Jul 1, 2012
1. Pekinese with right eye ulcer. Owners had run out of eye drops. Around 10 days since tarsorrhapy done by Dr Daniel.
Eyelid stitches removed. Dr Daniel used fluorescein eye stain. NO more staining indicating ulcer had healed. I took some images of pre- and post-injury corneal ulceration. I wil use this as a case study for video production. Excellent surgical outcome in this case. This was because the owner's mother knew how to care for this dog. The eyelids did not have any discharge or dirt on Day 12 when I saw him as contrasted to other dogs with similar problems and being cared for at home.
2. Foul-smelling "decomposed dog" case Shih Tzu had been warded here for 15 days. No more bad smell. Main problem is an intense ventral contact dermatitis. Dog just had to scratch belly -- traumatic injury and smells. Will follow up.
History. Shih Tzu, Male, Born Sep 2004.
Seen other vets in Dec 5, 2009, Apr 16 10, May 10, 10, Aug 6 10, Oct 31 10, Apr 5, 11, Jul 10 11.
Wanted to send dog to SPCA if I can't cure this "smell like dead dog" lower half of body. "The decomposed dog smell comes back 2nd day after bathing," the serious gentleman told me. "Not all skin diseases in the Shih Tzu are curable," I said to him. "Hospitalise the dog for a few days and let me observe him." The dog had a full coat with no hair loss. Some scales drop off from the lower belly and chest areas which were inflamed. I expressed the anal sacs.
They were filled with dark brown oil and very smelly. The flies appeared from nowhere and landed on this oil when I took the tissue with the oil for photography outside the Surgery. "Can't be the anal sac oil causing this smell," the owner disagreed with my findings and the fact that the flies were so interested in this anal sac oil. Normally, flies don't come at all. My hypothesis was that the oil might have licked out and stained the dog with the smell of dead flesh. The owner was not convinced as he said the groomer and the other vets had expressed the glands. Well, I had the pictures of the flies but it was poinless to show him since he had discounted this as a cause.
I smelt the dog's body on Day 3 of hospitalisation with medication given and skin washes done. There was a faint oily smell but not the decomposed meat smell. "Not that smelly," I said to the owner. But I observed that the dog's lower body was very red. As if the dog had rubbed it or more likely scratched it vigorously. The inflamed neck and groin was seen on and off. So, this was the problem. My hypothesis is that the dog just could not help scratching the lower body, due to conditioned reflexes. He had been scratching it for months as it was a way to relieve the itchiness. Some anal oil would have contaminated this traumatised skin and made the skin much more itchy and infected. So, 2 days after bathing, the rancid dead flesh smell came back.
Altogether, I hospitalised the dog for 14 days. "How much it will cost me?" the owner asked. "Not much," I said. "Since there is no surgery done." After 14 days of medication and washing, I sent the dog home with instructions that he wear a shirt to protect his lower chest and groin. The owner did that and on July 9, 2012, I phoned him. He was very happy as the dog did not smell anymore. Before sending the dog home, I expressed the anal sac. Another lot of dark brown anal oil came out.
This dog was not sent to the SPCA now and should live a normal life much loved by this serious gentleman. Dogs with skin diseases are sent to the SPCA to be put to sleep usually. Skin diseases in Shih Tzus are more common than in other breeds, in my practice experience. It is possible that the busy and time-pressed Singapore owners don't have time to do the daily brushing and grooming. This leads to skin infections and continuous itchiness. Many of these skin disease cases need reviews and strict compliance with medication prescribed. But this owner said that his dog passed blood in the stools when the other vets prescribed oral medication and so he did not do it. He did see 7 vets in 7 times as the vet practice has different vets on duty at times he went.
UPDATE:
Yesterday, July 9, 2012, I phoned the owner to find out the fate of this Shih Tzu. He said: "No smell,"
"Did you buy the shirt for him to wear?" I asked. "Yes," he sounded quite happy. I hope this Shih Tzu's anal sacs don't produce more of the stinking oil again. I doubt the owner will come for review when there was no apparent skin problems!
Sunday, July 1, 2012
1059. Carnaissal tooth abscess, bone cyst or tumour?
I am reviewing the following case at Toa Payoh Vets on Sunday Jul 1, 2012 at 9.11 am as this time is peaceful, being located aways from lots of residents.
The 12-year-old Golden Retriever had a big hard lump on the right face, below the eye, in the position of a carnaissal tooth abscess fistula. At first sight, I diagnosed a carnaissal tooth abscess as this is the most common location and problem in older dogs that do not have any dental work done in 12 years! Dr Daniel said it could be a bone cyst or tumour.
As the owner did not want any X-ray to be done, Dr Daniel extracted the right maxillary 4th premolar.
I noted that the roots are shrivelled and blackened but I was not present during the dental work. According to Dr Daniel, this would not be a carnaissal tooth abscess. "I have seen two cases of bone cysts in Australia" he was doing internship then.
"Did you see the bone cyst in a similar location, below the eye?" I clarified with him later.
"Not in this location but bone cyst can occur in anywhere as a hard swelling from the bone. Bone cyst is a differential diagnosis."
"I have seen none in my past 30 years of practice," I said.
99% of my cases are small breeds as over 80% of Singaporeans live in apartments and so Golden Retrievers are uncommon patients and so I have not seen one with carnaissal tooth abscess in this breed.
So, is this a case of a carnaissal tooth abscess or not? The owner did not want histopathology or biopsy but agreed to X-rays after the tooth extraction. I have cropped the X-rays to focus on the relevant areas and to scrutinise them. What do you think?
X-ray after extraction of the maxillary PM4 showed a large dense globular lump (Y). It is hard to say whether it is a bone cyst, bone tumour or encapsulated abscess of the root of the carnaissal tooth.
MY HYPOTHESIS
Due to its unique location, I would say this hard lump is associated with the carnaissal tooth infection going on for many years. This dog did not have dental work for the last 12 years and the tooth root had rotted away sending bacteria into this area, infecting the bone. The reaction is a hard lump which the owner noticed recently. The dog was still "eating" and the owner consulted us for the lump.
FOLLOW UP
The 12-year-old Golden Retriever had a big hard lump on the right face, below the eye, in the position of a carnaissal tooth abscess fistula. At first sight, I diagnosed a carnaissal tooth abscess as this is the most common location and problem in older dogs that do not have any dental work done in 12 years! Dr Daniel said it could be a bone cyst or tumour.
As the owner did not want any X-ray to be done, Dr Daniel extracted the right maxillary 4th premolar.
I noted that the roots are shrivelled and blackened but I was not present during the dental work. According to Dr Daniel, this would not be a carnaissal tooth abscess. "I have seen two cases of bone cysts in Australia" he was doing internship then.
"Did you see the bone cyst in a similar location, below the eye?" I clarified with him later.
"Not in this location but bone cyst can occur in anywhere as a hard swelling from the bone. Bone cyst is a differential diagnosis."
"I have seen none in my past 30 years of practice," I said.
99% of my cases are small breeds as over 80% of Singaporeans live in apartments and so Golden Retrievers are uncommon patients and so I have not seen one with carnaissal tooth abscess in this breed.
So, is this a case of a carnaissal tooth abscess or not? The owner did not want histopathology or biopsy but agreed to X-rays after the tooth extraction. I have cropped the X-rays to focus on the relevant areas and to scrutinise them. What do you think?
X-ray after extraction of the maxillary PM4 showed a large dense globular lump (Y). It is hard to say whether it is a bone cyst, bone tumour or encapsulated abscess of the root of the carnaissal tooth.
MY HYPOTHESIS
Due to its unique location, I would say this hard lump is associated with the carnaissal tooth infection going on for many years. This dog did not have dental work for the last 12 years and the tooth root had rotted away sending bacteria into this area, infecting the bone. The reaction is a hard lump which the owner noticed recently. The dog was still "eating" and the owner consulted us for the lump.
FOLLOW UP
1058. Medical negligence - failure to examine the baby's eyes
Sunday Jul 1, 2012
Blue skies, white clouds. I came to the Surgery at 8am and took some pictures of the yellow flowers and lime against the bright morning sun. My air-conditioning lady neighbour had planted them on the flower lots separating the car parking lots and cared for them well. I managed to take a picture of a butterfly and a solitary busy bee. There was a small bird with a yellow neck seen for a short while. Taking flower images with a working Sunday bee in bright morning sun make them look better.
MEDICAL NEGLIGENCE - FAILURE TO EXAMINE THE BABY'S EYES
Earlier, I read a Straits Time report about a 52-year-old paedectrician having to settle with a parent whose 12-year-old child's eyes (one blind and one in poor visual health) were not examined by him 12 years ago.
I always emphasized to Drs Vanessa and Daniel that certain procedures must be done and recorded. If the pet owner does not want the procedures, this must be written on the case file. Failing to perform certain procedures will lead to "medical negligence" litigation. They are to write "AMA" - procedures informed but not wanted to be done.
As each vet or doctor has his or her own sensibility and responsibility, it is up to the licensee to ensure that best practices are followed. For example, in a haematuria case, urine analysis is mandatory. No excuses. If the dog dies subsequently, a failure to get the urine analysed opens the vet to medical negligence litigation. As simple as that. It takes a lot of patience to ensure that the clinic is well managed so as to minimise litigation.
Blue skies, white clouds. I came to the Surgery at 8am and took some pictures of the yellow flowers and lime against the bright morning sun. My air-conditioning lady neighbour had planted them on the flower lots separating the car parking lots and cared for them well. I managed to take a picture of a butterfly and a solitary busy bee. There was a small bird with a yellow neck seen for a short while. Taking flower images with a working Sunday bee in bright morning sun make them look better.
MEDICAL NEGLIGENCE - FAILURE TO EXAMINE THE BABY'S EYES
Earlier, I read a Straits Time report about a 52-year-old paedectrician having to settle with a parent whose 12-year-old child's eyes (one blind and one in poor visual health) were not examined by him 12 years ago.
I always emphasized to Drs Vanessa and Daniel that certain procedures must be done and recorded. If the pet owner does not want the procedures, this must be written on the case file. Failing to perform certain procedures will lead to "medical negligence" litigation. They are to write "AMA" - procedures informed but not wanted to be done.
As each vet or doctor has his or her own sensibility and responsibility, it is up to the licensee to ensure that best practices are followed. For example, in a haematuria case, urine analysis is mandatory. No excuses. If the dog dies subsequently, a failure to get the urine analysed opens the vet to medical negligence litigation. As simple as that. It takes a lot of patience to ensure that the clinic is well managed so as to minimise litigation.
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