23 October 2011

Case for the week:

1.      Process of Tick Fever

2.      History

3.      Examination

4.      Blood test and Blood smear

5.      Treatment

1)      Process:

Dogs get Ehrlichiosis (Tick fever) from the brown dog tick, which passes an Erlichia organism into the bloodstream when it bites. There are three stages of Ehrlichiosis, each varying in severity. The acute stage, occurring several weeks after infection and lasting for up to a month, can lead to fever and lowered peripheral blood cell counts due to bone marrow suppression. The second stage, called the subclinical phase, has no outward signs and can last for the remainder of the dog's life, during which the dog remains infected with the organism. Some dogs are able to successfully eliminate the disease during this time. In some dogs the third and most serious stage of infection, the chronic phase, will commence. Very low blood cell counts (pancytopenia), bleeding, bacterial infection, lameness, neurological and ophthalmic disorders, and kidney disease, can result. Chronic ehrlichiosis can be fatal.
[Reference: http://en.wikipedia.org/wiki/Ehrlichiosis_(canine)#Disease_overview]

Babesia canis are protozoal parasites that infect red cells and can produce hemolytic anemia. Transmission is primarily by the brown dog tick.

[Reference: http://en.wikipedia.org/wiki/Babesiosis]

2) History:

Dog have been exposed to ticks

3) Examination:

Presented with symptoms of lerthargic-ness and loss of appetite, signs of pale gums which signifies anemia



Pale gums signify anemia

4) Blood Smear:

Reveals pathogen such as Babesia Canis and potential Ehrlichia Canisa

Babesia Canis in blood smear
[Reference: http://ahdc.vet.cornell.edu/clinpath/modules/rbcmorph/b-canis.htm]

Ehrlichia Canisa in blood smear
[Reference: http://www.marvistavet.com/html/body_ehrlichia_infection_in_dogs.html]

Blood test results before treatment:

Liver profile= Normal

Kidney profile= Normal

Hematology=

*Hemoglobin- 7g/dL  [Normal range: 12-18]

*Red Blood Cells- 2.8 x10^12/L [Normal range: 5.5-8.5]

White Blood Cells- 13.2 x10^9/L [Normal range: 6-17]

Packed Cell Volume= 0.19 [Normal range: 0.37-0.55]

Platelets= 52 [Normal range: 200-500]

Nucleated Red Blood Cells seen [Severe demand for RBC to be release from Bone Marrow]

No platelet clump seen

Blood test results after 1 day of treatment:

Liver profile= Enzymes increased

Kidney profile= Normal

Hematology=

*Hemoglobin- 7g/dL [Normal range: 12-18]

*Red Blood Cells- 2.9 x10^12/L [Normal range: 5.5-8.5]

White Blood Cells- 9.6 x10^9/L [Normal range: 6-17]

Packed Cell Volume= 0.2 [Normal range: 0.37-0.55]

Platelets= 64 [Normal range: 200-500]

No platelet clump seen but few giant platelets present

What is the importance of platelets?
a) Numbers:
The analyzer counts the number of platelets in the blood, and the reported platelet count gives a general indication of the clotting ability of the blood. If the number of platelets falls below a certain critical level, spontaneous bleeding may occur. A low platelet count may indicate a problem with platelet production in the bone marrow, or may signal the presence of disease that is causing the platelets to be used up or destroyed.  An increased platelet count often reflects excitement, exertion, or an activated bone marrow. In rare cases, an extremely high platelet count may indicate there is underlying bone marrow cancer.
b) Size:
The size of a platelet is related to its age; young platelets are large and plump, and older platelets are generally smaller. This can be important if the platelet count is low; the presence of large, plump, young platelets in the blood indicates that the bone marrow is functioning well, and is responding to the need for more platelets.
c) Appearance:
 Very rarely, bizarre giant platelets, or abnormal immature platelets may be found, and these may signal the presence of an underlying bone marrow disorder or cancer

[Reference: http://www.fetchdog.com/learn-connect/dog-resource-library/health/diagnostic-tests/Complete-Blood-Count-for-Dogs/D/300600/P/1:5:55:601:6103/I/AR000010025]

5) Treatment:

Supportative therapy: IV-drip of Dextrose Saline

For anti-bacterial activity: Oral Vibravet 100mg twice a day for up to 21 days

For anti-protozoal activity: Imidocarb 0.5ml

Working hours:
9.45am- 5.30pm

Admin stuffs completed:
Updated Client's database and found several empty details in older records

16 October 2011

Case 1:

What should a vet do if a puppy that was recently purchased was brought in with complaints of blood in stools?

First few questions we should ask the owners are:

1. When is the onset of the blood in the stools?
2. When is the puppy vaccinated?
3. When did the breeder sell the puppy to the pet shop?
4. When did the pet shop sell off the puppy to the owner?

What the vet should consider:

1. Possible infections or reasons for the problem?
2. Type of tests to look into to find out, or rule out the possible reasons
3. Meanwhile, what should be done to the puppy

My mentor walked me through the case. Firstly, we need to find out the history of the puppy before it was purchased by owner and when the symptom was discovered.

1st Vaccination	13.09.11	Breeder in charge
2nd Vaccination	27.09.11	Pass on to Pet shop
3rd Vaccination	Due on 27.10.11	Owner’s responsibility
Date of purchase	09.10.11
Blood found in stools	15.09.11

Troubleshooting starts by stating the possible reasons for having blood in stools in puppies. Could it be a simple intestinal problem? Or bigger problem like parvovirus infection (Prone in puppies without complete dose of vaccination)? How did the vet think that it is parvovirus infection? According to the history, the puppy is moved from the breeder’s ground to the pet shop before the second vaccination shot was given. Puppy might pick up the virus during transport.

In order to rule out the possibility of being infected by parvovirus, a quick and simple canine parvovirus Antigen test kit was used by testing it with some blood samples. Result was revealed within minutes and showed negative for virus antigen.

So what can be the factor that causes the symptoms? Another blood sample was taken, this time it was sent for a more complete blood test. This test will focus on the cellular level, showing the activity of the immune cells.

Meanwhile, the puppy is required to be hospitalized. In order to re-hydrate the puppy, it was fed with oral electrolytes by syringe; twice a day. Furthermore, to prevent bacteria infection, it was given antibiotics and also multi-vitamins to boost its immune system.

Awaiting blood test results

Puppy under observation in the clinic



Medication provided

Short case of overgrowth frontal teeth of hamsters

A small procedure was done to alleviate the eating problem of the hamsters.



Front view of the teeth



Side view; more obvious cave-in of teeth towards the upper palette



Clippings of teeth after removal



Case 2:

An old dog (8-9 years old) was spotted with swollen paws with dry, scaly skin with the lack of hair coat. Ear edge was found to be crusty.

Possible problems:

1. Scabies mite infection
2. Fungus infection

Solutions:

1. Fur was plucked and analyzed on microscope slide for signs of mites
2. Inflammation injection was given to reduce symptoms on paws

Case 3:

On 11^th September, I met this client whom presented the dog to the vet with the complaint of fits. The pug was sent home with the idea that there is bacteria infection. Recently, the pug returned to the clinic with the same complaint.

History of the fit occurring as follows:

1^st fit occurred during hospitalization after urinary bladder stones removal

2^nd and 3^rd fit occurred at home

Another episode of fit (4^th) lasted 3-4mins on Thursday night (13.10.11)

Current 2 episodes appeared the day after on Friday night (14.10.11), which happens within an hour

Majority of the causes of fits are unknown, may be a metabolic cause, hereditary or induced by food. Need further analysis to rule out those possible reasons.

Admin work completed:

1)     Made electronic copies of bank statements for December 2010 for Toa Payoh Vets

Working hours:

9.45am- 5.30pm

02 October 2011

Case 1

Dog with a pair of eyes with a greenish blue tinge was brought in with a complaint of swollen right paw. Upon closer inspection of the right paw, the vet found that phalanx 3 of both digit 4 and 5 felt swollen. It was suspected that it is due to a sprain of the ligaments. Looking at the teeth, there are signs of periodontal disease which is of at stage 4.

How does periodontal disease develop? I have researched online and found a very informative passage (http://www.peteducation.com).
“Food particles and bacteria collect along the gumline forming plaque. If plaque is not removed, minerals in the saliva combine with the plaque and form tartar (or calculus) which adheres strongly to the teeth. Plaque starts to mineralize 3-5 days after it forms. The tartar is irritating to the gums and causes an inflammation called gingivitis. This can be seen as reddening of the gums adjacent to the teeth. It also causes bad breath.
If the calculus is not removed, it builds up under the gums. It separates the gums from the teeth to form "pockets" and encourages even more bacterial growth. At this point the damage is irreversible, and called "periodontal" disease. It can be very painful and can lead to loose teeth, abscesses, and bone loss or infection.”

	Grade	Plaque and Calculus	Gum Health	Radiologic Changes	Prognosis
Early Gingivitis	Grade I	Mild amount of plaque	Mild redness	No change	Reversible
Advanced Gingivitis	Grade II	Subgingival* plaque	Redness and edema	Little change	Reversible
Early Periodontitis	Grade III	Subgingival* calculus	Redness, edema, gums bleed with gentle probing, gum recession or hyperplasia	Subgingival calculus, 10-30% loss of bone support	Irreversible
Established Periodontitis	Grade IV	Larger amounts of subgingival calculus	Severe inflammation, gum recession, loose teeth and/or missing teeth, pus, gums bleed easily, deep pockets	Over 30% bone loss	Irreversible

Case 2

Looks like generalized ring worm throughout the body of a 7 years old dog, which started 3 weeks ago. Suspected auto-immune disease but was not able to take a closer look as client is only willing to be consult by his preferred vet.

Case 3

Shih tzu was suspected to have recurring scabies, this time round it occurred in the ears.



Scabies in ear

“Scabies is a skin disorder caused by infection with scabies mites (sarcoptes scabei). Those microscopic mites burrow in the dogs skin surface, storing their eggs in a trail behind them. The tunnels are visible as thin, scaly lines at the dogs’ skin. The itchy scalp and skin rashes of scabies occur because an allergy to the scabies mite. Scabies is one of the most itching skin disorders in dogs.”

[Reference: http://www.doggiesparadise.com/itching.shtml]

There are obvious ring worm infection on the hind legs and left cornea central ulceration too.



Cornea ulceration as recognized as a whitish patch in the centre of the cornea

Admin work completed:

1)     Made electronic copies of bank statements for months from January-September 2011 for Toa Payoh Vets

2)     Made electronic copies of both vet’s consultation and salary from January-September 2011

3)     Updated the client’s database

4)     Helped vet nurse with the tabulation of vet’s consultation for the month of September

Working hours:

9.45am- 5.30pm

18 September 2011

Case one:
Initially, hamster was sent to the clinic for complaint of foul smell from ears. Then surgery was done twice due to growth in the ears. Right ear canal ablation was carried out and irrigated to clean and remove pus caused by bacteria infection. The fourth time it came in the clinic due to another bout of bacteria infection, which causes itchy ears. Another surgery was carried out to remove pus and hamster was sent home.

Case two:
Updates on the first case I observed on the first day I came to the clinic (28 August 2011), it is regarding the 10years old Shi Tzu with suspected oral tumors. After much debate within the family members, they decided to go ahead with the surgery to help their beloved dog. Vet removed all three protuding tumors from the mouth area and returned home happily.

This a photo of the dog before surgery; i got this photo from my mentor's website
[http://2010vets.blogspot.com/2011/09/619-two-weeks-after-surgery-treatment.html]

This is photo after the removal of the three tumors

Case three:
Jack russell was brought in with an obvious 9 '0' clock ulcer on the right eye the second time. Apparently, few months ago the jack russell was brought in for two ulcers on the same eye and a surgery was done to stitch up the eyelid. This raised questions as to what actually happened after the surgery and after wound healed. After probing further, then we understand that the jack russell is living together with a golden retriever. Both of them often play together and owners noted that the golden retriever always raised it's paw towards the jack russell during their play. Vet therefore concluded that the most probable reason for the recurring ulcers on the eye is caused by traumatic injury from the golden retriever. To visualize the ulcer, a fluorescein strip is applied onto the moist eye surface and briefly rinsed off. With a torch, the ulcer will be more visible. After that, a small surgery is carried out to sew both upper and lower eyelids, with the addition of antibiotic oilment. Jack russell was sent home and advice was given to separate both dogs to prevent similar injuries.

Green fluorescent stain observed after rinsing off with saline, represents ulceration on the cornea

In the middle of the surgery, photo show 2 completed stitches

One emergency case turned up just before the end of the day, owner brought in a tiny pomeranian, so small that it fits in a mooncake paper carrier. Looking into the bag, there lie an emciated dog with no signs of activity. Vet took one look and suggested that the dog is hypoglycemic. Dog showed sunken eyes, slow breathing and very listless. Therefore, glucose have to be given to try to revive it. Glucose was given orally every 10minutess because the veins are too tiny to allow the insertion of catheter for IV drip. 30minutes later,  vet decided to force feed some A/D food and the owner took over the forced feeding as the vet have other clients to look at. The owner diligently force feed the pomeranian every few minutes. Initially, the dog is not responsive but after 20minutes or so, it's tongue started licking at the syringe with the food and the head started to move slowly. I went over to send the good news to the vet. Vet was very glad that the dog was slightly better than when it first reached the clinic. Advice was given to owners to keep dog warm as their current habitat (air-conditioned house) is not conducive for the growth of puppy, as puppy loses body heat fast and gains it slower. With that advice and a couple of A/D can food, they were sent back. Hopefully, the pomeranian is able to grow up to be stronger.  

Dog was presented to us with a listless and dishevelled look



Mentor mentioned that it is important to maintain productivity by balancing the output vs. input. (Output and  Input in terms of service provided)
For example: If a consult takes up to 2hours and the required surgery, perhaps an hour. Total time spent will be 3 hours. In terms of billing, the amount earned from the surgery time divides by the amount of time spent during consult will not be equal, or rather it results in an imbalance equation. Therefore, care must be taken on this notion.

Admin stuffs done for the day:

1) Made electronic masterlist of accounts for Toa Payoh Vets-
    Salary n Consultation fees of individual vets and other staffs
    Fax, phone n electricity

2) Keyed in new clients into database

Working hours:

10am to 5.30pm