638. Sunday Sep 25, 2011 - A kitten's generalised ringworm infected the owner

The kitten has generalised ringworm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
STORY 1
The pet transport man came to get the address to pick up two kittens from The Sails condo at Marina Bay. "Today is F1 day. The road to this condo will be closed," I said. Dr Vanessa will phone the owner to inform her.

The owner who had connections with my old school known to produce "nerds" according to her, had e-mailed to me for a house-call which was done by Dr Vanessa. She brought back a kitten full of ringworm on the skin. As I was around when the owner came, I had a word with her on ringworm. Sometimes it is fun to help the owner know more about their pet's treatment, reinforcing Dr Vanessa's advices and this communication from two vets instead of one makes the owner's visit much more interesting. Most times, I don't introduce myself and am mistaken for the receptionist or vet assistant. This owner had a lot of tattoos which surprised me as she was a young fair lady. She had ringworm lesions on her throat, her thighs and her belly and showed the anatomy to Dr Vanessa and I. Well, this is a modern world and I lifting the blouse to show ringworm lesions in the belly is not immodest.

She showed me a tube of cream to apply to her various ringworm lesions. "I feel so itchy," she said or that was what I heard. Well, she had so many infected skin spots shaped like a ring and ringworm is a very itchy disease. I am surprised that her finger nails have not been infected.

"Normally, the doctor will prescribe a tube of cream. You should ask your doctor to prescribe oral medication if it is widespread," I advised and told her that ringworm is common in Singapore's dogs and cats when she asked. "We are treating your kitten with medication and ringworm washes, but no cream as kittens lick away the cream and poison themselves in the long run."

"Long ago, I had ringworm in my hair when I was an undergraduate in Glasgow University. It was very itchy and took several weeks to be cured. I had to take tablets and de-contaminate my clothing as well. You need to de-contaminate your apartment, brushes and sleeping areas!"

"Can I have some of the tablets you prescribe for the kitten?" she asked.
"No, no," I said. "We are licensed to treat animals, not people. You can speak nicely to your general practitioner and ask for the oral tablets. I am sure he will give them to you." I don't know whether I had heard clearly whether she said she had ringworm in her back. It would be difficult to apply cream there herself. Fortunately, her hair was clear of ringworm.

"I have engaged a pest controller for my apartment," she said.
"They are a waste of money," I said. "You need to personally clean up the apartment daily while the controller comes once. You need to vacuum the corners, wash the brushes and clothing and bed sheets and other. You need to get your other two kittens clipped bald as well as ringworm is contagious. Put your kittens in a carrier and bring them down to the Surgery quickly."

Dr Vanessa said: "I am getting Martin to transport the two kittens to be clipped." But the day chosen was F1 Sunday and so Martin came for nothing. Martin is our pet taxi man.

This reinforcement of Dr Vanessa's advices about ringworm is good for the lady as ringworm is a zoonosis. It may help to retain clientele and that is how a vet practice sustains its profitability. It is not about the individual veterinary ego although most owners prefer the vet that treats their dogs and in this department, Dr Vanessa is dealing with most of them and is the hot favourite.


STORY 2
From the receptionist's counter, I learnt much more about the owner's needs than as a vet. There was one interesting owner, a business man who kept asking me for the bill as he came to get his daughter's dog home from an overnight stay for treatment.

However, Dr Vanessa was in her consultation room discussing another dog treatment with some owners. This took more than 15 minutes and he was getting restless. So I talked to him as I did my work.

"How did you locate Dr Vanessa?" I asked.
"The counter girl at her old practice told me," he said.
"I thought the practice would never reveal as this means a loss of customers." Nowadays, don't expect your staff to be loyal to the employer anymore. It is now more like biting the hand that feeds you as times have changed. It is up to the employer to create loyalty amongst the staff but that is not easy as the younger generation goes to another place for a few dollars more.

"Well," he said. "Dr Vanessa must have been nice to the counter girls."
I agreed with him and asked what occupation he was in as a part of conversation.

"I am retired," he said. "What were you doing before you retired?" I asked. He was a food and beverage man.

"Did you read about the case of the supplier bribing the Chinese restaurant chefs with millions of dollars?" I asked.

"It is still a common practice," he said. "Only that this supplier was caught by the anti-corruption agents. Unlike big hotels that have a purchasing department, Chinese restaurant chefs are in charge of purchasing. So, they ask for money. Otherwise they will reject the seafood as not fresh. If they are bribed, they don't bother with the freshness or the correct weight of the food received. The supplier just increase the price or decrease the weight of the seafood to pay for the bribes!"

It is hard to eradicate corruption even in Singapore with the anti-corruption agency. We talked more about his excellent achievements of his two daughters and property investments during our era of the 1980s when bank loan qualifications were not so stringently controlled by the MAS (Monetary Authority of Singapore), the bureaucrats, the academics and the politicians.

I got a first-hand view of how he did his overseas development business which books will never be able to explain. He was around my generation. Then he asked what I did before becoming a receptionist since I was at the reception counter. "Well," I said. "You can say that I am the original vet as I started this practice."

Finally Dr Vanessa was free for him. "You have kept our friend waiting for a long time," I said to Dr Vanessa. "No, no problem at all," he said and gave Dr Vanessa the name of his business that is very good for her. A Victoria Secrets type of business. Women's business are the best in this world of business, besides property development.


Webpage at:
http://www.sinpets.com/dogs/20110927kitten-generalised-ringworm-shih-tzu-singapore_ToaPayohVets.htm

637. Pemphigus follow up on Sunday Sep 26, 2011

I thank you for your photos emailed on Sep 24, 2011. We met at the Surgery on Sunday Sep 25, 2011. I have had discussed with you further the management of pemphigus in your dog.

An auto-immune disease has no cure and control is by medication that has to be given according to response. There is no fixed formula for medication in auto-immune diseases as dosage depends on response and this can only be known through weekly or regular assessment. Too high a dosage results in kidney damage. Too low a dosage and it does not work.

On Sun, Sep 25, 2011 at 9:24 AM, ...@yahoo.com> wrote:

Dear Dr Sing,

here is an update since the review on last sunday.
the lumps on the paws are getting bigger and started to be smelly for the past few weeks; even the small lump at the mouth is also getting visible and seems growing.

i have attached some photos taken for the mouth, ears & paws.
pls advise.


E-MAIL REPLY FROM DR SING AFTER DISCUSSION WITH THE OWNER

From your feedback of the paws and the right gum swelling, the disease needs a higher dosage of medication for the next 7 days. This dosage depends on response for the next 7 days and frequent monitoring and discussion with the vet.

MANAGEMENT
Washing of the ear flaps and each paws in a bowl of warm water + anti-fungal solution, keeping them very clean and dry, wearing of pad stockings, applying anti-fungal cream to blisters, wearing an e-collar at all times and taking medication of the two immuno-suppressive drugs and antibioics are part of the management of this disease for the next 7 days and beyond.

Best wishes.

Two toilet training advices - a Sheltie puppy and 7-month-old adopted Golden Retriever

Young Sheltie.
Playpen with newspapers occupying 1/3 of the playpen space. The lady owner said this was successful. A couple with the wife being an accountant and the husband being a financial professional. At the reception, I had good discussions about accounting, purchase of an HDB flat and not being allowed to invest in private property for 5 years, the good prospects of accountants, the shortage of auditors, secretarial fees of $600 being said to be amongst the lowest in Singapore, financial leverage in property asset accumulation and property rental investments which the wife is keen on. Vets are encouraged to read financial and property news to be able to carry on such a conversation with some clients like accountants.

An accountant can open his own shop and sign documents if he has been certified by CPA Singapore. "A finance and banking graduate can do insurance," the wife said to me. "But he can't open his own shop," I said. "Insurance professionals setting up a shop requires the person to be qualified as an actuary." An actuary is a professional who deals with the financial impact of risk and uncertainty.


Adopted Golden Retriever
"I used to think that it is cruel to confine the dog," the young lady said to me as this was what Dr Vanessa advised her. She adopted the dog as the other friend did not want him. He peed and pooped all over the kitchen floor and apartment.

"The best is to confine him inside the common bathroom for 2-4 weeks," I advised. "Put feed and water bowls in front. Observe where he sleeps (clean area) and put newspapers to cover his toilet area. Put up a fencing barrier at the door entrance so that the dog can see everybody.

"Or bring the dog out to the garden spot after he wakes up and after breakfast and dinner. Give a routine to this dog and he will eliminate outdoors."

A 16-year-old Golden Retriever with thyroid tumour and a 10-year-old Shih Tzu with oral tumours.

CASE 1

"It is best to ask the family to wait outside," I said to Dr Vanessa who wanted to catetherise the vein to euthanase the old Golden Retriever in the presence of a family of around 8 sad members inside the consultation room.

Earlier, a lady had phoned about the cost of euthanasia and subsequent preparations for cremation. As Dr Vanessa was very busy on this Sunday Sep 26, 2011 such that she had no time for lunch, I spoke to the lady. If Dr Vanessa answered every phone query, her cases would be delayed and it would be past 7 pm before anybody can go home on this fine Sunday. We close at 5 pm on weekends and from Min, I was told that last Sunday's cases were completed at 7 pm. I was not around and so did not know why but this would have to do with the vet's management of case flow, answering of client queries and surgeries being done on a Sunday.

Anaesthesia and surgeries do take up some time and there were two (dental extraction of a foul-smelly old Jack Russell Cross and skin wart removal of a Shih Tzu) on this Sunday. In between consultations, the vet may have to answer phone calls and if this can be done by an experienced receptionist, it would be fine but sometimes the technical questions may be best answered by the vet.

In this case of the Golden Retriever, it would be much kinder to euthanase as he was not eating and had lost weight. The dog did not want to get up to walk to the consultation room but was finally persuaded to do so. I could see that it was very emotional situation especially for one lady who had spoken to me earlier.

The best way to handle such a case is not to euthanase the dog in front of all grieving members of the family. Some dogs react to the lethal injection by screaming and some lose control of their bladder and bowels or vomit. Such a scene is not pleasant for the owners. So I advised the family members to leave the consultation room and go outside as the old dog could sense their grief, in my observation and might be more stressed.

In this case, the owners said good bye to the dog and waited outside the Surgery. I advised a Domitor+Ketamine IM sedation first and euthanasia injection after 10 minutes. The dog passed away peacefully. The lady who cared most for this dog came to say good bye.

CASE 2.
I was at the reception area when somebody inside the consultation room bashed his fist at the wall separating the reception area and the consultation room. A dog had been euthanased by Dr Vanessa and the family members of parents and adult children were inside.

"What's happening to your clients inside the consultation room?" I searched for Dr Vanessa who was inside the Surgery to do the dental scaling and extraction. "I just heard a loud bang against the gypsum board wall." This wall is not solid brick wall and I can't afford to let clients bang till it collapses.

Dr Vanessa did not hear the loud bang. She said: "They are waiting for the cremation man and are preparing prayers for the euthanased dog." I had not seen this case. The father brought in some leaves and I thought a pineapple. The cremation man came and I quickly got him into the consultation room. Dr Vanessa came soon. Later the father told me that the dog had oral tumours which could not be cured.

Regular dental care and scaling usually prevents oral tumours but few Singaporean dog owners bother with dental health of their dogs. More are getting dental check up and scaling done on old dogs. The best is to get dental check up yearly but older dogs are generally left alone after the initial burst of attention when they are puppies.

634. Circum-anal tumours in a 14-year-old Shih Tzu

A young couple who came on Sunday Sep 25, 2011 as their vet (Vet 1) had at first said that their dog was too old for surgery to remove growths around the anus. When the growths spilled discharge, Vet 1 decided that surgery was necessary. A flip flop decision can cause a loss of confidence in a dog owner.

"Your dog has circum-anal tumours," I said while Dr Vanessa examined the dog with a stethoscope. "It usually occurs in a old dog, not neutered, old age. In some cases, on a busy day, I do get into the consultation room to do joint consultations with Dr Vanessa.

The young lady smiled. I was right on 3 counts. "Do you know what is the meaning of circumference?"

The couple nodded as they would have studied this during secondary school in Singapore. "Vet 1 is correct in saying that your dog is 'too old' for surgery - meaning that it is highly risky to operate on your dog as he may die from general anaesthesia. He is already 14 years old and is very old." I told the couple of a 16-year-old Fox Terrier whose circum-anal tumours grew to large sizes such that they cause a lot of bleeding and infection set in. This would be what happen if the dog lives up to a very ripe old age.

A blood test had been taken. This is a very high risk anaesthesia. I spoke to the couple and Dr Vanessa. If the anaesthesia is less than 15 minutes, the old dog seldom dies from anaesthesia. "That means doing the operation in 3 or 4 stages," I said to the couple. "Neuter first to remove the male hormones stimulating the growth of the circum-anal tumours. After 3 weeks, remove the larger tumours within 15 minutes and repeat with the remainder some 4 weeks later."

The tumours had spread under the anal skin from 9-3 o'clock in the upper side. Then at 5 o'clock a large tumour protruded with another small one. I did not take a picture. But this would be a protracted surgery and highly risky. If neutering and Tardak injection shrinks the tumours, then there may be less operating time. But owners and vets need to be patient in the treatment of circum-anal tumours in a very old dog.

633. Cost to spay a cat at Toa Payoh Vets

Just picked up a stray.
Please tell me what the cost is to spay.

Thanks
Owner



E-MAIL REPLY FROM DR SING DATED SEP 26, 2011
For a cat, the spay is $100. The estimated cost will be around $150 including anaesthestic, spay surgery and post-op antibiotic and pain-killer injection and tablets. E-collar is excluded.
- Show quoted text -

632. Corneal degeneration in an old Miniature Pinscher, FS, 9 years

SUNDAY'S INTERESTING CASE

The owner wanted a diagnosis from me. She went to Vet 1 who referred her to Vet 1, but she said she still had to pay Vet 1 for a non-diagnosis. I showed her that Vet 1 did diagnose "lipid" deposits in the right eye and referred her to Vet 2.

"It must have been a long time since I usually keep older records stored outside the Surgery," I said. She showed me my 2006 Toa Payoh Vets receipt with my pen illustration of "left eye white central scarred ulcer - 3mm diameter". I was impressed that she kept records. That was 5 years ago! "It was the left eye affected," she said. "The spot disappeared after a while."

"Did you use the eye ointment?" I asked.
"No," she said. "My dog disliked it".

EXAMINATION
1. To check whether the right eye had corneal ulcers or not in addition to the lipid deposits.
I showed my assistant Min how I used the fluorets paper strip. I placed it onto the lower fornix and closed the eyelid. The dog blinked many times. Green dye gathered below the lower conjunctiva.
"Is it dangerous to my dog's eye?" the owner asked. "No," I showed her the seller was Bausch and Lomb which she had instant knowledge but said that there was a lawsuit against this company for the contact lens solution.

Results: No green ulcers in the right eye but there were 11 to 1 o'clock ulcers in the left eye!

2. Digital photography useful esp. side views of corneal degeneration. Axial central corneal degeneration 4x3 mmx3mm. It looks like it is going to bulge out and ulcerate. Owner had said the swelling suddenly appeared in the last month.

3. Blood tests for thyroid and cholesterol not done yet due to financial considerations. Hypothryoid and high cholesterol are said to be important in this degeneration where aqueous fluid enters the endothelium, causing edema and whiteness and swelling (side view of image).

DIAGNOSIS
Right eye - corneal endothelial dystrophy. No definite cure as this is due to aging. Blood tests for thyroid hormones and cholesterol levels advised.
Left eye - corneal ulcers due to eye rubbing of the 3 upper eyelid "melanomas". Excision of the melanomas will prevent ulcerations.

TREATMENT
Usually not curative. Low fat diet 8% fat? Check thyroid hormones and cholesterol levels.
Prevent further corneal degeneration? What drug?
E-collar and antibiotics to prevent left eye rubbing although the owner said she never saw actual rubbing.


Website with more photos
http://www.sinpets.com/F5/20110928corneal-ulcer-eyelid-melanoma-miniature-pinscher-singapore_ToaPayohVets.htm