Saturday, January 21, 2012

829. The chattering chihuahua

Jan 20, 2012 Friday

The young couple came with the Chihuahua as scheduled. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form hihglighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery."

I had seen the couple on last Sunday and had advised antibiotics for the next few days and getting the dental work done on Friday. I told Dr Vanessa I would be handling the case myself as there was great worries for the fair lady. Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal

Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.

Isoflurane + oxygen anaesthesia only.
Proper sized endotracheal tube which was 6.5
Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

Wednesday, January 18, 2012

826. Teeth scaling an 8 year old male silkie terrier

Dec 12, 2011

Nervous silkie terrier. Slight pain in larynx.


Blood test - SGPT/ALT 109 (<59) but otherwise all normal.
Urine test bacteria +++.
Surprising to find bacteria in the urine of a male dog. Licks ventral area.



Calculated dosage 10 kg young dog D=0.4 K=0.5
This is old dog, 7.4 kg. Give 50% of calculated dose

Domitor = 0.15 Ketamine = 0.18 Total 0.33 IV sufficient
Teeth still strong. So only dental scaling




Noted tip of epiglottis red but tonsils normal.

Tibetan Mastiff sedation

"Do you do house-calls for a very big dog with itchy ears?" an old client and friend asked me the fees to treat a very big dog at the home of her friend.

"It will be a waste of your money," I said. "Ear disease diagnosis need a microscope and other assistants to help out."

Tibetan Mastiff, Male, 7 months, 53kg. Healthy. Ear canals with black wax seen daily. Had lots of ticks recently when walked outdoors.

EAR IRRIGATION & LICK GRANULOMA INJECTION
A gentle giant but still it is best not to traumatise him. My client said: "My friend's dog was hit by a car, bit the owner's arm later."

SEDATION
Do a proper calculation as follows:
My guideline IV anaesthesia
10 kg young dog Domitor = 0.4 ml, Ketamine = 0.5 ml combined IV
53 kg young dog D= 2.12ml K=2.65ml
I gave 40%, D=0.85 K=1.06 Total = 1.85ml IV as this would be a short anaesthesia of around 10 minutes needed for me to irrigate the ears and inject the 3 lick granulomas with prednisolone intra-lesionally.

"My dog will not get up on the table," the owner said.
"No dog will climb up a veterinary table," I explained to the gentleman. "I will carry his back half and you carry his chest. Talk to your dog while we carry or he will feel he is being murdered."
The dog was carried up on the table by the owner and my assistant Min without a protest.

Now, to find that leg vein as the coat is so thick. The foreleg was thick as this was a man-sized dog. I don't clip off the hairs to see the vein as it is not acceptable.

"Tighten the tourniquet," I said to Min who had not seen large a gigantic dog. Singapore's dogs are usually small breeds and Tibetan Mastiffs are as rare as snowfall.

I pressed the swelling and drew the blood into the syringe. I injected the 1.85 ml IV.

The dog slept at this 40% of calculated dosage. I taught the owner how to check the ear canal and insert the cotton bud, smell it and then I irrigated the ear canals.

After that I injected pred into the 3 lick granulomas. The dog did twitched a little on the 3rd lick granuloma being injected but was otherwise knocked out.












4949 - 4958. Itchy ears and three interdigital cysts/lick granulomas must be treated early - Tibetan Mastiff. If itchiness of ears and paws are not treated early by your vet, the dog self-mutilates to relieve himself of the intense itchiness. Hair loss and skin infections present themselves soon
"I need to wake up the dog," I said as I injected Antisedan 1.0 ml IM on the right hip muscles. He woke up 10 minutes later and that was great.

The above 40% dosage was sufficient for a short painless ear irrigation and lick granuloma injection of less than 10 minutes.

Know how to check the ears and prevent interdigital cysts and lick granulomas in a big furry breed as it is a high maintenance breed. Brush daily and inspect daily. Clean ears. It is extremely difficult to avoid ticks. Wear booties or check paws after a walk. "I avoid the grass," the owner just walked the dog in the evenings along the road.

The following advices to the owner who had bought a very strong hair blower for Tibetan Mastiff were:

1. Daily brushing of the coat with the slicker and another brush rather than hot air blowing everyday as the dog has some skin itchiness and eczema, probably due to the earlier tick bite infestations.
2. Daily inspection of the ears
3. No rough cotton wool to dig the ears
4. There is no need to pour his ear lotion by pumping into the ears every day if the ears are clean. He use to do it every day. Daily ear dropping had resulted in brown black wax being produced.
To check the ear canals as to whether they are clean or not, I taught him how to insert the cotton bud into the ear canal. See the colour of the tip and smell it. If the colour is clear, the ear has no dirt.
5. Washing of the paws with an anti-fungal solution and rinsing.
6. A long bath tub is needed if he wants to de-tick his dog.
7. Get a big table (as long as my surgery table) and put the dog on top of the table to do his grooming. This is easier on his back.
8. Avoid tick areas. Inspect the four paws when the dog is back from outside walks. He had used Frontline sprays and spots-on insecticides but these have become ineffective over time. Wearing of booties when going out for walks is not practical as the dog needs to wear out his nails. So, daily inspection of the paws for the smallest baby tick after exercise.

This was about the biggest dog in Singapore. As big as a young man. A very gentle giant. If he bites the vet, the vet's fingers can be crushed to pieces. So it is important that he be treated gently and to use sedation if there is pain during treatment, as there is, in the intra-lesion injection of his lick granulomas.

Overall, he was good and could walk back to the car. I helped to carry him onto the boot of the friend's SUV. The owner's BMW was probably not big enough! It was great to meet up with this old client who had consulted Dr Vanessa for the past times as I was seldom around in the afternoons. I asked her to make an appointment to let me check out her dog's skin condition when she said that "old" vets are more experienced. Every vet needs to start at the beginning but young vets need to gain the experience with time. Experience is gained not only be practising but by reading a lot of veterinary literature on relevant situations and consulting other vets for how they treat certain conditions. It may sound stupid to ask other vets but much can be learned from asking.


NINE more images are at:
http://www.sinpets.com/dogs/20120119Tibetan-Mastiff-lick-granulomas-ear-itchiness-singapore_ToaPayohVets.htm

Tuesday, January 17, 2012

824. Vet surgery - productivity - cat spay

I am sharing my 30 years of experiences of a cat spay with others interested and to assess my timing as a guide for associate vets

Cat, 1 year +, Female, 2.6 kg
Sent in for spay toeday Jan 17, 2012
Surgeon: Dr Sing
Suture: 2-0 Polysorb braided lactomer C14 cutting 24 mm 3/8

Preparation: Cat was clipped bald before sedation. This saves a lot of time.

Sedation:
xylazine 0.1 ml + ketamine 0.4 ml IM
Wait 10 minutes. Still alert
Need top up isoflurane for few seconds - good analgesia


Timing
10.33am xylazine + ketamine IM
10.43 am Isoflurane 5% start reducing to 0.5%
10.52 am Skin incision started
10.54 am lst ovary (left) hooked
10.59 am 2nd overy (right) hooked
11.02 am uterine body ligated. 2 ligatures
11.08 am stitch linea alba 3 simple interrupted
11.11 am stitched skin 2 horizontal mattress
11.12 am skin stitched up

Sedation to skin stitched 10.33 - 11.12 am = 39 minutes

Tolfedine and baytril injection SC
One bandage on wound to be replaced on Day 3 with new one. I usually don't prescribe e-collar as cats hate them
Baytril x 1 tab 1/4 tab/day

Total cost of spay $150

Sunday Jan 15, 2012 interesting cases - tonsillar tumours

Bright sunshine, blue skies, white cloud.

Case 1.
A 12-year-old well cared for female, Golden Retriever, drooling on the left side only.
Vet 1 did dental scaling and extraction. Dog then started "drooling on left side."
Vet 1 then smoothened left lower PM4 since the upper PM4 and others had been extracted. Still the drooling persisted.
Vet 2 was "thorough" according to the owner. He X-rayed and ultrasound the whole body. "How about the head and neck area?" I asked. The owner did not think this was done.

According to the owner, said a big lump was present on the left back of mouth and a spherical lump on left neck below the submandibular. He recommended steroids as an alternative to euthanasia and surgery. When the dog was on steroids, she was very hungry and drank a lot. When given Tramadol, the drooling stopped. The dog had lost a lot of weight.

The dog did not want the mouth to be opened but I managed to open it and showed the owner and her sister (anaesthetist) the large tonsillar tumour (at least 3 cm x 2 cm). Pain and ulcerations there would be the cause of drooling.

CASE 2
Surprising an 8-year-old small breed came in for review after this Golden Retriever. I had done dental scaling 4 weeks ago. The dog objected strongly to the mouth being opened, but I could see the right tonsil as reddish lump 0.5 x 0.5 cm. I had told the owner of this lump seen during dental scaling. It could be a tonsillar tumour. The owner would wait and see.

If dog owners regularly check the dog's teeth and keep it cleaned or scaled yearly or two-yearly, many oral tumours would not form. This is the same with human beings too. A poor hygiene in the mouth predisposes to oral tumours and this is commonly reported.

CASE 3
"See the lump under the right eye," I had pointed it out to her at the waiting area. Later, she gave me permission to take a photo. "That is the beginning of a malar abscess - infection from the root of the back tooth into the sinus and bulging out." She had come for advice as Vet 1 wanted her to sign an indemnity form for dental work in case the dog dies under anaesthesia.

"How many deaths were under you while you did dental scaling?" the young lady was very worried about her 8-year-old chihuahua who had Stage 4 periodontal disease (the worst stage) and asked Dr Vanessa who was handling the case together with me. She did most of the talking. Many times, I would see the case together with her and most of the time, she would be doing the talking. Some owners would think I am an assistant and know nothing and so why was I giving medical advices? I usually identify myself as a vet first.

"How many?" the young lady asked again. "Ask Dr Sing," Dr Vanessa replied.

"In my over 30 years of dental scaling and I can only speak for myself, I don't have any cases of dogs doing dental work dying on the operating table," I replied. "Dental work or scaling takes a short time of less than 15 minutes unlike long surgeries and therefore, anaesthetic deaths are uncommon in many senior dogs. A very close focus on anaethesia by the vet and his assistant is very important. In old dogs, I don't give IV sedation but just isoflurane gas only."

The young lady was already red-eyed but well read about anaesthetic deaths of dogs on the operating table. I could understand her concern for the Chihuahua which was in good bodily condition unlike those skinny ones. A bit plump is better as this indicated that this dog was well cared for and had a good appetite (meaning good health too.)

"A blood test is taken to screen the dog's health first," Dr Vanessa said as she examined the heart and lungs and found them OK.
"A 10-day course of antibiotics before dental scaling is what I recommend usually to clients," I said. "The dental scaling is done around 7-10 days later and the mouth would be free of bacteria."
The boyfriend asked the young lady (in her late 20s) to wait for the blood test. So, it was quite an emotional consultation.

This Sunday was an eventful one as my assistant Min fell sick with flu. He left at 10 am to see the doctor and had the day off. Ms Ong, a junior college student with an offer from Glasgow Univ for vet studies came for her first day and so she got to see all the cases since the other three interns (Kim quitted suddenly as she found that it was too costly to study vet medicine, Mr Lim was said to have denque fever, Grace, going to 2nd year vet student from Sydney Univ would come only on Monday.

It was a bright sunshine Sunday and we managed to close at 5.30 pm. I advised Dr Vanessa to record as she communicate to the client as this is what I do, but she had her own style of writing only after everything. So there was much delay. Record what the client said e.g. history on the spot. That would be the efficient way as many clients dislike waiting too long. Some of the clients had to wait more than an hour and from my view at the reception, many prefer short consultations and getting the problem resolved. Waiting more than 15 minutes at the doctor is not a happy event for any Singaporean on a Sunday when there are so many things to do!

Sunday, January 15, 2012

822. A twitching eye. Acquired Oculomotor Nerve Palsy in a Golden Retriever

"Is the right sunken eyeball present since puppyhood?" I asked the lady owner who showed me a bottle of eyedrops prescribed by Vet 1. No other medication was given by Vet 1 who diagnosed eye infection and advised review if the eye condition did not improve.

Case of the Golden Retriever with a twitching eye
Golden Retriever, Male, 8 years. Weight below normal.
Complaint: Fits 2 days ago. I advised bringing the dog to the Surgery rather than a house-call which would waste money as the dog needed more detailed examination.
History: Right eye is smaller than left eye. Vet 1 prescribed eye drops.

Right eye: Drooping eyelid, retracted eyeball, twitching uncontrollably as if blinking at me when reviewed. Occasional twitching (videoed by Nicole).
3rd eyelid covered the right eyeball partially since it has sunken in.
Hospitalised. Blood and urine tests are minimum tests done.

Lumbar puncture for cerebrospinal fluid analysis, MRI scan of the brain are not done at this stage to lower vet costs.




Oculomotor nerve palsy and brain involvement leading to ptosis & fits





OCULOMOTOR NERVE is the 3rd cranial nerve. It innervates the muscles co controlling eye movements, the upper eyelid muscle and the muscles controlling pupil constriction.

In this dog, the Oculomotor nerve and its branches had been damaged or inflamed causing the eyeball to sink inwards, the eyelid to droop. However, since the dog suffered from fits, the lesion is likely to be inside the brain e.g. brain tumour or aneurysm near the Oculomotor nerve or inflammation.

Blood test - high serum urea
Urine test - proteinuria
Brain scan and lumbar puncture are costly options which need to be discussed with the owner.

Other contributing causes
Trigeminal neuralgia involving only the ophthalmic nerve? The trigeminal nerve has 3 branches - ophthalmic nerve, maxillary nerve and mandibular nerve. There does not appear to be facial spasm or dropped jaw and so, the maxillary and mandibular nerves are not involved. The ophthalmic nerve may be involved.

Diagnosis
Brain scan and lumbar puncture are needed for a definitive diagnosis of acquired Oculomotor nerve palsy in this dog but it is costly.


Treatment
Anti-fits and review. The dog can eat and drink and has no more fits when on anti-fit medication. Steroids were not prescribed. To review.


Updates and more pictures at:
http://www.sinpets.com/dogs/20120115oculomotor-nerve-palsy-golden-retriever-fits-singapore_ToaPayohVets.htm

Saturday, January 14, 2012

Educational Video from Toa Payoh Vets - Itchy joints in a dwarf hamster

http://www.youtube.com/watch?v=D3yl4GmBBU4&feature=youtu.be


UTI = Urinary Tract Infection