Tuesday, February 7, 2012

862. Sunday's interesting case - rabbit eye tearing

Sunday Feb 5, 2012

Bright sunshine. Dr Daniel Sing started his first Sunday of working life after graduation. As a mentor of my associate vets, I was present in this case as in other cases of associate vets. Trust and audit are my management style to ensure a high standard of veterinary care at Toa Payoh Vets and that is why I do intrude into the consultation of my associate vets now and then and review their case sheets. There is no short cuts to be successful in work and life. "Associate vets in Toa Payoh Vets must adopt a consistency in the treatment of similar processes and system to ensure good clinical outcomes," I said to Dr Daniel Sing and Dr Vanessa Lin.

Without a system or standard operating procedure, each vet does his own treatment and may miss out on certain steps. For example, in urolithiasis, a failure to send urine for analysis or stone for analysis unless the client objects to this steps due to economic reasons. So, this is why I am around in some consultations of associate vets.

On this fine Sunday, Dr Daniel had a rabbit which had tearing eyes. A large bald area below the weepy eye. He touched the lower part of this hairless area. I did so too. The rabbit reacted by moving away its face. Abscess or tooth pain?

I got a fluorescein strip from the box and Dr Daniel stained the cornea. Show, not tell is the best in veterinary practice. The rabbit had an eye corneal ulcer as evident by the green 11 o'clock to 2 o'clock stain. So there is an ulcer? What next? New vets tend to relate a list of differential diagnosis to the client, as this is what the vet professors teach them.





5008 - 5009. Corneal ulceration in a rabbit. What is the cure? This is more important than why? The primary cause was two ingrowing cheek teeth on the right side. Isoflurane anaesthesia was necessary to open the mouth as the rabbit was very nervous when the vet tried to open its mouth.
To me, this is OK but some clients just have little time and just want to know what's wrong and the solution. Since this rabbit had an "on-off" eye tearing in the past few weeks and felt pain at the lower maxillary cheek area, Dr Daniel diagnosed teeth problem.

I advised warding the rabbit for one or two days. On the next day, to get the rabbit anaesthesized to check the mouth.

Monday, Jan 6, 2012
Dr Daniel used isoflurane gas mask to anaesthesize the rabbit. Min helped. I was around to pull out the tongue. Inside the left cheek, food and two long curved teeth of around 1.5 cm long were stuck and causing pain. Dr Daniel used the forceps to pull out the two teeth and two broken fragments. I took some images. I quickly irrigate below the 3rd eyelid with 5 ml of clean water as Dr Daniel everted the 3rd eyelid, just in case debris had gone inside it.

The rabbit should feel better now. Will observe on Tuesday and update. Rabbit should be able to go home. "This rabbit eats only pellets", said the gentleman owner. "No hay." He had gone home to bring the rabbit pellets.

Show not tell is the best advice for a vet in private practice. In this case, it was not possible to show the anaesthesia but there were two bone fragments and images to show the owner to give him evidence of what happened and what was done to ensure a good clinical outcome. I don't expect any tearing. On the surface, this appears to be a case of eye corneal injury as there is green fluorescein staining. Veterinary medicine can be challenging. Rabbits can't talk and owners can't tell what's wrong. Therefore, it is up to the vet to palpate (pain in the teeth area) thoroughly and in this case, the primary diagnosis would be ingrowing cheek teeth causing facial pain and irritation and eye rubbing to relieve the pain. A hypothesis. If the rabbit has recovered within 2 weeks, then my hypothesis is correct.

No need to spend money X-raying as visual inspection under anaesthesia using gas mask and isoflurane and oxygen is the method of choice and cheaper. "SC anaesthetic drug injection can be used but not necessary as the gas method is safer and the rabbit wakes up fast," I said.

The cause of tearing of the eye would be due to the rabbit rubbing its facial area to relieve tooth pain of the right teeth cutting into its right cheek, not corneal injury. "This rabbit has to be separated from the other rabbit for some time," I advised the owner. "This is to prevent the other rabbit from grooming or licking its eye." The owner said: "It is difficult to do so." Well, vets should advise but it is up to the owner to accept it.

Updates and more images at:
http://www.sinpets.com/F6/20120217cheek-teeth-ingrown-rabbit-eye-tearing-toa-payoh-vets_Singapore_ToaPayohVets.htm

Monday, February 6, 2012

861. Review of recurrent urolithiasis in an 8-year-old lMini Schnauzer

History
Miniature Schnauzer, Male, 8 years
9.3 kg 39.3C

15.9.12 Dysuria >7 days. Eats dry food.
Urethral obstruction. Catheter relieved obstruction.

15.9.12 URINE ANALYSIS
pH=7 (5-8), SG 1.030 (1.005 - 1.030)
Protein +, Blood 4+, WBC 504, RBC 1440, Bacteria +, Crystals Nil

X-ray

BLOOD TEST
Urea = 7 (4.2 - 6.3)
Creatinine = 61 (89-177)
WBC = 13.6 (6-17) with neutrophils 93% absolute 12.6, lymphocytes 6.5%, absolute 0.88
No hypercalcaemia

STONE ANALYSIS - multiple fragmented uroliths. CANINE CALCIUM OXLATE
Calcium oxalaate monohydrate 100% stone 5% shell
Calcium oxalate dihydrate 95% shell

16.9.12 Cystotomy. Urinary stones removed by Vet 1


RECURRENT UROLITHIASIS
3.2.12
8.2 KG 38.4c
Dysuria. Fed home-cooked food.


3.2.12 URINE ANALYSIS
pH=9 (5-8), SG 1.025 (1.005 - 1.030)
Protein 2+, Blood 4+, WBC 0, RBC >2250, Bacteria +, Crystals Triple phosphate +, Amorphous phosphate 3+

STONE ANALYSIS - Sent stones to the lab

Owner did not want blood test
X-rays - 15 stones seen. bladder and behind os penis. see image.

CONCLUSION
This is not a recurrent case of calcium oxalate urinary stones as the 2nd episode showed struvite stone formation.

MANAGING Calcium Oxalate Urolith prevention - do urinalysis and X-rays.
If urine SG >1.020 give canned food or add water to food
If urine pH <6.5, consider diets that produce less acidic urine eg. u/d or use urinary alkalinizers eg. K citrate If urine pH>6.5, USG <1.020, no crystals, repeat urinalysis monthly, then every 3-6 montyhs.
Repeat X-ray every 6-12 months to detect urolith recurrence early.
Repeat urine test and X-rays if signs - haematuria, pollakiuria, dysuria recur.

STRUVITE stones are clinically insignificantg if no urinary tract infection as bacteria forming urease are rquired for struvite urolith formation in dogs.

UROLITHS
1. Voiding urohydropropulsio9n if small uroliths
2. No clinical signs of blood in urine etc, leave stones alone.
3. With persistent signs, remove uroliths
4. Send for stone analysis.

For calcium oxalate prevention,
1. Diets promoting urine pH <6.59 were at highest risk
2. Avoid risk factors like hypercalciuria due to hypercalcemia, metabolic acidosis, high sodium consumption and Vit D excess.
3. Feed canned foods and/or add more water to food so that urine pH is consistently <6.5
4. Consider hydrocholorothiazide (2mg/kg q 12 hr) with highly recurrent urolithaisais in dogs without hypercalcemia.
5. Consider potassium citrate (75mg/kg q 12-24 hr) if urine pH is consistently <6.5

The shih tzu coughs white mucus daily for 3 months. Why?

"My other dog has been treated by Vet 1 for the past 12 years," the owner said he had no veterinary report from the vet who had treated the presented Shih Tzu of 4 years old for coughing. "I feel bad to ask Vet 1 for the medical records and X-rays for this Shih Tzu."

"How long has this Shih Tzu been coughing?" I asked.
"5 months. My domestic worker says the dog has a tongue ulcer."

"There should be no problem with Vet 1 sending over your dog's records as this is a common practice. Shall I phone on your behalf?". The owner agreed and Vet 1 sent his report over. The coughing started 3 months ago and blood test and X-rays of the chest and abdomen were normal.

What's the cause of this persistent coughing? There was a tongue ulcer at the tip and one on the hard palate. I shone my torchlight at the ulcers to show the owner. The dog just would not cooperate, but the owner already knew of the existence of the ulcer. I palpated the dog's throat. It was very painful.

"My dog sometimes throw up liquid," the owner said. This is quite a complicated case as the heart and lungs were normal on auscultation using my stethoscope. What is the cause of this persistent coughing?

To complicate diagnosis, the right and left submandibular and popliteal lymph nodes were much enlarged. I let the owner feel the lumps. Could this be a concurrent case of lymphoma or lymphosarcoma?

"Did your tongue lick some poison?" I asked. "Tongue ulcer at the tip of a normal tongue usually indicated something corrosive had burnt the tongue. Like insecticide."









Persistent coughing for 3 months. Weight loss. Why?
"Well my dog has licked shampoo used to treat his dandruff."
Blood, urine and X-rays of the throat, chest and abdomen are being done as this are necessary to aid in the diagnosis of persistent coughing even though some tests were done earlier by Vet 1. Throat X-ray was not done and is usually not done in cases of coughing.

However, this must be done as there may be a piece of bone stuck inside the throat, leading to persistent coughing and weight loss as the dog ate little. The tongue ulcer could be due to licking of the shampoo over the last 3 months. Wait for the new X-rays to be done today.

"Dog owners may want to be loyal but the vet must be able to get the dog's problem resolved within two visits," I said to my associate vet. "Good bedside manners are great but repeat visits cost the owner money and time. So they go for 2nd opinions if the family vet can't come to a correct diagnosis and treatment."

"Why did Vet 1 not able to diagnose the case?" the man asked me twice after I had shown him the X-rays and asked him and his wife to palpate the enlarged submandibular and popliteal lymph nodes. It is show, not tell nowadays.

"Vet 1 is an experienced vet," I said. "The lung X-ray was normal and the lymph nodes have probably just enlarged in the last month. He did blood test and the result was normal as he had told you."

The second opinion vet has the benefit of the progression of the disease. I warded the thin dog. He did vomit white frothy mucus around 3 times per day and ate little. So, what is the diagnosis and what is the cure?

Use evidence-based medicine and do a thorough physical examination including turning the dog upside down and checking all lymph nodes and doing abdominal palpation. There was no fever, increased respiratory rate or anaemia or other abnormal signs other than the enlarged lymph nodes and tongue ulcers and severe weight loss. The X-rays were useful but the vet must take more than one X-ray. Vet 1 did one X-ray, the quality of which was not so good.






Take more than one view of a site but some vets just do one view to reduce veterinary costs to the client. This may not be in the interest of the canine patient. Study the X-rays again in the privacy of your home and review your case again and do research on similar cases, discuss with peers. This will make you a better vet over the years. There is no short-cut to be a better vet and veterinary medicine and surgery cannot be mastered even with a life-time of practice as the subject of the whole canine body has too many diverse medical and surgical conditions. Human medical or surgical specialists just focus on one area of the human body. Vets have to be know it all!
This is likely a case of canine lymphoma at an earlier stage. Late stage would show images as described in:
http://www.sinpets.com/F5/20110319canine-lymphoma-eye-bleeding-toapayohvets.htm. Due to economic reasons, more detailed tests cannot be done. As to the cure, chemotherapy is needed. Prognosis is not good and the owner knows it. He and his wife were quite satisfied with the diagnosis using evidence-based medicine.

Website and MORE IMAGES and any update will be at:
http://www.sinpets.com/F6/20120202persistent-coughing-young-shih-tzu_Singapore_ToaPayohVets.htm

859. Self-discipline. Dressing at work at Toa Payoh Vets

This new year of 2012, I will not try to be flexible as in the past years. I will not tolerate casual dressing by my vets or the staff or intern.

Sandals, T-shirts and jeans are out. Those who persists will get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.

Dressing casually is out in 2012 and those, including vets who insist on dressing casually will need to look for another job. I had asked intern Mr Lim whether his school had taught him the importance of being properly attired at the office. He said yes. Yet he and many others including some vets used to dress casually in the past years and needed to be reminded.

Last week, one vet told me she had left her shoes in the car when I asked why she wore sandals to work. This was after I had given her advice several times not to do it.
Then 3 days later, she had sandals on again. "A dog had peed on my shoes," she said. I asked: "That is a creative excuse. What will be your next excuse?"

No more nonsense from the younger generation when it comes to office work and productivity. "Toa Payoh Vets is like a baby or puppy," I said to Mr Min and Dr Daniel Sing at his first day of work on February 1, 2012. "It needs perpetual care and attention. It just dies over the next few years if it is poorly managed or not producing good clinical outcomes. Customers will run away. There will be no referrals. The practice just goes bankrupt and there will be no jobs for anyone."

For the younger generation of employees, they can work elsewhere when they don't like my instructions to adopt a proper behaviour at work. But a bad work attitude is not advised as there are some behaviour and common sense expected of a young adult at work. First impressions do count.

If employees want to challenge authority, it is best they find work somewhere. I will not hesitate to fire vets on the spot even if they have a great number of clientele as their attitude erodes the morale and productivity of the staff and other vets.

It is just not for vets, interns or staff to dress casually at work where there is interaction with the public. Vets who want to dress casually can open their own practices and I wish them good luck. I have enough of staff and intern who come to work at Toa Payoh Vets dressed casually as if the office is their parents' home. Young adult employees may know that they must learn to accept instructions and learn from the older generation before they can assume leadership positions as there are predatory veterinary competitors, litigation lawyers and regulatory officers in the real world, unlike in their school days.

Thursday, February 2, 2012

858. VET CASE STUDY: Anaesthesia old dog with heart murmurs - Swollen Right Ear. Aural haematoma surgical treatment

This case illustrates the importance of being scientific in giving IV anaesthesia. If the vet simply gives Domitor 0.1 ml IV for small dogs regardless of size and age and top up with isoflurane gas + oxygen at all times, this one dose fits all sizes is not a good practice. This is because a larger dog needs more Domitor to be sedated if the vet wishes to use the same amount of isoflurane gas + oxygen to anaesthesize the dog before intubation.

 
I have the following case to illustrate how a sound knowledge of the use of domitor + ketamine IV based on my formula and based on weight and age (in this case, 25% of the formula) enabled me to perform an aural haematoma surgery WITHOUT the need to top up.

PATIENT
Cross-bred terrier, 13 years old, 6.3kg, good condition, but machinery heart murmur. No coughing. Undescended testicle x 1. Bad teeth. Very high anaesthetic risk but surgery is the only option in this aural haematoma treatment.



This case - IV domitor and ketamine at 25%* of my calculated dosage was sufficient for an old dog not in good health for around 60 minutes of surgery. No blood test was done to screen the health as the owner wanted to keep veterinary costs minimal.


Get all materials and plan early before giving the IV anaesthetic injection

Right ear swollen. Heart disease
Clip hairs


Wash ear well
S-shaped incision of sufficient length. Remove all clots inside
2/0 nylon horizontal mattress suture x 1 packet


Ear irrigation to flush out blood and debris. Dog howls.
Antisedan wakes up dog. Before going home, handing over inspection
Knots are on lateral side of ear pinna. Pain-killers and antibiotics. Home nursing advices.


I audit how long it takes me to do this surgery. The times of my surgery and procedures are as follows:

10.35am
At 25%, D=0.07 ml K=0.09ml = 0.16 ml+ Hartmann to 0.9 ml given IV. Waited 5 minutes. Check blinking reflex which persisted throughout.

11.23 am
2/0 stitching ends.
11.24 am
Irrigate right ear to get rid of any dead ticks. The dog reacted by howling. This showed that the IV surgical anaesthesia lasted till from 10.35 am - 11.24 am. No need to use isoflurane for 48 minutes. This was a surprise to me as I was prepared for isoflurane gas top up.

*NOTES
In young healthy dogs, 25% will be insufficient. The dosage may be up to 100% for 48 minutes of analgesia without isoflurane gas top up.



However fast, I cut and stitched, the whole process was approximately 48 minutes for surgery without pain. At 11.35 am, I injected Antisedan 0.2 ml IM and the dog woke up fast as if he had an afternoon nap. The lady owner was quite happy and took the dog home.

POST-OP NURSING. I phoned the owner today Feb 8, 2012 about 5 days after surgery. The dog was trying to scratch its ears daily despite the e-collar being worn. I advised her to get a clean 10-20 ml syringe, fill it with lukewarm water and irrigate the ear canal which would have contained blood post-operation. This would reduce her costs.

I did not bandage the ear or plug the ear canal with cotton wool although in some cases I would do so. Usually the dog shakes off the bandage within 12 hours unless the whole ear is bandaged to the neck.

Some vets use X-ray plates to be stitched on the lateral and medial side of the ear to provide compression. I don't do it as the results of getting a normal ear back are not good.

NO SURGICAL IMAGES ARE PUBLISHED IN THIS BLOG, due to complaint of 'shocking content'.

Please go to the following webpage with more images of aural haematoma surgery at:
http://www.bekindtopets.com/stories/20120224aural-haematoma-terrier-heart-disease-toa-payoh-vets_Singapore_ToaPayohVets.htm

Travels broaden your mind if you know how

During my travels, shopping and more shopping and good food are not my interest. These activities will be likely most of my readers' interest as they are likely to be young ones.

However, if you want to broaden your mind intelluctually, be an adventurer and be observant of the local customs and culture of Bali.

LOCAL ARCHITECTURE AND CUSTOM
"After you have seen Myanmar villages, you have seen all," Marianne who represented the Singaporean who loves shopping and airconditioning comfort, said to me.
"After you have been to one shopping mall in Hongkong, you have seen all too," I replied. "Yet, every country's shopping mall has different products for sale, if you really investigate. Every country's rural areas are different". I was talking to the wall as Bali was hot and humid and not for Marianne.

On a morning of Jan 31, 2012 (Tuesday), my last day in Bali, I asked the driver to visit his home and got to understand much more the local cultures than reading from the travel guides. Then he brought me to a silversmith in a road lined with silversmith shops. The shop was closed as it was a day before the Gulang festival (Wednesday). But he went to the front gate and I was invited inside.

Wow, this silversmith and his sister spoke English very well. After purchasing two small pieces of ear rings for a 20% discount and no more, I asked about the architecture and layout of his house. It was a very beautiful house but the layout was similar to the driver who had a hard time explaining to me the functions of the layout.

"In the centre is the house for human beings. Ceremonies like filing teeth, deaths and marriages. In the north is the house for parents or grandparents. In the north-east is the land for the gods (various shrines). In the south is the kitchen (and his office factory). "How about to the west?" I asked him? "It can be used for any building," he said.

This explanation was good as the driver could not explain to me when he drove me past many village houses where I noted, from passing by in the car, that many of them have shrines to one side, like mini-temples. Most Balinese are Hindus and therefore religious rituals and ordinary ceremonies are conducted frequently.

GOOD DIGITAL IMAGES OF THE WAY OF LIFE OF THE LOCAL - THE WET MARKET
Practise and practise and you will retain memories of your travels when one day, you are unable to walk. For the young ones, this day will never come.




856. Persistent coughing in a young shih tzu - a 2nd opinion

"My other dog has been treated by Vet 1 for the past 12 years," the owner said he had no veterinary report from the vet who had treated the dog for coughing. "I feel bad to ask Vet 1 for the medical records and X-rays for this Shih Tzu."

"How long has this Shih Tzu been coughing?" I asked.
"5 months. My domestic worker says the dog has a tongue ulcer."

"There should be no problem with Vet 1 sending over your dog's records as this is a common practice. Shall I phone on your behalf?". The owner agreed and Vet 1 sent his report over. The coughing started 3 months ago and blood test and X-rays of the chest and abdomen were normal.

What's the cause of this persistent coughing? There was a tongue ulcer at the tip and one on the hard palate. I shone my torchlight at the ulcers to show the owner. The dog just would not cooperate, but the owner already knew of the existence of the ulcer. I palpated the dog's throat. It was very painful.



"My dog sometimes throw up liquid," the owner said. This is quite a complicated case as the heart and lungs were normal on auscultation using my stethoscope. What is the cause of this persistent coughing?

To complicate diagnosis, the right and left submandibular and popliteal lymph nodes were much enlarged. I let the owner feel the lumps. Could this be a concurrent case of lymphoma or lymphosarcoma?

"Did your tongue lick some poison?" I asked. "Tongue ulcer at the tip of a normal tongue usually indicated something corrosive had burnt the tongue. Like insecticide."

"Well my dog has licked shampoo used to treat his dandruff."
Blood, urine and X-rays of the throat, chest and abdomen are being done as this are necessary to aid in the diagnosis of persistent coughing even though some tests were done earlier by Vet 1. Throat X-ray was not done and is usually not done in cases of coughing. However, this must be done as there may be a piece of bone stuck inside the throat, leading to persistent coughing and weight loss as the dog ate little. The tongue ulcer could be due to licking of the shampoo over the last 3 months. Wait for the new X-rays to be done today.

"Dog owners may want to be loyal but the vet must be able to get the dog's problem resolved within two visits," I said to my associate vet. "Good bedside manners are great but repeat visits cost the owner money and time. So they go for 2nd opinions if the family vet can't come to a correct diagnosis and treatment."

More images at:
http://www.sinpets.com/F6/20120202persistent-coughing-young-shih-tzu_Singapore_ToaPayohVets.htm