Wednesday, February 9, 2011

Too good to be true Golden Retriever and Norwich Terrier from the SPCA, Singapore

CASE 1.
I was invited to the 2nd day of Chinese New Year dinner organised yearly by a remiser. Beautiful bungalow in a serene tranquil area of Margoulith Road. My wife and I had our food outside at the corner. I was with the owners of the skin and bone poodle with megaoesophagus (no more vomiting, a big relief to the lady owner as vomiting was presented daily for the past 3 years) and a widow in her late 60s who related an incredible tale.

"The Golden Retriever was so good looking that we adopted him even if he had no pedigree papers. My son was excited and we quickly signed the SPCA papers. This dog was recommended by my relative, a vet who helped out at the SPCA."

This vet was my intern over 20 years ago and when her name was mentioned, this woman related the incredible tale.

First the Golden Retriever chewed on plants, legs of tables and graduated to chewing metal. "The puppy chewed steel? Really?" I asked.
"Yes, it is true," the grandmother said. "The neighbour's cars parked outside the house would have no steel rims!"

"What happened to the dog after you returned him to the SPCA?" I asked.
"I don't want to know," the grandmother said. "Was there any solution to this problem? The dog trainer said no solution."

"How old is the puppy?" I presumed incorrectly.
"8 months old when I adopted him."
"Destructive chewing can be prevented when the Golden Retriever is a puppy. Put him inside the kennel when he starts to chew destructively and reward him with treats and exercise when he behaves. However this needs a lot of patience and time." The grandmother had given the dog much freedom and so he kept on destroying the garden and cars. A child not properly disciplined or trained with love will also end up being lacking in ethics and morals too. Parents need time to do the training but there will be handsome men and pretty women out to scam and con. It is best not to judge a book by its cover.

From this incident, she prohibited her grandchildren living in her house from keeping dogs! Despite the fact she enjoyed the company of dogs at a young age.


CASE 2.
I was surprised to see a Norwich Terrier puppy coming in for vaccination. This breed is expensive and rare in Singapore. It costs around $2,000 and the owners had adopted him from the SPCA Singapore. Fortunately he has no destructive chewing but he was adopted as a 4-month-old. The daughter in her pre-teens and the parents were very fond of this well behaved puppy.

326. pug with recurrent infected struvite stones - case report for vet students and owners

http://www.sinpets.com/dogs/20110207urinary-stones-pug-toapayohvets-singapore.htm
has the latest updates

Blogger can't display tables directly. The report is below:

FOR TOA PAYOH VETS VET REFERENCE BOOK FOR OWNER EDUCATION

Case study: Infection-induced struvite uroliths in the dog
Pug, Male, 2 and half years. Bladder stones removed by Vet 1 around one year ago. Dog was on Hill's SD on one month, CD for 3 months. The complaint was dysuria (straining to pee) for the past few days.

"Why?" the lady who had kept 3 pugs to an old age, had no urinary stone problems. The black pug lived up to 18 years of age. (3 pugs were fed home-cooked food by the mother but this 4th pug was given dry dog food as her mother had passed away.

However, she anticipated no problem after bladder stone removal by Vet 1. "Why did the vet not advise follow-up? I stopped giving the Hills' Prescription diet as my dog was showing allergy and feed home-cooked rice and meat." Her father asked me at another visit: "Is it because the vet (Vet 1) had not completely removed all urinary stones?" Residual stones could cause a recurrence but stones do recur even after complete stone removal.

urethral obstruction - used smaller catheter. pug drinks little. toapayohvets, singaporeA real case will interest the vet student as it can be sleep-inducing to read through the several hundreds of pages of urinary stones in dogs in various text books and the internet. The following case will help to explain to students the approach to one approach to the medical treatment of struvite uroliths in the dogs at Toa Payoh Vets.

There are 3 scenarios mentioned in the above website.
1. Medical dissolution of struvite uroliths in dogs
2. Prevention of infection-induced struvite uroliths
3. Prevention of sterile struvite uroliths in dogs

This pug has 1 and 2 and so the medical treatment (as contrasted to surgical treatment) is discussed below.
On 26.1.11, the pug strained to pass urine.
Urine Test results from lab:
Urine: amber & turbid
pH= 8.0 (5-8)
SG = 1.010 (1.005 - 1.030)
Bilirubin ++
Blood ++++
WBC 0
RBC 8
Casts Nil
Bacteria ++ Crystals
triple phosphate +,
calcium oxalate occasional, amorphous phosphate ++
Calcium oxalate crystalluria. Collect fresh urine and analyse within 30 minutes. If persistent and in breeds (Bichon Frise, Miniature Schnauzer, Yorkshire Terrier, Shih Tzu, Lhasa Apso), discontinue diets that promote formation of acidic urine and consult recommendations for Calcium oxalate prevention. Struvite crystalluria is insignificant if the dog has negative urine cultures. However this pug had bacteria in the urine. Struvite is also known as triple-phosphate, ammonium phosphate and urease stones and are invariably associated with urinary tract infections in people and dogs with alkaline urine (pH > 7.2).
Blood Test results from the lab:
% Absolute
WBC normal range. Biochemistry normal Neutrophils 71%
Lymphocytes 18%
Monocytes 9%
Eosinophils 0.2%
Basophils 1.8% 11.50
2.9
1.42
0.03
0.29
X-ray
No obvious urinary stones seen in the kidney, bladder or os penis. The alkaline pH, bacteria in the urine and struvite crystals indicated a recurrence of the urinary stone formation with urinary tract infection. The Owner wants medical (conservative) treatment. Acidifying tablets* (1 tablet 1 x/day for 10 days), canned CD diet and trimethoprim antibiotics were prescribed.
*1 tablet/5 kg twice a day is recommended by manufacturer. The pug is 9.5 kg and would be getting 2 tablets 2x/day in theory.

Feb 7, 2011. Owner is in her 30s and has good medical knowledge as she works in the medical profession. She probably does internet research on urinary stones in the dogs. She e-mailed to me the follow dipstick result I had asked her to do at home.
Feb 7, 2011

Greetings Dr Sing

Happy New Year to you, your family and your folks at Toa Payoh Vets! I had done a urine dipstix for XXX and results are as follows:
Leukocytes: Neg
Nitrate: Neg
Urobilinogen: 0.2 Protein: Neg
pH: 5.0-6.0
Blood: Neg Ketone: Neg
Bilirubin: Neg
Glucose: Neg

He's so much better with his urination though at times, his post void can be slightly delayed (meaning he puts his leg down quite some time even when there seems to be no more urine).

As I will be leaving for overseas for a week on Wed morning, do you need me to bring XXX over tomorrow?

Thanks and regards

The urine was not alkaline as on the first day of consultation. pH was 8.0 then. Dipstick results are not reliable but is easy for the owner to do. I advised a review of dog, urine bacterial culture and test 3-4 weeks after the first visit and get a urine test done (via catherisation since it is difficult for the owner to collect a mid-stream urine into the urine collection container! The pug would stop peeing when she tried to collect urine.)

On Feb 8, 2011, the lady owner came for acidurin tablets for another 20 days and said that since the dog does not have much difficulty in urination, the trimethoprim tablets must be effective and therefore there is no need for a urine antibiotic-sensistivity test.

PREVENTION OF INFECTION-INDUCED STRUVITE UROLITHS
1. Treatment: Control urinary tract infections. Select antibiotics based on urine bacterial culture and susceptibility results. Culture urine during therapy to verify effectiveness of antibiotics.

With additional recurrent infections, antibiotics for 4 weeks, then 1/2 daily doses for 9-12 months, 4-weekly urine cultures.

2. Acidify urine: medication
3. Diet which promotes acidic urine. These have reduced protein, phosphorus and magnesium.
4. Monitoring: Urine culture and urinalysis in 1 month and 3-monthly.

5. X-ray: Every 6 months or sooner if the patient has recurrent urinary tract infection symptoms*.

*excessive vulval licking, urinating in the house, pollakiuria, haematuria etc.

*identify and eradicate anatomic abnormalities (vaginourethrocystoscopy, contrast vaaginourethrocystography and ultrasonography) and functional (urine cortisol to creatinine ratio, serum biochemical and thyroid profiles and neurological exam) risk factors for recurrent infections.

Note 1: struvite crystalluria is insignificant if the dog has negative urine cultures. However this case has bacteria in the urine.

Note 2: Calcium oxalate crystalluria. Collect fresh urine and analyse within 30 minutes. If persistent and in breeds (Bichon Frise, Miniature Schnauzer, Yorkshire Terrier, Shih Tzu, Lhasa Apso), discontinue diets that promote formation of acidic urine and consult recommendations for Calcium oxalate prevention.

An American veterinary school (webpage not available to the members of the public) that does urolith analysis for Hills' samples, recorded that medical dissolution of struvite uroliths with Hills' s/d canine was 100% effective after 3-6 weeks for sterile struvite uroliths and 8-12 weeks with effective antibiotics for infection-induced struvite uroliths. It seems that this institution favours medical treatment (i.e. no surgery to remove stones).

Immature dogs should not be given low protein s/d for a long term. However, a short-term use with antibiotics has rapidly dissolved infection-induced struvite uroliths in 9-12 days without adverse events.

Owner/patient compliance when feeding s/d is easily determined with a urine SG (mean = 1.008+/-0.003) and pH (mean =6.2+/-0.7). If no urine sample, serum urea nitrogen is a reliable marker (mean 3.5+/- 2.4 mg/dl). The s/d diet is high in fat and high fat is a risk factor for pancreatitis.

Female Miniature Schnauzers and others with hyperadrenocortisicism risk pancreatitiis and UTI that includes urease-producing uropathogens. Respond by discontinuing s/d diet, maintain hydration if vomiting/pancreatitis occur. Consider alternative that also acidify urine eg. canned w/d Canine) to correct both diseases. 26% of canine nephroliths are composed of struvite. They can be dissolved medically as in bladder stones but this takes a much longer time due to reduced kidney function, reduced urine production and reduced nephrolith dwell time in therapeutically undersaturated urine.

CONCLUSION.
Approaches to treatment. Medical or surgical treatment? For large stones and urethral obstruction, I advise surgery to remove all the stones after antibiotic treatment. Stones do recur even after complete stone removal in some cases. Many Singapore owners do not comply with medical treatment and the follow-up reviews (urine tests 3-monthly, X-rays 6 monthly). I presume it is due to economics and lack of time. Surgery should be done only after effective antibiotic treatment rather than immediately.

In this case, the pug drinks little but drinks more after going outdoors for exercise. "Try adding some ice-cubes to the water," I said to the lady who loves pugs only. Regular urine monitoring will be needed for the next 6 months and no dry dog food or dog treats and biscuits must be given. The lady owner was satisfied with the outcome that the pug was no longer taking a long time to pee.

Urine-marking in male dogs may or may not lead to urinary tract infections as the male dog with-holds urine to have sufficient amount to mark the territory. The alpha male dog pees until the last drop and even tries to pee when there is no more urine in the bladder. Neutering the dog may help prevent urinary tract infection. The lady owner was not keen on neutering.
Old Golden Retriever passes smelly urine with blood. A gigantic bladder stone. toapayohvets singaporeStones submitted for analysis in one female golden retriever by Toa Payoh Vets showed magnesium ammonium phosphate (struvite) 95% in the stone and 100% in the shell with zero in the nidus and surface. Calcium phosphate carbonate was 5% inside the stone. More case studies, goto: urinary tract problems in dogs and cats

Monday, February 7, 2011

325. Young pug has difficulty in peeing

Pug, Male, 2 and half years
Bladder stone removed by Vet 1 around one year ago
On 26.1.11, the pug strained to pass urine.


Urine Test results:

Urine: amber & turbid
pH= 8.0 (5-8)
SG = 1.010 (1.005 - 1.030)

Bilirubin ++
Blood ++++
WBC 0
RBC 8
Casts Nil
Crystals triple phosphate +, calcium oxalate occasional, amorphous phosphate ++
Bacteria ++

Blood Test results:
WBC normal range

Neutrophils 71% Abs. 11.50
Lymphocytes 18% 2.9
Monocytes 9% 1.42
Eosinophils 0.2% 0.03
Basophils 1.8% 0.29

X-ray
No obvious urinary stones
Owner wants dog home but dog still pees in small amounts. Will come for review.
Acidurin, CD diet and antibiotics

Due to economics
1. No bacterial culture of urine
2. Owner did not come for review

Sunday, February 6, 2011

324. Youths have passion but no hunger to excel

Thanks for prompt reply and good wishes. Promptness in reply tells a lot about a person's seriousness and care in doing business.

As I don't take in more than 2 interns at any one time, I hope your son is still interested in vet medicine and meet me for a discussion before I go to Myanmar on Feb 17, 2011.

Presently I have one intern. I nearly terminated one intern on 3rd day of CNY when she phoned to ask "If she has to go to work". I told her that she may as well stop coming to Toa Payoh Vets as she does not show much passion in vet medicine. Work on 3rd day of CNY?

I had an interview with her to find out whether I am wasting my resources to accept her as an intern. Her excellent academic results should get her in Vet College in Australia easily but where's that "passion"? She did not study Biology during her pre-University levels but fortunately for her, Australia accepts such prospects unlike British Universities. However, she needed to "work" in a veterinary practice.

I asked if her mum had not been happy since she was not paid and if that was the case, she had better go home. I have other applicants but I can take one at a time and usually I accept one intern who has been accepted by the University's Vet School for the first year. She had no offers and no testimonials as to her work with animals in her 12 years of Singapore education. I did have my doubts about her "passion" for veterinary medicine but did accept her.

Her mum told her that companies don't open till 5th day of CNY but she had known that she would take 1st and 2nd day of CNY off and had my permission for that 2 days off. So, I expect her and my associate vets to be "working" on the 3rd day of CNY. In fact, I was working half day on lst and 2nd day of CNY and was surprised to receive her phone call at 9.15 am asking if "she has to come to work today."

"Internship is not a summer holiday camp," I told this young lady.

From this phone call, I know she really has no passion for vet medicine. I would have terminated her internship if she had not turned up for "work" but her mother must have had quickly driven her to the surgery from Changi for "work". I had a meeting with this young lady and told her that she could stop "working" as she had done 3 weeks. I would not to waste my time and resources on a young lady who had no interest in veterinary medicine. I told her that a mother of a 5th year vet student complained to me that this daughter worked till 12 midnight in a veterinary surgery and thus was exploited as an intern. The mother just could not understand why. That this 5th year student has a passion to excel in veterinary medicine and to top the class. These are rare birds.

I hope you will explain to your son that he should be expected to put in the hours if he wants to do internship in my veterinary surgery. If he has no time and cannot do the hours, please let me know soon.

Best wishes

Friday, February 4, 2011

324. Megaoesophagus case study report -

Chinese New Year. Feb 4, 2011.

The owner of the 8-year-old, spayed, female skin-and-bone dog phoned me to invite me to dinner of the 2nd day of Chinese New Year, tomorrow Feb 5, 2011.

"How's the poodle?" I asked. Yesterday, the wife was quite pleased that the dog did not vomit for the past 24 hours when I phoned for a feedback. I had hospitalised the emaciated dog that had refused to eat the reduced home-cooked food offered from Jan 28, 2011 to Jan 31, 2011.

"The poodle is OK," he asked his wife about the vomiting episodes while keeping me on hold. "She is playing with the Silkie in the balcony." This is where plants and grass are present, being a ground floor apartment.

"I had instructed your wife that the poodle should be separated from the Silkie (who bullies her) and not be near the plants (the poodle has a depraved appetite and would eat grass and soil, impacting the stomach and intestines).

"Don't worry," he said. "I am watching them."

"You monitor them every second?" I was incredulous. "You don't read your newspapers and do other things? All the poodle needed was access to the plants, branches and grass and take some mouthfuls and get constipation."

It was fortuitous that he had phoned me to let me know the time of dinner for tomorrow. I had expected his wife and him to be more careful and comply with the vet instructions.

The dog was emaciated and was going to die (of malnutrition) before Chinese New Year as she had lost appetite and was the thinnest dog in Singapore I had ever seen. I refer to dogs that had been well loved and cared for.

That was why the owners decided to consult me. The husband believed in giving the dog asparagus and multi-vitamins for the past 3 years but had not sought a second veterinary opinion since the first vet diagnosed stomach tumour some 3 years ago and had declared to me: "The vet predicted that this dog would not live more than 3 months and see..see...now, it is 3 years and she is still alive!" He was quite proud as he does his treatment with asparagus and multivitamins being his main methods much to the disappointment of his wife.

This foreseeing of the future continues to haunt vets who forecasted death as it is 3 years now and the emaciated poodle is still alive. "She will die before Chinese New Year," I said when I saw the dog with her pale gums on Jan 28, 2011 (6 days before CNY). Apparently his asparagus and multi-vitamin therapy and home-cooked food in small amounts must have failed after so many years.

"Unless your dog responds to the IV protein and dextrose multivitamin drips and treatment, she will not survive past the Chinese New Year." I showed the owners the pale gums. Other than pus in the eyes (a sign of poor health), the dog was looking normal if you consider a skin-and-bone dog that can stand up and walk a bit as being normal. She was still alive due to the perseverance of the wife feeding her small amounts of cereal and home-cooked food a few times a day. It was not a nice thing to say. There are other kinder ways of giving bad news, by beating around the bush. Unfortunately, owners do mis-construe and from experience, I have become frank and brutally honest about the prognosis.

As for the husband, he was introduced to me as he was in the veterinary field and so he did not object much. However he said: "Your student is not well trained by you," referring to the first vet who diagnosed stomach tumour. I had told him that this vet had interned with me some 20 years ago before she went to study "pre-vet course" in Malaysia and got admitted to am Australian Vet School. I am quite inspired by her perseverance as she did not complete her A levels and studies night classes for the A levels. Most vets get their A levels normally and go to study vet course. As a result of this remark by the husband, I should keep quiet about knowledge of my past interns in future!

Dr Vanessa got the owners to sign a hospitalisation consent form as we work as a team on this case and she was a hands-on vet. "She would be given anti-vomiting medication to prevent vomiting," she said in response to the complaint that the dog had been vomiting.

" Well, it is not as simple as that," I discussed the history of the case with her as this was the first time she saw this dog. I had visited the home of this dog and knew a bit about her life-style.

"I don't think anti-vomiting medication will work in the long term," I discussed with Dr Vanessa the history of this case. "This poodle had been 'vomiting' 1-2 hours after food per day for the past 3 years after a vet had diagnosed stomach tumour and advised against feeding dry dog food 3 years ago. She was not seen by another vet or reviewed again."

We hospitalised the dog, took blood samples, X-rays, gave the IV drips, antibiotics and Vit K1. My assistant gave her an enema and several hard stool lumps I had palpated in the abdomen passed out. No abdominal pain at all in this dog during palpation. The kidneys, liver and spleen could not be palpated. Some gas in the intestines. That was all in a shrunken abdomen with no fat.
Hospitalisation was important to observe the timing of the dog vomiting. Was vomiting just after eating and drinking or later? In this case, it does happen after and later!

However the dog did not vomit when given canned food in small amounts. The dog did vomit some hours after eating dry food I instructed to be given. She had an excellent appetite and would drink water as much as given. I deduced that the dog regurgitated rather than vomited due to retention of food in the distal oesophagus. There is a condition called megaoesophagus in dogs.

The dog is likely to suffer from megaesophagus. Earlier, I palpated her painful throat. She objected strongly, tilted her head and suddenly, around 50 ml of liquid just "spilled out of her throat." This was one sign of megaoesophagus.

My assistant Mr Saw quickly took a piece of towel to wipe off the liquid.
So this was not a vomiting case but a regurgitation case.

Other than megaoesphagus, this dog could be suffering from myasthenia gravis. The first symptom of this immune mediated disease in the older dog is due to megaoesphagus. Myasthenia occurs when nicotinic acetylcholine receptors malfunction. This leads to the muscles not contracting. The scenario would be as follows: the distal end of the oesophagus - oesophageal sphincter - not contracting and thereby accumulating food and water without being pushed them into the stomach, intestines not pushing stools out causing- constipation.

The owner's wife complained that the dog had been having constipation and passes rock-hard stools for a long time. This constipation would be due to this neuromuscular disease which is said to be an immune-mediated disease.

Yet if vets see the superficial view, this emaciated poodle was vomiting, not regurgitating based on the owner's complaint of vomiting. So, it was possible that the first vet diagnosed stomach tumour/dog food allergy, as claimed by the owner. Sometimes, the owner might have misconstrued the veterinarian's diagnosis as this was some 3 years ago.

Persistent vomiting in a dog needs reviews but the owners did not do so. Nor did they get a second opinion. It is usually a matter of economics.

"The dog could be suffering from megaoesophagus," I said to Dr Vanessa and my assistant Mr Saw who is a Myanmar vet graduate. I asked Mr Saw: "Have you heard of megaoesophagus?" Mr Saw shook his head. "This is an uncommon disease. This poodle could have acquired megaoesophagus at the age of 5 years. Now she is 8 years old."

Small animal veterinary medical cases are usually routine as in many professions. There are the usual common cases of skin problems and vomiting due to gastroenteritis. And we could get fooled by a rare case of regurgitation.

In megaoesophagus, the dog "vomits 1-2 hours" after eating. This is not vomiting but regurgitation. To the owner, it is vomiting and in many cases of foreign bodies or tumours in the distal oesophagus or stomach, it would be vomiting soon after eating.

Such cases needed more time in history taking and a house visit. The dog also ate sticks, grass and plants. So, it was possible that it had a piece of stick or branch had damaged proximal oesophagus such that it became dilated and trapped the small amounts of home-cooked food and water that the owner gave in the past 3 years (leading to emaciation). This condition could be existing at the same time as the acquired megaoesphagus.

I had 4 X-rays taken of the neck and the abdomen. "It should not be just one lateral view," I said to Dr Vanessa as we normally do that to lower veterinary costs for the owners. Was there a stomach tumour? It was possible. I had not thought of taking a chest X-ray to check aspiration pneumonia as the dog had no breathing difficulty and I had not diagnosed megaoesophagus definitely at the time of admission. I had a feeling that it could be megaoesophagus but the husband's complaint of expensive vets (vets making a lot of money, he always said to me) kept restraining me from doing the chest X-rays for this first consultation. It ought to have been done in retrospective review. I had told the owner the costs would be more than $500 and there was no guarantee that there was a cure. Yet, without the tests, the husband would save money and assumed it was stomach tumour. The dog would pass away soon and he would save money. Money was a hard fact of life and sometimes, the unwillingness of the owner to spend money affected the dog's diagnosis and treatment.

Back to the patient, I reviewed the X-rays. The poodle's abdomen was impacted with hard stools due to the lack of contraction of the muscle involving peristalsis (oesophageal sphincter and large intestines). The normal stools passed out after an enema and 3 days of hospitalisation and being fed canned food.

This "constipation" seem to support a diagnosis of megaoesphagus with myasthenia gravis. There could be an oesophageal carcinoma as a consequence of megaoesphagus.

An X-ray of the distal oesophagus with barium meal was not done. Or X-rays of the chest. The husband was frugal and so I had to be understanding. Not that he could not afford the veterinary fees but he had been cursing my mentor (another vet) regarding veterinary fees and had preferred self-treatment of his sick dogs. Times are hard and I can understand the need to be thrifty.

This case is tentatively diagnosed as megaoesophagus or megaesopohagus (in U.S spelling). The last two days had been "vomit-free" days and the wife was much relieved and happy. The dog would put on weight and if not much damage had been done to the heart or kidneys, this dog should live longer. Blood tests showed low red cells and haemoglobin. There was an unusually low level of serum urea and creatinine. This case needed further investigation for oesophageal tumours.

X-ray also revealed a dilated proximal oesphageal region. It was possible that there was a foreign body (stick or tree branch) stuck on the dorsal part of the proximal oesophagus, causing pain over the years and granulomatous tissues. Over the past 3 years of inflammation, the partially obstructed proximal oesophagus dilates to form a sac as seen by an opaque area in the cranial area of the oesopohagus distal to the epiglottis. Can you see it?

The dog is skin and bones now. If she is suffering from myasthenia gravis, anti-cholinesterase drugs will reverse the overall muscle weakness and there will be no "vomiting" and "constipation".






Veterinary medicine throws out a challenging case now and then. Red herrings like "vomiting" when they are actually "regurgitation." It is enough to make any vet go crazy. For the last 2 days, there was no regurgitation and the dog had regained pinkness in the gums and should put on weight. The wife would weigh herself and the dog and keep records of feeding. Usually it is the wife who is the care-giver and if she does comply with veterinary instructions (restricted prescription dog food canned mainly with a 3 pieces of pelleted food in small amounts and 30 ml of water each time, 6x/day every 2-hourly for the first week and reviews again) , this poodle would regain her weight and health first.

Further investigations would be needed and sometimes the owner has to be proactive and to want to spend the money on veterinary services.

I also forecasted death before the Chinese New Year since this was a dog with skin and bones. She survived past the Chinese New Year (2nd day of New Year as I write this article) but I had given her the necessary IV drips to live.

The prognosis is guarded. I don't think this poodle would live past 2 years. I dare not make a prediction as I may be proven wrong as what the first vet did. It is possible that there is a stick or branch stuck in the distal oesophagus. The dog can pass bowels normally in the last 2 days much to the delight of the wife. So, is it a case of myasthenia gravis or not? Another review if needed. The mystery has not been resolved yet.

Interesting case report written by a lady intern waiting for her 'A'-level results and before admission to vet course overseas.

Jan 31, 2011
Toy poodle “.....” with vomiting problem
Diagnosis
Dog has been vomiting regularly for 3 years
Blood test—normal, with slight anaemia; kidney tests show poor health
x-ray of stomach and neck taken
1st vet suspected problem with stomach but is likely to be in the throat—foreign body/tumour; dog has habit of eating grass and stones; 1st vet diagnosed an allergy to dog food hence home cooked food has been given to it since
2nd vet notes that dog vomits about ½ hour after eating and has advised the feeding of 1/3 portion home cooked food. Dog has become emaciated, is now unable to take anesthetic for surgery.
Treatment
Fed 5pcs of D/D and ¼ can K/D hourly; dog needs to gain weight and regain health before a surgery can be done. Antibiotics and multivitamins also given.
CONCLUSION
Megaoesophagus in the dog is a condition where there is a decreased or absent contraction of the muscles of the oesophagus. It can be congenital or acquired. Its cause may be idiopathic or it may be due to tumour (oesophageal carcinoma), vascular ring (heart blood vessels congenital) or obstruction (foreign body e.g. stick or bone inside distal oesophagus, endoscope or X-rays), neuromuscular dysfunction (myasthenia gravis).


Pic and updated webpage will be at:

http://www.toapayohvets.com/web1/20110204megaoesophagus-regurgitation-dog-toapayohvets-singapore.htm


Wednesday, February 2, 2011

322. Chinese New Year's Eve's discussion with intern - the economics of practice

Feb 2, 2011 Eve of Chinese New Year.

Old Silkie, 15 years, with two snow-white cataracts and fast-growing tumour on the neck area. Panting. The mum was much distressed. Teenaged daughter and dad were saddened. Euthanasia was the humane solution to stop the suffering and pain. It was Chinese New Year's eve and it was a joyous occasion but this had to be done.

I explained to intern Michelle (waiting for her A level results and getting to know much more about the practice of vet medicine) that a pyometra surgery could not be done for less than $1,000 - $2,000 if the surgery has lots of equipment as these assets need to be paid for. She had been impressed by one well equipped surgery in Singapore. In the end, the customer just would not want that vet to operate on her dog, due to economic reasons. I was charging $500 and that would be a lot of difference.

I don't know whether she understands. "If the surgery has a lot of clients, it will be possible to pay for more manpower," I said. "It has to charge higher fees too to pay for the expensive MRI scan equipment and others. Otherwise, there is no net profit at the end of the year and how is the owner going to earn a living? In reality, the owner may just lose the case to a more affordable vet, as in the case of pyometra in the Jack Russell you saw."


Feb 1, 2011
I visited an older vet to thank the vet for the oranges and bak kua present. The vet had just recovered from an illness. She explained to me her modus operandus when I told her that she should not reject big breeds neutering. A case from her had come to me. "No, I don't want to do it. Simple wounds and simple medical cases at the lowest cost will attract clients. I don't understand why vets would charge higher fees and get less cases."

This strategy was correct as most people prefer low fees. In Bishan, I used to see a general practitioner with a long queue compared to his competitor 4 doors away. Could be the former's low fees, I am sure.

I did not comment on her strategy as she was differentiating her services by not handling difficult surgery cases like neutering of big breed Golden Retriever or complicated ones like removal of stones in the dog's stomach. She just refers them to a big practice which calls itself the "... referral clinic" and whose staff from the Philippines run down her and others for not being so well equipped.

Besides being bad-mouthed by staff of referral clinics with their arrogant policies, if the vet charges low fees, it is hard to have sufficient savings to upgrade facilities and equipment as well as to pay staff. Many pet owners prefer to visit a "better-renovated" practice and pay a bit more as they enjoy the ambience and feel confident that the vet would do a better job. First impressions count.

321. Myanmar stories - The Psychic

Feb 1, 2011 (Monday)

"She's a very good psychic," Tun, a Myanmar businessman in his 40s and sporting a big paunch due to too many lunches and coffee meetings, related an incredible tale to me over lunch at Inle Lake Restaurant in Peninsula Plaza on Feb 1, 2011 after we had seen some office spaces for rent in Peninsula Plaza. "She goes overseas to consult. Even the top general seeks her advice (Tun mentioned his name)."

"This really happened?" I was incredulous.
"Yes," Tun said. "The used car salesman is working in Singapore. I can introduce him to you."
He had said that the used car salesman was owed a lot of money by an Indian man for a few years. So he consulted E.T who is a famous psychic in Myanmar. The debtor had said: "You can send gangsters to beat me up, the triads to kill me. I will not pay you." So, the salesman asked the psychic for help.

Tun related the following:

"E.T asked him to give me a dollar note. She then wrote 80% on the note and asked the salesman to bring it with him when he sees the debtor again. You will not get back 100% of your money but just 80%.

So the salesman left Yangon to fly back to Singapore. He saw the debtor carrying the note in his shirt pocket and asked for the return of his loan. The debtor said: "I am prepare to pay you but not every cent."

The salesman said: "Pay me 70% by September (of 2009) or 80% by December (of 2009).

The debtor said: "I will pay you 80% by December."

"Is that really true?" I asked again. "Yes," Tun said patiently. "I wanted my wife to make an appointment for me."

"Why?" I asked this congenial man.

"But my wife is overseas," he said.

There was another Myanmar couple at the lunch table but they did not doubt Tun's story. E.T charges US$40 per case and that is a lot of money for the average person in Myanmar. So, do you believe in this tale or not? Tun has no reason to tell a cock and bull story. I was talking about a Myanmar business man who was looking for old Jaguar cars from Singapore to sell in Myanmar. This was when Tun said that he knew of this large used-car company that had a lot of old Jaguars to sell. And that was then he related the story of E.T and this salesman in this company.

His friend who is an entreprenuer had said: "An old Jaguar in Yangon is half the price of a Toyota." I was surprised. He further surprised me by saying: "The housing agent in Yangon is called "worn-out sleepers and faded umbrellas. This is because he pounds the pavement till his slippers are worn out (unlike Singapore agents who drive a Mercedes) and worked under the hot afternoon sun till his umbrella colours fade away." I was surprised at such stereotypes of the realtor and did learn a bit about the culture in Myanmar. As for the psychic, I wonder whether I should make an appointment.














Psychic, clairvoyant, healer, master practitioner in the arts of black magic, tarot, numerology, palmistry and astrology.