601. Cardiac tamponade - before and after treatment

I hope the two newly created images of cardiac tamponade from my file will bring veterinary medicine alive to the final year students about to graduate from Australian Universities in Dec 2011.

The case study is at:
http://www.sinpets.com/F5/20110904cardiac-tamponade-labrador-retriever-heart-base-tumour-likely-ultrasound-singapore_ToaPayohVets.htm

During my final year exam in Glasgow University in 1974, I need to pass the final exam at one go. That was the system. Nowadays, the students pass exam by modules during the two semesters and the total of the modules add up. It is much less stressful than during my time as I need to study everything and anything to pass the final exam or not graduate.

I have a viva from a visiting professor. An animal will be presented and I need to diagnose and give treatment advice. I don't know whether the final year students in Australian University still gets this oral practical exam of a case presentation for the final exam. If they get cardiac tamponade like this case, they may at least do well, I hope.

Any heartworm in this Labrador Retriever?
No. See image of test.

600. Microchip details must be given to the AVA as from Sep 1, 2011

I reminded Dr Vanessa and my assistant Min that microchip numbers must be recorded properly and submitted to the AVA. It is a legal requirement in the sense that the AVA is the authority licensing the vet surgery and compliance is paramount.

As a licensee, I need to be monitoring the legal aspects of vet practice. So, I had to be on my toes in ensuring that compliance is done by my two vets. The younger vets have their own personalities and culture but legal requirements of a practice, the standard of care, the duty of care must be professionally done to ensure that Toa Payoh Vets has a good reputation.

The heavy responsibility falls on the licensee who is me. Generation Y Singaporeans have grown up in an environment of abundance and behave differently from the earlier generation that grew up from the school of hard knocks.
The world has changed but that does not mean that legal compliance and professionalism should be ignored.

As for Dr Vanessa, I had explained to her a few times that the breeders are taking advantage of a breeders-win, vets-lose situation with her services. The breeder buys the microchip and she implants it for him free of charge at Toa Payoh Vets.

This is providing free services, in addition to below cost Caesarean section and vaccination. "A vet studies hard for 5 years and here, the breeder and pet shop operators get him or her to provide below cost services! There is something not right," I said to the breeder.

I will be monitoring breeders and pet shop operators that take advantage and get free services from my associate vets. It is just not sustainable in the long run as the practice has overheads. I had just rejected a dog breeder who brought in puppies with vomiting and diarrhoea dying from parvovirus and dictated to my vet that he should not do parvoviral test.

599. Follow up on dwarf hamster with big cyst

The dwarf hamster was operated by me at the 3rd time for a stinking right ear problem. The vertical ear canal was excised (ear canal ablation surgery) and subsequent recurrence of infection for 2nd operation and the 3rd surgery was the big cyst excised. The case study is at:
http://www.sinpets.com/F6/20110906dwarf-hamster-cyst-abscesses-ear-canal-ablation-singapore_ToaPayohVets.htm

Now, a red swelling and pus discharge (from image sent from owner) from the horizontal ear canal and e-mail query on medication as follows:

E-MAIL FROM DR SING DATED SEP 11, 2011

Hi Dr Sing,

Bean will complete her 7-day course of anti-biotics this evening. But there is a yellowish lump?/discharge? (photo is attached) She also rubs her ear quite vigorously sometimes. Should I continue to give her anti-biotics for a few more days? And the anti-inflammatory med as well? Appreciate your advice please.

Thank you.


E-MAIL FROM DR SING DATED SEP 11, 2011
Just read your email but we spoke by phone earlier. Discharge is pus originating from the inflamed lump. Pl press it gently to get the pus out. Continue medication as spoken. Best to phone me rather than e-mail or text as sometimes I don't read emails immediately.

598. A gentle Alsatian with painful right ear

Friday 5 pm. Sep 9, 2011

"I have an appointment at 5 pm. How long must I wait?" the busy lady asked. There were two more cases waiting for Dr Vanessa and she was consulting with one. I estimated it would take an hour but it would not be within 15 minutes of waiting time.

Appointment times are not always on-time. The 12-year-old 37.5 kg Alsatian had a left ear haematoma operated by Dr Jason Teo some months ago. "The ear is bent," the lady said that the vet had told her that the ear would be upright after the haematoma surgery. It is not always true, depending on many factors. In this case, the right ear was very painful. The dog also had ticks which did not respond to the Frontline spot on.

"Have you boarded the dog recently?" I asked. She said: "The dog was lost and was found by the SPCA. Can I get some ear drops from you?"

This was a case that the ulcerated itchy right ear ought to be thoroughly irrigated. That meant anaesthesia rather than syringe the dog's ears. I do that sometimes if the case of ear infection is not serious. But this ear was bad.

Ear drops and medication would be expedient but would not help the dog. I asked Dr Vanessa whether she could take the case. She said she could. But that mean waiting as there was the other clients of hers.

I took over the case as it is best not to make clients wait. Big dogs with ticks are best treated promptly as their ticks will infest the surgery too.

SEDATIVE USED

For a healthy 10kg young dog, the IV anaesthesia I use is as follows:
Domitor 0.4 ml
Ketamine 0.5 ml
Total 0.9 ml IV for 10 kg dog

This was a 37.5 kg dog, very old.
So at 37.5 kg
Domitor 1.5 ml
Ketamine 1.9 ml

But this is a very old dog.
5.36 pm, I gave
Domitor 0.8 ml
Ketamine 1.4 ml
Total in one syringe 2.2 ml IV for 37.5 kg dog ie. at around 50% of calculated dose.
I gave Atropine 1.5 ml IM first.
Put the dog on the table. He was gentle and laid on his chest.

5.57pm, The dog was well sedated as I vigorously rubbed his ear canal to dislodge debri and he did not mind. Lots of oil, rubbish, clotted blood and yellow wax. The ear irrigation was completed at 5.57 pm. I asked my assistant to help me while I inject Antisedan antidote 1.0 ml IV. The owner was shown that there is light pink blood-tinged tip of cotton bud in right ear but nothing in left ear. I asked her to smell the tip. Not much of a smell but she said: "There is a smell." I said: "Some smell as the ear infections had been so long and ulcers are there." I scoped the right ear and asked her to look at the ulcer. She saw redness in the ear canal.

6.07 pm, the dog lifted his head and was alert after an increase in breathing rate. But could not stand up. I had a feeling that the Antisedan might not have gone 100% IV as there was some obstruction during the IV as the needle shifted. Other younger dogs do get up and stand up within 5 minutes after Zoletil. In this case, the old dog could not stand up. I analysed that he was old and took a longer time to recover. Or that my combination dosage was high on the ketamine side. In any case, a dog alive is what the owner wanted and he was very much alive, to the delight of the lady.

I got the dog down from the table onto the floor. He was in front of the surgery and everybody could see what was happening. He laid sideways and his back legs extended straight for a while. "Why this is happening?" the lady owner asked me.
"It is the effect of ketamine," I said. "Not serious."

The dog was not fully alert but could lift his head and see us. We carried him to the car. The lady carried the head, I carried the chest and Min carried the back. "Head in first," I said.

Overall, this was a satsifactory case. The dog should recover well with medication and a new brand of anti-tick Advantix.

"It is best not to make clients wait a long time," I advised Dr Vanessa. Sometimes it can't be helped and I will intervene to help out. But the main bulk of the case load is hers from 11 pm to 7 pm. Mine is from 9 am to 11 am and at other times when needed.

Two days ago, an American came during lunch-time. My assistant was out for lunch but Dr Vanessa was in. "You are the Vet Tech," he asked me since I was manning the reception. I explained I am a vet and was covering the lunch period. Service is much more personalised when the Surgery does not have many lay people and helping hands.

"So you just manage the practice?" the American asked. "Yes," I said. "I do some difficult operations but the routine ones are left to my two vets."
I had more time talking to him about his day-trading and learning much about his business. "You make $400 in 2 hours from trading the S&P index," I said. "It is not that easy," he said. "You have to study the patterns of past trading and know which scenario to apply. Stop loss or continue along the curve?"

I learnt there is a bigger S&P index for the big players and smaller mirror one for the day traders. I guess it is hard work to earn an honest living in any profession and that past precedents and cases make a day trader or vet successful. There is no short cut to success in earning an honest livelihood. But I can't sit in front of the monitor to do day trading. I also can't be a dentist sitting on the chair to do dental scaling or work on the mouth of people.

I enjoy seeing the dogs or pets recover from their pain and various diseases from head to toe, not just the mouth and that is what veterinary medicine and surgery offer. It is a privillege and few people have this opportunity and I hope I can share some anaesthesia knowledge to bring vet medicine alive to the poor undergraduates studying for their final exam in Australia now.

599. Update on the labrador retriever with the "double chin" - cardiac tamponade

I hope this article brings veterinary medicine alive to the final year students about to take their 5th year examinations in November 2011 in Australia and wish them all the best.


http://www.sinpets.com/F5/201108030cardiac-tamponade-labrador-retriever-heart-base-tumour-likely-ultrasound-singapore_ToaPayohVets.htm - Part 1

I sent the dog to a vet who did the X-rays and the ultrasound of the heart as well as pericardiocentesis as I don't have the equipment in my very small practice of 50 sq m.

"The X-ray of the lateral view does not show a mediastinal mass," he agreed that the ventral/dorsal view had shown such a mass. Therefore, he did not support my tentative diagnosis of mediastinal mass. More investigations will be needed.

The dog's skin swelling returned to normal after a few days of lasix. But the dog is fully cured.








X-rays of cardiac tamponade. Is there an anterior mediastinal mass or not? I say yes, but the vet I consulted say no as he says that the lateral view does not show the mass. Will need more investigation and review.
An anterior mediastinal mass could be due to a tumour like thymoma or thyroid enlargement extending backwards and other causes. The pericardial effusion fluid showed mitotic cells. The ultrasound showed a heart mass tumour. Reviews are necessary.






Pericardial effusion is seen on echocardiography (right and above) --->

The dog had no more "double chin" 3 days after pericardiocentesis and on furosemide injection and oral medication which lasted 8 days. 13 days after pericardiocentesis, the dog was reviewed. He had put on weight and is no longer short of breath as before. More alert and barks at outside dogs on walk at night. The furosemide medication is continued. "Spend more time with him," I advised the owner. This is a beloved companion and a most gentle big dog.

September 6, 2011 report
"Let him enjoy his life," I said to the lady owner as I phoned her about the 2nd blood test done on Sep 6, 2011 and compared it to that done in Aug 25, 2011 when the dog had anaemia. Blood transfusion cost $1,200 when she asked me. I had not advised her as I did not think that this dog whose gums were pinkish would need one and in any case, it would be costly. So, I advised good food like liver, egg yolk, iron, folic acid and multivitamin tablet supplementation.

Compare the blood results

Aug 25, 2011. Can't breathe. I couldn't hear sounds. Double Chin. Both paws swollen and other parts of body. I gave 60 mg Lasix Iv and sent to Vet 2 for ultrasound, X-ray and 3rd opinion as to the cause of this "double chin" which I suspected was due to a large mediastinal mass. Cardiac Tamponade. Pericardiocentesis done and goes home. Vet 2 said possible heart tumour at base of heart and mitotic figures seen in pericardial fluid indicated neoplasia.

Aug 25, 2011
Haemoglobin 8.1 (12-18)
Red cell count 3.5 (5.5-8.5)

Sep 6, 2011. Left paw swollen slightly. Heart sounds can be heard at 30% of the normal breed size which was used as benchmark and teaching for my assistant and the lady owner. The belly looked a bit swollen when lying sideways. Lasix tablets had been given for 8 days from Aug 25, 2011 to Sep 2, 2011. Then no furosemide. I had advised to continue for the life span of the dog and so had phoned the owner to come for review.

Sep 6, 2011
Haemoglobin 10.3 (12-18)
Red cell count 4.3 (5.5-8.5). > 20% increase in red cell count due to good nutrition and supplements.
I could feel the spleen much enlarged like a child's shoe. That was not possible earlier. X-ray did show splenomegaly. Bad news.

WHITE CELL COUNT normal range. However see the composition:

Aug 25, 2011
WBC 7.8 (6-17) - normal
Neutrophils 91%
Lymphocytes 7%
Monocytes 0.5%
Eosinophils 0.9%
Basophils 0%
Platelets 191 (200-500)
PCV 0.24 (0.37-0.55)


Sep 6, 2011
WBC 8.5 (6-17) - normal
Neutrophils 57%
Lymphocytes 21%
Monocytes 8.7%
Eosinophils 11.5%
Basophils 1.5%
Platelets 316 (200-500)
PCV 0.27 (0.37-0.55)
Why the increase in monocytes and eosinophils? Is it associated with splenomegaly and endo-parasites? Heartworm blood test on 6 Sep was negative.

The Labrador now barks at passers-by outside and is more active. No long walks. Urine colour now much lighter and normal said the owner. Not so thin as there is flesh above spinal process. But weight was 35kg compared to 38 kg on Aug 25, 2011. "The water inside the skin and heart must have weighed 3 kg," the owner remarked. It was possible.

HISTORY
Jun 21, 2011. Diarrhoea and fever. 2 days. Recovered with tolfedine medication.
Aug 11, 2011. Very weak. owner gave tolfedine medication 60mg tablet 2x/day for 2 days. Recovered
Aug 16, 2011. Appetite normal but lethargic.
Aug 22, 2011. Neck swelling prominent. double chin. Went to Vet 1 who diagnosed "fat" or suspect cancer. X-ray abdomen and blood test normal.
Aug 25. 2011. Consulted me. Cardiac tamponade based on ultrasound and X-ray. Pericardiocentesis done by Vet 2. Medication for 8 days and advised review after that.
Sep 6, 2011. Reviewed. Left fore paw swollen and other signs as above.

Overall, the owner said by August 29, 2011, no more double chin or preputial and other swellings.

Pericardial fluid taken one had cell with mitotic figures. A heart tumour could not be ruled out.

More images are at:
http://www.sinpets.com/F5/20110904cardiac-tamponade-labrador-retriever-heart-base-tumour-likely-ultrasound-singapore_ToaPayohVets.htm

596. The Yorkshire has a hard stomach area

The young lady was very worried as she waited for Dr Vanessa to finish the case before seeing her 6-year-old dog. Her taxi father recognised me from some 2 years ago when I was consulted about this dog.

She had seen Vet 1 who gave two injections two days ago. "My dog is still not well. She is not eating," the undergraduate said. She turned the small dog upside down and placed her on her lap. "See the big hard lump," she pointed to the "paunch" from below the rib cage.

I palpated this gently. "It could be a full stomach. Full of gas or water," I said. "Has she been spayed?" I asked.
"No," the young lady replied.
I noted the enlarged nipples and a slight swelling of the mammary gland. I placed my thumb and forefinger on the nipples. Creamy white milk gushed out. The lady was surprised. So was the father.
"Your dog has false pregnancy," I said. "Your dog has not been mated but still produced milk and this medical condition is called false pregnancy."
"Is it due to me not vaccinating her for the past two years?" the lady asked.
"No," I said. "It is due to an abnormal female reproductive system. Spaying her will prevent such problems."

I continued: "The hard lump is probably due to a lot of gas inside the stomach or a lot of water." Her dog had been drinking a lot but not eating much. "Very fussy about food, like me," the slim lady said to me.

When Dr Vanessa was available, the young lady, her father and dog went into the consultation room. The dog was given injections and an enema. She passed out some stools outside the clinic. No more tense stomach lump. The lady was happy.

Increasing the standard of veterinary practice - weight

"Taking the cat's weight and temperature is not necessary" one vet I visited at the evening clinic said to me. "Taking weight is a waste of time."

I had said that the dog's weight and temperature must be recorded before vaccination. This vet jabbed the cat at the scruff of the neck with the cat vaccine one week before spaying.

"The weight is important," I said. "If the cat loses weight, you can compared to his original weight of first visit. It is not only for litigation or complaint investigation."

Even the hamster's weight must be taken but sometimes I noted that my assistant did not do so.