September is Animal Pain Awareness Month

Pet Pain1

While we are different species, we all process and feel pain similarly. As advances in modern medicine have increased our lifespan, our animal family members are also reaping the benefits of advances in modern veterinary medicine. More of our beloved pets are undergoing elective surgical procedures to treat a variety of disease processes, from a torn cruciate ligament to extractions of infected teeth.

Pain management has become an important specialty area in veterinary medicine just as it has in human medicine. You want the best for your family members and that includes top-of-the-line treatments for pain management.

Because their pain is our pain

It was once thought that animals did not experience pain in the same way people do. But research supports that if a procedure is thought to be painful to us, it will also be painful to our furry friends as well, even though they may go to great lengths to hide it from us. So proper pain management must be offered to all of our patients.

What you can do

  1. Ask our veterinary team about the customized steps we will take to manage your pet’s pain.
  2. Talk to our veterinary team about common signs of osteoarthritis pain in senior pets, such as reluctance to go up or down stairs, being slow to rise after sleeping and loss of interest in playing, running or jumping.
  3. Request a pain consultation for your pet. Lange Animal Clinic veterinarians offer tailored pain management protocols for patients at risk for chronic pain such as osteoarthritis.
  4. Ask about rehabilitation options and other steps to manage any chronic pain your pet experiences.

Pain management is an important aspect of any surgical or medical procedure.  Together with our veterinary team, you can make your pets as comfortable as possible in the postoperative period or into their senior years.


For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

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Properly Removing a Tick from Your Pet

Tick

The forecast for ticks in the Central, IL area is on the rise this year.   The veterinarians at Lange Animal Clinic recommend a minimum of once-yearly examinations and year-round parasite control for all dogs and cats in your home. The best way to reduce your dog’s risk for ehrlichiosis is to follow our veterinarians’ advice and consistently use appropriate tick control products for your pets.

With that being said —how do you deal with removing a tick if you happen to find one or more on your dog or cat? While it’s important to get these little suckers off quickly, our veterinarians advise that you stay calm and don’t rush it. Moving too fast when removing a tick could potentially create more problems, both for your pet and for you.

While the following instructions employ tweezers, be aware that there are some very good products on the market designed specifically for safe tick removal. If you live in a tick-heavy area or are taking your pets to a place where they are likely to get ticks, it’s a good idea to buy one of these tools and have it on hand. They generally work better than tweezers at getting out the whole tick, and are relatively inexpensive.

Step-by-Step Tick Removal Instructions

Step 1—Prepare a Container

Throwing a tick in the trash or flushing it down the toilet will not kill it, and it’s actually best to hold on to it for a while for veterinary testing in case your pet falls ill from the bite. Be ready with somewhere to put the tick after you’ve removed it—the best option is a screw-top jar containing some rubbing alcohol.

Step 2—Wear Protective Gloves

Put on latex or rubber gloves so you’ll never have direct contact with the tick or your pet’s bite area. Ticks can carry infective agents that may enter your bloodstream through breaks in your skin or through mucous membranes (if you touch your eyes, nostrils or mouth).

Step 3—Get a Partner to Help Restrain Your Pet Safely

You don’t want your pet squirming away before you’re finished, so if possible, have a helper on hand to distract, soothe or hold your pet still.

Step 4—Removal of the Tick

Treat the bite area with rubbing alcohol and, using a pair of tweezers, grasp the tick as close to your pet’s skin as possible. Pull straight upwards with steady, even pressure. Place the tick in your jar.  Do not twist or jerk the tick! This may leave the mouth-parts embedded in your pet, or cause the tick to regurgitate infective fluids.  Also, do not squeeze or crush the body of the tick, because its fluids (saliva and gut contents) may contain infective organisms.

Step 5— Check the Area

Sometimes, in spite of doing everything right, a tick’s mouth-parts will get left behind in your pet’s skin. If the area doesn’t appear red or inflamed, the best thing to do is to disinfect it and not to try to take the mouth-parts out. A warm compress to the area might help the body expel them, but do not go at it with tweezers.

Step 6—Clean and Disinfect

Thoroughly disinfect the bite site and wash your hands with soap and water (even though you were wearing gloves). Sterilize your tweezers with alcohol or by carefully running them over a flame.

Step 7—Monitor the Affected Area

Over the next few weeks, closely monitor the bite area for any signs of localized infection. If the area is already red and inflamed, or becomes so later, please bring your pet—and your jarred tick—to us for further evaluation.


For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

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National Dog Bite Prevention Week- May 17th – 23rd

DBPW

In honor of National Dog Bite Prevention Week from May 17 to May 23, Lange Animal Clinic in Pekin, IL and the ASPCA are helping pet owners and those who come in contact with dogs stay safe by offering helpful reminders and warning signs.  The American Veterinary Medical Association (AVMA) says regardless of breed, all dogs can bite. Pit bull breeds are most commonly named, but the most frequent breeds associated with serious bite injuries also include German Shepherds, Jack Russell Terriers, Rottweilers, Labradors, Collies, Spaniels, and more.

More than four million people are bitten by dogs each year despite the fact that these incidents are very preventable.  Dogs may show signs that they are stressed or anxious if they yawn, put their ears back, stiffen and stare at you, change body language quickly, growl or otherwise act out of the ordinary.

How do you avoid getting bit by a dog? Start by being polite and respecting the dog’s personal space. Never approach an unfamiliar dog, especially one who’s tied or confined behind a fence or in a car. Don’t pet a dog—even your own—without letting him see and sniff you first.

Don’t disturb a dog while she’s sleeping, eating, chewing on a toy or caring for puppies. Be cautious around strange dogs. Always assume that a dog who doesn’t know you may see you as an intruder or a threat.

Pay attention to the dog’s body language

Put a safe amount of space between yourself and a dog if you see the following signals indicating that the dog is uncomfortable and might feel the need to bite:

  • tensed body
  • stiff tail
  • pulled back head and/or ears
  • furrowed brow
  • eyes rolled so the whites are visible
  • yawning
  • flicking tongue
  • intense stare
  • backing away

Teach Your Children to Interact with Dogs Correctly

Even if you trust your pet, more than 70 percent of dog bites happen at home. Your family pet may not mean to harm you, but often times children don’t know how to approach a dog or know when to stop bothering them.   When a child is very outgoing, they forget that the animal may not want to be approached at certain times, and that it may react because it’s startled or protecting its food. The good news is, kids can learn the right way to interact with animals.

The ASPCA says some things to remember when dealing with children around pets are:

  • Always supervise children around pets, even if that pet belongs to you
  • Never surprise or scare a dog who is sleeping, eating or not expecting you
  • Never take food, toys or bones away from a dog
  • Do not let your child approach, touch or hug a dog that does not belong to them unless the owner gives permission

What to do if you think a dog may attack

If you are approached by a dog who may attack you, follow these steps:

  • Resist the impulse to scream and run away. When putting space between yourself and a dog who might bite, never turn your back on him and run away. A dog’s natural instinct will be to chase you.
  • Remain motionless, hands at your sides, and avoid eye contact with the dog.
  • Once the dog loses interest in you, slowly back away until he is out of sight.
  • If the dog does attack, “feed” him your jacket, purse, bicycle or anything that you can put between yourself and the dog.
  • If you fall or are knocked to the ground, curl into a ball with your hands over your ears and remain motionless. Try not to scream or roll around.

What to do if you’re bitten by a dog

If you are bitten or attacked by a dog, try not to panic.

  • Immediately wash the wound thoroughly with soap and warm water.
  • Contact your physician for additional care and advice.
  • Report the bite to your local animal care and control agency. Tell the animal control official everything you know about the dog, including his owner’s name and the address where he lives. If the dog is a stray, tell the animal control official what the dog looks like, where you saw him, whether you’ve seen him before and in which direction he went.

Safety and proper interaction with dogs can prevent bites from occurring.  To learn more, speak with a Lange Animal Clinic veterinarian.


For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

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FDA Warns Popular Topical Pain Medication Toxic to Pets

Fernpelt

The U.S. Food and Drug Administration (FDA) issued an official warning that topical pain medications containing flurbiprofen are dangerous to animals, even in tiny amounts. The warning was the result of several reports of household pets becoming ill or dying after the guardians used flurbiprofen topical pain relief formulations.

Flurbiprofen is a non-steroidal, anti-inflammatory drug (NSAID) used to treat arthritis, joint pain, muscular discomfort and other aches. It was originally marketed as Ansaid® (Pfizer), then Froben® (Abbott), and is now widely available in generic form. It is similar to ibuprofen (Motrin® or Advil®), naproxen (Naprosyn®), and other NSAIDs. Flurbiprofen is commonly added to pain relieving creams and lotions, and that may be how pets, especially cats, are being accidentally poisoned.

Pets and medications

Cats seem particularly sensitive to NSAIDs such as flurbiprofen. For years veterinarians have warned cat owners to avoid Tylenol (acetaminophen) and never give your dog or cat aspirin, ibuprofen, or other NSAIDs without consulting with your veterinarian first. Add flurbiprofen to that No-Try List.

What prompted this warning?

The FDA revealed that the guardian of two cats sickened by flurbiprofen had recently used a pain-relieving cream on the neck and feet. The guardian did not recall the two cats eating, licking or otherwise directly contacting the cream. These two cats developed kidney failure and fortunately recovered with veterinary care.

Another household had three cats that became sick and died, despite aggressive veterinary care. The guardian had also used a flurbiprofen-containing product prior to the cats developing clinical signs. All three cats eventually died and had necropsies performed, confirming NSAID toxicity.

Clinical signs of flurbiprofen and NSAID toxicity are severe and abrupt. Many cats will progress to critical condition within 24 to 72 hours of NSAID exposure. Dogs may also be affected by flurbiprofen and NSAIDs, although they appear to be less sensitive to developing life-threatening toxicity.

What are the signs of NSAID poisoning?

Clinical Signs of Flurbiprofen and NSAID Toxicity in Cats and Dogs include:

  • Decreased appetite and reluctance to eat
  • Lethargy
  • Vomiting and diarrhea
  • Blood in stool
  • Melena (black, tarry stools)
  • Abdominal pain
  • Anemia
  • Increased thirst or urination

How can you protect your pet?

Lange Animal Clinic veterinarians in Pekin, IL urge the that if you use a topical pain relief product, it’s critical to keep these medications away from your dog or cat. If you apply a topical cream or lotion, avoid touching your pet for several hours and only after thoroughly washing. Be careful contacting couches, chairs and bedding with these preparations. Curious cats and dogs may lick residues and become poisoned. Cats may be affected by tiny amounts of flurbiprofen and there may be risk of continued exposure to tiny amounts over several days or weeks.

Our veterinarians have been seeing an increase in inadvertent poisonings from topical medications over the past several years. Hormone and testosterone gels, cancer medications, nicotine patches, topical steroids and pain treatments have all been reported to cause accidental toxicity in pets. This latest FDA warning reminds us that as we seek convenience and relief for ourselves, there may be unintended consequences for our pets. Treat your pain, but remember even our most seemingly safe medications may be deadly to our furry family members.


For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

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Canine Influenza Information and Prevention

civ

Canine influenza (CI, or dog flu) in the U.S. is caused by the canine influenza virus (CIV), an influenza A virus. It  is highly contagious and easily spread from infected dogs to other dogs through direct contact, nasal secretions (through coughing and sneezing), contaminated objects (kennel surfaces, food and water bowls, collars and leashes), and by people moving between infected and uninfected dogs. Dogs of any breed, age, and sex or health status are at risk of infection when exposed to the virus.

Unlike seasonal flu in people, canine influenza can occur year round. So far, there is no evidence that canine influenza infects people. However, it does appear that at least some strains of the disease can infect cats.

Canine influenza symptoms and diagnosis 

CIV infection resembles canine infectious tracheobronchitis (“kennel cough”). The illness may be mild or severe, and infected dogs develop a persistent cough and may develop a thick nasal discharge and fever. Other signs can include lethargy, eye discharge, reduced appetite, and low-grade fever. Most dogs recover within 2-3 weeks. However, secondary bacterial infections can develop, and may cause more severe illness and pneumonia. Anyone with concerns about their pet’s health, or whose pet is showing signs of canine influenza, should contact their veterinarian.

CIV can be diagnosed early in the illness (less than 4 days) by testing a nasal or throat swab. The most accurate test for CIV infection is a blood test that requires a sample taken during the first week of illness, followed by a second sample 10-14 days later.

Transmission and prevention of canine influenza

Dogs are most contagious during the two- to four-day incubation period for the virus, when they are infected and shedding the virus in their nasal secretions but are not showing signs of illness. Almost all dogs exposed to CIV will become infected, and the majority (80%) of infected dogs develop flu-like illness. The mortality (death) rate is low (less than 10%).

Lange Animal Clinic veterinarians in Pekin, IL strongly suggest the following items to significantly reduce the spread of canine influenza:

  • Avoiding taking your dog to dog parks, social events, and boarding. Avoid interaction with other dogs to minimize the possibilities of being exposed to the virus. 
  • Isolating ill dogs as well as those who are known to have been exposed to an infected dog and those showing signs of respiratory illness.
  • Good hygiene and sanitation, including hand washing and thorough cleaning of shared items and kennels, also reduce the spread of canine influenza.
  • Use disinfectants when cleaning around the house and make certain to safely sterilize dog supplies such as food bowls, dog toys, and bedding.

There are vaccines against the H3N8 strain of canine influenza, which was first discovered in 2004 and until 2015 was the only strain of canine influenza found in the United States. However, a 2015 outbreak of canine influenza in Chicago was traced to the H3N2 strain – the first reporting of this strain outside of Asia – and it is not known whether the H3N8 vaccine provides any protection against this strain. The CIV vaccination is a “lifestyle” vaccination, recommended for dogs at risk of exposure due to their increased exposure to other dogs – such as boarding, attending social events with dogs present, and visiting dog parks.


For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

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Thunderstorms and Easing Your Pets’ Fear

tstorm

It is still relevantly unknown as to why some pets become afraid of noises such as thunderstorms.  This is a common problem in dogs, but less so in cats. The fear can soon become a phobia for a pet causing irrational fear response(s) and behavior issues. In the case of thunderstorms, pets may be fearful of storm-associated events such as a change in barometric pressure, lightning, electrostatic disturbances, and even smells associated with the storms. Noise phobias can include fear of thunder and severe gusts of wind knocking down larger outdoor items.

Some studies suggest that certain breeds of dogs have an above average risk of developing noise phobias. These include such breeds as: Collies, German Shepherds, Beagles, and Basset Hounds. A noise phobia may be traced to a particular bad experience of a noise, but often, no triggering event can be ascertained. In most cases, the fear of noises and storms can progressively worsen. Over time, a pet may become fearful of similar sounds or events associated with the noise.

Lange Animal Clinic veterinarians in Pekin, IL believe that an owner’s attitude can influence the severity of the fear. For instance, if owners themselves are nervous during storms, noise phobias in their pets may occur more often or become more severe. Similarly, if the owner attempts to overly comfort the animal, the animal interprets it as confirming there really is something to be afraid of. The over petting or comforting is really positive reinforcement of an undesirable behavior.

Signs or behaviors to watch for during Thunderstorms

Dogs or cats may display different signs of noise phobias which may include one or more of the following:

  • Hiding (most common sign in cats)
  • Urinating
  • Defecating
  • Chewing
  • Panting
  • Pacing
  • Trying to escape (digging, jumping through windows or going through walls, running away)
  • Drooling
  • Seeking the owner
  • Expressing anal glands
  • Not eating
  • Not listening to commands
  • Trembling or shaking
  • Vocalizing (barking or meowing)

Consult with a Lange Animal Clinic veterinarian to help you address any animal behavior problems.  We will assist you in developing the appropriate treatment plan for your pet.

How do you treat noise phobia?

There are no guarantees that a noise phobia can be eliminated completely, but in most cases the fear can be effectively managed. The type of treatment and success levels depend on several factors including the severity of the phobia, how long your pet has had to deal with it, how often it is occurring, seasonality, and the amount of time you are willing to dedicate to correcting the behavior.

The first thing to remember is that you should refrain from giving excessive attention or punishment for fearful behavior. Continuous petting or coddling may be perceived by the pet as a reward for the fearful response. In the event of overcompensating comfort a dog during a storm, for example, it may signal to the pet that the storm really is something he should be afraid of. Similarly, the pet should not be punished for showing fear. This will only increase his anxiety level. Instead, emit confidence, and provide your dog attention in the form of playing, grooming, or other activities he or she enjoys.

The following are some techniques to use to help change the phobia of thunderstorms:

Change the surroundings
By changing the surroundings of the animal during the storm or noise, the anxiety level can be reduced. Changing the pet’s surroundings may reduce the volume level of the sound or help make the pet less aware of it.  “White noise,” such as running a fan or air conditioner may aid in blocking out some of the fear-producing noise. Playing a TV or radio can have a similar effect. Allowing the pet access to the basement or a room without outside walls or windows may decrease the noise level

Exercise your pet (and yourself too!)
The pet should receive consistent exercise on a daily basis, and more so on a day when the thunderous noise occur during storms. The exercise will help to wear down your animal, both mentally and physically, and may reduce the pet’s responsive to the noise. In addition, exercise has the effect of increasing natural serotonin levels, which can act as a sedative.

Create a safety zone for your pet
Pets may feel more comfortable and relaxed in a small space such as a crate or a small room like a bathroom (run the fan and leave the lights on). Some pets seek out the safety of the bathtub or shower during a storm. (Some have hypothesized that a pet may feel less static electricity if on tile or porcelain.) If the pet is comfortable in a crate, the crate can be covered with a blanket to add to the feeling of security. The door to the crate should be left open and the pet should not be confined to the crate, which could dramatically increase the stress level.

Maintain calm and composure
Pets can very easily pickup on the mental state of their owners. If you too are nervous because of the storm- this will only add to the dog or cat’s fear. Your pet will look to you for direction, so keep an “upbeat” and “in charge” attitude.

Maintain good health and nutrition
Health problems may increase the stress level of pets, and increase their anxiety. For instance, a dog in pain because of hip dysplasia may be more irritable and prone to other behavior changes. Diets too high in protein have been linked to some behavioral problems. Consult one of the Lange Animal Clinic veterinarians if you would like advice about changing your pet’s diet.

Special techniques can be used to help change the animal’s response to the noise.  We can offer guidance and suggestions to help.  Second level alternatives may include anti-anxiety medications but we strongly encourage following the above techniques first to identify whether or not success can be achieved using those methods before relying on medications.


For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

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How to Clean Your Dog or Cat’s Ears

Ear Cleaning
There are three very important things that you need to know about dogs’ and cats’ ears before reading these guidelines being presented.  If you are not comfortable performing an ear cleaning on your own or wish to see a demonstrations on how to do so- contact a Lange Animal Clinic veterinarian:

–  Pets’ ears are sensitive, so they need regular maintenance to prevent infections.
–  Dogs or cats don’t want their ears cleaned, so you’re going to have to work with them.
–  If you don’t do it the right way, you can cause serious damage.

Regular routine cleaning of your dog or cat’s ears is recommended as part of his grooming protocol. Regular cleaning will help keep your pet’s ears healthy, clean and free of disease.  There are numerous ear cleansing solutions that can be used to clean your dog or cat’s ears that we have in stock. If in doubt, speak to one of our associates to recommend an appropriate cleanser for your pet.

  1. Start the cleaning process by filling your pet’s ear canal with the cleansing solution.
  2. Massage the outside of the ear canal gently to break up any debris within the canal. If you release your dog or cat’s head at this point, he will likely shake his head and send cleansing solution and debris everywhere.
  3. Use a cotton ball and your finger to swab the inside of your pet’s ear to remove the excess cleansing solution and debris from your dog or cat’s ear. Repeat this process until your pet’s ear is clean.
  4. Proceed to the opposite ear. Never use Q-Tips or similar types of products to clean your dog or cat’s ears. These tools can rupture your pet’s ear drum if used incorrectly.

Clean your pet’s ears as often as necessary to keep them free of debris and wax. Some pets may need to have their ears cleaned as often as once or twice a week.

Examine Your Pet’s Ears for Signs of Infection, Inflammation or Other Ear Disease While Cleaning

While you are cleaning your dog or cat’s ears, take a moment to look closely at them.  Healthy ears should have little to no discharge, should not reddened or inflamed, and should not have an unpleasant odor.  These signs may an indication of infection or other disease and should be checked by a Lange Animal Clinic Veterinarian if present.  Also, check your pet’s ears for lumps and bumps that are not part of the natural contours of the ears, for foreign bodies and other abnormalities.  Spotting the signs of ear disease early, before the disease has become severe, can make management of the disease much simpler and save your pet from needless pain and discomfort as well.

For over 45 years, Lange Animal Clinic has provided veterinary services in Pekin, IL and the surrounding areas for over three family generations. Our expert staff of Veterinarians, Veterinary Technicians, and Veterinary Assistants are trained to ensure the best quality medical care for your beloved pets-whether it be as a routine medical examination to more complicated surgical procedures. We are a small companion animal clinic providing services for dogs, cats, and exotic pets.

Dr. Colleen O’Rourke, owner and senior Doctor of Veterinary Medicine, takes great pride in making certain that every patient’s experience is handled with the utmost care, compassion, and economically in the best interests of our clients. Visit us at www.langeanimal.com.  

About Us 
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Setup an Appointment