"My children are grown up and so I don't have any responsibilities now. I have a capsule," the pet shop operator said when I asked him how he would cope if he were to suffer another stroke. He was paralysed some 4 years ago and now he is normal. He could talk to me like any normal person and so he has recovered fully. His various tablets enabled him to live a normal life but his weight has not decreased.
We had known each other for over 30 years. His son had grown up to take over his thriving business. His wife is an excellent dog groomer.
I visited his pet shop this sunny weekday evening as he had invited me a few times when he brought puppies for me to vaccinate. He had shifted to another location as the old one was put up for en bloc sale. I was impressed with his big pet shop with a large inventory of various brands of dog food. I can judge how successful a pet shop business is by the inventory of dog food. Nowadays, dog food sales are not on credit terms as many pet shops close every year. So his large inventory means he must have a big clientele of dog owners in this relatively affluent area of Singapore.
I could see a Caucasian woman in her late 30s taking back a well-grown red miniature poodle from the shop and admiring it outside where her silver sports Mercedes was parked. Besides other clients, a woman in her 30s came in to buy her big bag of dog food and recognised me first.
"My Husky does not bite his tail anymore," she said. "However the patch over the tail gland is hairless," she promised to e-mail to me a picture. What a coincidence as I had not been to this pet shop for at least 2 years as it was quite far from Toa Payoh.
I seldom visit pet shops nowadays as I have so many things I want to do. "How much it costs to feed your Husky?" I ask this young lady with 2 Huskies and a small car. I always wonder how she could pack in 2 Huskies in such a small car to the dog park.
The pet shop operator has her loyalty as he gives loyalty cards which entitle buyers to discounts and some privileges. As for me, I wonder if the loyalty card system to retain clients applies to the vets. In theory it should. In reply to my query on feeding costs, the lady said, "Excluding canned food which I feed in the evening and two meals of dry food (Pinnacle brand) a day, it will be S$36.00 a month. So, it is S$1.20 a day.
Returning to my mission to get the pet shop operator to change his lifestyle, I said to him, "I read a book written by a doctor specialising in heart attack cases. It mentioned that heart attack patients would revert back to the old life-styles after a while," I sipped the Chinese tea he poured into a small tea cup for me.
"Yes, I was very afraid of death for the first few months after my stroke," the operator told me. "Now, my doctor said that I have so many tablets to take. I ought to be OK eating all my favourite seafood, pork-belly meat and laksa (fat-filled noodles with prawns). After all, my children are grown up and I have no more responsibility." His wife could take care of herself.
His wife and son had voiced their worries about his life-style to me when they brought the puppies for vaccination and I enquired about the head of the household.
I said I would talk to him sometime. Many months had passed. Here I was now visiting his pet shop. He had become an invincible man as he did not reduce his weight, did not exercise much nor become a vegetarian. After all, his doctor had prescribed him all the medication to prevent another stroke. If all fails, he certainly had a plan - a capsule to end his life if he were to suffer another stroke.
"If you have stroke, you will be paralysed. How will you be capable of taking this capsule? In any case, the ones who suffers most will be your wife and son, rather than you if you die. They have to take care of you 24 hours a day while you remain paralysed. Have you thought of this?"
He did not reply. I did not probe further what type of capsule he had but I am sure he had some medical knowledge to do what he wanted if he suffered another stroke.
"A friend recommends me to take the tablets from India to slim down," he told me. "My friend says it works for him."
I was surprised that he did not learn from a well known medical case where an actress who took slimming tablets made in China had to accept a liver transplant from her boyfriend. Another woman taking the same pills had actually died. I reminded him of the case. "It is best to stop taking such pills, cut down drastically on your fatty food. Do more walking. Weigh yourself daily. I can say you avoid the weighing machine so as not to know you have put on weight, am I right?"
"No, I don't weigh myself any day," the operator laughed. "It is hard to stop eating all the fatty food. After all, my doctor tells me he has prescribed medication to lower the high blood pressure and the cholesterol level in the blood. So I should have no problems."
Just take the medication and all strokes will be prevented. It is not so simple as that. One's liver will be tolerant to the medication and that means the medication dosage needs to be increased or the type changed.
Some people just need to eat at different hawker stalls and restaurants, sampling different types of cooking. What is living if one does not live to eat? Eat to live, more vegetables and fish and monitoring the weight weekly is far from the mind of most recovered heart attack or stroke person. What can be done to help loved ones to change their lifestyle?
Sometimes, changing one's unhealthy lifestyle or becoming vegetarian will do and the medication may be dispensed with in some cases, with the doctor's regular check up. It is hard to be alive and eat the bland vegetable, fish diet and fruits most of the time for many years. I believe that such a regime works. So far, I am nearing 60 years of age and have not needed any medication for diabetes, heart attacks or strokes. So far, so good. As for the operator, I hope he stops taking the slimming pill made in India if he does not know what it contains. Otherwise, he may suffer liver failure rather than a stroke! I will follow up on him.
Saturday, January 30, 2010
Friday, January 29, 2010
25. Maroon bluish tongue
The colour of the tongue tells a lot about the prognosis. In this case, I showed the owner that the dog's tongue was abnormally maroon and bluish. "In my experience, dogs with this colour of tongue and a dry tongue is going to die soon. Your dog also has heart disease."
"I require a blood test in this case as this was the second time the dog had poisoning signs and his kidney and liver may be damaged." The owner gave her consent.
Shih Tzu, F, 2 years.
Presenting Sign: Salivation. Non-stop vulva licking for 2 days upset the owner. The pest control people fumigated the apartment the previous day for a second time.
Tentative Diagnosis:
Insecticide poisoning. Unknown insecticide used by the pest control people.
History
4.8 kg 39.3 deg C. Jan 19, 2010
Pest control came yesterday. Salivation. Vet 1.
IV treatment, atropine recovered next day.
4.2 kg 39.8 deg C. Jan 27, 2010.
Pest control came yesterday.
Dog started salivation. Non-stop watery and profuse. Vulval itchiness seen as continuous licking. "She passed black stools," the owner said. "The dog had bleeding in the stomach from insecticide poisoning," I replied.
The tongue colour - maroon red and bluish and dry. A sign of poor health. Is she going to die soon?
Blood test results:
Liver SGPT/ALT above normal
Kidney Urea above normal.
Creatinine below normal.
Haematology:
Haemoglobin above normal. Red cell count normal but total White Cell Count was above normal. PCV above normal. MCV above normal. MCHC below normal.
Insecticide unknown. IV treatment, atropine and Lasix IV. But no vomiting or coughing. Recovered and went home after 2 days. Tongue became normal pink after 2 days of treatment. The dog went home.
However, if my assistant tried to open the mouth to for me to take photograph, it turns bluish. The dog does not show signs of heart disease presently.
The apartment floor should have been thoroughly cleaned as I presumed that the pest control man must have fogged the whole place it to death.
The dog had stepped on the chemicals and her private parts had been burned chemically, hence the non-stop vulval licking on presentation. She was doing it all the time on the consultation table.
The pest control people had fumigated the apartment twice at 7-day intervals. They must have exploded a big bomb of chemicals into the apartment and blanketed the whole place with insecticide poison. The dog was contaminated when he walked he floors and licked away the strong smelly poison as best as she could. Her mouth started drooling. She got intoxicated and infected by bacteria as her total white cell counts were raised. Fortunately, she survived the two poisoinings.
Blood tests cost money and increase veterinary fees. If the dog dies, a blood test will answer some questions regarding the possible causes of death. This result gives some owners and the family members some answers and a closure. Otherwise there might be some doubts regarding the veterinary treatment and competence.
Update and pictures are at: www.toapayohvets.com
"I require a blood test in this case as this was the second time the dog had poisoning signs and his kidney and liver may be damaged." The owner gave her consent.
Shih Tzu, F, 2 years.
Presenting Sign: Salivation. Non-stop vulva licking for 2 days upset the owner. The pest control people fumigated the apartment the previous day for a second time.
Tentative Diagnosis:
Insecticide poisoning. Unknown insecticide used by the pest control people.
History
4.8 kg 39.3 deg C. Jan 19, 2010
Pest control came yesterday. Salivation. Vet 1.
IV treatment, atropine recovered next day.
4.2 kg 39.8 deg C. Jan 27, 2010.
Pest control came yesterday.
Dog started salivation. Non-stop watery and profuse. Vulval itchiness seen as continuous licking. "She passed black stools," the owner said. "The dog had bleeding in the stomach from insecticide poisoning," I replied.
The tongue colour - maroon red and bluish and dry. A sign of poor health. Is she going to die soon?
Blood test results:
Liver SGPT/ALT above normal
Kidney Urea above normal.
Creatinine below normal.
Haematology:
Haemoglobin above normal. Red cell count normal but total White Cell Count was above normal. PCV above normal. MCV above normal. MCHC below normal.
Insecticide unknown. IV treatment, atropine and Lasix IV. But no vomiting or coughing. Recovered and went home after 2 days. Tongue became normal pink after 2 days of treatment. The dog went home.
However, if my assistant tried to open the mouth to for me to take photograph, it turns bluish. The dog does not show signs of heart disease presently.
The apartment floor should have been thoroughly cleaned as I presumed that the pest control man must have fogged the whole place it to death.
The dog had stepped on the chemicals and her private parts had been burned chemically, hence the non-stop vulval licking on presentation. She was doing it all the time on the consultation table.
The pest control people had fumigated the apartment twice at 7-day intervals. They must have exploded a big bomb of chemicals into the apartment and blanketed the whole place with insecticide poison. The dog was contaminated when he walked he floors and licked away the strong smelly poison as best as she could. Her mouth started drooling. She got intoxicated and infected by bacteria as her total white cell counts were raised. Fortunately, she survived the two poisoinings.
Blood tests cost money and increase veterinary fees. If the dog dies, a blood test will answer some questions regarding the possible causes of death. This result gives some owners and the family members some answers and a closure. Otherwise there might be some doubts regarding the veterinary treatment and competence.
Update and pictures are at: www.toapayohvets.com
Thursday, January 28, 2010
24. Subluxation hip Golden Retriever puppy 4.5 months
Case 1:
Danish lady in her 30s with mum.
Purchased from the same pet shop.
Golden Retriever 3 months.
Consultation: Came for 3rd vaccination. Puppy purchased 1 month ago.
Housing: A house with a small garden
Feeding: 2 times per day as advised by the seller. Wolfs down food fast.
This case was a lot of fun for the mum. Every time Alice, a 4th year vet student put the puppy onto the electronic weighing scale, he dashed off the scales elsewhere. Alice had to catch him again. She placed him on the scale. Before she could read the weight, the puppy sprinted off making the mum laugh. Alice and I looked serious as such incidents happen with other puppies too.
Toilet Training: Newspapers 100% covering playpen. Then reduce the covered area as advised by the pet shop puppy seller.
"What happened during the first 7 days?" I asked. "Did he poo and pee onto the newspapers?"
"The puppy was confused and did it everywhere inside the playpen. After 5 days, the puppy now eliminates onto newspapers in a separate half of the playpen.
"How did you train him to do it?" I asked.
"Lots of praises. Praise him and give treats when he eliminates on the newspapers." Successful paper-training due to hard work and training.
Question 1: When can the puppy go out to the grass to eliminate? The owner did not want the puppy to do it in the small garden.
The seller had advised going out till after the 3rd vaccination to prevent parvoviral infections.
The puppy can go out to places where there are no dogs or puppies e.g. pet shops, dog runs, boarding houses 2 weeks after the 2nd vaccination. However, 2 weeks after the 3rd vaccination, the puppy can mix with other dogs as he has full protection against the lethal parvoviral and distemper viruses.
"Put the newspapers with urine smell onto the grass outside, so that the puppy will commence eliminating outdoors," I advise. "It is a good idea," the owner said.
Question 2: When does my puppy get his heartworm vaccination and does he need one?
It is best to protect him against heartworms which is present in Singapore. Vaccinate at 5 months of age. She will make an appointment.
Clinical Findings:
Ears full of wax but no ear scratching surprisingly. I advised the puppy to go back to the pet shop seller to get ears cleaned. I advised deworming for intestinal worms once a week for the next 4 weeks.
Conclusion:
This puppy will have plenty of love and great fun exercising outdoors since he lives in a house and can get out without the problem of having to bring him to the lift and go downstairs. There is a small garden but he will not be permitted to go there and destroy the plants. But he can go outdoors easily compared to Case 2.
Case 2:
Australian gentleman in his 30s
Purchased from the same pet shop over 2 months ago. Paper trained on a pee pan. Now apparently lame. Owner was worried about hip dysplasia.
Golden Retriever 4.5 months. All 3 vaccinations done.
Feeding 3x/day. Poops 3-4 times per day.
Purchased puppy 2.5 months ago.
Consultation: Dog has "hip dysplasia"
Housing: Condo with smooth marble and wooden floors.
Playpen: Sleeps at night with bed.
Toilet area: Pee pan + newspapers in the balcony. Feed and water bowl in the balcony.
HISTORY: Last 2-3 weeks, in the morning, the puppy had been walked for around 30 minutes. The puppy would stop walking after some distance. But he had to do it. In the evening, he would be exercised. Sometimes he would be at Sentosa to swim. Lately, he was lame in his hind legs. great difficulty standing up using the back legs in the morning. Has great difficulty moving down slope or moving down from the car seat. No problem getting up the car as he used his front legs.
"Could this be hip dysplasia?" the young man asked. "What should I do with this puppy?"
EXAMINATION:
1. Outside the surgery.
General visual examination of conformation and muscle of the back leg - cow hocks with right hind having toe out.
Gait - The owner walked the dog up and down concrete flooring on a loose leash - no obvious lameness on slow walk. Puppy was said to "hop" on 3 legs at a run.
2. Inside the surgery.
On the examination table, put the puppy sideways on his left and right side to manipulate the joints.
Abduct and adduct hips and all other joints of the hind limbs - no pain surprisingly.
Put puppy standing and extend 2 hind limbs - right hind limb is shorter than left hind.
Back muscles of right hind are smaller than left hind.
Spinal cord pressure - no pain in general. There seemed to be some mild pain at the lumbo-sacral spinal area. Could this be the cause of pain in the morning on waking up and being unable to get up normally as a young puppy should?
HYPOTHESIS FOR SPLAYED HIND LIMB AND SUBLUXATED HIP:
"Where does the puppy spend 90% of his day?" I asked.
"Inside the apartment," the man worked from home and therefore knew what he said.
"Does he walk on very smooth marble flooring when at home?" I asked although I know the answer since all modern condos are marble-floored and wooden-tiled with waxy wood.
"Yes. The wooden flooring upstairs are also very smooth, being waxed."
Based on my experiences with the professional dog breeders, I would say that this puppy had no chance to walk on firm surfaces as they are usually crated before sale.
Therefore, the Golden Retriever's hind legs become splayed slightly before sale. The splay was not very obvious as he did not walk like a cowboy if you don't observe closely.
He had also cow hocks which would account for his "hip dysplasia" style of walking with the hocks lower and right toe pointing outwards.
In addition, he was over-exercised in the morning going to the school with the children for the past 2-3 weeks. He had over 30 minutes of road walk. "He was keen to go out in the morning," the young man said. "But he would stop walking after some distance."
"He had pain in his hip area," I said. "So he stopped walking". "Sometimes, he hops," the man said. Sparing weight onto the hind limbs," I said.
"The puppy could climb up the car but would hesitate to climb down from the car later," the man gave me this good clue to pain in the hip area. Climbing up involved the front limbs. That was OK for the pup. Climbing down involved the back limbs and hip area. There was pain. Similarly to getting up in the morning using the hind limbs. There was some pain in the hip area. But none was elicited or shown when I palpated, extended and flexed the hips. Or the knees. So, it was very difficult to prove my hypothesis to the young man.
There was muscle atrophy in the right hip area would indicate some pain in the right hip area for some time. This was accepted by the young man.
I pressed the hip joint. Yet there was no pain response from the puppy. I extended both hips to compare the length of the hind limbs. The right hind was noticeably 3 cm shorter. But there was no pain.
The puppy now splayed his hind limbs out and flopped onto my examination table. He had enough of all these palpations. He was a very friendly puppy and had not bitten me once. As I pressed the spinal area from the neck to the tail, there was a very slight pain at the lumbo-sacral area. I don't think the young man saw the response as it was very slight.
This pain and the subluxation of the right hip joint could account for the difficulty in standing up on the hind limbs.
"Is there a cure for the hip dysplasia?" the man asked. "Must he be put to sleep later?"
"I don't think he has hip dysplasia now. He has subluxation of his right hip. He will recover if you let him rest for at least 4 weeks and confine him to a rough floor area for the next 3 months. No over-exercising. Let him walk and run within his limits rather than force him to do more road walk. No morning road walk.
For hip dysplasia, he needs to be over 6 months of age for X-rays to confirm. His history indicated over-exercise (probably running up and down the 2-level condo with the children) and just having too much of a good time. A very active life-style."
The puppy lies down with hind limbs splayed out unlike other puppies with limbs tucked under the abdomen. This was observed and pointed out by the owner as the puppy flopped onto my consultation table. "With a smooth flooring over the past months, the puppy's hind limbs stretched outwards and now he just splays his hind limbs outwards when he lies down. With a rough flooring, his hind paws may be able to get a grip to stand up."
The last paragraph supported my hypothesis that this puppy had a lifestyle that caused splaying of his hind limbs. As he grows older, the splaying is not obvious. However, his right back muscles were not well developed compared to his left. Both had poor development considering that the puppy "hops" when over-exercised.
DIAGNOSIS:
Right hip subluxation but not so serious to cause obvious lameness. This accounted for his occasional hopping when he runs.
ADVICES:
1. No over-exercising for the next 4 weeks and preferably 3 months. He should have no walking exercise or running up and down stairs for the next 7 days but confined to the balcony-part-living room area.
2. X-rays of the hip would be done at over 6 months to properly confirm hip dysplasia. Presently he is 4.5 months.
3. Chances of him recovering are good. 50:50 if he continues to walk on floors where his legs can get a grip. A garden would be best but this dog must live in the apartment for the next 5 months of lease. So, what to do?
4. "Install anti-slip mats onto the flooring. Confine him to a room with baby gate or use the kitchen and utility area for him when he is at home," I said. This was not practical advice as there was no room and the kitchen was small for such a big breed.
"The balcony?" I asked. "Will it be too hot when the sun is out?" The man said, "Yes."
"Where does he sleep nowadays?" I asked.
"A big playpen near the balcony." the man replied. I asked him to draw the floor plan. He would fence up part of the living area next to the balcony and connect this area to the balcony. His plan was good as the puppy would be confined to and have over 15 sq metres of anti-slip space to walk when staying at home.
CONCLUSION:
The gentleman propose converting the corner of the living room near to the balcony into a fenced up area with anti-slip mats. So, the puppy can walk to the pee pan and newspapers in the balcony for his toilet and back to the living room to see the family. No more free roaming on slippery smooth floors and he should recover fully. I prescribed non-steroidal Rimadryl tablets for 7 days.
I am quite confident that this puppy will be fully recovered as he was sent to the vet early. He has an enlightened and educated owner who has not delayed seeking veterinary advice unlike many Singapore puppy owners who don't bother after the three vaccinations and seek advices from the groomer.
A house will be best for this puppy but a condo has so many facilities for the expatriate family with young children. In any case, by the time the lease ends, this puppy should be normal as the owner knows what to do and his wife has the architectural knowledge to execute this floor plan for the puppy. If the expatriate had waited for some time, this puppy would have dislocated his right hip and it will be very difficult to recover. This is a case where clinical signs were presented at home. At the vet, the puppy behaved quite normally. There are many such cases and the owner's history and observations count a lot more than clinical findings. Some puppies or dogs just behave normally at the vet as they have a high tolerance to pain. Showing pain is not good for survival in the wild and this may explain why the puppy shows no pain readily. He may not have very serious pain and so suppress it in front of the vet who is a stranger to him. Is this another hypothesis? As for hip dysplasia, we would have to wait and see.
Danish lady in her 30s with mum.
Purchased from the same pet shop.
Golden Retriever 3 months.
Consultation: Came for 3rd vaccination. Puppy purchased 1 month ago.
Housing: A house with a small garden
Feeding: 2 times per day as advised by the seller. Wolfs down food fast.
This case was a lot of fun for the mum. Every time Alice, a 4th year vet student put the puppy onto the electronic weighing scale, he dashed off the scales elsewhere. Alice had to catch him again. She placed him on the scale. Before she could read the weight, the puppy sprinted off making the mum laugh. Alice and I looked serious as such incidents happen with other puppies too.
Toilet Training: Newspapers 100% covering playpen. Then reduce the covered area as advised by the pet shop puppy seller.
"What happened during the first 7 days?" I asked. "Did he poo and pee onto the newspapers?"
"The puppy was confused and did it everywhere inside the playpen. After 5 days, the puppy now eliminates onto newspapers in a separate half of the playpen.
"How did you train him to do it?" I asked.
"Lots of praises. Praise him and give treats when he eliminates on the newspapers." Successful paper-training due to hard work and training.
Question 1: When can the puppy go out to the grass to eliminate? The owner did not want the puppy to do it in the small garden.
The seller had advised going out till after the 3rd vaccination to prevent parvoviral infections.
The puppy can go out to places where there are no dogs or puppies e.g. pet shops, dog runs, boarding houses 2 weeks after the 2nd vaccination. However, 2 weeks after the 3rd vaccination, the puppy can mix with other dogs as he has full protection against the lethal parvoviral and distemper viruses.
"Put the newspapers with urine smell onto the grass outside, so that the puppy will commence eliminating outdoors," I advise. "It is a good idea," the owner said.
Question 2: When does my puppy get his heartworm vaccination and does he need one?
It is best to protect him against heartworms which is present in Singapore. Vaccinate at 5 months of age. She will make an appointment.
Clinical Findings:
Ears full of wax but no ear scratching surprisingly. I advised the puppy to go back to the pet shop seller to get ears cleaned. I advised deworming for intestinal worms once a week for the next 4 weeks.
Conclusion:
This puppy will have plenty of love and great fun exercising outdoors since he lives in a house and can get out without the problem of having to bring him to the lift and go downstairs. There is a small garden but he will not be permitted to go there and destroy the plants. But he can go outdoors easily compared to Case 2.
Case 2:
Australian gentleman in his 30s
Purchased from the same pet shop over 2 months ago. Paper trained on a pee pan. Now apparently lame. Owner was worried about hip dysplasia.
Golden Retriever 4.5 months. All 3 vaccinations done.
Feeding 3x/day. Poops 3-4 times per day.
Purchased puppy 2.5 months ago.
Consultation: Dog has "hip dysplasia"
Housing: Condo with smooth marble and wooden floors.
Playpen: Sleeps at night with bed.
Toilet area: Pee pan + newspapers in the balcony. Feed and water bowl in the balcony.
HISTORY: Last 2-3 weeks, in the morning, the puppy had been walked for around 30 minutes. The puppy would stop walking after some distance. But he had to do it. In the evening, he would be exercised. Sometimes he would be at Sentosa to swim. Lately, he was lame in his hind legs. great difficulty standing up using the back legs in the morning. Has great difficulty moving down slope or moving down from the car seat. No problem getting up the car as he used his front legs.
"Could this be hip dysplasia?" the young man asked. "What should I do with this puppy?"
EXAMINATION:
1. Outside the surgery.
General visual examination of conformation and muscle of the back leg - cow hocks with right hind having toe out.
Gait - The owner walked the dog up and down concrete flooring on a loose leash - no obvious lameness on slow walk. Puppy was said to "hop" on 3 legs at a run.
2. Inside the surgery.
On the examination table, put the puppy sideways on his left and right side to manipulate the joints.
Abduct and adduct hips and all other joints of the hind limbs - no pain surprisingly.
Put puppy standing and extend 2 hind limbs - right hind limb is shorter than left hind.
Back muscles of right hind are smaller than left hind.
Spinal cord pressure - no pain in general. There seemed to be some mild pain at the lumbo-sacral spinal area. Could this be the cause of pain in the morning on waking up and being unable to get up normally as a young puppy should?
HYPOTHESIS FOR SPLAYED HIND LIMB AND SUBLUXATED HIP:
"Where does the puppy spend 90% of his day?" I asked.
"Inside the apartment," the man worked from home and therefore knew what he said.
"Does he walk on very smooth marble flooring when at home?" I asked although I know the answer since all modern condos are marble-floored and wooden-tiled with waxy wood.
"Yes. The wooden flooring upstairs are also very smooth, being waxed."
Based on my experiences with the professional dog breeders, I would say that this puppy had no chance to walk on firm surfaces as they are usually crated before sale.
Therefore, the Golden Retriever's hind legs become splayed slightly before sale. The splay was not very obvious as he did not walk like a cowboy if you don't observe closely.
He had also cow hocks which would account for his "hip dysplasia" style of walking with the hocks lower and right toe pointing outwards.
In addition, he was over-exercised in the morning going to the school with the children for the past 2-3 weeks. He had over 30 minutes of road walk. "He was keen to go out in the morning," the young man said. "But he would stop walking after some distance."
"He had pain in his hip area," I said. "So he stopped walking". "Sometimes, he hops," the man said. Sparing weight onto the hind limbs," I said.
"The puppy could climb up the car but would hesitate to climb down from the car later," the man gave me this good clue to pain in the hip area. Climbing up involved the front limbs. That was OK for the pup. Climbing down involved the back limbs and hip area. There was pain. Similarly to getting up in the morning using the hind limbs. There was some pain in the hip area. But none was elicited or shown when I palpated, extended and flexed the hips. Or the knees. So, it was very difficult to prove my hypothesis to the young man.
There was muscle atrophy in the right hip area would indicate some pain in the right hip area for some time. This was accepted by the young man.
I pressed the hip joint. Yet there was no pain response from the puppy. I extended both hips to compare the length of the hind limbs. The right hind was noticeably 3 cm shorter. But there was no pain.
The puppy now splayed his hind limbs out and flopped onto my examination table. He had enough of all these palpations. He was a very friendly puppy and had not bitten me once. As I pressed the spinal area from the neck to the tail, there was a very slight pain at the lumbo-sacral area. I don't think the young man saw the response as it was very slight.
This pain and the subluxation of the right hip joint could account for the difficulty in standing up on the hind limbs.
"Is there a cure for the hip dysplasia?" the man asked. "Must he be put to sleep later?"
"I don't think he has hip dysplasia now. He has subluxation of his right hip. He will recover if you let him rest for at least 4 weeks and confine him to a rough floor area for the next 3 months. No over-exercising. Let him walk and run within his limits rather than force him to do more road walk. No morning road walk.
For hip dysplasia, he needs to be over 6 months of age for X-rays to confirm. His history indicated over-exercise (probably running up and down the 2-level condo with the children) and just having too much of a good time. A very active life-style."
The puppy lies down with hind limbs splayed out unlike other puppies with limbs tucked under the abdomen. This was observed and pointed out by the owner as the puppy flopped onto my consultation table. "With a smooth flooring over the past months, the puppy's hind limbs stretched outwards and now he just splays his hind limbs outwards when he lies down. With a rough flooring, his hind paws may be able to get a grip to stand up."
The last paragraph supported my hypothesis that this puppy had a lifestyle that caused splaying of his hind limbs. As he grows older, the splaying is not obvious. However, his right back muscles were not well developed compared to his left. Both had poor development considering that the puppy "hops" when over-exercised.
DIAGNOSIS:
Right hip subluxation but not so serious to cause obvious lameness. This accounted for his occasional hopping when he runs.
ADVICES:
1. No over-exercising for the next 4 weeks and preferably 3 months. He should have no walking exercise or running up and down stairs for the next 7 days but confined to the balcony-part-living room area.
2. X-rays of the hip would be done at over 6 months to properly confirm hip dysplasia. Presently he is 4.5 months.
3. Chances of him recovering are good. 50:50 if he continues to walk on floors where his legs can get a grip. A garden would be best but this dog must live in the apartment for the next 5 months of lease. So, what to do?
4. "Install anti-slip mats onto the flooring. Confine him to a room with baby gate or use the kitchen and utility area for him when he is at home," I said. This was not practical advice as there was no room and the kitchen was small for such a big breed.
"The balcony?" I asked. "Will it be too hot when the sun is out?" The man said, "Yes."
"Where does he sleep nowadays?" I asked.
"A big playpen near the balcony." the man replied. I asked him to draw the floor plan. He would fence up part of the living area next to the balcony and connect this area to the balcony. His plan was good as the puppy would be confined to and have over 15 sq metres of anti-slip space to walk when staying at home.
CONCLUSION:
The gentleman propose converting the corner of the living room near to the balcony into a fenced up area with anti-slip mats. So, the puppy can walk to the pee pan and newspapers in the balcony for his toilet and back to the living room to see the family. No more free roaming on slippery smooth floors and he should recover fully. I prescribed non-steroidal Rimadryl tablets for 7 days.
I am quite confident that this puppy will be fully recovered as he was sent to the vet early. He has an enlightened and educated owner who has not delayed seeking veterinary advice unlike many Singapore puppy owners who don't bother after the three vaccinations and seek advices from the groomer.
A house will be best for this puppy but a condo has so many facilities for the expatriate family with young children. In any case, by the time the lease ends, this puppy should be normal as the owner knows what to do and his wife has the architectural knowledge to execute this floor plan for the puppy. If the expatriate had waited for some time, this puppy would have dislocated his right hip and it will be very difficult to recover. This is a case where clinical signs were presented at home. At the vet, the puppy behaved quite normally. There are many such cases and the owner's history and observations count a lot more than clinical findings. Some puppies or dogs just behave normally at the vet as they have a high tolerance to pain. Showing pain is not good for survival in the wild and this may explain why the puppy shows no pain readily. He may not have very serious pain and so suppress it in front of the vet who is a stranger to him. Is this another hypothesis? As for hip dysplasia, we would have to wait and see.
Wednesday, January 20, 2010
23. Moral ethics and economic reality in carnaissal tooth abscess
Old dogs do suffer from carnaissal tooth (maxillary 4th premolar) abscesses and unless the vet has not diagnosed the non-healing facial wound as due to the abscess, the owner will need to consult him or her for several months. Medicines will be given and yet the facial wound still does not heal. If the diagnosis of this oro-nasal fistula is correct, the only option is surgery to remove the infected tooth. Unfortunately, the dog is old, in poor health and has a high risk of dying on the operating table.
When told of a high risk anaesthetic death on the operating table, many owners opt for no surgery. The dogs become older and sicker. Finally, the owner has no choice. It would be a prolonged painful death or a possible death on the operating table.
Vets are not Gods. It is foolish for the vet to say that the dog has a high percentage of survival when the dog is in poor health. Well, if the dog has a poor chance of survival, the vet must be no good. The vet can sense that there is a loss of confidence in him or her. There is a tension in the consultation room air when the owner expresses his or her sentiments about the failure of treatment. What should the vet do?
Advise the owner to seek second opinions rather than continue conservative medical treatment for several months. Is it morally ethical to milk the owner as a cash cow knowing that surgery will cure but the risk of anaesthetic death on the operating table is extremely high.
If the vet feels that it is too risky to do anaesthesia on old dogs or pets, ask the owner to seek other vets who may take the risk and ruin his reputation. Death on the operating table spreads like wildfire on the pet internet forums but the reality of the situation is that the dog will not be cured on conservative medical treatment. Therefore the owner must be told firmly and given written notice to prevent misunderstanding.
Economic reality may override the moral ethics in a private practice with so much competition and high overheads. The staff and associate vets see what you do if you are the leader in the practice. Do the right thing by asking the owner to seek treatment elsewhere once the owner has had lost the trust in the veterinary-client relationship with the vet. Vets are not Gods. Deaths on the operating table will present themselves and bad-mouthing do spread like wild fire when you handle high risk anaesthetic cases in old dogs as there will always be owners who delay treatment or ignore veterinary advices till they have no choice except surgery.
In this carnaissal tooth case recorded here, I did not phone Vet 1 as to why medical treatment and cleaning of the facial wound were performed for one year for "sinusitis" due to a yellowish nasal discharge from the left nostril for one year. The owner had confirmed that Vet 1 had diagnosed correctly the condition. "He just would not operate on the dog." This was the point of view of the owner whose mother was the one in contact with Vet 1. The mother would have to visit him many times to seek a cure. Finally, the son took the high anaesthetic risk to get the dog operated.
A blocked left nostril with yellow discharge. A cyanotic tongue indicating a lack of oxygenated blood or toxicity. These symptoms signal high anaesthetic risk.
This 11-year-old Chihuahua was in excellent body condition, not being thin. I auscultated the heart. Surprisingly, she had no heart disease. These were the pluses but still one cannot be too complacent.
Only 11 out of 42 teeth existed and they were loose ones with tartar built up over the years. Vet 1 had done one dental scaling some years ago. So, there was a good veterinarian-client relationship with the owner's mother. But that facial wound. That rubbing of the left eye. That left nostril discharge. These had gone on for almost 12 months. The mother could be stressed out. In real life, it is the aged parents who feel so much more for the companion dogs since the children have left the nest and have practically no time for the senior citizens. So, it would not be a surprise to me if this case had become extremely volatile and emotional for the mother and family members.
The irony of this case is that surgery would cure. Yet Vet 1 just did not want to do it due to the high risks involved. In such cases, I would pass the buck to other vets. In this case, the son took matters in his hand to seek my opinion. He accepted the high risks. We had never met before. Much was at stake for the mother. If the outcome was good, the mother would be most happy as this Chihuahua is family to her.
I used isoflurane gas anaesthesia with no sedative injections. It was difficult to mask the dog as she had this left nostril discharge. I intubated using a smaller endotracheal tube. This type of cases must be on short anaesthesias to achieve a good outcome. The vet must have all instruments ready. I even had the dental scaling machine switched on just in case it was needed.
The 11 teeth were extracted. It was possible to leave the canine teeth alone to impress or comfort the owner that the chihuahua had some teeth.
But that would not be in the interest of the dog. They were only slightly loose. But I know that this old dog would get gum diseases later and this would be her only chance under anaesthesia. So, I took out all the teeth.
7 days later, I phoned the son. He was quite grateful and said: "Mum does not need to wipe away the runny nose (left nostril discharge) or clean the tearing eye (left facial wound, dog rubs itchy wound and eye). I know I will never see the mother who must be in her sixties. She is now a happy mother and there will be peace in the family after 12 months of worries. I did notice a swelling on the right cheek and a possible carnaissal tooth abscess on the right side. Now, since all 2 carnaissal teeth had been extracted, I would not see a case with two oro-nasal fistulas - a rare case.
More pictures of the case are at: www.toapayohvets.com
When told of a high risk anaesthetic death on the operating table, many owners opt for no surgery. The dogs become older and sicker. Finally, the owner has no choice. It would be a prolonged painful death or a possible death on the operating table.
Vets are not Gods. It is foolish for the vet to say that the dog has a high percentage of survival when the dog is in poor health. Well, if the dog has a poor chance of survival, the vet must be no good. The vet can sense that there is a loss of confidence in him or her. There is a tension in the consultation room air when the owner expresses his or her sentiments about the failure of treatment. What should the vet do?
Advise the owner to seek second opinions rather than continue conservative medical treatment for several months. Is it morally ethical to milk the owner as a cash cow knowing that surgery will cure but the risk of anaesthetic death on the operating table is extremely high.
If the vet feels that it is too risky to do anaesthesia on old dogs or pets, ask the owner to seek other vets who may take the risk and ruin his reputation. Death on the operating table spreads like wildfire on the pet internet forums but the reality of the situation is that the dog will not be cured on conservative medical treatment. Therefore the owner must be told firmly and given written notice to prevent misunderstanding.
Economic reality may override the moral ethics in a private practice with so much competition and high overheads. The staff and associate vets see what you do if you are the leader in the practice. Do the right thing by asking the owner to seek treatment elsewhere once the owner has had lost the trust in the veterinary-client relationship with the vet. Vets are not Gods. Deaths on the operating table will present themselves and bad-mouthing do spread like wild fire when you handle high risk anaesthetic cases in old dogs as there will always be owners who delay treatment or ignore veterinary advices till they have no choice except surgery.
In this carnaissal tooth case recorded here, I did not phone Vet 1 as to why medical treatment and cleaning of the facial wound were performed for one year for "sinusitis" due to a yellowish nasal discharge from the left nostril for one year. The owner had confirmed that Vet 1 had diagnosed correctly the condition. "He just would not operate on the dog." This was the point of view of the owner whose mother was the one in contact with Vet 1. The mother would have to visit him many times to seek a cure. Finally, the son took the high anaesthetic risk to get the dog operated.
A blocked left nostril with yellow discharge. A cyanotic tongue indicating a lack of oxygenated blood or toxicity. These symptoms signal high anaesthetic risk.
This 11-year-old Chihuahua was in excellent body condition, not being thin. I auscultated the heart. Surprisingly, she had no heart disease. These were the pluses but still one cannot be too complacent.
Only 11 out of 42 teeth existed and they were loose ones with tartar built up over the years. Vet 1 had done one dental scaling some years ago. So, there was a good veterinarian-client relationship with the owner's mother. But that facial wound. That rubbing of the left eye. That left nostril discharge. These had gone on for almost 12 months. The mother could be stressed out. In real life, it is the aged parents who feel so much more for the companion dogs since the children have left the nest and have practically no time for the senior citizens. So, it would not be a surprise to me if this case had become extremely volatile and emotional for the mother and family members.
The irony of this case is that surgery would cure. Yet Vet 1 just did not want to do it due to the high risks involved. In such cases, I would pass the buck to other vets. In this case, the son took matters in his hand to seek my opinion. He accepted the high risks. We had never met before. Much was at stake for the mother. If the outcome was good, the mother would be most happy as this Chihuahua is family to her.
I used isoflurane gas anaesthesia with no sedative injections. It was difficult to mask the dog as she had this left nostril discharge. I intubated using a smaller endotracheal tube. This type of cases must be on short anaesthesias to achieve a good outcome. The vet must have all instruments ready. I even had the dental scaling machine switched on just in case it was needed.
The 11 teeth were extracted. It was possible to leave the canine teeth alone to impress or comfort the owner that the chihuahua had some teeth.
But that would not be in the interest of the dog. They were only slightly loose. But I know that this old dog would get gum diseases later and this would be her only chance under anaesthesia. So, I took out all the teeth.
7 days later, I phoned the son. He was quite grateful and said: "Mum does not need to wipe away the runny nose (left nostril discharge) or clean the tearing eye (left facial wound, dog rubs itchy wound and eye). I know I will never see the mother who must be in her sixties. She is now a happy mother and there will be peace in the family after 12 months of worries. I did notice a swelling on the right cheek and a possible carnaissal tooth abscess on the right side. Now, since all 2 carnaissal teeth had been extracted, I would not see a case with two oro-nasal fistulas - a rare case.
More pictures of the case are at: www.toapayohvets.com
Friday, January 15, 2010
22. Injectable Anaesthetics - Dogs + Cats - Siem Reap, Cambodia
Thursday, Jan 14, 2010. I visited The No. 1 Animal Place, 645 Hup guan Street, Siem Reap, Cambodia today. I thought it was a pet shop with fishes, birds, rabbits and hamsters for sale. Puppies and kittens are never sold here. The operating room is upstairs. The following is practical anaesthetic knowledge shared by an English lady vet graduated from London. She practised for one year in Siem Reap.
DOGS
Xylazine 2% 0.05ml/kg
Ketamine 5% 0.3 ml/kg (human ketamine is 5% i.e. 50mg/100 ml unlike veterinary ketamine which is available as 10%).
Separate syringes, one injection another instead of waiting 15 minutes as this was found to be more effective. IM injection.
Onset 10-15 minutes (to sleep)
Duration 20-25 minutes (before topping up)
Top up: Mix above 2 drugs in one syringe and give at half dose.
CATS
Xylazine 2% 0.1ml/kg
ketamine 5% 0.2 ml/kg
Both drugs in one syringe
Onset 5 minutes
Duration 45 minutes
Top up: Mix 2 drugs in one syringe and inject.
Disadvantage: Wakes up suddenly. Wait 5 minutes before proceeding to surgery. Takes a long time to wake up. Vomiting. Tends to vomit with dogs and cats even on empty stomachs. For sick cats, the dosage is reduced by 1/3.
REVERSAL
Yohimbine use in cats to wake them up sooner. No need to use in dogs in her cases. Rapid recovery was obtained with Yohimbine in cats in her experience. Is it possible that her xylazine dosage was higher such that the cats take a longer time to be mobile? See Discussion below.
DISCUSSION
CATS around 2 kg in Singapore Toa Payoh Vets, www.toapayohvets.com
I use Xylazine 2% @ 0.1ml and Ketamine 10% @ 0.4 ml in one syringe IM
Onset 5 minutes
Duration 20 minutes
Comparing this to the English vet's formula, she would use
Xylazine 2% @ 0.2 ml
Ketamine 5% @ 0.4 ml (Since I use 10%, this would be equivalent to 0.2 ml)
Her dosage permits her a longer duration of 45 minutes. She needed 15 min pre-op. She needed a reversal drug which i don't need.
That meant she used xylazine 2% @ 0.2 ml and ketamine 10% @ 0.2 ml while I used xylazine 2% at 0.1 ml and ketamine 10% at 0.4 ml.
DOG, 5 kg Jack Russell
Xylazine 2% @ 0.25 ml IM
Ketamine 5% @ 1.5 ml IM (For me, it should be 0.75ml for 10% ketamine I use).
Worked very well for her. Recovery is smooth.
Separate syringes.
Ketamine 1.5 ml is large amount. It stings and is painful for dog. Dog bites. Muzzle dog.
Top up, use one syringe.
As I don't use above for dogs, I am happy to receive her valuable feedback. I use Xylazine 2% at 0.2ml IM, Wait 5-10 minutes and gas mask isoflurane and intubate.
RABBIT
In a practice in England, the following is used for anaesthesia, according to the English vet:
Domitor 0.1 mg/kg
Ketamine 10% @ 10mg/kg
Torbugesic 0.5mg/kg
In one syringe.
Need to monitor rabbit. Stops breathing. Give reversal Antisedan.
Rabbits do not need to be starved prior to anaesthesia unlike dogs and cats since they are incapable of vomiting and the most common post-op problem is intestinal stasis. They should be given hay as soon as possible to prevent post-operative ileus or gut stasis.
Sedation
Domitor 0.1 mg/kg
Ketamine 10% @ 5mg/kg
Torbugesic 0.5 mg/kg
In one syringe.
NOTES: Torbugesic (butorphanol) produces additive effects when used with other sedative or analgesic drugs. In horses, 0.1 mg of butorphanol/kg IV is recommended for the alleviation of visceral pain. Ketamine is a dissociative drug that is analgesic and does NOT depress cardiovascular function. Xylazine causes muscle relaxation, sedation and analgesia.
Molar spur trimming (injectable anaesthesia sufficient without gas anaesthesia.
A common drug combination in rabbit anesthesia is butorphanol (Torbugesic) and midazolam (Versed). Butorphanol is an opiod with analgesic (pain-killing) and sedative properties. Midazolam is related to diazepam and produces sedation and muscle relaxation. Anaesthetic induction can be gas or a combination of ketamine, midazolam and xylazine. Propofol is a new drug that is expensive but relatively safe. It is not known how it works.
Spaying and neutering are not popular in Siem Reap in 2009. The majority of the locals don't vaccinate, spay or neuter nor feed commercial dog food. Parvovirus is rampant from puppies imported from Thailand. The small animals at this Shop is part of the business model to get clients coming in. In Singapore, it will not be permitted if there is no separate entrance for the pet shop and vet surgery premises. A thriving fully equipped vet practice in Phnom Pem has been started by a French vet for many years.
In countries like Cambodia and Myanmar, it may be too expensive to set up a gas anaesthesia machine for small animals. Therefore injectable anaesthesia is commonly used by the local vets.
DOGS
Xylazine 2% 0.05ml/kg
Ketamine 5% 0.3 ml/kg (human ketamine is 5% i.e. 50mg/100 ml unlike veterinary ketamine which is available as 10%).
Separate syringes, one injection another instead of waiting 15 minutes as this was found to be more effective. IM injection.
Onset 10-15 minutes (to sleep)
Duration 20-25 minutes (before topping up)
Top up: Mix above 2 drugs in one syringe and give at half dose.
CATS
Xylazine 2% 0.1ml/kg
ketamine 5% 0.2 ml/kg
Both drugs in one syringe
Onset 5 minutes
Duration 45 minutes
Top up: Mix 2 drugs in one syringe and inject.
Disadvantage: Wakes up suddenly. Wait 5 minutes before proceeding to surgery. Takes a long time to wake up. Vomiting. Tends to vomit with dogs and cats even on empty stomachs. For sick cats, the dosage is reduced by 1/3.
REVERSAL
Yohimbine use in cats to wake them up sooner. No need to use in dogs in her cases. Rapid recovery was obtained with Yohimbine in cats in her experience. Is it possible that her xylazine dosage was higher such that the cats take a longer time to be mobile? See Discussion below.
DISCUSSION
CATS around 2 kg in Singapore Toa Payoh Vets, www.toapayohvets.com
I use Xylazine 2% @ 0.1ml and Ketamine 10% @ 0.4 ml in one syringe IM
Onset 5 minutes
Duration 20 minutes
Comparing this to the English vet's formula, she would use
Xylazine 2% @ 0.2 ml
Ketamine 5% @ 0.4 ml (Since I use 10%, this would be equivalent to 0.2 ml)
Her dosage permits her a longer duration of 45 minutes. She needed 15 min pre-op. She needed a reversal drug which i don't need.
That meant she used xylazine 2% @ 0.2 ml and ketamine 10% @ 0.2 ml while I used xylazine 2% at 0.1 ml and ketamine 10% at 0.4 ml.
DOG, 5 kg Jack Russell
Xylazine 2% @ 0.25 ml IM
Ketamine 5% @ 1.5 ml IM (For me, it should be 0.75ml for 10% ketamine I use).
Worked very well for her. Recovery is smooth.
Separate syringes.
Ketamine 1.5 ml is large amount. It stings and is painful for dog. Dog bites. Muzzle dog.
Top up, use one syringe.
As I don't use above for dogs, I am happy to receive her valuable feedback. I use Xylazine 2% at 0.2ml IM, Wait 5-10 minutes and gas mask isoflurane and intubate.
RABBIT
In a practice in England, the following is used for anaesthesia, according to the English vet:
Domitor 0.1 mg/kg
Ketamine 10% @ 10mg/kg
Torbugesic 0.5mg/kg
In one syringe.
Need to monitor rabbit. Stops breathing. Give reversal Antisedan.
Rabbits do not need to be starved prior to anaesthesia unlike dogs and cats since they are incapable of vomiting and the most common post-op problem is intestinal stasis. They should be given hay as soon as possible to prevent post-operative ileus or gut stasis.
Sedation
Domitor 0.1 mg/kg
Ketamine 10% @ 5mg/kg
Torbugesic 0.5 mg/kg
In one syringe.
NOTES: Torbugesic (butorphanol) produces additive effects when used with other sedative or analgesic drugs. In horses, 0.1 mg of butorphanol/kg IV is recommended for the alleviation of visceral pain. Ketamine is a dissociative drug that is analgesic and does NOT depress cardiovascular function. Xylazine causes muscle relaxation, sedation and analgesia.
Molar spur trimming (injectable anaesthesia sufficient without gas anaesthesia.
A common drug combination in rabbit anesthesia is butorphanol (Torbugesic) and midazolam (Versed). Butorphanol is an opiod with analgesic (pain-killing) and sedative properties. Midazolam is related to diazepam and produces sedation and muscle relaxation. Anaesthetic induction can be gas or a combination of ketamine, midazolam and xylazine. Propofol is a new drug that is expensive but relatively safe. It is not known how it works.
Spaying and neutering are not popular in Siem Reap in 2009. The majority of the locals don't vaccinate, spay or neuter nor feed commercial dog food. Parvovirus is rampant from puppies imported from Thailand. The small animals at this Shop is part of the business model to get clients coming in. In Singapore, it will not be permitted if there is no separate entrance for the pet shop and vet surgery premises. A thriving fully equipped vet practice in Phnom Pem has been started by a French vet for many years.
In countries like Cambodia and Myanmar, it may be too expensive to set up a gas anaesthesia machine for small animals. Therefore injectable anaesthesia is commonly used by the local vets.
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