellow tip to check what type of bacteria or yeast infection it could be. This is not scientific as an ear discharge smear to check for yeast and bacteria would be done soon.
The smell was like some rotten flesh kept for some time. I asked my assistant and the owner to smell the tip as I waved it in front of their nose. The left ear was perfectly normal. "I ran out of your ear drops," the husband said.
There were 10 warts on the back spinal area (after I had the dog clipped bald. We thought it was 3 warts before clipping). 10/76 warts. Yet Vet 1 had told the owner: "The dog is old already. The warts are not serious. No point removing the warts. They will return back." I did say there is a possibility of recurrence too. The dog was 12 years old and a very high anaesthetic risk.
WHY DID THE OWNER SEEK A SECOND OPINION?
I asked the wife over the phone as Vet 1 had been their regular vet and they were a loyal client. "The dog was bleeding every day," the wife said. "A lot of blood. The dog was in pain. He was sleepy most of the day. I had to do something." In other words, the wife was very concerned and went into the internet to do research. Then the couple came to consult me.
WHAT DID I DO 8 MONTHS AGO?
Admitted: August 8, 2011, 2011, 9.3 kg, 38.1 C.
76 warts from head to toe literally.
R ear - rotten smelly skin. L eye - dry eye.
8 months ago, 76 warts were electro-excised under general anaesthesia
HIGH ANAESTHETIC RISK
It is not surprising that the family vet (Vet 1) did not want to perform surgery to excise the warts. He probably did not relish the blame and hassles if the old dog died on the operating table. So, over the 5- 6 years, the warts multiplied to number 76! The dog was lethargic most of the day. "What do you expect?" you would say. "He is an old dog!"
Anaesthesia & Surgery on Day 1 - August 11, 2011 and goes home on Day 2.
IV saline drip with Baytril 0.5 ml and Tolfedine 0.5 ml IV
Domitor 0.1 ml IV. Isoflurane gas maintenance. Electro-surgery. Excised 76 warts (a packet of warts given to the owner is still remembered).
2/0 absorbable stitches.
Baytril x 3 tablets, Trimethoprim and multivitamin for home.
The owner came 2 weeks later for antibiotics and no more news from the owner till today to consult about the smelly right ear. The wife was knowledgeable and had agreed that it was too risky to get the lateral ear canal resection surgery done. This surgery would have eliminated this recurring right ear infection (since 8 months ago, if you referred to my notes dated August 2010 (image below).
Procedures used to excise 76 warts
BLOOD TEST ON AUGUST 11, 2011
Liver enzymes high, urea high, creatinine low.
White Cell Count 19.8 (6-17)
Neutrophils 88% Abs 17.55
Lymphocytes 9.6% 1.90
Monocytes 1.1% 0.22
Eosinophils 0.71% 0.14
Basophils 0% 0
PCV, platelets, haemoglobin and RC etc - normal.
URINE TEST ON AUGUST 11, 2011
pH 6.5 (5-8)
SG 1.038 (1.005-1.030)
Protein trace
Blood negative
White blood cells 8
Bacteria Occasional
Crystal Calcium oxalate+
TODAY'S TREATMENT
Clipped bald. 10 warts. 2 most prominent between eyes and behind midline of eyes.
1. Right ear discharge sample. Stained exudate (fixative, air dry, S1, air dry, S2, air dry) to check for yeast and bacteria. Bacteria present. The owner had been giving his own ear drops for the past 8 months from some sources.
2. Irrigated the ear and bathed the dog after clipping the coat.
3. Froze 10 warts seen after clipping coat, 1 minute. Prominent one between eye. biggest cauliflower shaped at 4 mm x 4 mm. Others were much smaller appearing as small lumps under the skin. No need for sedative or anaesthesia.
PERFORMANCE COUNTS
This is a rare case of generalised warts in Singapore. The warts multiplied and spread over a period of 5-6 years. Why?
Food fed - home-cooked chicken and dog treats and canned Caesar. Sometimes diarrhoea, the wife said.
Given k/d canned and dry (last 2 months). Stools well formed and no diarrhoea.
OVERALL
Need to treat right ear infection and dry eyes if the dog is going to live longer with no pain and discomfort. Warts must be frozen when they are small. 10 very small warts were frozen without the need for anaesthetic and sedative as this dog was OK with the freezing. The biggest one was around 4mm x 5 mm between and above the eyes in the midline as shown below.
8 months ago. Under general anaesthesia and for around one hour, the 76 warts were excised by electro-surgery!
8 months later. The wart above and between the eye has recurred but was hidden by the hairs. Clipping exposed this wart. This was deep frozen.
Small warts <4mm x 4mm can be frozen and usually they will disappear 7-14 days later. Note that the large wart above the left ear (as in 8 months ago) has not recurred! So, the owner was happy with the outcome. But the war can be lost if one battle is won if the owner is not vigilant to get small warts excised.
PHONE ADVICE TO THE WIFE - REDUCE STRESS AS WARTS ARE SAID TO BE VIRAL AND GROW WHEN IMMUNE SYSTEM IS DONE.
A very busy working couple. I told them I do consult on Sundays and other days by appointment only. Fortunately, the dog's 10 warts discovered early - can be frozen. Only 10 small ones. The husband did not want a blood test as advised. Here are instructions given for this dog:
1. EYE CARE TO BE DONE DAILY (2 types of eye drops and Atopica) to prevent dog going blind with dry eyes 2 years later. Put dog on table. Teach mum how to do it if couple goes overseas for 2 weeks.
2. NO DIRECT WIPING OF EYEBALL by husband to clear pus around eyelids. Close the eyelids first after applying eye drops, I advised.
3. RIGHT EAR INFECTION MUST BE DILIGENTLY CONTROLLED AND FOLLOWED UP WITH THE VET. Rotten flesh smelly pus. Should be able to cure this one soon. Should review with the vet (me) 4 weeks later.
Warts do come back and can be frozen if detected early. Warts had caused pain and infection if left for several years (WCC high in Day 1). Owners are happy with the outcome. If the dog had died under anaesthesia, it would be bad for the vet. So, it is understandable that Vet 1 was reluctant to do surgery. Too many large warts, deep freezing is impractical.
A rare case in Singapore. Many older dogs have a few skin warts but this old Shih Tzu had 76 warts. The warts started with a few over the back area some 5 years ago, according to the wife. Then more and more appeared. The family vet would not want to excise them saying that the warts would come back again. So, no point removing them. The dog started rubbing his infected warts onto the floor and bloodied the apartment. "The Shih Tzu just could not stop scratching the large wart above his left ear. I have to do something," the wife checked the internet and contacted me.
What causes these warts? They are believed to be caused by papilloma viruses. Poor immune system in very young and old dogs lead to wart formation. What is the cure? Reduce the stresses.
PERFORMANCE counts in the veterinary practice. This case needs the owner to take care and follow up with the vet monthly or regularly. It had been 8 months since I saw the dog. I said diplomatically to the wife that an old dog needs more care than a young one and that stress due to pain and infection must be reduced considerably to prevent wart formation in old age. Also, good nutrition and no dry feed (urine crystals). The dog has a very good coat and skin and I presume k/d diet and some home-cooked food were sufficient.
RETROSPECTIVE REVIEW. In hindsight, I should have operated the dog after 24 hours as he was lethargic. Sometimes I want to save the owner some money by doing a same-day operation as in closed pyometra and urinary stone cases. It may not be wise to take such a risk as many dog owners never really forgive and never forget if the dog passes away on the operating table. Deaths of pets on the operating table are very highly emotional events even for the vet and his or her staff.
GET YOUR DOG WARTS EXCISED BY YOUR VET WHEN THE WARTS ARE SMALLER.
This case has a happy ending but owners are advised that skin warts in their dogs are best removed when they are few in number and are smaller. Happy endings are not always the case in high anaesthetic risky old and sick dogs with warts!
A YOUNG MAN WITH FOOT WARTS
Skin warts occur mainly in very young and old dogs as both groups have a much lower immune system. What about young people?
Do people get the cauliflower skin warts? I remember this young man in his early 20s in National Service. His shoes were damp from military training.
At first he had one and then more foot warts presented below his feet as he had to wear his boots for military service. Moe warts kept appearing on his hand as well. I can't remember how many he had. I advised him to see the doctor who made him an appointment with the surgeon as these warts seem to thrive and spread.
Like many young Singaporean males hooked onto the online gaming, he did not have sufficient rest. He would go online gaming till past 3 am every day.
He ate noodles most of the time. He saw the doctor who removed some warts. He reduced his online gaming of WOW II and other games. Slept more hours and earlier. I got him a freezing solution. He applied on the remaining two warts. Now he has no warts recurring. It seems that the warts are best excised early as they seem to spread to nearby skin areas. How he got the skin warts, I don't know. Now he has no warts at all and that is a relief for him as such warts can be quite painful.
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