The shih tzu coughs white mucus daily for 3 months. Why?

"My other dog has been treated by Vet 1 for the past 12 years," the owner said he had no veterinary report from the vet who had treated the presented Shih Tzu of 4 years old for coughing. "I feel bad to ask Vet 1 for the medical records and X-rays for this Shih Tzu."

"How long has this Shih Tzu been coughing?" I asked.
"5 months. My domestic worker says the dog has a tongue ulcer."

"There should be no problem with Vet 1 sending over your dog's records as this is a common practice. Shall I phone on your behalf?". The owner agreed and Vet 1 sent his report over. The coughing started 3 months ago and blood test and X-rays of the chest and abdomen were normal.

What's the cause of this persistent coughing? There was a tongue ulcer at the tip and one on the hard palate. I shone my torchlight at the ulcers to show the owner. The dog just would not cooperate, but the owner already knew of the existence of the ulcer. I palpated the dog's throat. It was very painful.

"My dog sometimes throw up liquid," the owner said. This is quite a complicated case as the heart and lungs were normal on auscultation using my stethoscope. What is the cause of this persistent coughing?

To complicate diagnosis, the right and left submandibular and popliteal lymph nodes were much enlarged. I let the owner feel the lumps. Could this be a concurrent case of lymphoma or lymphosarcoma?

"Did your tongue lick some poison?" I asked. "Tongue ulcer at the tip of a normal tongue usually indicated something corrosive had burnt the tongue. Like insecticide."

Persistent coughing for 3 months. Weight loss. Why?
"Well my dog has licked shampoo used to treat his dandruff."
Blood, urine and X-rays of the throat, chest and abdomen are being done as this are necessary to aid in the diagnosis of persistent coughing even though some tests were done earlier by Vet 1. Throat X-ray was not done and is usually not done in cases of coughing.

However, this must be done as there may be a piece of bone stuck inside the throat, leading to persistent coughing and weight loss as the dog ate little. The tongue ulcer could be due to licking of the shampoo over the last 3 months. Wait for the new X-rays to be done today.

"Dog owners may want to be loyal but the vet must be able to get the dog's problem resolved within two visits," I said to my associate vet. "Good bedside manners are great but repeat visits cost the owner money and time. So they go for 2nd opinions if the family vet can't come to a correct diagnosis and treatment."

"Why did Vet 1 not able to diagnose the case?" the man asked me twice after I had shown him the X-rays and asked him and his wife to palpate the enlarged submandibular and popliteal lymph nodes. It is show, not tell nowadays.

"Vet 1 is an experienced vet," I said. "The lung X-ray was normal and the lymph nodes have probably just enlarged in the last month. He did blood test and the result was normal as he had told you."

The second opinion vet has the benefit of the progression of the disease. I warded the thin dog. He did vomit white frothy mucus around 3 times per day and ate little. So, what is the diagnosis and what is the cure?

Use evidence-based medicine and do a thorough physical examination including turning the dog upside down and checking all lymph nodes and doing abdominal palpation. There was no fever, increased respiratory rate or anaemia or other abnormal signs other than the enlarged lymph nodes and tongue ulcers and severe weight loss. The X-rays were useful but the vet must take more than one X-ray. Vet 1 did one X-ray, the quality of which was not so good.






Take more than one view of a site but some vets just do one view to reduce veterinary costs to the client. This may not be in the interest of the canine patient. Study the X-rays again in the privacy of your home and review your case again and do research on similar cases, discuss with peers. This will make you a better vet over the years. There is no short-cut to be a better vet and veterinary medicine and surgery cannot be mastered even with a life-time of practice as the subject of the whole canine body has too many diverse medical and surgical conditions. Human medical or surgical specialists just focus on one area of the human body. Vets have to be know it all!
This is likely a case of canine lymphoma at an earlier stage. Late stage would show images as described in:
http://www.sinpets.com/F5/20110319canine-lymphoma-eye-bleeding-toapayohvets.htm. Due to economic reasons, more detailed tests cannot be done. As to the cure, chemotherapy is needed. Prognosis is not good and the owner knows it. He and his wife were quite satisfied with the diagnosis using evidence-based medicine.

Website and MORE IMAGES and any update will be at:
http://www.sinpets.com/F6/20120202persistent-coughing-young-shih-tzu_Singapore_ToaPayohVets.htm

859. Self-discipline. Dressing at work at Toa Payoh Vets

This new year of 2012, I will not try to be flexible as in the past years. I will not tolerate casual dressing by my vets or the staff or intern.

Sandals, T-shirts and jeans are out. Those who persists will get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.

Dressing casually is out in 2012 and those, including vets who insist on dressing casually will need to look for another job. I had asked intern Mr Lim whether his school had taught him the importance of being properly attired at the office. He said yes. Yet he and many others including some vets used to dress casually in the past years and needed to be reminded.

Last week, one vet told me she had left her shoes in the car when I asked why she wore sandals to work. This was after I had given her advice several times not to do it.
Then 3 days later, she had sandals on again. "A dog had peed on my shoes," she said. I asked: "That is a creative excuse. What will be your next excuse?"

No more nonsense from the younger generation when it comes to office work and productivity. "Toa Payoh Vets is like a baby or puppy," I said to Mr Min and Dr Daniel Sing at his first day of work on February 1, 2012. "It needs perpetual care and attention. It just dies over the next few years if it is poorly managed or not producing good clinical outcomes. Customers will run away. There will be no referrals. The practice just goes bankrupt and there will be no jobs for anyone."

For the younger generation of employees, they can work elsewhere when they don't like my instructions to adopt a proper behaviour at work. But a bad work attitude is not advised as there are some behaviour and common sense expected of a young adult at work. First impressions do count.

If employees want to challenge authority, it is best they find work somewhere. I will not hesitate to fire vets on the spot even if they have a great number of clientele as their attitude erodes the morale and productivity of the staff and other vets.

It is just not for vets, interns or staff to dress casually at work where there is interaction with the public. Vets who want to dress casually can open their own practices and I wish them good luck. I have enough of staff and intern who come to work at Toa Payoh Vets dressed casually as if the office is their parents' home. Young adult employees may know that they must learn to accept instructions and learn from the older generation before they can assume leadership positions as there are predatory veterinary competitors, litigation lawyers and regulatory officers in the real world, unlike in their school days.

858. VET CASE STUDY: Anaesthesia old dog with heart murmurs - Swollen Right Ear. Aural haematoma surgical treatment

This case illustrates the importance of being scientific in giving IV anaesthesia. If the vet simply gives Domitor 0.1 ml IV for small dogs regardless of size and age and top up with isoflurane gas + oxygen at all times, this one dose fits all sizes is not a good practice. This is because a larger dog needs more Domitor to be sedated if the vet wishes to use the same amount of isoflurane gas + oxygen to anaesthesize the dog before intubation.

 
I have the following case to illustrate how a sound knowledge of the use of domitor + ketamine IV based on my formula and based on weight and age (in this case, 25% of the formula) enabled me to perform an aural haematoma surgery WITHOUT the need to top up.

PATIENT
Cross-bred terrier, 13 years old, 6.3kg, good condition, but machinery heart murmur. No coughing. Undescended testicle x 1. Bad teeth. Very high anaesthetic risk but surgery is the only option in this aural haematoma treatment.

This case - IV domitor and ketamine at 25%* of my calculated dosage was sufficient for an old dog not in good health for around 60 minutes of surgery. No blood test was done to screen the health as the owner wanted to keep veterinary costs minimal.


Get all materials and plan early before giving the IV anaesthetic injection

Right ear swollen. Heart disease
Clip hairs


Wash ear well
S-shaped incision of sufficient length. Remove all clots inside
2/0 nylon horizontal mattress suture x 1 packet


Ear irrigation to flush out blood and debris. Dog howls.
Antisedan wakes up dog. Before going home, handing over inspection
Knots are on lateral side of ear pinna. Pain-killers and antibiotics. Home nursing advices.


I audit how long it takes me to do this surgery. The times of my surgery and procedures are as follows:

10.35am
At 25%, D=0.07 ml K=0.09ml = 0.16 ml+ Hartmann to 0.9 ml given IV. Waited 5 minutes. Check blinking reflex which persisted throughout.

11.23 am
2/0 stitching ends.
11.24 am
Irrigate right ear to get rid of any dead ticks. The dog reacted by howling. This showed that the IV surgical anaesthesia lasted till from 10.35 am - 11.24 am. No need to use isoflurane for 48 minutes. This was a surprise to me as I was prepared for isoflurane gas top up.

*NOTES
In young healthy dogs, 25% will be insufficient. The dosage may be up to 100% for 48 minutes of analgesia without isoflurane gas top up.



However fast, I cut and stitched, the whole process was approximately 48 minutes for surgery without pain. At 11.35 am, I injected Antisedan 0.2 ml IM and the dog woke up fast as if he had an afternoon nap. The lady owner was quite happy and took the dog home.

POST-OP NURSING. I phoned the owner today Feb 8, 2012 about 5 days after surgery. The dog was trying to scratch its ears daily despite the e-collar being worn. I advised her to get a clean 10-20 ml syringe, fill it with lukewarm water and irrigate the ear canal which would have contained blood post-operation. This would reduce her costs.

I did not bandage the ear or plug the ear canal with cotton wool although in some cases I would do so. Usually the dog shakes off the bandage within 12 hours unless the whole ear is bandaged to the neck.

Some vets use X-ray plates to be stitched on the lateral and medial side of the ear to provide compression. I don't do it as the results of getting a normal ear back are not good.

NO SURGICAL IMAGES ARE PUBLISHED IN THIS BLOG, due to complaint of 'shocking content'.

Please go to the following webpage with more images of aural haematoma surgery at:
http://www.bekindtopets.com/stories/20120224aural-haematoma-terrier-heart-disease-toa-payoh-vets_Singapore_ToaPayohVets.htm

Travels broaden your mind if you know how

During my travels, shopping and more shopping and good food are not my interest. These activities will be likely most of my readers' interest as they are likely to be young ones.

However, if you want to broaden your mind intelluctually, be an adventurer and be observant of the local customs and culture of Bali.

LOCAL ARCHITECTURE AND CUSTOM
"After you have seen Myanmar villages, you have seen all," Marianne who represented the Singaporean who loves shopping and airconditioning comfort, said to me.
"After you have been to one shopping mall in Hongkong, you have seen all too," I replied. "Yet, every country's shopping mall has different products for sale, if you really investigate. Every country's rural areas are different". I was talking to the wall as Bali was hot and humid and not for Marianne.

On a morning of Jan 31, 2012 (Tuesday), my last day in Bali, I asked the driver to visit his home and got to understand much more the local cultures than reading from the travel guides. Then he brought me to a silversmith in a road lined with silversmith shops. The shop was closed as it was a day before the Gulang festival (Wednesday). But he went to the front gate and I was invited inside.

Wow, this silversmith and his sister spoke English very well. After purchasing two small pieces of ear rings for a 20% discount and no more, I asked about the architecture and layout of his house. It was a very beautiful house but the layout was similar to the driver who had a hard time explaining to me the functions of the layout.

"In the centre is the house for human beings. Ceremonies like filing teeth, deaths and marriages. In the north is the house for parents or grandparents. In the north-east is the land for the gods (various shrines). In the south is the kitchen (and his office factory). "How about to the west?" I asked him? "It can be used for any building," he said.

This explanation was good as the driver could not explain to me when he drove me past many village houses where I noted, from passing by in the car, that many of them have shrines to one side, like mini-temples. Most Balinese are Hindus and therefore religious rituals and ordinary ceremonies are conducted frequently.

GOOD DIGITAL IMAGES OF THE WAY OF LIFE OF THE LOCAL - THE WET MARKET
Practise and practise and you will retain memories of your travels when one day, you are unable to walk. For the young ones, this day will never come.

856. Persistent coughing in a young shih tzu - a 2nd opinion

"My other dog has been treated by Vet 1 for the past 12 years," the owner said he had no veterinary report from the vet who had treated the dog for coughing. "I feel bad to ask Vet 1 for the medical records and X-rays for this Shih Tzu."

"How long has this Shih Tzu been coughing?" I asked.
"5 months. My domestic worker says the dog has a tongue ulcer."

"There should be no problem with Vet 1 sending over your dog's records as this is a common practice. Shall I phone on your behalf?". The owner agreed and Vet 1 sent his report over. The coughing started 3 months ago and blood test and X-rays of the chest and abdomen were normal.

What's the cause of this persistent coughing? There was a tongue ulcer at the tip and one on the hard palate. I shone my torchlight at the ulcers to show the owner. The dog just would not cooperate, but the owner already knew of the existence of the ulcer. I palpated the dog's throat. It was very painful.

"My dog sometimes throw up liquid," the owner said. This is quite a complicated case as the heart and lungs were normal on auscultation using my stethoscope. What is the cause of this persistent coughing?

To complicate diagnosis, the right and left submandibular and popliteal lymph nodes were much enlarged. I let the owner feel the lumps. Could this be a concurrent case of lymphoma or lymphosarcoma?

"Did your tongue lick some poison?" I asked. "Tongue ulcer at the tip of a normal tongue usually indicated something corrosive had burnt the tongue. Like insecticide."

"Well my dog has licked shampoo used to treat his dandruff."
Blood, urine and X-rays of the throat, chest and abdomen are being done as this are necessary to aid in the diagnosis of persistent coughing even though some tests were done earlier by Vet 1. Throat X-ray was not done and is usually not done in cases of coughing. However, this must be done as there may be a piece of bone stuck inside the throat, leading to persistent coughing and weight loss as the dog ate little. The tongue ulcer could be due to licking of the shampoo over the last 3 months. Wait for the new X-rays to be done today.

"Dog owners may want to be loyal but the vet must be able to get the dog's problem resolved within two visits," I said to my associate vet. "Good bedside manners are great but repeat visits cost the owner money and time. So they go for 2nd opinions if the family vet can't come to a correct diagnosis and treatment."

More images at:
http://www.sinpets.com/F6/20120202persistent-coughing-young-shih-tzu_Singapore_ToaPayohVets.htm

855. KINDLE STORIES - Travel Stories - Bali, Jan 30, 2012. Perseverance in sales

Tuesday, Jan 31, 2012. Last day in Bali


Jan 30, 2012. Pushpapuri Villa
Drizzling. No more beautiful blue sunrise as yesterday. Can't see Mount Agung due to fog on mountain.

Morning. Visited Mt Batur and Lake Batur. An active volcano 1700 metres above sea level. Perseverance is the key to success as I noted that the little girls of around 7 years old do get some sales if they persevere. The roadside vendors do not bother and their sales will be low since there are so many proactive roadside sellers. Usually ladies including a mother carrying a child.

Many roadside stalls sell various types of fruits as I approach Mt Batur. I bought from an aged woman, some bananas and mangosteens as they were sweet. The rambutans and tangerines were not sweet and I did not buy them. A little girl from the stall further up persevered in asking me to buy her wooden spoons or flowers. Since she persevered, I bought three spoons.

Visited a nursery nearby where coffee plants are labelled for tourism. The best coffee is the one from the stools of a wild cat-like creature but I do not want to drink such coffee.

Religious rituals. Many villagers are preparing for "Galungan", a major Hindu holiday on Wednesday when Balinese Hindus celebrate victory of virtues over vices. Not seen in Singapore.

Offerings are made with Pacar Cina flowers and coconut leaves which soared in prices. The coconut leaves are made into square containers to keep the offerings. Also cakes, incense, fruits to make 18 small offerings, 3 large fruit offerings of gebogan. What cannot be missed during my travel to Mt Batur passing the villages, is the making of the "penjor" which is a decorated bamboo pole to be placed in front of the house.
(Pictures).

A researcher of 405 households in all 9 regency-level regions in Bai reported in The Jakarta Post, Jan 30, 2012, Pg 6 - Balinese Edition that Balinese Hindus spend 10.5% of the household revcenue per year to finance routine religious festivals. Around 108 routine religious festivals per year excluding events like the rites of passage (e.g baby's first tooth drops off, adulthood) and "Ngaben" cremation.

Afternoon
While the others went shopping at the Sogo etc, I asked the driver to bring me to see the 2002 Bali Bombing site. Over 200 party-goers had died in this blast. There is a memorial on this site. Amongst the names, 88 were from Australia. The first bomb site is a car park lot. The second blast is a memorial with the names of the dead from various countries. None from Singapore. It is very sad as these must be young adults if what I saw in this famous road is representative. Over 99% of the tourists are Caucasians and young adults. Bars and pubs are numerous. The sun and surf in Bali attracts many young people.

A little girl of around 7 years suddenly dashed in front of our moving car travelling back to the Villa along Legen beach where the surfers and hotels are packed. My 23-year-old driver braked in time. I saw one adult Balinese put a hand on his heart area as he witnessed this scene. It is really hard to grow into adults when little children are left alone to wander. Another little girl came to our car to beg for money at a traffic junction crossing the busy road.

Three thin ponies in their carriage waited in between small yellow orange buses for the tourists to go home after surfing or a day at this beach.

From this trip and from limited observations of 2 days in Bali, I learnt that perseverance is the key to successful sales and that the female gender is better at sales, being highly motivated to earn as I don't see the boys doing any sales at the tourist spots. Maybe they are somewhere working.

854. A difference of veterinary opinions but a good outcome counts

A young lady consulted the vet. Her kitten had diarrhoea for a few days. It was adopted from the SPCA and had been fed chicken and rice. The kitten was given to the SPCA the day before, according to the young lady. It was therefore not vaccinated.

COMPLAINT
The main concern was diarrhoea. Watery. What should the vet do?

VET 1's OPINION
"No treatment is necessary," Vet 1 said to her. "It is due to the change of environment and diet. Just give boiled chicken and rice and wait a few days.

MY OPINION
Though the kitten is active and eating, it does not mean that it is not incubating a viral infection picked up at the SPCA. It takes 7-14 days to show the symptoms of diarrhoea and the young lady had the kitten for around 7 days.

In this case, to save on costs, no blood was done. A stool test should be done. If I treat this case, I would have given a drug to stop the diarrhoea, SC fluid and ask the owner not to feed the kitten for 24-48 hours and to give oral electrolytes. "But the kitten is not dehydrated," Vet 1 said.

Oral electrolytes should be given because the kitten has been having diarrhoea for several days. It is not severely dehydrated. Does the university professor teaches that electrolytes should be given when there is severe dehydration? I don't know. Each vet will treat a case differently but in the end a good clinical outcome is what counts.

This kitten has loose stools but no watery stools. No deworming had been done nor had the faecal sample been checked for worms. Sometimes it may be a case of endo parasites since this is a stray kitten. Time will tell.