921. The vet's suture protruded the skin - Good stitching patterns count.

921. The vet's suture protruded the skin - Good stitching patterns count.

Two days ago, two ladies and their father brought a 17-year-old cat to the Surgery. The cat had been pawing her neck trying to get rid of a nodule 1 cm x 1 cm. Dr Daniel handled the case. The over 70-year-old slim built father was at the waiting room and I was at the reception and since he was chatty, I had an interesting conversation with him.

"Why do you not go to the vet nearby your house?" the father mentioned that he lived near a vet. However, his daughter did not want to consult this vet.

"The vet spayed this cat. But the cut was very long," he said. "The skin protruded from the stitches. So my daughter did not want to go there."

"Standard spay wounds are around 2 cm long," I said. "Unless there are complications of bleeding or other reasons such as pyometra."

In this case, I did not know what had happened. This is one of the times that a neat and good stitching pattern does impress and count in retaining client loyalty. And this was 17 years ago when the daughter would be in her teens. This daughter-in-charge looked to be in her earlier 30s and was in the IT field, according to the father. So, the internet brought her to Toa Payoh Vets, according to the father. The internet is a double-edged sword and could drive clients away when there are bad reviews from one or two vocal unhappy owners or competitors.

Well, the 17-year-old cat had this irritating neck nodule (1 cm x 1 cm) that she scratched. Dr Daniel's advice of a blood test prior to surgery was accepted by the IT daughter. Serum urea and creatinine levels were above normal and though the cat was normal, the daughter was not in favour of surgery.

"This cat has white strong teeth," Dr Daniel told me. "Can this cat be younger?"
"Very rare for a 17-year-old cat to have good teeth," I said. "But many cat owners do know the age of their cats."

As the father was complaining about a specialist earlier, I asked him what was the problem. "The specialist told me what was the big fuss I was making about my health since the brain scan showed no brain tumours? Why would I pay for a brain scan?"

Sometimes, it is best for a doctor or vet not to comment on personal behaviour but stick to the medical facts.

"What's exactly happened to your father's eye?" I asked the IT daughter later as her father did not speak English but the Hokkien dialect. The daughter put her fore-finger on the lateral side of her left eye and pulled up the eyelid at 45 degrees. "His eyelid flicked sideways and upwards now and then."

"The specialist said he had no problem in the brain MRI," I said. "That may be because the problem could be somewhere between the eyeball and the brain!"

"We are not refined cultured people like the specialist," the father was still mad about the poor bedside manners of this specialist.

Yet he does have a real medical problem. Earlier he had a hard lump below his left eye but this lump had disappeared.

So, what was he suffering from? He had no diabetes, no hypertension and was not obese.

"He does have a medical problem," I told the IT daughter to do an internet search of nerve pathways between the eyeball and the brain. "It is likely that a small tumour had impinged onto the nerve in this pathway. It irritates the nerve and the left eye's upper eyelid twitches suddenly, pulling up the eyelid."

It must be embarrassing for the father when that happened.

"It is best to consult a good neurologist or eye specialist." I said. "The problem is to find that particular one in Singapore. It is extremely hard to find one with the experience with this problem."

I had a similar sudden flicking up of my middle finger of my left hand two years ago. It would flick up now and then. Finally I had a non-malignant nerve tumour behind my wrist excised and the problem disappeared. So, I could empathise with this senior citizen. It was no laughing matter for him. And he does have a medical problem. "Only that the particular specialist he consulted could not diagnose this problem!"

Life is hard for senior citizens when twitches and spasms of eyelids are not diagnosed and removed. A trigger finger is not so obvious to outsiders but a twitching upper eyelid could be most embarrassing when it occurs during a conversation with somebody. I hope this IT daughter will find the correct specialist - neurologist or Ear Nose and Throat surgeon probably, I advised her. If anybody can do it, it will be this IT daughter, but would she have the time to do it? I had pointed the direction to her. It is up to her to be diligent to find out the correct specialist to pin-point the tumour affecting the father's eyelid before it grows immensely.

919. Follow up on 48-hour panting dog

Visited Clare in her new grooming shop today with Dr Daniel. Just started 2 days on her own. "How's the dog?" I asked. "No serious panting yesterday," she said.
"That's good," I said as it is bad for the dog to die while being boarded in a groomer's apartment. Some do die, from heart failures.

"This dog would have died if you had delayed vet treatment," I was told that the owner would only be back from overseas on Wednesday (today being Friday). "The blood was bluish. Her tongue was cyanotic."

So, it was good news. She started her own shop and already had clients as she had been in the grooming business for over 15 years. "This Shih Tzu was groomed by me when she was a puppy," she showed me a black and white Shih Tzu with white scars on the left eyeball protruding. "Dr Jason Teo stitched up the eyelid one time when it was bleeding."

"You can remember every dog?" I asked. "Yes," she said. "I remember all my grooming dogs." In grooming, the owner sees the groomer often. "Contact is by telephone,"Clare told me. "So, shifting to new address will not be a problem." This is unlike a vet who moved out from old positions to start up a new place. Unless the vet sends cards; if not, it is hard to find them unless the owner is persevering.

Went to see a run down building near Singapore Zoo for the pet trade today with another groomer. "It is to be tendered for the pet-trade," he said. I told Dr Daniel that the government authorities have all their nonsenses rules and regulations and by the time this dilapidated building is fixed up, at least $200,000 will be spent and unless one is in contact with contractors, the amount will be astronomical to do "pet trade."

"Only a casket company came to see this month," the officer told us.

The dog died after the operation by the vet

This is quite a typical remark from 3rd parties and from owners.
This 50-year-old lady told me about a 12-year-old dog that no vets would want to operate

917. Follow up on 48-hour panting dog 7 years old

Today Mar 22, 2012, I follow up with care-giver groomer.


19.3.12 Emergency 11 pm came in with panting non-stop. Case written earlier.

20.3.12 Groomer came to pick up dog at 7pm from Toa Payoh Vets. Dog was OK then. At 11 pm, was the worst. At 11 pm, panted and tongue came out like shortage of breath. Gave medicine fortekor half tab. Dog OK after 1 am.
Not panting badly. In morning, still pant but not badly.

21.3.12 Groomer gave the following:
9am Fortekor first, 1/2 tab
9.10 am Lasix 1/2 tab
9.20 am Vetmedin cap

Came home. 8 pm. Only gave Lasix 1/2.


21.3.12 Last night 11 pm , did not pant. Heavy breathing. Does not put out tongue

22.3.12 Repeat the same as morning of 21.3.12. The dog was normal. Appetite OK, eat Caesar canned food at 1/2 can. Normally 1/2 can 2X/day as instructed by owner. Urinated a lot.
11.31 am I spoke to groomer. Dog OK now.

INTERESTING ASPECT OF THIS CASE - In my observations and findings.
1. Heart sounds muffled on ausculation compared to normal dogs with heart disease or CCF (congestive cardiac failure). A case of hydro-pericardium?
(X-ray showed enlarged heart).

2. Heart murmurs - slight or absent
3. Tongue cyanotic during emergency admission on 19.3.12 and blood collected were bluish
4. Blood test - ALT high, serum urea and creatinine very low. Yet WBC and RBC within normal limits.
5. Heartworm test not done.

A "sudden onset" and persistent panting case. So what is the actual cause? Congestive cardiac failure? Overweight? Heat stress? Bacterial or viral infections starting? Dog eats well and is active. Puzzling?

916. Follow up: Guinea Pig with right ear tumour

Thursday Mar 22, 2012 11 am Toa Payoh Vets recording

The case of the big ear tumour

Yesterday I text messaged the owner of the GP with right ear tumour electro-excised some days ago to tell him the good news that the tumour was not cancerous. The lab report stated trichoepithelioma. The message could not be sent. So I phoned him at 10.30 am today. He was pleased with the good news. This guinea pig did not like the miniature tomatoes as much as the companion who is one-year old. "The other GP eats 3 a day," the gentleman whom I had not met, said. "He stops eating tomatoes and I gave him cucumber slices which he eats all. Also, he likes timothy hay."

The guinea pig was well cared for and loved.
"How did he get such a big ear lump?" I asked as the vet he consulted was Dr Jason Teo who worked on Saturday when he came. I took over the surgery and anaesthesia which is quite risky for GP compared to the bigger dog or cat of similar age.

"I noticed hair loss around his right ear one month ago. Then a white swelling."

"Did the other GP bite the lump since there was bleeding and ulcers when you brought him in for treatment on Saturday?" I asked.

"I don't know but he did have bite marks on his body. So he could have been bitten by the other GP."

"He could have scratched the big lump," I said. "It could be irritating as it was heavy. Is he normal now?"

"He is OK. He eats well, drinks and is active. No blood in the urine. Clear coloured urine peed. However, sometimes he shakes his head."

This case illustrates the importance of following up post-op. The owner did not call me to report on head shaking as it was not causing the guinea pig to stop eating.

"There is something inside the ear," I said. "Some blood from the bleeding and some powder from the purple permanganate applied to the wound to stop bleeding."

"What shall I do?" he asked.
"Buy a new syringe. Fill with boiled water. Squirt a few drops into the ear ear canal 3X/day. Massage the ear canal to clear the blood clots and chemicals for the next 5 days. Phone me after that."

Timely treatment of the ear canal by removing the debris will prevent infection. It must be done at home a few days. But in the dog and cat, I have to do it at the Surgery if the owner can't do it well. In this GP, it is best that the owner who cares much for the GP is assessed and can do it.

Always follow up esp. on ear surgery, if possible, in this hectic paced working llife in Singapore. The owner would not know about otitis externa aand this would worsen in time.

Follow up on the two guinea pigs with urinary problems.

Further to my earlier case study of 2 GP with urinary tract problems, the results are as follows:

1. GP with blood in the urine for 2 weeks. X-ray by Vet 2 showed several bladder stones and advice given was euthanasia. When the GP came to me, he was very thin and weak. The young lady got permission from her mum to get the bladder surgery done by me.

I advised against immediate surgery as the GP was not fit to be under anaesthesia. He would just die on the op table. The owner was to hand feed and make him well first. On the 2nd day at home, he passed away. In this type of case, the interest of the GP is paramount rather than the bottom line of the surgery, since the GP practically had no chance of survival on the op table.


2. GP not eating, had a grossly swollen bladder. Dr Daniel and I palpated the abdomen. Looked so much like ascites although I could feel the faint outlines of a very full bladder as big as an orange. Suddenly whitish cloudy urine dribbled out. More and more urine was released like a storm flood. I got the urine inside a syringe and sent to the lab. Came back with struvite crystals +++, bacteria + and urine pH = 9.0. Evidence of urinary tract infection caused by amorphous phospate or struvites +++. So what to do now?

"In dogs, acidify the urine or give S/D diet," I said to Dr Daniel and Dr Vanessa. "What to do for a GP with struvites in the bladder?"

The lady owner returned my text message this morning. She had left all medication to the sister who stays at home. After 3 days, the sister stopped the antibiotics and the pain-killer as the GP was eating and drinking.

"But he sits in a corner," the young busy career lady said. "When can I send him down for another check up?" I scheduled next week. She has only one GP and believed that her sister had increased the intake of Vit C tablets to 1.5 tab/day causing the GP to stop eating.

Overdosage of Vit C can lead to kidney stones in people. In this case, the GP had a UTI

Follow-up on the 48-hour panting dog

At 10 am, the 7-year-old Maltese dog that panted non-stop for 48 hours behaved as normal as any other dog. Groomer Clare was relieved of worries. I was happy for this now energetic companion of somebody. He ate a little and is as active as a puppy.

As to the cause of his medical problem, it is hard to say exactly.
"Don't need X-ray now that the dog has recovered," Clare said over the phone.
"As long as the owner has been advised that an X-ray is recommended," I said. "If the dog should die the next few days, the owner will demand to know why the vet did not recommend a simple chest X-ray."

Clare phoned the owner who is overseas and got the permission to X-ray. I told Dr Daniel and intern Mr Lim to get it done. The blood test result will come in soon.

The clinical outcome is what the owner wanted. Diazepam via a rectal tube did enable this dog to sleep and the other drugs helped her to recover. But what was the original cause of this sudden onset of continuous panting? Viral infection? Unlikely. I suspect it may be an allergic hypersensitivity reaction in the groomer's apartment affecting her. But this is pure speculation. Wait for blood test result.