April 17, 2012
"Nothing much can be done," Vet 1 told the stray cat care-giver and her domestic worker some 3 months ago when she adopted a skinny malnourished cat with bad breadth and a leg wound and a very bad breath. "This stray cat has FIV. Give him clindamycin one capsule per day for 15 days." Vet 1 treated the cat's leg wound and neutered him.
The cat's bad breath returned after the end of the course of antibiotics.
So she gave clindamycin for 15 days for another 15 days by sprinkling the powder from the capsule into the cat's food. The cat still ate but was not so active.
The cat looked plump and had a rectal temperature of 39.3 C. No runny nose. No bad breath or diarrhoea. Just not eating.
"Unlikely to be FIV as this cat looked so plump at 5 kg and has no upper respiratory tract infections or drooling of saliva," I gave the owner the option as to whether to test for FIV or not since she was fostering at least 5 stray cats. "Of the two, a blood test is more useful." Vet 1 assumed this stray cat has FIV but did not do the test to save the owner costs.
FIV/FeLV TESTS - Negative
MOUTH EXAMINATION
It is important that the owner actually see the inside of the mouth. I asked my assistant to shine a white torchlight into the mouth as I pried open the mouth. The cat was quiet but there was pain and objected to it. I opened the sides of the mouth - gum ulcers, tongue ulcers and two large ulcers at the back of the mouth, beside the tongue on both sides.
DIGITAL IMAGES
Best to take pictures to document the oral ulcers at presentation. I took several pictures on April 17. Today, April 19, I took some images. The cat was eating and was less hostile now.
BLOOD COLLECTION
The cat was quite fed up since I had pried opened his mouth a few times. Dr Daniel collected blood from his veins but there was insufficient. The cat started clawing in self-defence.
"It is not easy to collect sufficient amount of blood from an angry cat," I said. "I will tranquilise him and Dr Vanessa will collect the blood from the jugular vein after 10 minutes." 3 ml of blood was colllected by Dr Vanessa.
Blood Test Results - significant findings
1. Glucose elevated 11.0 (normal 3.9 - 6.0) - "stressed induced hyperglycaemia" in the cat.
2. Liver enzymes ALT & AST elevated.
3. Urea below normal.
4. Platelets low 146 (300-800). Large platelets present.
RBC and WBC are normal.
Differential count:
N 64% 8.69
L 24% 3.19
M 6% 0.77
E 6% 0.81
B 0.3% 0.04
Could the oral ulcers be due to eosinophilia? Need to review my past report at:
http://www.asiahomes.com/singaporepets/0747cat_tonsils_overwhelmed_Singapore.htm
An extract from the above webpage is as follows:
3. RODENT ULCERS IN CATS (feline eosinophilic granulomatosis). Salivation and ulcers are signs.
Eosinophilic Granuloma Complex -
Three distinct but related clinical syndromes comprise the granuloma complex:
3.1 Eosinophilic (or rodent) Ulcer. This may occur on the skin or in the mouth but usually affects the upper lips. The lesions are well-demarcated ulcers.
3.2 Eosinophilic Plaque. These are raised, moist, red eroded or ulcerated areas with a well demarcated border. Pruritus is usually severe. lesions usually occur on the underside of the cat (abdomen, brisket or inside the thighs.)
3.3 Linear Granulomata. These can occur at most sites, especially behind the hind legs and within the mouth. They are well-demarcated lesions which are raised and yellow to
yellowish-pink in colour. They are often thin, hence the name *linear* granuloma.
CONCLUSION
Could this be a case of Eosinophilic (or rodent) Ulcer? The mouth ulcers are well demarcated. The eosinophils are high. This could be a case of "rodent ulcer" and there is a treatment for it.
Thursday, April 19, 2012
Wednesday, April 18, 2012
947. Post-op lateral ear resection, spay female shih tzu 6 months old and stray cat with "FIV"
April 18, 2012
LATERAL EAR RESECTION POODLE
I was reviewing the poodle with the lateral ear resection case operated by me 24 hours ago. The ears were still bleeding. My assistant Min had changed a new bandage and the bleeding had stopped. It was a bright sunshine morning. So, I had some pictures taken for record.
EFFECTS OF BANDAGING
1. There was some swelling below the neck seen at 9 am today. This was inevitable as the bandage had to be tight to stop the bleeding. My assistant Min had changed bandage overnight. I had the bandage removed.
2. Yesterday, I bandaged the ear 2 hours after the surgery at around 1 pm. The poodle had cyanotic tongue colour and so I loosened the bandage and re-bandage. No breathing difficulty. Why the tongue was purplish and the gums pale? This could be due to the bleeding and surgery as this was a small poodle. I gave the duphalyte and normal saline drip, Vit K1 2 ml SC and tolfedine and baytril. The dog was monitored closely and was OK.
ANAESTHESIA
1. Domitor and Ketamine at 10% IV. Normally 50% but this poodle looked weak. "Nothing wrong with the ears (to justify the ear surgery)," Dr Daniel examined the ears. He did not know the history. "You are seeing the ears after one week of medication," I said. "The dog had been scratching the ears for several months and there were vet treatments before."
2. Isoflurane gas top up via endotracheal tube. Minimal 1% anaesthesia as this dog needed >30 minutes of anaesthesia. At the last stitch, the dog woke up with some crying as the gas anaesthesia wore off fast. It is better safety as dog would be unlikely to die from isolfurane anaesthesia during and post-op, but the disadvantage is the crying at the last stitch. Tolfedine was given SC and the crying stopped.
SURGERY
Over one hour due to bleeding. If there was no bleeding, it would be faster but every case differs.
HEAVY BLEEDING
There was heavy bleeding on the right ear at the end of surgery. Ligation of the blood vessels in the region cranial to the lateral wall would be best. Some cases don't have bleeding as the main vessels were not electro-incised. In this case, I bandaged the ears overnight and the bleeding of the left ear had stopped.
EATING
The dog usually ate dry food, according to the owner. "It would be better to fed canned food as the dog could have pain in swallowing." The dog ate one can of A/D overnight.
SPAYING A 6-MONTH-OLD SHIH TZU THAT EATS STOOLS
"Do you want Dr Vanessa to operate on your dog?" I asked the young man as his dog had been vaccinated and attended to as recently as last week. He came in at 10 am and I was on duty. Dr Vanessa usually comes around 12 noon. "If not, I will do the spay and you come back at 12 noon." He opted to have me operate.
3 kg. very thin. Ate 3x/day by hand-feeding. Still hungry after feeding.
ANAESTHESIA
Domitor and Ketamine IV at 50%. Waited 5 minutes.
The dog was sufficiently sedated to intubate.
Large tonsils of around 8mm x 4mm. Normally, can't see tonsils. I took a pic to show the owner as this is abnormal. Could be due to eating stools? I had a long chat with the young man about his management of this dog (very thin and eating stools) at around 12 noon when he came for his dog.
"If you don't spend time training him not to eat stools now, she will eat stools as an adult for the rest of her life." I advised. The dog would wait till the owner goes to work before pooping and would eat the stools.
The dog is crated in a cage of around 3-foot wide. A yellow plastic pee pan (with small holes for urine to flow through but not stools) covers 50% of the grated area. The dog lies on the grated area and poops and pees on the yellow pan.
These are my recommendations to reduce poo eating:
1. Don't confine the dog inside the crate when the owner goes to work as the dog is adult and the crate is not big. So, the dog starts to eat stools due to lack of space to move about.
1.1 When the owner goes to work at 9 am, put the dog inside a bigger space e.g. bathroom. On one side, put the crate (cleaned and neutralised with white vinegar: water at 1:3), water and feed bowls. On the other end, put the pee pan. Get a baby gate.
1.2 The owner feeds the dog at 8 am, brings her down to pee and poop as a routine (except on weekends, 9 am). Bring newspapers to scoop up poo. Bring some poo in the newspaper and put on the grass to let the dog smell it as part of the training.
1.3 Feed 2X/day instead of 3. Now the owner hand-feeds the dog as she swallows all dry food within 30 seconds and begged for more.
1.4 Antibiotics to be given for the next 7 days and repeat. There is a possible urinary tract infection as the dog passed white urine (no smell) and yellow urine (very smellay) many times a day. Dogs at this age can control their bladder unless not trained or do urine marking (female dogs do urine marking but this is uncommon). Poo-marking is possible too.
1.5 Training may take more than 4 weeks. Patience and spend time doing the training.
LARGE TONSILS
See image. Both tonsils incredibily large. Bacterial infection or toxins from eating stoolsl over past 3-6 months?
SPAYING AT 6 MONTHS
Some vets believe that bones have not been fully formed. So don't spay at 6 months. I usually advise spaying 2 months after the end of the first heat. Sometimes, as in this case, the owner prefers the spaying to be done at 6 months. Singapore dog licence - $75 if not spayed at next renewal of licence. Otherwise $14 if spayed. There used to be $14 licence only if the dog is less than 5 months old but the AVA may have changed this.
LATERAL EAR RESECTION POODLE
I was reviewing the poodle with the lateral ear resection case operated by me 24 hours ago. The ears were still bleeding. My assistant Min had changed a new bandage and the bleeding had stopped. It was a bright sunshine morning. So, I had some pictures taken for record.
EFFECTS OF BANDAGING
1. There was some swelling below the neck seen at 9 am today. This was inevitable as the bandage had to be tight to stop the bleeding. My assistant Min had changed bandage overnight. I had the bandage removed.
2. Yesterday, I bandaged the ear 2 hours after the surgery at around 1 pm. The poodle had cyanotic tongue colour and so I loosened the bandage and re-bandage. No breathing difficulty. Why the tongue was purplish and the gums pale? This could be due to the bleeding and surgery as this was a small poodle. I gave the duphalyte and normal saline drip, Vit K1 2 ml SC and tolfedine and baytril. The dog was monitored closely and was OK.
ANAESTHESIA
1. Domitor and Ketamine at 10% IV. Normally 50% but this poodle looked weak. "Nothing wrong with the ears (to justify the ear surgery)," Dr Daniel examined the ears. He did not know the history. "You are seeing the ears after one week of medication," I said. "The dog had been scratching the ears for several months and there were vet treatments before."
2. Isoflurane gas top up via endotracheal tube. Minimal 1% anaesthesia as this dog needed >30 minutes of anaesthesia. At the last stitch, the dog woke up with some crying as the gas anaesthesia wore off fast. It is better safety as dog would be unlikely to die from isolfurane anaesthesia during and post-op, but the disadvantage is the crying at the last stitch. Tolfedine was given SC and the crying stopped.
SURGERY
Over one hour due to bleeding. If there was no bleeding, it would be faster but every case differs.
HEAVY BLEEDING
There was heavy bleeding on the right ear at the end of surgery. Ligation of the blood vessels in the region cranial to the lateral wall would be best. Some cases don't have bleeding as the main vessels were not electro-incised. In this case, I bandaged the ears overnight and the bleeding of the left ear had stopped.
EATING
The dog usually ate dry food, according to the owner. "It would be better to fed canned food as the dog could have pain in swallowing." The dog ate one can of A/D overnight.
SPAYING A 6-MONTH-OLD SHIH TZU THAT EATS STOOLS
"Do you want Dr Vanessa to operate on your dog?" I asked the young man as his dog had been vaccinated and attended to as recently as last week. He came in at 10 am and I was on duty. Dr Vanessa usually comes around 12 noon. "If not, I will do the spay and you come back at 12 noon." He opted to have me operate.
3 kg. very thin. Ate 3x/day by hand-feeding. Still hungry after feeding.
ANAESTHESIA
Domitor and Ketamine IV at 50%. Waited 5 minutes.
The dog was sufficiently sedated to intubate.
Large tonsils of around 8mm x 4mm. Normally, can't see tonsils. I took a pic to show the owner as this is abnormal. Could be due to eating stools? I had a long chat with the young man about his management of this dog (very thin and eating stools) at around 12 noon when he came for his dog.
"If you don't spend time training him not to eat stools now, she will eat stools as an adult for the rest of her life." I advised. The dog would wait till the owner goes to work before pooping and would eat the stools.
The dog is crated in a cage of around 3-foot wide. A yellow plastic pee pan (with small holes for urine to flow through but not stools) covers 50% of the grated area. The dog lies on the grated area and poops and pees on the yellow pan.
These are my recommendations to reduce poo eating:
1. Don't confine the dog inside the crate when the owner goes to work as the dog is adult and the crate is not big. So, the dog starts to eat stools due to lack of space to move about.
1.1 When the owner goes to work at 9 am, put the dog inside a bigger space e.g. bathroom. On one side, put the crate (cleaned and neutralised with white vinegar: water at 1:3), water and feed bowls. On the other end, put the pee pan. Get a baby gate.
1.2 The owner feeds the dog at 8 am, brings her down to pee and poop as a routine (except on weekends, 9 am). Bring newspapers to scoop up poo. Bring some poo in the newspaper and put on the grass to let the dog smell it as part of the training.
1.3 Feed 2X/day instead of 3. Now the owner hand-feeds the dog as she swallows all dry food within 30 seconds and begged for more.
1.4 Antibiotics to be given for the next 7 days and repeat. There is a possible urinary tract infection as the dog passed white urine (no smell) and yellow urine (very smellay) many times a day. Dogs at this age can control their bladder unless not trained or do urine marking (female dogs do urine marking but this is uncommon). Poo-marking is possible too.
1.5 Training may take more than 4 weeks. Patience and spend time doing the training.
LARGE TONSILS
See image. Both tonsils incredibily large. Bacterial infection or toxins from eating stoolsl over past 3-6 months?
SPAYING AT 6 MONTHS
Some vets believe that bones have not been fully formed. So don't spay at 6 months. I usually advise spaying 2 months after the end of the first heat. Sometimes, as in this case, the owner prefers the spaying to be done at 6 months. Singapore dog licence - $75 if not spayed at next renewal of licence. Otherwise $14 if spayed. There used to be $14 licence only if the dog is less than 5 months old but the AVA may have changed this.
946. Hamster nose wart enquiry from overseas
E-MAIL TO DR SING DATED APRIL 18, 2012
Dwarf Hamster Tumor or Wart
Haven for Hamsters havenforhamsters@gmail.com
12:13 AM (3 hours ago)
to judy
Hi Dr. Sing & Associates.
You helped me several years ago with a hamster who had a eye condition. I am in Albuquerque, NM and run Haven for Hamsters Rescue. Last night I discovered a large rough lump on one of our dwarf hamsters. It is blood red in color, firmly attached to her nose, does not seem to cause her any pain or discomfort. It has no hair on it and seems to be the consistence of a human wart. Do you have any suggestions on what to do. Our vet is afraid if they remove it she will bleed excessively and not survive. Can she live with this on her comfortably?
Any help you or your staff can offer would be greatly appreciated.
Thank you,
E-MAIL REPLY FROM DR SING DATED APRIL 18, 2012
Pl send two images of the nose wart if possible. Bleeding can be controlled by the vet using pressure, ligation, electro-cautery or powder depending on the size of the wart and the situation. You may need to find a vet who knows what to do.
E-MAIL TO DR SING DATED APRIL 19, 2012
I have attached some pictures of the little hamsters wart/tumor. Any information would be great. Thank you,
E-MAIL REPLY FROM DR SING DATED APRIL 19, 2012
Thank you for pictures. Surgery is the only option if you want a good clinical outcome.
Electro-surgery is preferred. General anaesthesia and stitching are required. One anaesthetic method is zoletil sedation IM + isoflurane gas and then into electro-excision and stitching.
You may need to find a vet who does hamster surgeries.
E-MAIL TO DR SING DATED APRIL 19, 2012
Do you have any idea what it is?
E-MAIL FROM DR SING DATED APRIL 19, 2012
It is a large skin tumour. How old is the dwarf hamster?
E-MAIL TO DR SING DATED APRIL 19, 2012
I'm thinking about 6 months old or so.
E-MAIL FROM DR SING DATED APRIL 19, 2012
Your vet may need to do a skin biopsy or fine needle aspirate to check whether the growth is malignant or not and whether it is inflammmatory. This may not be feasible economically. Excision seems to be the only option. If it is inflammatory, your vet may try intra-lesion injection of antibiotics and steroids but this is not a guaranteed to work treatment. It does work for cases of lick granulomas (inflammatory) in my dog cases. E-MAIL TO DR SING DATED APRIL 21, 2012
Thank you so much for all your great advice. Our vet has determined there is just not much she can do. Here vets are very nervous about treating hamsters, no one really has the skills or knowledge. We are just getting them to learn about guinea pigs and rats. For now she is doing okay, but I can see her going down hill pretty quickly. Once again, thank you for all your help and advice. It is greatly appreciated.
Dwarf Hamster Tumor or Wart
Haven for Hamsters havenforhamsters@gmail.com
12:13 AM (3 hours ago)
to judy
Hi Dr. Sing & Associates.
You helped me several years ago with a hamster who had a eye condition. I am in Albuquerque, NM and run Haven for Hamsters Rescue. Last night I discovered a large rough lump on one of our dwarf hamsters. It is blood red in color, firmly attached to her nose, does not seem to cause her any pain or discomfort. It has no hair on it and seems to be the consistence of a human wart. Do you have any suggestions on what to do. Our vet is afraid if they remove it she will bleed excessively and not survive. Can she live with this on her comfortably?
Any help you or your staff can offer would be greatly appreciated.
Thank you,
E-MAIL REPLY FROM DR SING DATED APRIL 18, 2012
Pl send two images of the nose wart if possible. Bleeding can be controlled by the vet using pressure, ligation, electro-cautery or powder depending on the size of the wart and the situation. You may need to find a vet who knows what to do.
E-MAIL TO DR SING DATED APRIL 19, 2012
I have attached some pictures of the little hamsters wart/tumor. Any information would be great. Thank you,
E-MAIL REPLY FROM DR SING DATED APRIL 19, 2012
Thank you for pictures. Surgery is the only option if you want a good clinical outcome.
Electro-surgery is preferred. General anaesthesia and stitching are required. One anaesthetic method is zoletil sedation IM + isoflurane gas and then into electro-excision and stitching.
You may need to find a vet who does hamster surgeries.
E-MAIL TO DR SING DATED APRIL 19, 2012
Do you have any idea what it is?
E-MAIL FROM DR SING DATED APRIL 19, 2012
It is a large skin tumour. How old is the dwarf hamster?
E-MAIL TO DR SING DATED APRIL 19, 2012
I'm thinking about 6 months old or so.
E-MAIL FROM DR SING DATED APRIL 19, 2012
Your vet may need to do a skin biopsy or fine needle aspirate to check whether the growth is malignant or not and whether it is inflammmatory. This may not be feasible economically. Excision seems to be the only option. If it is inflammatory, your vet may try intra-lesion injection of antibiotics and steroids but this is not a guaranteed to work treatment. It does work for cases of lick granulomas (inflammatory) in my dog cases. E-MAIL TO DR SING DATED APRIL 21, 2012
Thank you so much for all your great advice. Our vet has determined there is just not much she can do. Here vets are very nervous about treating hamsters, no one really has the skills or knowledge. We are just getting them to learn about guinea pigs and rats. For now she is doing okay, but I can see her going down hill pretty quickly. Once again, thank you for all your help and advice. It is greatly appreciated.
Monday, April 16, 2012
945. Sunday's interesting cases - old dog with heart disease - dental
Sunday April 15, 2012
The past week had been quiet. Economic recession sets in? Yet the Certificate of Entitlement (COE) to buy new cars of 1600 cc in engine size was over $80,000 last week. The Health Science Authority had decided to charge high fees to inspect every medical equipment being imported to make sure they are of good quality. This will , lead to higher medical costs of health care. Property cooling measures means increase fees for property purchasers. So, the average pet owner has less to spend. So, less visits to the vet while more vets start up their own practices.
Case 1.
Old Maltese Cross with bad breath.
Last Sunday, this case was seen last week by Dr Daniel as the Chinese father and his daughter brought in a dog for dental work. I noted that Dr Daniel took some time in consultation and Sundays are busy days. If the dog comes for dental work, then, the dog ought to be examined within 5 minutes and sent in for the anaesthesia, not taking a lot of time in talking. It is good to have long chats with clients but the review of cases hospitalised is not done early due to insufficient time and consultations if the vet does not do time-management.
I had intervened to say that tooth brushing and diet would not resolve the tartar build up and bad breath as Dr Daniel was explaining the pros and cons of brushing. "The dog has Stage 4 periodontitis," I said and pointed to the photos of Stage 3 and 4 on the left side of the consultation table. "Tooth brushing cannot get rid of the tartar." It was frank advice but we can't afford to take too much time on Sundays to chat like old friends and charge affordable fees. Owners have to understand this.
"The father had asked about tooth brushing," Dr Daniel said to me later as I asked why he had been spending so much time talking about tooth brushing when it was clear that this "alternative" treatment would never be effective. I don't like wasting the time of clients or the vets as Sunday is a busy day and in any case, there is a lot of administrative work like reviewing cases and records that the vets ought to do daily.
The father and teenaged daughter brought in the dog for dental work. He did not want a blood test. The dog coughed when I palpated the throat. I took over the case and advised antibiotics for 7 days before dental today.
I checked the heart. A faint machinery murmur on the left side. The dog still had a sore throat but not so painful now. This would be a high risk anaesthesia case. "Does the dog cough at night or sometimes?" I asked the daughter. She nodded her head but the father said no.
ANAESTHESIA
Isoflurane gas mask directly would be best. But this dog had s sore throat and might vomit or swallow vomitus into the lungs. The owners had not fed the dog since last night.
The following was given.
Maltese, 11 years old. 6.5 kg. Blood test advised but not accepted. So, the health status is unknown. Has left sided cardiac murmurs. A history of "coughing". Anaesthesia has to be very careful. All owners expected a dog alive at the end of dental work.
Furosemide 0.6 ml IM. Waited 5 minutes
Domitor + Ketamine IV at 10% of the calculated dosage. For healthy old dogs, I usually give 50%.
Dog was very weak as 10% could sedate him heavily. At one stage, he stopped breathing when isoflurane gas was given by mask.
Top up with isoflurane gas by mask whenever the dog moved.
"Intubation" would be preferred there was some irritation of the throat and intubation might worsen this inflamed throat.
Four molar and premolar teeth were loose and extracted.
The dog woke up as the surgery took some 30 minutes. But this was a safer method. The dog went home to a happy mum. The dad was in hurry and so he did not say much. The teenaged daughter was absent, but I could see that she was most worried about the anaesthesia. She did not voice her concerns to me.
"Better move fast," I said to the mum who came with her husband around lunch-time when Mr Min, my assistant had gone for lunch on this Sunday (Myanmar new year for one week). "No more bad breath," she said to me happily.
This case was done by Dr Daniel. It was a typical dental case but because the dog was old and had heart murmurs and coughing, this case was a very high anaesthetic case and I had to intervene. A happy ending is not guaranteed as there are dog deaths during dental work if the dog is very ill or a high standard of veterinary care is not provided (e.g. vets and assistants joking during anaesthesia).
Case 2.
The kitten had swollen conjunctiva in the left eye for more than 2 weeks. The couple had consulted 2 vets and given eye drops and medication. But the conjunctiva of the left eye was still as swollen as ever since the conjunctiva had swollen so much that the upper and lower eyelids swell to prevent any view of the eyeball.
"The kitten needs to be sedated to check whether the eyeball is infected," I said. "If the eyeball is ruptured and badly infected with bacteria, the only solution is to remove the eyeball. There is no chance of the eye returning to normal in such situations."
The other two vets had not done so. In such severe cases, eye drops don't work.
The Malay couple was concerned about this type of suggestion. "We will go home and ask my mum," the husband said after asking about the fees involved in enucleation of the eye.
Case 3.
An old cat came in for 2 black pigmented spots on the backside hip skin. "Could this be fleas?" the young adult daughter asked. The Indian father and daughter loved this cat very much and as I had "retired," I seldom see this cat. Dr Daniel was collaborating me in this case. I used a razor blade to scrape the black pigment. It was superficial jet black epidermis and examined under the microscope. "No ringworm," I said. "Was there any cream applied or any rubbing?" I asked. "No cream," the daughter said. "But the cat did rub her backside now and then."
I held the cat's tail high with one hand and expressed the anal sacs with the other. Copious amounts of brown oil shot out. I had taught the daughter how to express the glands but she said the cat would not permit it. This could be a cause of itchiness in the back area and licking. I noted a fine growth of hair coming out from the back quarters instead of the usual wiry hair. This could be due to the cat excessively grooming himself. I checked the scrotal area as the daughter did not want the cat neutered. "The scrotum is very dirty," I said. "Most cats do clean this area, but not this cat." In this case, the owner must clean for him.
"Are you retired?" the daughter asked me. "No," I said. "However, many cases have to be done by the younger vets as part of succession handing over and training."
The past week had been quiet. Economic recession sets in? Yet the Certificate of Entitlement (COE) to buy new cars of 1600 cc in engine size was over $80,000 last week. The Health Science Authority had decided to charge high fees to inspect every medical equipment being imported to make sure they are of good quality. This will , lead to higher medical costs of health care. Property cooling measures means increase fees for property purchasers. So, the average pet owner has less to spend. So, less visits to the vet while more vets start up their own practices.
Case 1.
Old Maltese Cross with bad breath.
Last Sunday, this case was seen last week by Dr Daniel as the Chinese father and his daughter brought in a dog for dental work. I noted that Dr Daniel took some time in consultation and Sundays are busy days. If the dog comes for dental work, then, the dog ought to be examined within 5 minutes and sent in for the anaesthesia, not taking a lot of time in talking. It is good to have long chats with clients but the review of cases hospitalised is not done early due to insufficient time and consultations if the vet does not do time-management.
I had intervened to say that tooth brushing and diet would not resolve the tartar build up and bad breath as Dr Daniel was explaining the pros and cons of brushing. "The dog has Stage 4 periodontitis," I said and pointed to the photos of Stage 3 and 4 on the left side of the consultation table. "Tooth brushing cannot get rid of the tartar." It was frank advice but we can't afford to take too much time on Sundays to chat like old friends and charge affordable fees. Owners have to understand this.
"The father had asked about tooth brushing," Dr Daniel said to me later as I asked why he had been spending so much time talking about tooth brushing when it was clear that this "alternative" treatment would never be effective. I don't like wasting the time of clients or the vets as Sunday is a busy day and in any case, there is a lot of administrative work like reviewing cases and records that the vets ought to do daily.
The father and teenaged daughter brought in the dog for dental work. He did not want a blood test. The dog coughed when I palpated the throat. I took over the case and advised antibiotics for 7 days before dental today.
I checked the heart. A faint machinery murmur on the left side. The dog still had a sore throat but not so painful now. This would be a high risk anaesthesia case. "Does the dog cough at night or sometimes?" I asked the daughter. She nodded her head but the father said no.
ANAESTHESIA
Isoflurane gas mask directly would be best. But this dog had s sore throat and might vomit or swallow vomitus into the lungs. The owners had not fed the dog since last night.
The following was given.
Maltese, 11 years old. 6.5 kg. Blood test advised but not accepted. So, the health status is unknown. Has left sided cardiac murmurs. A history of "coughing". Anaesthesia has to be very careful. All owners expected a dog alive at the end of dental work.
Furosemide 0.6 ml IM. Waited 5 minutes
Domitor + Ketamine IV at 10% of the calculated dosage. For healthy old dogs, I usually give 50%.
Dog was very weak as 10% could sedate him heavily. At one stage, he stopped breathing when isoflurane gas was given by mask.
Top up with isoflurane gas by mask whenever the dog moved.
"Intubation" would be preferred there was some irritation of the throat and intubation might worsen this inflamed throat.
Four molar and premolar teeth were loose and extracted.
The dog woke up as the surgery took some 30 minutes. But this was a safer method. The dog went home to a happy mum. The dad was in hurry and so he did not say much. The teenaged daughter was absent, but I could see that she was most worried about the anaesthesia. She did not voice her concerns to me.
"Better move fast," I said to the mum who came with her husband around lunch-time when Mr Min, my assistant had gone for lunch on this Sunday (Myanmar new year for one week). "No more bad breath," she said to me happily.
This case was done by Dr Daniel. It was a typical dental case but because the dog was old and had heart murmurs and coughing, this case was a very high anaesthetic case and I had to intervene. A happy ending is not guaranteed as there are dog deaths during dental work if the dog is very ill or a high standard of veterinary care is not provided (e.g. vets and assistants joking during anaesthesia).
Case 2.
The kitten had swollen conjunctiva in the left eye for more than 2 weeks. The couple had consulted 2 vets and given eye drops and medication. But the conjunctiva of the left eye was still as swollen as ever since the conjunctiva had swollen so much that the upper and lower eyelids swell to prevent any view of the eyeball.
"The kitten needs to be sedated to check whether the eyeball is infected," I said. "If the eyeball is ruptured and badly infected with bacteria, the only solution is to remove the eyeball. There is no chance of the eye returning to normal in such situations."
The other two vets had not done so. In such severe cases, eye drops don't work.
The Malay couple was concerned about this type of suggestion. "We will go home and ask my mum," the husband said after asking about the fees involved in enucleation of the eye.
Case 3.
An old cat came in for 2 black pigmented spots on the backside hip skin. "Could this be fleas?" the young adult daughter asked. The Indian father and daughter loved this cat very much and as I had "retired," I seldom see this cat. Dr Daniel was collaborating me in this case. I used a razor blade to scrape the black pigment. It was superficial jet black epidermis and examined under the microscope. "No ringworm," I said. "Was there any cream applied or any rubbing?" I asked. "No cream," the daughter said. "But the cat did rub her backside now and then."
I held the cat's tail high with one hand and expressed the anal sacs with the other. Copious amounts of brown oil shot out. I had taught the daughter how to express the glands but she said the cat would not permit it. This could be a cause of itchiness in the back area and licking. I noted a fine growth of hair coming out from the back quarters instead of the usual wiry hair. This could be due to the cat excessively grooming himself. I checked the scrotal area as the daughter did not want the cat neutered. "The scrotum is very dirty," I said. "Most cats do clean this area, but not this cat." In this case, the owner must clean for him.
"Are you retired?" the daughter asked me. "No," I said. "However, many cases have to be done by the younger vets as part of succession handing over and training."
Saturday, April 14, 2012
944. An old cat with multiple seizures
"I want a house-call as I prefer my cat to be euthanased at home," the woman phoned me. I asked Dr Daniel to do the house-call. This would be his first house-call and I advised that he get an assistant and place the cat on the table for injection.
He had no problems with this house-call. The cat was having continuous fits. He gave the IV after the fits. I would have preferred sedation first. Each vet does his own way, being the vet on the spot.
He had no problems with this house-call. The cat was having continuous fits. He gave the IV after the fits. I would have preferred sedation first. Each vet does his own way, being the vet on the spot.
943. Maltese with seizure goes home on Day 2 - acute bacterial meningitis
The owner came for the Maltese in the morning. She accepted my advice to let the 5-year-old dog stay overnight at Toa Payoh Vets for observation. No fits. As good as gold. The active dog just jumped and pawed her legs as she settled the bill. Tongue pinkish as normal.
"Most likely a bacterial infection based on increase in total white cell count and a very high neutrophil count. Neutrophils are produced in large numbers by the dog's body to fight against bacterial infection. Did the dog go outdoors last few days?"
"No," she said. "This dog stays indoors and if he goes out, is not allowed to sniff the grass."
It was a surprising finding in the blood test. Evidence-based medicine is the best way as the owner wants answers and in this case, the blood test had been taken before treatment and provided some answers.
"There is a possibility of low blood gluocse which can lead to (hypoglycaemic) fits in your Maltese," I said. "The lab report mentioned a possible glycolysis and a repeat test. A blood test 2-4 weeks later is needed."
This is one of the cases where the owner got the vet to treat the seizure dog promptly and the blood test was taken. All dogs with fits must have blood tested unless the owner objects to them. Practise evidence-based medicine.
In this case, bacterial meningitis was likely to be present in the dog. As the owner had not delayed treatment, the antibiotics given had got rid of the bacteria and the dog recovered the next day.
NOTES ON ACUTE BACTERIAL MENINGITIS
1. Bacterial meningitis is an infection of the meninges which are the membranes surrounding the brain and spinal cord.
2. Causes: viral, bacterial and fungal infections.
3. Most common bacteria in people meningitis include
3.1 Streptoocccus pneumoniae (pneumonococcus),
3.2 Neisseria meningitidis (meningococcus)- upper respiratory infection bacteria enters bloodstream
3.3 Haemophilus influenzae (haemophilus) - upper respiratory infection, ear infection (otitis media) or sinus infections.
3.4 Listeria monocytogenes (listeria) - soil, dust, contaminated food.
When I was studying vet medicine in Glasgow in 1969-1974, I still remember my lectures about listeria in British pigs causing brain diseases. Antibiotics erythromycin were very effective.
Probably this dog had got listeria (blood test - total white cell count and neutrophils increase). The inflammation and swelling of the meninges caused "headache" (collapse suddenly according to the owner and vomiting), fever (not present in this case), neck stiffness (see image of the dog looking skywards I took) and abnormal mental state (eye-staring, salivation due to fits).
SPINAL FLUID TEST will confirm what type of bacteria is involved. Due to economic reasons, this was not done.
Bacterial meningitis can occur over a few hours or in 2 to 3 days. Delays in treatment can lead to permanent brain damage (coma, fits) or death.
Prompt antibiotic treatment enabled him to recover fully. Where the dog got infected (contaminated food, sniffing soil etc) is a mystery. This dog seldom goes out and therefore may not have the resistance to the bacteria. I had treated him for an ear infection two months ago but his ears had only a bit of yellow wax.
P.S. Reference to human acute bacterial meningitis.
There is an interesting case of a woman who contacted acute bacterial meningitis while holidaying in Bangkok and became unconscious for 3 months.
(Straits Times, Apr 18, 2012, Home, Pg B3, ex-coma patient in flap over lease)
"Most likely a bacterial infection based on increase in total white cell count and a very high neutrophil count. Neutrophils are produced in large numbers by the dog's body to fight against bacterial infection. Did the dog go outdoors last few days?"
"No," she said. "This dog stays indoors and if he goes out, is not allowed to sniff the grass."
It was a surprising finding in the blood test. Evidence-based medicine is the best way as the owner wants answers and in this case, the blood test had been taken before treatment and provided some answers.
"There is a possibility of low blood gluocse which can lead to (hypoglycaemic) fits in your Maltese," I said. "The lab report mentioned a possible glycolysis and a repeat test. A blood test 2-4 weeks later is needed."
This is one of the cases where the owner got the vet to treat the seizure dog promptly and the blood test was taken. All dogs with fits must have blood tested unless the owner objects to them. Practise evidence-based medicine.
In this case, bacterial meningitis was likely to be present in the dog. As the owner had not delayed treatment, the antibiotics given had got rid of the bacteria and the dog recovered the next day.
NOTES ON ACUTE BACTERIAL MENINGITIS
1. Bacterial meningitis is an infection of the meninges which are the membranes surrounding the brain and spinal cord.
2. Causes: viral, bacterial and fungal infections.
3. Most common bacteria in people meningitis include
3.1 Streptoocccus pneumoniae (pneumonococcus),
3.2 Neisseria meningitidis (meningococcus)- upper respiratory infection bacteria enters bloodstream
3.3 Haemophilus influenzae (haemophilus) - upper respiratory infection, ear infection (otitis media) or sinus infections.
3.4 Listeria monocytogenes (listeria) - soil, dust, contaminated food.
When I was studying vet medicine in Glasgow in 1969-1974, I still remember my lectures about listeria in British pigs causing brain diseases. Antibiotics erythromycin were very effective.
Probably this dog had got listeria (blood test - total white cell count and neutrophils increase). The inflammation and swelling of the meninges caused "headache" (collapse suddenly according to the owner and vomiting), fever (not present in this case), neck stiffness (see image of the dog looking skywards I took) and abnormal mental state (eye-staring, salivation due to fits).
SPINAL FLUID TEST will confirm what type of bacteria is involved. Due to economic reasons, this was not done.
Bacterial meningitis can occur over a few hours or in 2 to 3 days. Delays in treatment can lead to permanent brain damage (coma, fits) or death.
Prompt antibiotic treatment enabled him to recover fully. Where the dog got infected (contaminated food, sniffing soil etc) is a mystery. This dog seldom goes out and therefore may not have the resistance to the bacteria. I had treated him for an ear infection two months ago but his ears had only a bit of yellow wax.
P.S. Reference to human acute bacterial meningitis.
There is an interesting case of a woman who contacted acute bacterial meningitis while holidaying in Bangkok and became unconscious for 3 months.
(Straits Times, Apr 18, 2012, Home, Pg B3, ex-coma patient in flap over lease)
Thursday, April 12, 2012
942. Lack of humility in the young
Yesterday I was at Khin Khin Employment Agency to advise on her business operations as she was new to the game of entrepreneurship.
"This girl is very good staff material. Very pretty. Can speak English very well as she has worked in Singapore for 2 years. She's got an Employment Pass. I would like to employ her as the other girl can't even speak good English."
She phoned the pretty woman and asked me to interview her by phone after showing me the resume. Certainly, the woman could not stop carrying on a conversation by greeting me and taling.
Of the few questions, I asked this: "What do you mean by increasing 72% of the sales since you joined the Singapore company?". Her resume also showed that she had increased 72% of the sales when she worked for a Myanmar company before joining this Singapore company. This was not possible. Exactly 72% increase in sales in both companies.
She gave an evasive answer and was quite impatient. I passed her back to Khin Khin who told me that the pretty woman said that if I was serious to employ her, she would bring her manager down from Kuala Lumpur to testify for her.
"I am not employing her," I said to Khin Khin. "You are the one interested."
"She's aggressive and much better than this other girl. I need such aggressive and able to speak good English staff for my business."
"Then, employ her," I said. "She does not have an E Pass and you, as the boss of the agency should present the facts correctly. She had an S Pass. An aggressive employee will be good for sales.
"But you can get your tail bitten off by an aggressive dog if you are not careful. You have need always to be careful. Besides she does not have the relevant experience. How do you know she will produce sales?
Khin Khin thinks that a pretty face and good English will get into the hearts of prospective Singapore employers. There is some truth in this.
However, this interview revealed an aggressiveness, lack of humility and respect and impatience to a young pretty woman looking for a good job. This is a time bomb when the interview reveals such a personality and I don't employ such a person if I was the prospective employer. Unlikely to be a team player. No respect for the boss or anyone.
Young people looking for good jobs need to be humble and respectful. The world does not owe them a living.
"This girl is very good staff material. Very pretty. Can speak English very well as she has worked in Singapore for 2 years. She's got an Employment Pass. I would like to employ her as the other girl can't even speak good English."
She phoned the pretty woman and asked me to interview her by phone after showing me the resume. Certainly, the woman could not stop carrying on a conversation by greeting me and taling.
Of the few questions, I asked this: "What do you mean by increasing 72% of the sales since you joined the Singapore company?". Her resume also showed that she had increased 72% of the sales when she worked for a Myanmar company before joining this Singapore company. This was not possible. Exactly 72% increase in sales in both companies.
She gave an evasive answer and was quite impatient. I passed her back to Khin Khin who told me that the pretty woman said that if I was serious to employ her, she would bring her manager down from Kuala Lumpur to testify for her.
"I am not employing her," I said to Khin Khin. "You are the one interested."
"She's aggressive and much better than this other girl. I need such aggressive and able to speak good English staff for my business."
"Then, employ her," I said. "She does not have an E Pass and you, as the boss of the agency should present the facts correctly. She had an S Pass. An aggressive employee will be good for sales.
"But you can get your tail bitten off by an aggressive dog if you are not careful. You have need always to be careful. Besides she does not have the relevant experience. How do you know she will produce sales?
Khin Khin thinks that a pretty face and good English will get into the hearts of prospective Singapore employers. There is some truth in this.
However, this interview revealed an aggressiveness, lack of humility and respect and impatience to a young pretty woman looking for a good job. This is a time bomb when the interview reveals such a personality and I don't employ such a person if I was the prospective employer. Unlikely to be a team player. No respect for the boss or anyone.
Young people looking for good jobs need to be humble and respectful. The world does not owe them a living.
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