Thursday, June 14, 2012

1024. Follow-up. CKC still has skin problems but ears are fine

Jun 14, 2012, a young man came to buy the green shampoo again as his CKC is still scratching his body after his groomer clipping the coat short a 1-cm length as requested by his mum. That is, no balding look.

"The dog's ears are OK. No more ear odour," he told me that the lateral ear resection canal had been effective. I took out the thick file of 27 medical records from Jul 18, 2009 to Apr 20, 2012.


SIGNIFICANT CLINICAL FINDINGS FROM CASE FILES

CKC, Blenheim, Male, DOB Apr 2, 2008
Jul 20, 08  Neuter
Apr 3, 10  2 years old. Two ears infection
May 3, 09  Pus in ears. Ear irrigation
Jul 11, 10  Ear discharge
Jul 11, 10  Left ear canal resection. Dr Sing
Sep 6, 10  Right ear canal resection. Dr Vanessa
Sep 20 10 Ear infection
Oct 18, 10 Ear scratching and head shaking
Oct 19, 10 Lab test. L ear swab Candida krusei isolated after 2 days of incubation
Jun 6, 11  Ear ointment x 1
Oct 21, 11 Ear ointment. Smell from the rear
Apr 6, 12  Generalised skin infections
Jun 14, 12  Came for anti-fungal wash for skin rashes which develop when the coat is long. However, he is very satisfied with the ear surgeries done as there is no more foul ear smells.

CONCLUSION
Many dog owners don't bring their dogs for further check-ups for skin infections and prefer to take medication like drugs or shampoos in the belief that these will be sufficient. I advised actual examination as the dog may still have a generalised skin fungal and yeast infection.





1023. Adopted young cat with low platelet count spayed




On Wed, Jun 13, 2012 at 9:18 PM, <...@gmail.com> wrote:

Hi Dr Sing,

XXXi appears almost recovered from surgery already.

Her appetite is tremedous, and she has finally pooped tonight.

A lot !

Attached is a picture of her belly.

Sorry we couldn't get a more overt and clear one.

She appears & behaves normal.

Are there any signs we should look out for, that might indicate otherwise ?
We were also wondering when we can remove the e-collar, and also when can we let her out of confinement ?

She is getting progressively faster in trying to escape.

Like a game !

Thank you so much, and looking forward to your reply.



EMAIL REPLY FROM DR SING DATED JUNE 14, 2012

Hi


I was quite busy past 2 days. Thanks for 2 emails. Low platelets and low total white cell count indicate that the cat had some toxicaemia a few days ago. It is hard to say what it is but the eosinophils of 5.5% is high. There is the eosinophila granulomatous complex in cats (mouth ulcers, salivation) but this may not be the disease in your cat.

Your cat was FIV negative and that is good news.

Blood tests are an aid to diagnosis and the clinical signs are much more important. Presently, she is in good health and so that is the present status.

Can't see anything in your image of the surgical wound area. Please clean it and apply a new plaster for the next 10 days. E-collar can be taken out after 7 days if the stitches are strong and if the cat is not bothered. Best wishes.

Total WCC 5.3  (5.5 -19.5)
N   63%
L    28%
M   3.5%
E    5.5%
B   0.1%

RBC  6.8 (5-10)
Platelets   38   (300-800)
No platelet clumps seen
Large platelets present

Fed on Barf Diet changing from canned commercial diet and was losing weight compared to previous check up at 2nd vaccination.


E-MAIL TO DR SING DATED JUN 15, 2012
Hi Dr Sing,

Thanks for the comforting reply. Good to know that there's nothing to worry about.

Hopefully, the next time she has to see u is when she is due for her annual vaccination.

Once again, thanks very much.

Sunday, June 10, 2012

1022. Sunday June 10, 2012 interesting cases

Sunday June 10, 2012
Bright sunshine, blue skies.

Case 1. Golden Retriever shakes and trembles after Antisedan IM injection.
As the electricity supply to Toa Payoh Vets and nearby tenants was cut off due to the need to maintenance by the Landlord, it was too dark to do 3rd eyelid irrigation and right elbow granuloma injection.

So I did it outside. This was not ideal but the lighting from the morning sun was good.

At 10.15 am, the 28kg GR was given Dom + Ket at 50% IV by Dr Daniel. The dog fell asleep fast. I got the table outside the surgery where there was bright sunshine. Time was of the essence and I hurried my assistant Min, intern Sally and Dr Daniel to move on with the preparations. There was no isoflurane gas back up now as we were outside the surgery and the couple (owners) were watching.|

The GR was still asleep. So I decided to give Antisedan 1.0 ml IV. But Dr Daniel and then I could not locate the cephalic vein. Around 4 clients with barking dogs and a cat came and there was no time to waste. I gave the Antisedan IM. Nothing happened for 2 minutes. "It takes a longer time to wake up when IM injection is given," I said to the concerned wife. Then the dog inside the waiting room held his head up. There was much barking from other dogs. A contractor across the block was using his machine to drill something.

The GR started to shake and tremble non-stop. He panted. He could not get up to walk. "He is excited by the barking and the machine noises," I said. I rushed into the Surgery to get the atropine injection and gave him IM. Still his whole body was trembling.
"Put the dog inside the boot of the SUV," I said. "He needs to be far away from the barking dogs." The owner drove the dog to the other end of the block and parked the car there. The dog was still trembling but much less. I brought a bowl of water. He did not want it, as if afraid of water. "His head keeps turning right and left," the wife said. "It is part of the excitation effects of the ketamine," I explained. "Normally, the dog should wake up in a quiet place at the back of my surgery, but this morning was unusual in that there was so much barking from the other dogs." 

After 30 minutes, the dog had stopped trembling, drank his water and was sent home. This side effect of excitation by ketamine after Antisedan reverses domitor, during recovery is rare but does occur. The vet must know what to do as it can be quite stressful to the owner. It is best to let the dog wake up in the back of the Surgery, away from the crowds and barking dogs.

Case 2. "The Westie's skin disease is much better due to a change of diet," the man in his early 30s said to me as he did not want any steroid injection. He had been to Vet 1 to treat the Westie's lacerated interdigital D3-D4 left hindpaw. Vet 1 had given injections and the paw wound is much less inflamed. "What injection did Vet 1 give?" I asked. "I don't know," he said. "My Westie has much steroid to cure his skin disease (lower body) and I don't want him to have any."
"It is because of the steroid that his skin disease is under control," I said.
"No," the man said. "It is due to a change of diet."
"If it is due to the change of diet, then the Westie should not have any steroids for the last 6 months. Just purely the diet. Has he got the steroid in the last 6 months?"
"Yes," the man said. "But not much."

"I am just trying to educate pet owners. Steroids are to be used carefully and they help to relieve the dog of itchiness and injuries due to licking and scratching. Many owners and younger vets seem to think that steroids are to be avoided at all cost as they suppress the immune system. Many diseases, even in people, need careful dosage of steroids to live a normal life."    

As he just wanted antibiotics for the lacerated wound and washes, I gave him what he wanted and a wash. The dog had an e-collar and should recover after many days. However, the lacerated wound between Digits 3 and 4 was long and between the digits, stitching up would be best option but it was declined. Healing by granulation could work.

Case 3. The 5-year-old Jack Russell passed fresh blood copiously yesterday. The owners wanted Dr Vanessa but she was off duty on Saturday. So it was Dr Jason Teo and myself. Anyway, I got them to see Dr Vanessa in the consultation room since she was present. "Dr Vanessa would not know anything about this case," I said. "The dog is more active and has not passed blood due to the drug injection. Blood test and stool test results would be known tomorrow. I did not feel any abdominal pain or foreign body and so no X-ray is done. It will take 3-5 days to know whether the dog has recovered from ulcerative colitis (bleeding from the colon).

"Did the dog eat chicken bones?" I asked again.
"No," the wife said. The husband and young adult daughter came.
"He eats wood, plastic and anything," the husband said. "Could this be the cause of the bleeding?" The dog had vomited once and passed stools followed by red fresh blood yesterday. This seemed to indicate that there was a foreign body lacerating the rectal area, causing large amounts of bleeding at the anus. Parvovirus test was negative and that was good news.

We had 2 or 3 cases of dogs passing blood in the stools recently.  My ideal treatment would be IV drip with IV to prevent dehydration and antibiotics and anti-spasmogesic in the drip to give more effective and prompt cure. Other vets may prefer antibitoic and anti-spamogesic SC as in this case. "The dog bites," the owner had warned Dr Jason Teo and I on Saturday (yesterday).

"Muzzle the dog and give IV glucose saline 500 ml as it is more effective," I said when Dr Jason suggested drip SC.  The dog was quite lethargic and would not bite when muzzled. The dog had stayed overnight. "I am worried that the dog may feel home-sick," the wife had told me as she wanted an injection and take the dog home. But the mucus and tissue from the rectum had red blood and we collected a sample to send to the lab for check up of parasites and abnormal cancer cells.

"Well, it is not the dog that is worried. He is already so sick and will prefer to rest quietly. It is the owner who feels it. If the dog goes home after the drip and wanders around the apartment, he cannot rest and recover fast. Worse of all, he may pass more blood and then there will be extra after-hours emergency costs."  So, it is best to hospitalise the dog with bloody stools at least overnight.  This dog was much active today on Sunday and the wife had great difficulty in muzzling him so that my assistant Min could remove the IV cathether. The dog had been eating all wood and other things from a young age. So, there could be chronic damage to the colon and ulcers form, leading to ulcerative colitis with profuse bleeding on Saturday yesterday.  

UPDATE Jun 15, 2012. 6 days later.
"My dog is passing black stools, once a day instead of twice a day," the daughter said today. "He doesn't poop more than twice a day as before. The stools are black. Why?"
"Your dad says your dog eats wood, chews wood and any plastic. Some of the big chewed pieces would have cut the small and large intestines. The small intestines bleed and the blood becomes black when it arrived at the anus. Hence you can see black stools."

"But my dog was passing lots of red blood," she said. "So scary. What is the cause of this red blood?"
"Most likely the rectum or the area near the anus had been injured by a large piece of wood or object. So the bleeding is fresh red blood and lots of it."

The dog had recovered from anal bleeding. "Stool sample showed RBC and WBC. That means there is infection in the intestines." I said.

The dog had been chewing wood from young. How to stop him is a problem. Lifestyle changes are needed. The owner bought canned food for the dog for the time being.

  

Saturday, June 9, 2012

1020. Caterwauling cat with low platelet count spayed

Case study on this Sat Jun 9, 2012 morning at Toa Payoh Vets.
Cat spayed yesterday against medical advice. The cat had been caterwauling noisily for the past week and the owner took the risk to spay despite my advice that a cat losing weight (from 2.55kg on April 29, 12 to 2.40 kg on Jun 8, 12, day of spay, Friday).

Blood test reviewed and the owner informed.

BLOOD TEST RESULT - Significant results
Total WCC 5.3 (5.5 - 19.5) & very low platelet count.
I was surprised to see the very low platelet count of this adopted young female cat, around
10 months old. The owners came for Vit K1 tablets to be given for a week.

SUNDAY JUNE 10, 2012  3 pm. I phoned the owner at his home as both he and his wife had not answered their handphones. "The cat is active. Eats, drinks, pees but has not pooped." So, it is good news.

As to the cause of the low platelet count, it is a mystery. Could it be the "Barf diet"? The owners had changed to this diet instead of the commercial canned cat's food. There was really a weight loss over the period of time stated above. To be safe, I advised using commercial canned food for a month. The cat was losing weight and the spay was done with informed consent of the risks of dying.

1019. Old Border had a large ear tumour

"I will operate for free to cut off the 1/3 of the ear," I said to the owner of the 12-year-old Border Collie. The ear tumour was 2 x 3 cm, disc-shaped wart-like and there were two other warts in the face and I had advised sectioning off the ear with the tumour on the first consultation on May 13, 2012.

Surgery would be in 7 days after a course of antibiotics. However, Dr Daniel saw the case. As each vet or doctor has his or her own way of handling a case of an ear tumour and my way was not the other way, Dr Daniel decided to excise the ear tumour when he was presented the case and I was not around. Blood test was declined.

The owner's daughter agreed to a histopathology. Diagnosis was squamous cell carcinoma.

WHY I ADVISE SECTIONING OF THE EAR?
Old dog, the ugly-looking large ear tumour looked cancerous. The owner wanted the least cost treatment and that meant no blood test or biopsy of the tumour or histopatholgoy.

Cutting off the 1/3 of the ear would ensure that any cancerous cells would be cut off by a wide margin. Healing would be easier.  Excising off the wart would leave a big wound and lead to long healing. This was the case.

Each vet has his or her own mindset and experience. There is no one surgical approach in ear wart surgery. Usually the warts are excised but not a portion of the ear. In old dogs, it is best to cut off part of the ear to ensure no spread of the cells and early recovery. A large  hole after a large tumour excision of the ear is hard on the old dog as it is itchy. Healing by granulation takes a longer time, since the dog is old and the healing is slow. But the dog still has his ear shape!




1018. Two eyes tearing young Schnauzer

Today Sat Jun 9, 2012, another bright and blue-sky morning, I came to Toa Payoh Vets at 9.30 am for a trust and audit check and an appointment of a lady owner who had a rabbit with a red nose.

I phoned a Miniature Schnauzer lady owner from Punggol at 9.15 am but her phone was switched off. I left a message of the blood test done on 2 days ago. "Blood test for XXX.  A high cell count indicates bacterial infection. Are eyes still tearing? Please tel me". My i phone displayed: "Message failure"

The lady owner wanted to consult me specifically on Jun 7, 2012, as her Miniature Schnauzer, female, 1 year 2 months old, has tearing eyes for the past 4 days. No fever. Still eating and drinking but pus in the eye discharge for 4 days.

There are two Dr Sings in Toa Payoh Vets and sometimes, there is a confusion. She confirmed she wanted to consult me.

Red eyes. Pus in tearing areas for 4 days. Swollen submandibular and adjacent lymph nodes on both sides.

I diagnosed the dog as having "glanders" and told Dr Daniel who was assisting me that this is a rare case nowadays. "Usually puppies and treatment is effective."




The submandibular lymph nodes were enlarged like 10-cent coins on both sides and I taught the owner how to palpate them. She was surprised. They should not be felt at all in normal dogs, including young ones. "Glanders is a bacterial infection of puppies," I said. "However, this dog is still young. Your dog must have an active lifestyle!"
 

I asked: "Does he go to the Bishan Dog Park and dig the soil and eat grass and lick soil?"

Yes," she said. "He loves to do that when we take off the lease at the park."

"Why do you bring her to the Bishan Dog Park since you live in Punggol?"

"The Bishan Dog Park is the place where the dog can run around without a lease," she replied.

"Any construction nearby?" Dr Daniel asked.

"Yes," she said. There are new HDB flats being built in this pretty new town with waterfronting views, so there was dust all around.

"The soil bacteria could have gone into the eyes, nose and mouth and then the submandibular lymph nodes," I said. " A blood test will be important to help in the diagnosis."  I got permission for a blood test.

BLOOD TEST RESULTS - Significant findings were:
Total white cell count 17.4 (6-17)
N=71%, L=23%, M=6%, E=0.2%, B=0.6%
Urea 10.5 (4.2-6.3)

Use evidence-based medicine to come to a diagnosis if the owner can afford the blood test as it tells a lot of causes but the vet must know how to interpret them in relation to the clinical signs. In this case, glanders was confirmed by the increase in total white cell count in the blood test as a result of a systemic bacterial infection. 

What is the significance of increase in monocytes? This could mean a long-standing chronic infection and well, this young dog had an active outdoor digging and eating soil and so, the infection from the soil had been going on for some months. Hence, an increase in monocytes.

Based on clinical signs, blood test helps in coming to a correct diagnosis of "glanders". The owner would know simply that her dog had a bacterial infection.

I tried phoning the owner again to close the case by giving her the blood test results.  As I typed, the happy owner phoned me and said that the dog was still eating and drinking as before and had the following improvements as compared to 2 days before treatment

"Both eyes are still tearing but much less," she said. "No more redness in the eyes."  She was referring to the acute conjunctivitis which she saw when I pulled down the eye lids.

"How about the size of the submandibular lymph nodes?" I asked.

"I don't know whether it is psychological but I feel them as being much smaller than on that day."
"You are correct in finding that the size had gone down considerably due to the injection," I said. "Continue the antibiotics and change his life-style".

So, no more soil digging and eating grass for the active pet as the soil bacteria had infected her. 

P.S The owner got the dog treated early and so the total white cell count had not reached a much higher level and the young dog was still eating and drinking. The submandibular lymph nodes could have expanded bigger and ulcerate.

The owner was worried about the dog having pus in both eyes for the last 4 days and made an appointment to see me. The bacteria had gone to the eyes as well but  antibiotics and anti-inflammatory injections I gave had nipped the infection in the bud. So, the owner was happy with the recovery when I phoned 2 days later. This was good news for everyone. Except for the Schnauzer as he has to change his free soil digging and eating life-style.

P.S "Glanders" is more a disease of horses in the older days. It is rare to get a case in the young Singapore dogs and puppies nowadays as the standard of hygiene is much higher in Singapore kennels. I remember my professor's lecture about this disease and that was in 1973 as a final year vet undergraduate. I did see a few puppy cases from breeders some years ago but no more.  This is not just a case of acute conjunctivitis. Just prescribing some eye drops will not help to resolve the problem. 

P.S It is best to follow up on the owner 2 days and do a blood test.


 UPDATES AT:
http://www.sinpets.com/dogs/20120609glanders_young_Schnauzer_singapore-ToaPayohVets.htm


Friday, June 8, 2012

"Red eye" in a dwarf rabbit

E-MAIL REPLY FROM DR SING DATED JUNE 6, 2012


Hi,

I pondered upon your vet webpage and would like to make a appointment for consultation for my pet rabbit.

It is a Netherland dwarf, about 2 months old. Recently it has eye dirt found on its eyes and one of the eye is seemingly reddish around it and opening not as wide as the other eye. Is it sick or suffering from eye infection?

Warmest Regards,

Name of owner











5359 -5363. Blood inside the anterior chamber of the right eye

E-MAIL REPLY FROM DR SING DATED JUNE 8, 2012

I am Dr Sing. Thank you for your email. Your rabbit suffers from hyphema (bleeding inside the eye). Pl continue to confine the rabbit in a SMALL cage for the next 14 days to prevent further bleeding inside the eye. The bleeding is due to a forceful injury to the eye and needs some 14-21 days to resolve.

Continue medication for another 10 days.

UPDATE AND MORE PIC AT:http://www.bekindtopets.com/animals/20120608hyphema-netherland-dwarfd-rabbit-2months-old-ToaPayohVets.htm