Sunday Dec 11, 2011
1. Post-spay complications do occur now and then to all vets performing spays in female dogs. It is hard to prevent every case.
Post-op 7 days later, an active Jack Russell came with swelling and inflammation at the spayed area. It looked as if the dog had irritated the spayed area due to itchiness as the owner said he had never taken out the e-collar. The dog was warded. There was no complaint till recently. The dog had pain-killers and antibiotics post-op.
2. 18-year-old cat with 2 large sores on back spinal area. "Would you advise euthanasia?" the owner asked me. "This cat was paralysed last year and treated by you," the owner said. "He could walk later."
"How long it took to walk normally?" I recorded injury T10-L3, jumped upon by the Golden Retriever. I was much surprised that he could be alive.
"A year of walking on front legs and then all 4 legs,.
"It is up to the owner to decide," I said. "Is the cat eating?"
The owner said: "Yes,".
"Many times it will be the children who are against euthanasia," I said.
"No euthanasia," the pre-teen child who listened intenly decided.
I don't advise euthanasia and it should be the owner's decision as treatment may or may not cure. But euthanasia denies a chance of living.
Gave the old cat a warm bath after Min had clipped bald. Got a kettle of water boiled and bathe this aged feline who went into fits when I touched the two big scabs on his back, somewhere on either side of the T10-L3 area Had fleas. Needed grooming and ear cleaning.
3. 4-year-old Schnauzer with globular skin tumour around 8mm x 8mm on right neck
"Any drugs to make it disappear?" the lady in her 30s asked me.
"Not advised," I said. "This is a skin growth. It may or may not be cancerous."
"How much?"
"Anaesthesia and surgery and medication estimated around $250," I said. "Do you want to know whether it is cancerous or not. If you want to know, I will send to the lab for histopathology."
"What if the growth is cancerous?" the husband asked. "Is there a cure?"
"It is not guaranteed," I said. "Depends on type of malignancy."
So, it was decided that the lump be removed and dental scaling be done at the same time to save on costs.
4. Paralysed Shih Tzu.
This Shih Tzu could lift his head but would not stand on his four legs as 2 days ago. His tongue was peculiarly a dark pinkish red. I took him outside the Surgery at 1.10 pm for review. He peed, looked at me. Later he pooped a large amount of soft brown black stools.
Same eye reflex as before when I shone the bright light on both eyes. The left one was dilated while the other constricted on light shone on the pupils. The left one dilated lesser amount than 2 days ago. I asked Dr Vanessa to pinch the front toes of both front paws. Both paws showed withdrawal reflex.
Blood sample taken to check for infection. Glucose, duphalyte and IV drip given. "It takes a long time to recover," I said to Dr Vanessa. "It is not going to be so soon."
Sunday, December 11, 2011
768. Dietary management to dissolve struvite stones in the dog - no surgery
Below is an update of what I wrote from Perth in Sep 2010 when I was there on holiday and sat down to read the very thick book "Small Animal Clinical Nutrition" far away from the distractions of practice in Singapore.
The website is at:
http://www.sinpets.com/F5/20100697struvite-dietary-management-voiding-urohydropropulsion_ToaPayohVets.htm
The following is copied from the website:
After the surgical removal of the struvite urinary stones or for medical and dietary treatment, how much of the prescription diet should the owner give the dog/day?
I took some time just to read about Canine Struvite Urolithiasis case studies in the sleep-inducing thick book "Small Animal Clinical Nutrition" by Hand et. al, 5th Edition while on holiday in Perth, Australia. The following is some general guideline for Toa Payoh Vets in advising on Prescription Diet s/d to dogs based on 3 case studies in the book.
How much of the s/d diet to be given?
1. Puppy X-breed, 9 weeks,
5 kg.
700kcal (2.83MJ)
1/2 can 3x/day
2. Rottweiler, 5 years, 41 kg
1,800kcal (7.5MJ)
1.5 cans 2x/day
3. German Shepherd, 12 years, 27 kg
1,150kcal (4.8MJ)
1 can 2x/day
Other procedures to ensure compliance from the owner:
1. Antibiotics from 14-30 days and review using urine cultures
2. Monthly urine analysis (check for UTI) and blood tests (esp. serum urea nitrogen, magnesium, phosphorus and calcium and alkaline phosphatese)
3. Monthly x-rays of kidney (V/D view), bladder (lateral views).
Back to normal commercial food for the puppy as soon as X-rays show no stones. For adult dogs, give prescription food for one more month after negative X-ray results. No commercial dog treats or snacks during the period of treatment. In practice, I advise initially 3 months of the S/D diet and get urine tests done monthly in most cases. The Singapore dog owner seldom complies with the above-mentioned procedures or with monthly urine tests! Till blood in the urine returns!
RECURRENT UTI
Specialised tests like double-contrast cystography (to check out anatomic abnormalities of the bladder, obstruction of urine flow from kidneys), retrograde positive-contrast urethrocystography (to check out anatomical abnormalities of the urinary tract to the prostate gland area, bladder tumours) if there is recurrent uroliths or UTI (see case study of the old Corgi with recurrent UTI.
Recurrent UTI in an old Corgi - Part 1 http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm
Voiding urohydropropulsion is used in cases where the uroliths are small. The owner must be informed that it takes 2-4 months or longer to get all struvite stones dissolved. The owner must be aware of the need for reviews and to note the costs involved in the dietary management to dissolve struvite urinary stones.
VETERINARY SURGERY --- VOIDING UROHYDROPROPULSION IN DOGS AND CATS
What is urohydropropulsion? Basically it means pumping saline into the bladder (3ml/kg) and suck out the fluid together with the small uroliths (urinary stones) with a catheter. The stones in the bladder are too small and therefore no surgical removal is needed.
ANAESTHESIA. May or may not be need.
APPROACHES. Two methods described in Small Animal Clinical Nutrition 5th edition.
POSITION 1. Hold the dog or cat upright so that the vertebral column is upright. The urine and stones will be at the bottom (neck) of the bladder.
POSITION 2. Lateral recumbency.
In both positions, catheterise, irrigate with saline (3ml/kg), massage or press bladder to shake up the stones, suck out the saline + stones with a syringe. X-rays to check if all are taken out but not all small ones can be seen.
Dietary and medical treatment.
More information is at: Small Animal Clinical Nutrition" by Hand et. al, 5th Edition
This webpage:
http://www.sinpets.com/F5/20100697struvite-dietary-management-voiding-urohydropropulsion_ToaPayohVets.htm
The website is at:
http://www.sinpets.com/F5/20100697struvite-dietary-management-voiding-urohydropropulsion_ToaPayohVets.htm
The following is copied from the website:
After the surgical removal of the struvite urinary stones or for medical and dietary treatment, how much of the prescription diet should the owner give the dog/day?
I took some time just to read about Canine Struvite Urolithiasis case studies in the sleep-inducing thick book "Small Animal Clinical Nutrition" by Hand et. al, 5th Edition while on holiday in Perth, Australia. The following is some general guideline for Toa Payoh Vets in advising on Prescription Diet s/d to dogs based on 3 case studies in the book.
How much of the s/d diet to be given?
1. Puppy X-breed, 9 weeks,
5 kg.
700kcal (2.83MJ)
1/2 can 3x/day
2. Rottweiler, 5 years, 41 kg
1,800kcal (7.5MJ)
1.5 cans 2x/day
3. German Shepherd, 12 years, 27 kg
1,150kcal (4.8MJ)
1 can 2x/day
Other procedures to ensure compliance from the owner:
1. Antibiotics from 14-30 days and review using urine cultures
2. Monthly urine analysis (check for UTI) and blood tests (esp. serum urea nitrogen, magnesium, phosphorus and calcium and alkaline phosphatese)
3. Monthly x-rays of kidney (V/D view), bladder (lateral views).
Back to normal commercial food for the puppy as soon as X-rays show no stones. For adult dogs, give prescription food for one more month after negative X-ray results. No commercial dog treats or snacks during the period of treatment. In practice, I advise initially 3 months of the S/D diet and get urine tests done monthly in most cases. The Singapore dog owner seldom complies with the above-mentioned procedures or with monthly urine tests! Till blood in the urine returns!
RECURRENT UTI
Specialised tests like double-contrast cystography (to check out anatomic abnormalities of the bladder, obstruction of urine flow from kidneys), retrograde positive-contrast urethrocystography (to check out anatomical abnormalities of the urinary tract to the prostate gland area, bladder tumours) if there is recurrent uroliths or UTI (see case study of the old Corgi with recurrent UTI.
Recurrent UTI in an old Corgi - Part 1 http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm
Voiding urohydropropulsion is used in cases where the uroliths are small. The owner must be informed that it takes 2-4 months or longer to get all struvite stones dissolved. The owner must be aware of the need for reviews and to note the costs involved in the dietary management to dissolve struvite urinary stones.
VETERINARY SURGERY --- VOIDING UROHYDROPROPULSION IN DOGS AND CATS
What is urohydropropulsion? Basically it means pumping saline into the bladder (3ml/kg) and suck out the fluid together with the small uroliths (urinary stones) with a catheter. The stones in the bladder are too small and therefore no surgical removal is needed.
ANAESTHESIA. May or may not be need.
APPROACHES. Two methods described in Small Animal Clinical Nutrition 5th edition.
POSITION 1. Hold the dog or cat upright so that the vertebral column is upright. The urine and stones will be at the bottom (neck) of the bladder.
POSITION 2. Lateral recumbency.
In both positions, catheterise, irrigate with saline (3ml/kg), massage or press bladder to shake up the stones, suck out the saline + stones with a syringe. X-rays to check if all are taken out but not all small ones can be seen.
Dietary and medical treatment.
More information is at: Small Animal Clinical Nutrition" by Hand et. al, 5th Edition
This webpage:
http://www.sinpets.com/F5/20100697struvite-dietary-management-voiding-urohydropropulsion_ToaPayohVets.htm
Saturday, December 10, 2011
767. No more smelly urine after the end of antibiotics for an old corgi
On Friday Dec 9, 2011, at 11.40 am, I was in the consultation room facing Dr Vanessa and Mr Min on the other side of the consultation table. I conducted a meeting regarding work performance to ensure that the quality of veterinary service is up to my standard and to be free of clientele complaints.
"In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it monthly as I expect both of you to do your part and to adopt my advices for changes. However, I have to discuss with both of you work matters today."
One of the topics I spoke about was the need for direct eye-contact with clients to connect well.
"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."
I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.
As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.
I said: "A quadriplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadriplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.
"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.
P.S. In the evening, the lady and her husband who read on the internet about IVDD (intervertebral disc disease) came after work. I was still around as I booked in a 6-week-old male guinea pig for neutering and showed another Shih Tzu with eye injury in to Dr Vanessa's room for her to treat.
As for the couple, I placed their Shih Tzu on the table and shone bright lights onto each eye. The left eye pupil was dilated despite the bright light. The right eye pupil was constricted. I said to the couple: "This showed that the left eye does not have a direct pupillary response to light." As for consensual pupillary response, the left eye does not constrict even when the bright light was shone onto the right eye.
So, the left eye also did not have consensual pupillary response. The neurological explanation will sound too technical to the owners and so I did not want to confuse them by elaborating.
"Basically, I would say that the traumatic injury is around the brain stem," I said. "The X-rays showed two microchips. One was on top of the cervical spinal bone. Whether this would cause the present problem, I do not know. The other one was in the armpit area.
However, the dog could put weight on the right fore limb and this morning, he could walk upright or limped a distance of over 5 metres before collapsing," I said. I pinched the toes of all 4 limbs in front of the couple. Only the left fore limb had no withdrawal to pinching reflex pain sensation. In veterinary practice, showing is communication to the owner as nowadays, the young Singaporeans are so much more sophisticated.
"There is some improvement," I said and the couple could see it too. "We feed the dog around 4 times a day and give the necessary vitamins. He can't eat on his own. He has got the energy and alertness now. But he needs complete rest and so please do not stay long." The couple adjusted the water bottle height and reluctantly left at 7.30 pm.
A HAPPY LADY IN RED CAME TO THE SURGERY
A fair lady in red sheath dress, with black eyeliner suddenly came into the waiting room and waved at me from the outside. My consultation room's door has a glass window on the top half and so I could see who was coming into the waiting area. This lady, in her prime at around early 30s, looked quite familiar and since she waved to me, she must have met me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of my reiterations of things to do, government and legal processes to be complied with and records to be written meticulously. Reminders to staff appear to be part of a manager's job and it is a role I rather not be involved in. But I was the licensee and the ultimate responsibility of any clientele complaint, investigation and litigation is with the licensee.
I said hi to the lady in red. Fairness and bright red always demand attention. The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do remember Oreo. She had seen a few vets and always passed smelly urine after a course of antibiotics. For at least 2 years or so. Is she OK now?" I had thought of following up but had not done so and now one month had flown by. Just like that.
"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken and is no more. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment after the end of antibiotics as in the past."
"How many times does Oreo pee and how much does she drink per day?" I asked. "Did you measure the amount of water she drinks a day?" It was difficult for her to answer precisely as she did not take note. She said: "I can't measure the amount because Oreo drinks only fresh water and so the bowl of left over water has to be replaced."
I was surprised that her female spayed dog peed all over the apartment at such an old age. "An adult dog usually pees twice a day, in most cases," I said. "The fault lies with the owner if she pees many times a day," I said. "The owner has no properly house-training the dog as a puppy." This frankness was not good bedside manners.
"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"
"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month.
"You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine. No other food, dog treats or any other pills."
"My dog loves apples," she said. "Can I give her apples? She looks at me appealingly for apples when I eat one."
"It is best not to," I said. "You had suffered over 2 years of this problem of smelly urine after antibiotics after seeing a vet. Now, her urine is not smelly without antibiotics. Why take risks? Let her urinary tract system stabilise over 3 months of eating S/D diet and drinking plain water. Then you may give her apples."
As regards whether the Corgi was harshly disciplined when she was younger, the lady in red said: "Yes, she got spanked when she peed everywhere." the lady said. "This may be why she withholds her urine till the last moment and urinated a very large puddle of urine onto the floor. What do you suggest I do now?"
At first I advised confinement and removing the urine smell in the floor apartments using white vinegar + water at 1 part to 3 parts water.
As she was moving to a new apartment away from Woodlands soon, I advised: "Complete confinement for 24 hours in a room, with a baby gate, for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success. Let the dog out when you are at home and pick her up when she is about to pee on the floor and put her into the confined area. Say in a firm tone 'Pee here.' Give a treat if she does that or a praise. Persevere. Old dogs can learn new tricks too especially when you start from a new house."
This case of recurrent UTI seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.
Will wait and see. The "living happily ever after" story has not concluded but it seems that there is a good clinical outcome of my recommendations and that is what the lady in red wanted and what all owners whose pets have long suffering diseases demanded.
PREVIOUS REPORT
Written in Oct 31, 2011 (>1 month ago), Recurrent UTI in an old Corgi is at:
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
The blog has brief version:
http://2010vets.blogspot.com/2011/10/717-recurrent-uti-in-old-corgi-is-hard.html
THE WEBSITE FOR THIS FOLLOW UP REPORT WRITTEN DEC 10, 2011 IS AT:
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm
"In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it monthly as I expect both of you to do your part and to adopt my advices for changes. However, I have to discuss with both of you work matters today."
One of the topics I spoke about was the need for direct eye-contact with clients to connect well.
"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."
I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.
As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.
I said: "A quadriplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadriplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.
"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.
P.S. In the evening, the lady and her husband who read on the internet about IVDD (intervertebral disc disease) came after work. I was still around as I booked in a 6-week-old male guinea pig for neutering and showed another Shih Tzu with eye injury in to Dr Vanessa's room for her to treat.
As for the couple, I placed their Shih Tzu on the table and shone bright lights onto each eye. The left eye pupil was dilated despite the bright light. The right eye pupil was constricted. I said to the couple: "This showed that the left eye does not have a direct pupillary response to light." As for consensual pupillary response, the left eye does not constrict even when the bright light was shone onto the right eye.
So, the left eye also did not have consensual pupillary response. The neurological explanation will sound too technical to the owners and so I did not want to confuse them by elaborating.
"Basically, I would say that the traumatic injury is around the brain stem," I said. "The X-rays showed two microchips. One was on top of the cervical spinal bone. Whether this would cause the present problem, I do not know. The other one was in the armpit area.
However, the dog could put weight on the right fore limb and this morning, he could walk upright or limped a distance of over 5 metres before collapsing," I said. I pinched the toes of all 4 limbs in front of the couple. Only the left fore limb had no withdrawal to pinching reflex pain sensation. In veterinary practice, showing is communication to the owner as nowadays, the young Singaporeans are so much more sophisticated.
"There is some improvement," I said and the couple could see it too. "We feed the dog around 4 times a day and give the necessary vitamins. He can't eat on his own. He has got the energy and alertness now. But he needs complete rest and so please do not stay long." The couple adjusted the water bottle height and reluctantly left at 7.30 pm.
A HAPPY LADY IN RED CAME TO THE SURGERY
A fair lady in red sheath dress, with black eyeliner suddenly came into the waiting room and waved at me from the outside. My consultation room's door has a glass window on the top half and so I could see who was coming into the waiting area. This lady, in her prime at around early 30s, looked quite familiar and since she waved to me, she must have met me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of my reiterations of things to do, government and legal processes to be complied with and records to be written meticulously. Reminders to staff appear to be part of a manager's job and it is a role I rather not be involved in. But I was the licensee and the ultimate responsibility of any clientele complaint, investigation and litigation is with the licensee.
I said hi to the lady in red. Fairness and bright red always demand attention. The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do remember Oreo. She had seen a few vets and always passed smelly urine after a course of antibiotics. For at least 2 years or so. Is she OK now?" I had thought of following up but had not done so and now one month had flown by. Just like that.
"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken and is no more. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment after the end of antibiotics as in the past."
"How many times does Oreo pee and how much does she drink per day?" I asked. "Did you measure the amount of water she drinks a day?" It was difficult for her to answer precisely as she did not take note. She said: "I can't measure the amount because Oreo drinks only fresh water and so the bowl of left over water has to be replaced."
I was surprised that her female spayed dog peed all over the apartment at such an old age. "An adult dog usually pees twice a day, in most cases," I said. "The fault lies with the owner if she pees many times a day," I said. "The owner has no properly house-training the dog as a puppy." This frankness was not good bedside manners.
"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"
"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month.
"You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine. No other food, dog treats or any other pills."
"My dog loves apples," she said. "Can I give her apples? She looks at me appealingly for apples when I eat one."
"It is best not to," I said. "You had suffered over 2 years of this problem of smelly urine after antibiotics after seeing a vet. Now, her urine is not smelly without antibiotics. Why take risks? Let her urinary tract system stabilise over 3 months of eating S/D diet and drinking plain water. Then you may give her apples."
As regards whether the Corgi was harshly disciplined when she was younger, the lady in red said: "Yes, she got spanked when she peed everywhere." the lady said. "This may be why she withholds her urine till the last moment and urinated a very large puddle of urine onto the floor. What do you suggest I do now?"
At first I advised confinement and removing the urine smell in the floor apartments using white vinegar + water at 1 part to 3 parts water.
As she was moving to a new apartment away from Woodlands soon, I advised: "Complete confinement for 24 hours in a room, with a baby gate, for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success. Let the dog out when you are at home and pick her up when she is about to pee on the floor and put her into the confined area. Say in a firm tone 'Pee here.' Give a treat if she does that or a praise. Persevere. Old dogs can learn new tricks too especially when you start from a new house."
This case of recurrent UTI seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.
Will wait and see. The "living happily ever after" story has not concluded but it seems that there is a good clinical outcome of my recommendations and that is what the lady in red wanted and what all owners whose pets have long suffering diseases demanded.
PREVIOUS REPORT
Written in Oct 31, 2011 (>1 month ago), Recurrent UTI in an old Corgi is at:
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
The blog has brief version:
http://2010vets.blogspot.com/2011/10/717-recurrent-uti-in-old-corgi-is-hard.html
THE WEBSITE FOR THIS FOLLOW UP REPORT WRITTEN DEC 10, 2011 IS AT:
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm
Friday, December 9, 2011
766. A happy lady in red
Friday Dec 9, 2011
I was in the consultation room facing Dr Vanessa and Mr Min as I conducted a meeting regarding work performance. "In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it as I expect both of you to do your part and to adopt my advices for changes."
One of the topics I spoke about was the need for direct eye-contact with clients to connect well.
"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."
I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.
As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.
I said: "A quadraplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadraplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.
"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.
A fair lady in red with black eyeliner suddenly came into the waiting room and waved at me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of me.
The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do remember (name of dog). He had seen a few vets and always passes smelly urine after antibiotics. For at least 2 years or so."
"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment."
I was surprised that her female spayed dog peed all over the apartment. "The fault lies with the owner," I said. "For not properly house-training the dog as a puppy."
"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"
"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month. You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine."
"Yes, she got spanked" the lady said. "What do you suggest I do now?"
As she was moving to a new apartment away from Woodlands, I advised complete confinement for 24 hours in a room for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success.
This case seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.
Will wait and see.
4.40 pm. Back to work. A shih tzu with central eye ulcer.
I was in the consultation room facing Dr Vanessa and Mr Min as I conducted a meeting regarding work performance. "In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it as I expect both of you to do your part and to adopt my advices for changes."
One of the topics I spoke about was the need for direct eye-contact with clients to connect well.
"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."
I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.
As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.
I said: "A quadraplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadraplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.
"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.
A fair lady in red with black eyeliner suddenly came into the waiting room and waved at me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of me.
The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do remember (name of dog). He had seen a few vets and always passes smelly urine after antibiotics. For at least 2 years or so."
"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment."
I was surprised that her female spayed dog peed all over the apartment. "The fault lies with the owner," I said. "For not properly house-training the dog as a puppy."
"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"
"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month. You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine."
"Yes, she got spanked" the lady said. "What do you suggest I do now?"
As she was moving to a new apartment away from Woodlands, I advised complete confinement for 24 hours in a room for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success.
This case seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.
Will wait and see.
4.40 pm. Back to work. A shih tzu with central eye ulcer.
765. Adopt sick or old dogs
Today I had a woman in her late 40s bringing in a 9-year-old male and a very thin 5-year-old pregnant female cocker spaniel for examination as she had adopted them. The dogs needed dental cleaning but she would not want to pay for the services. She went to get something from her van.
Suddenly she rushed back to say that a gasping puppy was present on the floor of her front van seat. I got the puppy which was attached to the placenta out and tried to revive it. Her teenaged daughter was not afraid of the smell and I taught her how to clean the puppy. The dam had little milk and so I asked them to buy milk powder.
Below is another example of adoption of sick dogs
EMAIL Dec 5 (4 days ago)
to drsing
I have an enquiry to make and would really appreciate if you could help. I have decided to adopt a 6 months old Shetland sheepdog and border collie mix, but the breeder told me that he has skin problems, (he thinks it is fungus) on his back. I would like to know if I should wait for the wounds to heal before adopting it or i can adopt it and bring it to the vet for a check. If I were to bring the dog for a check at your veterinary, how much would it cost, ad how long would it take for the skin problem to recover?
Thank you,
Name given
EMAIL Reply
Kong Yuen Sing
Dec 5 (4 days ago)
I am Dr Sing. It is best to adopt a dog with no skin disease. As for vet costs, it depends on what is the cause of the skin disease and prices vary from $60 to over $200 for complicated skin disease cases.
EMAIL TO DR SING DEC 7, 2011 (2 days ago)
to me
Thank you for the reply. I have decided to get a healthy 3 months old Sheltie. May I know how much will it cost for the third vaccination and microchip at your veterinary?
Thank you,
Name given
EMAIL FROM DR SING On Dec 9, 2011, at 1:40 PM, Kong Yuen Sing <99pups@gmail.com> wrote:
Vaccination is around S$40 and microchip $50. Pl phone 6254 3326 for appointment. Thank you.
Suddenly she rushed back to say that a gasping puppy was present on the floor of her front van seat. I got the puppy which was attached to the placenta out and tried to revive it. Her teenaged daughter was not afraid of the smell and I taught her how to clean the puppy. The dam had little milk and so I asked them to buy milk powder.
Below is another example of adoption of sick dogs
EMAIL Dec 5 (4 days ago)
to drsing
I have an enquiry to make and would really appreciate if you could help. I have decided to adopt a 6 months old Shetland sheepdog and border collie mix, but the breeder told me that he has skin problems, (he thinks it is fungus) on his back. I would like to know if I should wait for the wounds to heal before adopting it or i can adopt it and bring it to the vet for a check. If I were to bring the dog for a check at your veterinary, how much would it cost, ad how long would it take for the skin problem to recover?
Thank you,
Name given
EMAIL Reply
Kong Yuen Sing
Dec 5 (4 days ago)
I am Dr Sing. It is best to adopt a dog with no skin disease. As for vet costs, it depends on what is the cause of the skin disease and prices vary from $60 to over $200 for complicated skin disease cases.
EMAIL TO DR SING DEC 7, 2011 (2 days ago)
to me
Thank you for the reply. I have decided to get a healthy 3 months old Sheltie. May I know how much will it cost for the third vaccination and microchip at your veterinary?
Thank you,
Name given
EMAIL FROM DR SING On Dec 9, 2011, at 1:40 PM, Kong Yuen Sing <99pups@gmail.com> wrote:
Vaccination is around S$40 and microchip $50. Pl phone 6254 3326 for appointment. Thank you.
New graduates of Murdoch Univ - Dec 2, 2011
On Dec 2, 2011, the 5th year Murdoch Univ vet students were informed of their exam results in a graduation dinner. I had met some of the Singaporeans last year and there was one I was particularly concerned. Did this person pass or not? Has this person wasted 5 years studying a most-sought after profession? I was glad this person had passed and has become a vet.
Apparently, according to this person, in Australia, a new vet earns around A$3,500 per month while a dentist earns A$10,000 a month and a doctor earns A$500/day. I don't know why as vet undergraduates are straight As or are top in their cohort during 'A' levels. In Singapore, a new vet earns around S$3000 - $4,000 a month generally.
Those Singaporeans with rich parents open their own practice after one year of experience as the regulatory authorities permit this. That is why we have around 50 vet clinics in 2011. Flyers are distributed into letterboxes by some of the new practices to announce their presence. This practice had been done by some of the previous vets too. Some did it by proxies using the groomer.
Will a vet earn more when they start their own practices? Maybe in the long term for many of them and if they are much less "expensive" than the older vets. But there are vets who have had closed their practices.
Good communication with the owners is usually lacking, according to this new vet I spoke to yesterday. It is very important in private practice but seldom taught in vet school. Technical skills can be picked up from books. "Doesn't Murdoch Univ teach communications with clients?" I asked. "There is a video presentation of consultation with clients and feedback."
Communications with clients is easily taught. It is part of the personality. Some do it very well. Some can't do it. I said to the new vet: "But at the end of the day, it is still a correct diagnosis." When a diagnosis is correct, the dog gets well and the owner returns or refers.
Academic results at Murdoch Univ batch in 2011
Probably 60 students in the 5th year
9 get high distinctions (HD) (over 80% in Year 3,4 and 5).
1 failed
Distinctions (70% - 79%)
From what I know, two ladies in the HD are from Singapore. One of them got 79.5% and I am glad that she got the award as the professors recognised her hard work and efforts. "What if she got 79.4%?" I wondered.
Being top in academic performance in vet school is great. It can lead to great arrogance that the world is their oyster. To succeed in private practice, academic excellence with arrogance leads to disaster for the practice and possible sacking as clients provide adverse feedback to the principal.
Apparently, according to this person, in Australia, a new vet earns around A$3,500 per month while a dentist earns A$10,000 a month and a doctor earns A$500/day. I don't know why as vet undergraduates are straight As or are top in their cohort during 'A' levels. In Singapore, a new vet earns around S$3000 - $4,000 a month generally.
Those Singaporeans with rich parents open their own practice after one year of experience as the regulatory authorities permit this. That is why we have around 50 vet clinics in 2011. Flyers are distributed into letterboxes by some of the new practices to announce their presence. This practice had been done by some of the previous vets too. Some did it by proxies using the groomer.
Will a vet earn more when they start their own practices? Maybe in the long term for many of them and if they are much less "expensive" than the older vets. But there are vets who have had closed their practices.
Good communication with the owners is usually lacking, according to this new vet I spoke to yesterday. It is very important in private practice but seldom taught in vet school. Technical skills can be picked up from books. "Doesn't Murdoch Univ teach communications with clients?" I asked. "There is a video presentation of consultation with clients and feedback."
Communications with clients is easily taught. It is part of the personality. Some do it very well. Some can't do it. I said to the new vet: "But at the end of the day, it is still a correct diagnosis." When a diagnosis is correct, the dog gets well and the owner returns or refers.
Academic results at Murdoch Univ batch in 2011
Probably 60 students in the 5th year
9 get high distinctions (HD) (over 80% in Year 3,4 and 5).
1 failed
Distinctions (70% - 79%)
From what I know, two ladies in the HD are from Singapore. One of them got 79.5% and I am glad that she got the award as the professors recognised her hard work and efforts. "What if she got 79.4%?" I wondered.
Being top in academic performance in vet school is great. It can lead to great arrogance that the world is their oyster. To succeed in private practice, academic excellence with arrogance leads to disaster for the practice and possible sacking as clients provide adverse feedback to the principal.
763. Pupillary light refex - A paralysed Shih Tzu
Yesterday, Dec 8, 2011, I was consulted about a Shih Tzu that was "paralysed". The sister had phoned me on Dec 7 for a 3rd opinion and I had asked her to send the dog in for examination as it is difficult to know what is going on by phone diagnosis.
The dog was treated by Dr Vanessa on Dec 7 and so I asked her where was the area of pain. I had seen the dog lying sideways in the crate. My assistant Min said Dr Vanessa had treated the dog. She came in around 11.30 am. I was about to talk to Dr Vanessa when the brother came in. This was the best time as it is always good for the owner to be involved in the examination.
AREA OF SPINAL PAIN
The dog had been treated by Vets 1 and 2 with steroids and so the area of spinal pain was not specifically known to Dr Vanessa when she received the dog. "Which area of the spine is painful?" I asked her since she had given a steroid injection and any pain would be masked.
The dog was able to lift his head but was unable to stand on four legs and that was definitely injury to the central nervous system. "Slight pain is further to the back area," Dr Vanessa said. It would be difficult to diagnose pain in the spinal area when the dog had been treated with pain-killers by Vets 1 and 2. Their medical records were brief. Acupuncture was done by Vet 2. But both of them had not done any X-ray. Later in the evening, the sister who had taken the dog to the vet spoke to me and said that she was given the choice of "X-ray" and/or "MRI."
There seemed to be some miscommunication here. Since I did not speak to Vets 1 and 2, I would presume that they had advised X-ray and the owners had opted out but the owner had said she was not a professional and should not be given a choice. It is extremely difficult nowadays. I usually advise X-ray in such traumatic cases and if the owner declines, I will record it down in my medical record. This is to avoid this type of "mis-communication".
For this report, I would focus on the pupillary light reflex done on the Shih Tzu in the presence of the brother. A bright light was shone directly on each eye to check the consensual and direct pupillary light reflex
DIRECT EYE REFLEX
Left eye - pupil does not constrict
Right eye - pupil constricts
So, what is the problem?
See notes from Wikipedia below.
Clinical significance
In addition to controlling the amount of light that enters the eye, the pupillary light reflex provides a useful diagnostic tool. It allows for testing the integrity of the sensory and motor functions of the eye.[1]
Under normal conditions, the pupils of both eyes respond identically to a light stimulus, regardless of which eye is being stimulated. Light entering one eye produces a constriction of the pupil of that eye, the direct response, as well as a constriction of the pupil of the unstimulated eye, the consensual response. Comparing these two responses in both eyes is helpful in locating a lesion.[1][5]
For example, a direct response in the right pupil without a consensual response in the left pupil suggests a problem with the motor connection to the left pupil (perhaps as a result of damage to the oculomotor nerve or Edinger-Westphal nucleus of the brain stem). Lack of response to light stimulation of the right eye if both eyes respond normally to stimulation of the left eye indicates damage to the sensory input from the right eye (perhaps to the right retina or optic nerve).[1]
Emergency room physicians routinely assess the pupillary reflex because it is useful for gauging brain stem function. Normally, pupils react (i.e. constrict) equally. Lack of the pupillary reflex or an abnormal pupillary reflex can be caused by optic nerve damage, oculomotor nerve damage, brain stem death and depressant drugs, such as barbiturates.
Normally, both pupils should constrict with light shone into either eye alone. On testing each reflex for each eye, several patterns are possible.[6]
Optic nerve damage on one side: (Example in parens.: Left optic nerve lesion)
The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, neither pupil constricts, as no signals reach the brain from the left eye due to its damaged optic nerve)
The ipsilateral consensual reflex is INTACT (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
The contralateral direct reflex is intact (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
The contralateral consensual reflex is lost (because light shone into the eye on the damaged side cannot signal to the brain; therefore, despite the right eye's motor pathway (oculomotor nerve) being intact, no signals from the left eye are able to stimulate it due to the damage to the sensory pathway (optic nerve) of the left eye)
Oculomotor nerve damage on one side: (Example in parens: Left oculomotor lesion)
The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, only the right pupil constricts)
The ipsilateral consensual reflex is lost (Example: when the right eye is stimulated, only the right pupil constricts)
The contralateral direct reflex is intact (because light shone into both eyes can still signal to the brain, and the pupil on the undamaged side will still be able to constrict via its normal oculomotor nerve)
The contralateral consensual reflex is intact (because light shone into the left eye can still signal to the brain via the normal optic nerve, causing attempted constriction of both pupils; the contralateral pupil constricts via its normal oculomotor nerve, but the ipsilateral pupil is unable to constrict due to its damaged oculomotor nerve)
I will write more later
The dog was treated by Dr Vanessa on Dec 7 and so I asked her where was the area of pain. I had seen the dog lying sideways in the crate. My assistant Min said Dr Vanessa had treated the dog. She came in around 11.30 am. I was about to talk to Dr Vanessa when the brother came in. This was the best time as it is always good for the owner to be involved in the examination.
AREA OF SPINAL PAIN
The dog had been treated by Vets 1 and 2 with steroids and so the area of spinal pain was not specifically known to Dr Vanessa when she received the dog. "Which area of the spine is painful?" I asked her since she had given a steroid injection and any pain would be masked.
The dog was able to lift his head but was unable to stand on four legs and that was definitely injury to the central nervous system. "Slight pain is further to the back area," Dr Vanessa said. It would be difficult to diagnose pain in the spinal area when the dog had been treated with pain-killers by Vets 1 and 2. Their medical records were brief. Acupuncture was done by Vet 2. But both of them had not done any X-ray. Later in the evening, the sister who had taken the dog to the vet spoke to me and said that she was given the choice of "X-ray" and/or "MRI."
There seemed to be some miscommunication here. Since I did not speak to Vets 1 and 2, I would presume that they had advised X-ray and the owners had opted out but the owner had said she was not a professional and should not be given a choice. It is extremely difficult nowadays. I usually advise X-ray in such traumatic cases and if the owner declines, I will record it down in my medical record. This is to avoid this type of "mis-communication".
For this report, I would focus on the pupillary light reflex done on the Shih Tzu in the presence of the brother. A bright light was shone directly on each eye to check the consensual and direct pupillary light reflex
DIRECT EYE REFLEX
Left eye - pupil does not constrict
Right eye - pupil constricts
So, what is the problem?
See notes from Wikipedia below.
Clinical significance
In addition to controlling the amount of light that enters the eye, the pupillary light reflex provides a useful diagnostic tool. It allows for testing the integrity of the sensory and motor functions of the eye.[1]
Under normal conditions, the pupils of both eyes respond identically to a light stimulus, regardless of which eye is being stimulated. Light entering one eye produces a constriction of the pupil of that eye, the direct response, as well as a constriction of the pupil of the unstimulated eye, the consensual response. Comparing these two responses in both eyes is helpful in locating a lesion.[1][5]
For example, a direct response in the right pupil without a consensual response in the left pupil suggests a problem with the motor connection to the left pupil (perhaps as a result of damage to the oculomotor nerve or Edinger-Westphal nucleus of the brain stem). Lack of response to light stimulation of the right eye if both eyes respond normally to stimulation of the left eye indicates damage to the sensory input from the right eye (perhaps to the right retina or optic nerve).[1]
Emergency room physicians routinely assess the pupillary reflex because it is useful for gauging brain stem function. Normally, pupils react (i.e. constrict) equally. Lack of the pupillary reflex or an abnormal pupillary reflex can be caused by optic nerve damage, oculomotor nerve damage, brain stem death and depressant drugs, such as barbiturates.
Normally, both pupils should constrict with light shone into either eye alone. On testing each reflex for each eye, several patterns are possible.[6]
Optic nerve damage on one side: (Example in parens.: Left optic nerve lesion)
The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, neither pupil constricts, as no signals reach the brain from the left eye due to its damaged optic nerve)
The ipsilateral consensual reflex is INTACT (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
The contralateral direct reflex is intact (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
The contralateral consensual reflex is lost (because light shone into the eye on the damaged side cannot signal to the brain; therefore, despite the right eye's motor pathway (oculomotor nerve) being intact, no signals from the left eye are able to stimulate it due to the damage to the sensory pathway (optic nerve) of the left eye)
Oculomotor nerve damage on one side: (Example in parens: Left oculomotor lesion)
The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, only the right pupil constricts)
The ipsilateral consensual reflex is lost (Example: when the right eye is stimulated, only the right pupil constricts)
The contralateral direct reflex is intact (because light shone into both eyes can still signal to the brain, and the pupil on the undamaged side will still be able to constrict via its normal oculomotor nerve)
The contralateral consensual reflex is intact (because light shone into the left eye can still signal to the brain via the normal optic nerve, causing attempted constriction of both pupils; the contralateral pupil constricts via its normal oculomotor nerve, but the ipsilateral pupil is unable to constrict due to its damaged oculomotor nerve)
I will write more later
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