Monday, January 30, 2012

855. Travel Stories - Bali, Jan 30, 2012. Perseverance in sales

Tuesday, Jan 31, 2012. Last day in Bali


Jan 30, 2012. Pushpapuri Villa
Drizzling. No more beautiful blue sunrise as yesterday. Can't see Mount Agung due to fog on mountain.

Morning. Visited Mt Batur and Lake Batur. An active volcano 1700 metres above sea level. Perseverance is the key to success as I noted that the little girls of around 7 years old do get some sales if they persevere. The roadside vendors do not bother and their sales will be low since there are so many proactive roadside sellers. Usually ladies including a mother carrying a child.

Many roadside stalls sell various types of fruits as I approach Mt Batur. I bought from an aged woman, some bananas and mangosteens as they were sweet. The rambutans and tangerines were not sweet and I did not buy them. A little girl from the stall further up persevered in asking me to buy her wooden spoons or flowers. Since she persevered, I bought three spoons.

Visited a nursery nearby where coffee plants are labelled for tourism. The best coffee is the one from the stools of a wild cat-like creature but I do not want to drink such coffee.

Religious rituals. Many villagers are preparing for "Galungan", a major Hindu holiday on Wednesday when Balinese Hindus celebrate victory of virtues over vices. Not seen in Singapore.

Offerings are made with Pacar Cina flowers and coconut leaves which soared in prices. The coconut leaves are made into square containers to keep the offerings. Also cakes, incense, fruits to make 18 small offerings, 3 large fruit offerings of gebogan. What cannot be missed during my travel to Mt Batur passing the villages, is the making of the "penjor" which is a decorated bamboo pole to be placed in front of the house.
(Pictures).

A researcher of 405 households in all 9 regency-level regions in Bai reported in The Jakarta Post, Jan 30, 2012, Pg 6 - Balinese Edition that Balinese Hindus spend 10.5% of the household revcenue per year to finance routine religious festivals. Around 108 routine religious festivals per year excluding events like the rites of passage (e.g baby's first tooth drops off, adulthood) and "Ngaben" cremation.

Afternoon

While the others went shopping at the Sogo etc, I asked the driver to bring me to see the 2002 Bali Bombing site. Over 200 party-goers had died in this blast. There is a memorial on this site. Amongst the names, 88 were from Australia. The first bomb site is a car park lot. The second blast is a memorial with the names of the dead from various countries. None from Singapore. It is very sad as these must be young adults if what I saw in this famous road is representative. Over 99% of the tourists are Caucasians and young adults. Bars and pubs are numerous. The sun and surf in Bali attracts many young people.

A little girl of around 7 years suddenly dashed in front of our moving car travelling back to the Villa along Legen beach where the surfers and hotels are packed. My 23-year-old driver braked in time. I saw one adult Balinese put a hand on his heart area as he witnessed this scene. It is really hard to grow into adults when little children are left alone to wander. Another little girl came to our car to beg for money at a traffic junction crossing the busy road.

Three thin ponies in their carriage waited in between small yellow orange buses for the tourists to go home after surfing or a day at this beach.

From this trip and from limited observations of 2 days in Bali, I learnt that perseverance is the key to successful sales and that the female gender is better at sales, being highly motivated to earn as I don't see the boys doing any sales at the tourist spots. Maybe they are somewhere working.

Sunday, January 29, 2012

854. A difference of veterinary opinions but a good outcome counts

A young lady consulted the vet. Her kitten had diarrhoea for a few days. It was adopted from the SPCA and had been fed chicken and rice. The kitten was given to the SPCA the day before, according to the young lady. It was therefore not vaccinated.

COMPLAINT
The main concern was diarrhoea. Watery. What should the vet do?

VET 1's OPINION
"No treatment is necessary," Vet 1 said to her. "It is due to the change of environment and diet. Just give boiled chicken and rice and wait a few days.

MY OPINION
Though the kitten is active and eating, it does not mean that it is not incubating a viral infection picked up at the SPCA. It takes 7-14 days to show the symptoms of diarrhoea and the young lady had the kitten for around 7 days.

In this case, to save on costs, no blood was done. A stool test should be done. If I treat this case, I would have given a drug to stop the diarrhoea, SC fluid and ask the owner not to feed the kitten for 24-48 hours and to give oral electrolytes. "But the kitten is not dehydrated," Vet 1 said.

Oral electrolytes should be given because the kitten has been having diarrhoea for several days. It is not severely dehydrated. Does the university professor teaches that electrolytes should be given when there is severe dehydration? I don't know. Each vet will treat a case differently but in the end a good clinical outcome is what counts.

This kitten has loose stools but no watery stools. No deworming had been done nor had the faecal sample been checked for worms. Sometimes it may be a case of endo parasites since this is a stray kitten. Time will tell.

853. Day 2 of travel. The Balinese and Pushpapuri Villa

Jan 30, 2012 Sanur, Bali, Pushpapuri Villa

Some info about the pictures I took from the Pusphapuri Villa and the Balinese culture

The Balinese are Hindus although Indonesia is predominantly a Muslim country.
Most of them live in a village (desa) which has 3 main temples (pura). These are the origin temple (pura puseh), the village temple (pura desa or pura bale agung) and the death temple (pura dalem). All villagers worship at these temples.

I had a unique chance to talk to the Manager of the Pushpapuri Villa on arrival on the morning of Jan 29, 2012. He told me that the temple on the left was the death temple. I could visit it but must wear a sarong (skirt-like). I could borrow one from the staff. In the death temple, no ashes are put there. All bones are crushed and ashes in a piece of cloth are scattered into the sea. Those Balinese who can't afford the costly cremations will bury first. Later, the government will offer money for a mass cremation and each family is responsible for the preparation.

Each village has a hamlet (banjar) which is the community. In each hamlet, there is the elected leader and another government appointed leader. There are cooperative groups of neighbours to help each other. The worst punishment is to be exiled from the village. So all Balinese have roots and are never isolated.

He said Mount Agung has not erupted since 1963. I wanted to visit it or trek but it is drizzling this morning Jan 30, 2012.

BEACH CLEANING
"The old man comes early to pick up the plastic bottles for recycling," the young Manager who is in sole charge of only Pushpapuri Villa and no others said to me. "Later there are women who come to clean the beach in front of the villas. In the afternoon, I saw two cleaners.

SECURITY GUARDS
At 3 am I woke up to listen to the sea waves. There were two men in their 30s patrolling the garden and checking the beach for intruders. One of them appeared to carry a short knife. I was impressed with the security of the management. It was drizzling but no thunderstorm. The waves roared. No brilliant blue sunrise and flashes of lightning as yesterday (some pictures to show what I mean). I guess I was lucky to have such good pictures. It is a pity that the website of this Villa has not much images of the beautiful surroundings and its activities. Yet February is fully booked.

BUILDING QUALITY
Other villas had collapsed due to poor construction but this villa is solidly built and was built in 2007. It is well maintained as I can see from the cleanliness and the structure. The only disadvantage is that the master bedroom has no power point on the dressing table for me to write and use my computer at 3 am. There are no writing tables in the master bedroom at all.

There is a library but somebody may be sleeping on the couch if there are more than 8 people. Sometimes, the architects may plan for what they think the user should do. So, no writing table in the master bedroom.

The same applies to some vets and groomers. They think what the client would want but is actually mistaken. For example, some groomers clipped the coat but leave the head and a bit of the tail end with hairs in a skin-diseased dog. This is not what the owners want. For vets, they may want blood tests and all tests to be done but this may not be what the owners can afford or want.

As I write, it is drizzling. The old man had come to collect the bottles and gone. Another man in the distance, near the death temple appeared to collect bottles. Plastic bottles can be sold for recycling. But this beach yields a few when the tide comes in. Still, I am inspired by this old man who still comes when it is drizzling. Now he has a competitor but that man came later. The waves are now stronger. Grey blue sky. No beautiful sunrise. The young men have not come back from their party which is an hour's drive away. It is already 7.20 am. I wonder what has happened to them.

852. Exile from a village in Bali

Jan 30, 2012

There is one village in Bali that has traditional houses in the whole village and popular with tourists. It does not permit any villager, no matter how rich he is, to build grand houses. Any villager who is found to be against the interest of the village will be judged by the elders and exiled. Exile is the worst punishment for the offender, said the hotel manager of the Pushpapuri Villa. The rich man can build his grand house elsewhere and will still be permitted to attend to the customs and visit his family.

The local head and the government representative work together in the village. There may be over 100 villages in Bali. Singapore has its RCC, CCC and the mayor.

There was a case of a surgeon who falsified his surgical consent form and I believe, all hospitals will ban him from operating in their theatres. Professionals need to obey the rules of the trade too or face exile. I heard of a story of a lawyer who applied to be reinstated as he was banned for conveyancing misdeed. He did not mention about some misdeed in his application for reinstatement. So, he was not given back the licence.

There are rules and regulations of a society that a young adult wants to rebel against. The consequences may be bad for them and they may need to think of the consequences.

851. Badung Strait, Sanur, Bali

Jan 30, 2012 Monday.
3.02 am, Sanur, Bali, Pushpapuri Villa

I went out to view the sea as I had waken up at 2.30 am as my iPhone rang. I usually wake up around this time.

Two security guards were patrolling. Young men in their 30s were flashing their torchlights towards the sea. There is a retaining wall but it is easy to climb up. However, this village area appears to be peaceful and safe and more beachfront houses nearby are being constructed for sale.

Pitch black night. No stars. Relentless pounding white waves towards the beach remind me of the intense competition in the real world of Singapore. Lightning flashes in the distance. Mount Agung cannot be seen now, being so dark. Yesterday dawn, after a heavy thunderstorm the night before, I could see Mount Agung and took some beautiful pictures. Then during the dog, a fog started appearing on the mountain top and in the afternoon and evening, Mount Agung was invisible. It is an active volcano, the last eruption being in 1963. The whole area was blanketed with volcanic dust for a month, according to the young manager in charge of this place. He was not born yet but his father had told him.

I was invited by Daniel to stay with his friends at this luxurious 4-bedroom real beachfront villa which rents from US$850 per night.

Its website is at:
http://www.pushpapuri.com/ in Bali. Built in 2007 by an Englishman and managed by Bali Hotel Management. Solid construction and well designed in an elevated ground so that the guests can see the waves directly from the dining room which is further away from the pool and manicured carpet grass garden.

This is my first visit to Bali which I knew was a famous tourist place for young people in the past. Two Bali bombings in the past had discouraged me from visiting this world famous place but all countries would have terrorist bombings now and then. Singapore had one in the 1960s.

Service and facilities are very good in this class of luxurious villas based on my reading of other similar properties. Black sand from the volcanic ashes instead of white sand. Can do surfing here as I saw some young men doing it. Good for families. Peak season in Christmas and New Year and around June/July.

There are 13 staff including 2 cooks. A driver with 6-seater SUV is on call. The Villa is well located and gives an excellent view of the Badung Strait, the Hindu temple, a river and Mount Agung and some islands in the distance. Good views for photography and painting. The surrounding areas have plots of farmland. I saw rice and corn fields with crops growing. Durian seller on the roadside. Wood and statues are seen everywhere in this area. Motorcycles and cars seem to be in large numbers on the main road outside.

Yesterday, I did not go to the bars unlike the young people as I know the party will end past 4 am. Young adults seem to love this type of entertainment with loud music and alcoholic drinks. Probably some drugs.

I had my discos in the 1960s and now they are called bars and pubs and are not for the senior citizens. I also did not go out at night to the busy night market to do shopping for T-shirts and bargains.

For young people, my advice is that life is unpredictable and they must stay healthy as the pounding waves of changes in the real world to earn a living are relentless. If the young people cannot stay healthy (being sleepy at work due to late nights), they become ineffective employees and unless they have certain skills in great demand, they will be replaced and sacked. The commercial world demands performance as not every business, including veterinary practice will succeed in the long term if they have sleepy not interested veterinarians. The bad word of mouth will spread and soon the practice is not well patronised.

Saturday, January 28, 2012

850. Minimising complaints and litigation against vets at Toa Payoh Vets

Bali, Indonesia, Jan 29, 2012. 12.23 pm

In Bali, I have time to reflect on the plans to make Toa Payoh Vets one of the top 5 vet practices in Singapore. New clients have come in from other parts of Singapore probably from the internet and some old clients of 10-30 years ago have returned to consult me. "The vets are very young," one mother of two young men said to me when she saw me after an absence of 10 years. Her sons had brought the 11-year-old Jack Russell with a big swelling below the right eye and they are now in University. Of course, I did not know that the mother had brought the Jack Russell to see me 10 years ago till she told me. I was phoning her sons to bring the dog home on Day 3 and she was in the Surgery visiting the dog. The dog was barking like nothing had happened to his loss of masseter muscle tissue eaten up by bacteria. Big hole if you see the images.

The mother identified herself as the owner of the Jack Russell and said to me that for convenience, she had gone to other vets. "You still look the same," she complimented me. I was surprised and happy to see her and the two boys who have grown so tall.

I guessed the other vets closed on the 2nd day of Chinese New Year and I was on duty. So that was how we met. I said to her, "All vets started young. They have to learn from being hands on over the years and gain the experience."

COMPLAINTS AND LITIGATION AGAINST VETS
In 2011, there was no complaint or litigation against the vets of Toa Payoh Vets. This is not a given.

1. One way to minimise complaints is for me to check all cases done by my younger vets. Sometimes I am inside the consultation room with Dr Vanessa Lyn, Dr Jason Teo or Dr Daniel Sing to assess their management of the cases. The new vets may feel uncomfortable as this may give an impression to the client that they are being supervised. They prefer to be alone with the client, thereby generating confidence. But this is not the way to increase the standard of care.

As an experienced older vet and the licensee, it is my duty to mentor the younger vets for the long-term good of Toa Payoh Vets. I have explained the rationale to them. "A complaint to the AVA or litigation takes up a lot of time and will involve me as a licensee', I said to them. "My licence can be revoked for failure to ensure an expected duty of care by my vets."

2. The internet complaints are the worst and I did come across one or two complaints of poor service by Toa Payoh Vets and also good comments. There were some clients who consulted me due to some good comments.

Recently I read in an internet forum about complaints against a brand name vet practice. Just one vocal writer but there were others agreeing with this writer. Another complimented about excellent services from another practice and got blasted for "advertising" for this practice. An ex-employee vet of the brand name practice put up a defence that the vets were good but that was some years ago and got blasted. There should be a law requiring internet complainants to reveal their real names as it is very easy to libel others under the cloak of anonymity. So far, I have not come across such venom as in the above-mentioned internet forum.

So, the associate vets or new vets must tolerate my presence and intervention and be humble. There are predatory vets in the regulatory field and amongst competitors and so, it is not as simple as in the university attending lectures and passing examinations.

In the real world of private practice, there are many aspects involving the bottom-line and younger vets must be able to accept and comply with instructions from me. Recently, one associate wore slippers to work. The excuse was that she forgot to change to shoes. A few days later, she wore slippers again. Her excuse was that the dog had peed on her shoes and therefore she had to wear slippers. I had told her that one Saturday when I dropped in (I don't work on Saturdays) and saw my vet assistant Mr Saw and old man James all wearing slippers. I have dropped hints that slippers are not permitted.

Young vets are role models for the staff as they are in the top of the ladder. If they dress casually, come to work late and go off without warning or do not bother with the management in my absence, the staff will do what they like. First impressions do count a lot to clients. If the vet and the staff cannot be bothered with their office wear, what about their standard of care? It is likely to be casual too.

I have decided that associate vets who don't accept instructions again and again will be, to put it frankly, sacked on the spot. The vet may be most popular but he or she can open their own practice and do what they like. Such behaviours cannot be tolerated as it affects the morale of the lay staff and the reputation of the practice in the long term.

849. Owner's e-mail query about spaying a young Chihuahua

Sun, Jan 29, 2012 at 10:59 AM, <...@gmail.com> wrote:

Hi,

I would like to inquire what is the cost for the above?
She 7 months old and just began her season today, 29/01.
When is a good time to have the procedure?
Will she require hospitalization?

What are the possible side-effects?

Regards,
Name given

E-MAIL REPLY FROM DR SING DATED JAN 29, 2012

Thank you for your email. I am Dr Sing from Toa Payoh Vets. The cost of the spay is around $250 depending on whether there are complications. Best time to spay her is 2 months after the end of her season ie. around April 1, 2012. She does not need hospitalisation normally. Bring the dog in at 10 am and bring her back, usually in the evening. Appointments are best.

Possible side effects of surgery are anaesthetic deaths, infection, bleeding and pain. A blood test is advised to screen the dog's health and if there are no disorders of the kidney and liver, the risks are very low. As for bleeding and pain, there are prevention of further bleeding by careful haemorrhage control and check up. There is medication to relieve pain and prevent infections post-op.

In my experience of spays over the past 30 years of small animal practice, 99% of spayed cases of young healthy dogs do NOT die from anaesthetic risk as anaesthesia is safe nowadays. They do not get bleeding to death, infections or stitch breakdown. The majority of my dog spays are done during 2-3 months after the season.

Pl make an appointment at 6254-3326 for surgery. Best wishes.

848. The dog passes gas for a long time - flatulence

I followed through today by phoning the owner. Some 5 days ago, his wife brought a container of semi-wet greenish stools, a medical swab of blood-stained vomit to me.

"My dog vomited blood", she had also told me she was a nurse and her husband was a doctor. They don't self-treat their own dog. The two samples were useful. I got the stools sent to the lab and the blood tested.

That was some 5 days ago. "Farting for so many months is not a normal thing for a dog or human being," I said. "There is something wrong with the stomach and intestines. So you get gas production and then smelly stinky smell in the room. If not treated, the intestines can get much irritated leading to "telescoping of one segment into another (intussusception) or rectal prolapse,"

This appeared to be a simple case of vomiting of blood. But the main problem could be the gastrointestinal system causing flatulence for very long time.

I gave the dog a 500 ml IV drip, antibiotic and anti-spasmodic and boarded overnight. I recommended the Prescription i/d canned diets for 1 month. No treats and any other food. Just the i/d 1.5 cans per day.

Now 5 days later, the husband answered my phone at 4 pm (Air Asia plane to Bali delayed as it was to leave at 4 pm, so I typed this story).

The husband said first: "The stools are solid for the first time. Where can I buy it? It is not sold in the shops."

Performance counts. This is what I always tell my younger vets. Stop the vomiting and flatulence. I did not give anti-vomiting injection at all. Just treat for chronic enteritis. You get good clinical outcome after the visit, you get referrals. As simple as that.

The stool sample showed blood but no white cells or parasites. The blood test was not significant. I/d for one month and go on good quality food and treats. The cheap treats sold at Singapore's pet shops should not be fed to your dogs as they are cheap for one reason.

Friday, January 27, 2012

847. An 82-year-old father can't sit up at all

"Why can't my father sit up for more than a minute?" Khin Khin asked me. Her father had difficulty in breathing and lower back pain on the left and she went home to Yangon to get him treated by the Specialists. I rushed down to her Peninsular Office to see if I could help as her father was 82 years old and had alertness of mind and body. "He can walk to the hospital and now he can't sit up," Khin Khin was sad.

Basically, I checked the drugs given to him asking her to google for info since a doctor in Peninsula Plaza told her that he did not know about the drugs given to her dad. Tramadol, Lyerica and celophrix (non-steroidal anti-inflam). No wonder he could not sit up as the first two cause drowsiness. Being so old, his body could not eliminate the drug fast like a young person!

With this knowledge, what did Khin Khin do? Nothing. So today, before I left for Bali on Air Asia, I followed through and phoned her to ask the father to stop taking the 3 drugs if he has no more pain (CT scan catheter in Yangon via femoral vein had hit the kidney and cause intense pain, Khin Khin said).

If pain returns, take the Tramadol first and consult the doctors for a review. For 2 weeks, the poor father could just lie down the whole day and night and had no appetite. I asked Khin Khin to speak to him over the phone. He could not answer me promptly as if his throat was choked. Most likely water in the lungs had returned. But there was some medicine to reduce the phlegm and none to remove the lung oedema. The CT scan said there was an atypical RCC which I presume to be Renal Cortical Carcinoma?

If her father can sit in the wheel chair, his daughter would spare no expense to fly him to Singapore for a second opinion. He is a very intelligent educated man, working duing the old British colonial days of Yangon in a bank. It is so sad that he could not sit up for a minute and was vomiting and drowsy and did not enjoy his life. That was why he had not wanted to go to the Hospital but his daughter got him there. Now he can't walk!

Thursday, January 26, 2012

845. An unusual complaint about puppy vaccination at Toa Payoh Vets

Yesterday, Jan 26, 2012, I received a phone call from a home breeder saying that her buyer had brought a 8-week-old gold/white Shih Tzu puppy to me on Jan 25, 2012 for vaccination. I had told the buyer that the puppy was 5 weeks old and therefore too young to vaccinate. "I delivered the puppies myself," the breeder said. "They are 8 weeks old but the buyer said you told her she is 5 weeks old."

I was surprised as I do not age a puppy so accurately as being 5 weeks. No vet can do this because it is not possible to pin-point the exact age just by looking at the puppy's teeth. There is a range and 8 weeks is plausible. So, I told her I would check Jan 25 cases and none of the 4 vets had such a puppy presented on that day.

The home breeder's message to me:

Dr Sing, indly assist to investigate the following:
Name and tel of buyer given

She claimed she had brought the puppy shih tzu, female, gold/white, 2 mths old to your clinic appointment on 25 Jan, for puppy's lst vaccination and microchip. However she had informed me yesterday that your vet told her the puppy is only 5 weeks old.

I suppose in that instance no vaccination or microchip done? N what is the assessment for no vaccine for the puppy? That constitutes to the buyer claiming your vet said so. If this is the case, I will make report and take action accordingly.

The puppies were born on 28 Nov 2011. I was the one who helped my dog gave birth to the puopies. I would like your assistance to investigate and clarification to this matter soonest. Thank you.

----------------------------------------



My reply to the breeder:

On 25 Jan 2012, none of the 4 vets including myself had a case of a female shih tzu puppy, gold and white, 8 weeks or 5 weeks for vaccination. I have checked all cases done on that day. Give me her tel number to verify with her.



-------------------------------------------
I have not contacted the buyer yet. This is quite an emotional issue and it is best not to rush into phoning the buyer since she had not come on Jan 25, 2012. How to handle this case since the buyer had stopped responding to the breeder's phone call?

Based on this case, home breeders who are concerned about their puppies sold may find it important to give a paper of birth when they sell their puppies.

844. Character and Competence of interns and new employees

To: The young interns and employees

Please note that you may want to do everything in a project at once according to your "better" way and your timing with no limits. That is the mark of your internet generation. But that takes lots of times and in the end, you take so much time that "opportunity costs" (if this is the correct word) have passed you by.

What I usually suggest to my younger interns at Toa Payoh Vets is to produce results within 3 days by doing smaller segments of the project.

For example, in doing a stock inventory of drugs, I have this young man, Mr Lim who has taken 2 months and has not been able to produce the complete list of unit pricing etc. This is because he tries to do all categories at one time. I have asked him to do one category at a time e.g. "Prescription Diets", then "Eye Drops" and that should be the way to produce results to show to your boss that you have achieved some results for discussion and editing.

The google generation will always switch on their computer to do the writing. Sometimes, a piece of paper and pencil achieve faster results.

I hope you will be open to receiving instructions to adopt the existing processes and not try and do new things for the time being.

By "opportunity costs", I mean that the opportunity to make money has slipped by if a person takes a long time to produce results like trying to get every information about a big project in place.

In the commercial world, performance counts and time is money. For the youths, time is eternal and I note that many simply waste their time daily in not being productive, efficient and able to accept instructions from old fogies whom they think are outdated and close-minded.

Old fogies have learnt from the hard knocks of life and some processes and systems have been produced through trials and errors that are not explained to the interns instantly, due to lack of time, pressure of work and the need to assess of the intern's motivations and diligence.

It takes a lot of time to explain the rationale of why the processes and systems are being used and unless the intern or youth has shown character and competence, there is so much the old fogies have to perform such that there is little time to just talk about the history of why certain tasks need to be performed in the present situation.

If there are improvements and innovations, the youths can propose later. But first, the new intern or employee must learn to adopt existing processes first and become productive. Performance and prompt results count in the commercial world and this is not taught in the junior colleges and universities, in my observations of the interns and new employees.

Wednesday, January 25, 2012

843. Dressing casually as a vet or veterinary staff

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

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

Dressing casually is out in 2012 and those who insists on dressing casually will need to look for another job.

842. Chinese New Year 3rd day - follow-up 3 cases

National Library, Jan 25, 2012 7.42 pm
Dr Daniel Sing's first day at work

3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.

That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."

Case 1.
Jack Russell. Male, 12 years old.

After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.

The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.

As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.

For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.

But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.

Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.

There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."

I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.

What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.

He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.

Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.

Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.

Tuesday, January 24, 2012

841. Email advice about a fast-growing hamster leg tumour

On Tue, Jan 24, 2012 at 4:44 PM, ...@yahoo.com> wrote:

Dear Doctor,
I need your advise regarding my daughter's winter white hamster.
It is abt 2years 2mths old and had a tumour on the right leg. We
noticed this tumour last year and its about a pea size.
Had brought her to a vet in Jan 2011 and advise against surgery due to old age.Within 2 weeks in Dec 2010 the tumor had grown very fast to a walnut size. She is eating and drink fine only her movement is rather slow and she keep bitting the tumour.
Is it too late to have the tumour remove now? If surgery is possible how much does it cost?We really love her sooo much, how do we know if she is in pain?
Would really appreciate your advise.
Thank You.
Regards
Owner's name







Thank you for your email. I am Dr Sing from Toa Payoh Vets

There is only one option to prevent death by infections and great pain from the growing tumour and that is surgical excision. Pain is shown by self-biting and being not active or eating in hamsters.

There is always an anaesthetic risk of death on the operating table for the older pet. You have to decide yourself. Cost is approximately $150-$200 for surgery and anaesthesia.

Coincidentally, I just saw a case of a dwarf hamster with a big growth on the back leg near the ankle. The lady had been advised by my associate vet Dr Vanessa to do leg amputation. But she did not want to as she did not want her hamster to be 3-legged. The tumour grew fast into a fatty ball of around 1 cm in diameter. Just as she arrived in a taxi to consult me, the hamster passed away. She could have saved this 1-year-old by permitting surgery 2 weeks earlier.

Therefore, decisions are made by the owner. The vet should give the proper advice and in your case, the advice from your vet was good. Pl make appointment at 6254 3326 if you decide on surgery. Best wishes.

840. The case of the Chattering Chihuahua - video production

DRAFT


HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA
Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent

INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
25 January, 2012

What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv


AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Singapore, Jan 24, 2012

MIDDLE

CAUSES OF TEETH CHATTERING

1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"

2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.

3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.

4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.

CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."

Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.

"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.

I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."

I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.


"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."




The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"

The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.

Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.


ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.

3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs


How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.

She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.

Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.

Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.

For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.

I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.

SECOND VISIT
Friday, January 20, 2012

Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.


ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures

Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.

Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.

In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.

An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5

Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.

Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.

CREDITS

COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:

Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS

Singapore, Jan 24, 2012

For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468


Webpage with pictures at:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm

Monday, January 23, 2012

839. Chinese New Year 2nd day - salivation - stinks the whole apartment

Tuesday Jan 24, 2012
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed

I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration.

INTERESTING CASES
1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.

"Whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"

"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."

"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever.

2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye.What is it?"

No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked. "Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth. Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.

3. Persian cat of son who is overseas. F, 13 years, not spayed. EMACIATED. Drooling. Emaciated. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.

4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."

5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.

"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."

"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.

So, this CNY Eve 2nd day showed a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.

838. The case of the teeth chattering Chihuahua - follow up

The teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
24 January, 2012
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
DRAFT


HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA


Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent

INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
24 January, 2012

What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv


AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Singapore, Jan 24, 2012

MIDDLE

CAUSES OF TEETH CHATTERING

1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"

2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.

3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.

4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.

CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."

Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.

"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.

I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."

I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.


"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."

The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"

The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.

Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.


ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.

3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs


How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.

She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.

Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.

Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.

For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.

I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.

SECOND VISIT
Friday, January 20, 2012

Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.


ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures

Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.

Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.

In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.

An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5

Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.

Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.

CREDITS

COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:

Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS

Singapore, Jan 24, 2012

For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468




DRAFT FOR VIDEO PRODUCTION IS AT:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm

837. Singapore vet dog dental scaling - google search

The following articles are from Toa Payoh Vets and associates and are found based on google search of:
"Singapore vet dog dental scaling" on Chinese New Year 2012, Jan 23, 2012 9.14 pm.

RANKING AND WEBSITES ARE:
No. 2. http://www.toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm
Toa Payoh Vets Clinical Research
Dental & Oral Care in Singapore's Dogs, Cats, Rabbits & Other Animals

No. 3. http://www.toapayohvets.com/surgery/20100618cheek_tumour_old_dog_electrosurgery_ToaPayohVets.htm
A LARGE CHEEK TUMOUR & 15 ROTTEN TEETH IN AN OLD DOG
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
20 June, 2010


No. 4.
http://www.asiahomes.com/book2/20100664dental_extraction_16-year-old-Pomeranian_dogs_singapore_ToaPayohVets.htm
DENTAL WORK WITHOUT ANAESTHESIA IN A VERY OLD POMERANIAN WITH HEART DISEASES
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Written: 04 September, 2010


No. 5.
http://www.bekindtopets.com/dogs/20080828Dog_Dental_Problems_Singapore_ToaPayohVets.htm
DENTAL HEALTH CARE OF
THE DOG IN SINGAPORE
Case written: May 5, 2009
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Update: 04 September, 2010


No. 8 (Not Toa Payoh Vets, but Singapore Veterinary Association webpage) http://ctrlaccess.info/websysdocs/218.186.8.243201011335950_SVA_Position_Paper_on_Veterinary_Dentistry.pdf
SVA Position Statement on Veterinary Dentistry by
Non-Veterinarians and Veterinary Dentistry without Anaesthesia

No. 12 PAGE 2
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm
Veterinary Productivity:
A Schnauzer has two loose front teeth
and an ear lump
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
10 January, 2012

No. 13 PAGE 2
http://www.sinpets.com/F5/20110914Bad-breath-old-dog-toapayohvets-singapore_ToaPayohVets.htm
The old dog still has bad breath after dental scaling and extraction of 6 teeth
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Sep 14, 2011


No. 14 PAGE 2
http://www.toapayohvets.com/about_toapayohvets_Singapore_Apr807.htm
ABOUT US Jan 17, 2012


No. 15
http://www.toapayohvets.com/fees.htm
FEES 29 June, 2010

No. 17
http://veterinarymedicinesingapore.blogspot.com/
Sunday, April 18, 2010
485. Urine peeing anywhere. Rebellious age at 7 months

No. 18
http://www.bekindtopets.com/dogs/20080919Pyometra_heart_disease_old_dog_ToaPayohVets.htm
Open pyometra in an old Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 06 June, 2010


No. 20 PAGE 3
http://www.kongyuensing.com/animals/20110815domitor-ketamine-sedation-chinese-crested-schnauzer_ToaPayohVets.htm
Sedation worries of a daughter
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 08 September, 2011

PAGE 3
http://www.asiahomes.com/angelfire/20100657testicular_tumours_oral_old_dogs_male_singapore_ToaPayohVets.htm
Three old dogs with tumours
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 21 August, 2010 )


PAGE 3
http://www.sinpets.com/F5/20110629gum-tumour-old-dogs-singapore-ToaPayohVets.htm
Gum Tumours In Old Dogs
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case done: May 25, 2009
Date: 28 June, 2011

PAGE 3
http://2010vets.blogspot.com/
Monday, January 23, 2012
837. Singapore vet dog dental scaling - google search

PAGE 3
http://www.bekindtopets.com/animals/tpvets_Jun2910.htm


PAGE 4
http://www.sinpets.com/F6/20110819pyometra-old-female-dog-survival-anaesthesia-spay-neuter_ToaPayohVets.htm

Survival after pyometra surgery in two old dogs
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 18 August, 2011

PAGE 5
http://www.asiahomes.com/singaporeaur/0703hunting_4_5k.htm
2000 CASE: THE 6-MONTH-OLD DOG'S MOUTH IS FULL OF SALIVA
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 3 July, 2000
Updated: 21 July, 2010


PAGE 5
http://www.kongyuensing.com/animals/20090634Internet_Beagle_Sore_Hocks_Elbows_Singapore_ToaPayohVets.htm
The Internet Beagle Bites Any
Toothbrush into Two Pieces
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: 15 June 2006
Updated: 06 July, 2009


PAGE 5
http://www.bekindtopets.com/dogs/20101025veterinary_cost_dental_oronasal-fistual-dog-toapayohvets-singapore.htm

ORONASAL FISTULA IN A DOG - ESTIMATED VETERINARY COST IN 2010
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: November 15, 2007
Update: 25 October, 2010


PAGE 6
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
Recurrent Blood in the Urine in a Corgi - Part 1
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
11 December, 2011

Sunday, January 22, 2012

835. SPCA Singapore reported parvoviral infection in its kennels

Around 3 days ago, I read a Straits Times Report that SPCA Singapore will not be accepting any stray dogs as it had to clean and disinfect its kennels affecting parvoviral infections.

For some months, I have been telling my associate vets to check for parvoviral infections in older dogs that come in with blood in the watery stools. If the owner is against the test, record this in the medical case sheet. Adult dogs can also die from parvoviral infection as many are NOT vaccinated yearly. Most Singapore owners don't bother with annual vaccinations judging from my research in vaccination reminders.

Two years ago, I had an adult dog that had stayed in a boarding kennel. The owner wanted her spayed after boarding. I spayed her. She developed bloody diarrhoea 3 days after spay and was diagnosed with parvoviral infections. She died. From one of my do breeder sources, the owner had complained about me to him but the breeder tod the owner that it was not my fault. The dog was just not vaccinated and protected.

Subsequently, I had another similar request. The owner was fed up with me for asking her to wait 7-14 days before spay and so did not return to do the spay. It takes 7-14 days to know whether the dog has parvoviral infections from the boarding kennels. Many kennel operators do not bother with updated vaccinations too.

834. Perseverance v. passion to become a vet

Today, Chinese New Year, I phoned Kim to thank her for her SMS "Happy New Year Dr Sing! May your business prosper."

She had quit doing Sunday vet internship in 2012 saying that she had no money to study vet medicine anyway. I said: "Kim, Nobody can predict the future. There are ups and downs in life. Who knows? You may get an inheritance or good fortune. Or a vet scholarship with your track record of internship over the years. But do you really have the passion for vet medicine? If your father is rich, there is no need to have passion as the father pays all fees and open the clinic for you as well."

Kim said: "Maybe in 4 to 5 years' time, I will do the vet internship."

"Is it your husband who is against you doing Sunday internship? It is hard for a married woman to waste a Sunday afternoon instead of spending time with the husband!"

"No," she said. Well, I wish her good luck. This passion for veterinary medicine is difficult to define and harder to find in a Singaproean as it is hard work to excell and succeed to be a good vet.

833. A dog with recurrent bladder stones - The Standard Operating Procedures (SOP)

First Written: Chinese New Year Jan 23, 2012 1.06 pm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

RECURRENT UROLITHIASIS - CALCIUM PHOSPHATE URINARY STONES

When a dog has urinary stones again, the following will be the Standard Operating Procedures (SOP) at Toa Payoh Vets to provide the highest standard of care. This SOP defends the vet during allegations of negligence litigation or complaint if the dog has another episode of recurrent urolithiasis.

1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your analysis of why the dog had recurrent urolithiasisa. In this case study of the Shih Tzu with 13 calcium phosphate urinary stones, the dog came to Toa Payoh Vets for recurrent urolithiasis and I took charge of this case which was operated by Vet 1.

Vet 1 had not done stone analysis, did not advise (in writing) on post-operation prevention and follow-through tests which would permit non-surgical treatment (e.g. voiding urohydropropulsion and urinary catheterisation when small stones are detected via X-rays 3-monthly). Could it also be some metabolic disorders of the parathyroid glands as calcium phosphate is quite rare in dogs?





2. GENERAL EXAMINATION. Demeanour. Weight, rectal temperature, pulse and respiratory rate. Abdominal pain, gas in the GIT and other observations.

3. DETAILED EXAMINATION. Urine test, blood test, radiography (calcium phosphate isradio-dense, check kidneys for calcium phosphate), ultrasonography (possible in calcium phosphate) and calculi analysis. There may be a case for veterinary negligence if the tests has not been advised or done. The advices must be recorded in the case sheets clearly.

4. TREATMENT. According to symptoms. IV, SC or oral fluid therapy depending on dehydration situation. Antibiotics to treat UTI. Urinary catheterisation to relieve urethral obstruction.

The vet in charge of the case is responsible for details of time, amount and other information will be recorded in the hospitalisation sheet.

5. COMMUNICATIONS WITH THE OWNER IN WRITING. A veterinary report explaining the significance of the tests and case must be given to the owner on discharge/death of the puppy. It is best to keep the owner informed daily of the health of the dog. Such phone calls must be recorded in the medical case files.

6. RECORD AMA (Against Medical Advice) the owner's rejection of advices of the test in your medical record. Failure to do so implies that the vet has not advised at all in cases of litigation/complaint. As Singapore is becoming a litigious society, I advise that the highest standard of care to be given at all times. An example of a case done by me is down shown in the images.

TOA PAYOH VETS CASE STUDY BY DR SING

Chinese New Year Eve 4.56pm
Jan 22, 2012

PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.

It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.

The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.

DIAGNOSIS: Calcium phosphate urolithiasis

CASE MANAGEMENT AT TOA PAYOH VETS

14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.

8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.

13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.

Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.

X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.

TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.

2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.

4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.

HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).

REFERENCE: The 5-min veterinary consult - Tiley Smith

1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.

2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder

OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.

PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.

INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D

FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.

TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet

A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm

B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.

Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)

BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)

Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.

TOA PAYOH VETS webpage will be written later:

833. Chinese New Year's Eve Reunion Dinner stories

Jan 22, 2012 Sunday was Chinese New Year's Eve Reunion Dinner. Time to catch up. My advice to the young adults would be to ask questions to sustain a conversation rather than keep looking at their smartphones and texting. Ask what your cousins or uncles and aunties have been doing and you can learn much.

There were two Chinese idioms which I can't translate into English.

1. Teochew expression of 6 words. The Teochew mother expresses herself in Teochew and has dropped hints to the late 20s son who does not contribute one cent to the household by giving a bit of his salary to the mother. The daughter gives money monthly but the son forgets about it. In Chinese custom, children should give some part of their pay to the mother as they still live with the parents. So she said the six words. Nobody could translate into English. "It means scrounger," Julia said. Well, that is a public hint to the son to part with a bit of his salary to the mum. It will be like talking to the wall as he said that he is on hard times, having to save up for his wedding and his new HDB apartment renovation. In any case, the parents don't need his money. It is just a custom of some Chinese mothers to expect children to give some token to them when they start work and still live in the parents' house. As for the father, he said to me when I asked his opinion: "If my children don't ask money from me, I am OK!"

2. Teochew expression regarding a "golden chair". This refers to a young man who should marry an older woman. After all, an older woman is secure financially (hence the golden chair) while a younger woman wants money and security from the man. So, the niece with the fairest famed complexion of the Teochew ladies advised Jason not to marry wives younger than himself. "2 years older," she gave an example of a man dating a woman 8 years older but failing in the relationship. "Why not build your own golden chair?" her brother suggested.

Conversations can be sustained if you asked about the other party's welfare. Dogs are one favourite part in conversation. "How do you know it is dangling?" I asked the brother of the fair lady who had asked Daniel some advice about the cost of removal of a lump which keeps growing bigger in a 13-year-old Cross bred of her boyfriend. This boyfriend loves animals and she related an incredible story. One day, his favourite Jack Russell escaped and was hit by a car. The dog waited for him to return home from work. Once he reached home, the dog passed away. "He was holding on to life till he had seen his owner," she said.

To return to the dangling lump, the brother of the fair lady said he had not seen the dog. Daniel presumed it to be a growth from the groin area. I asked in more detail from the fair lady: "Where is the lump? Is it in the breast area?" She said: "No, it is dangling from between the legs and keeps growing bigger fast every day."

Since this is a male old dog, I said: "It is likely to be a testicular cancer. I can arrange a transport man to bring it down for surgery. The earlier it is done, the better for the dog." I doubt that there will be any follow through action by this young lady as it is not her dog.

Sadly, many dog owners feed their dogs and do not bother when there are growths or bad breath. However, recently, it seems that there are more cases of dental work being requested on dogs.

As can be seen in a last-minute request by a mother and her two pre-teen daughters bringing a 13-year-old small breed dog today at 4pm as the dog was not eating. As the dog had eaten at 6 am, I proposed dental work after a general examination. "This dog will not bite," I said to Dr Vanessa as she tried to muzzle him and examine his mouth via the muzzle. This small breed does look ferocious and open-eyed, being a mini-pinscher cross and so I did not blame her for being careful. I lifted the side of the dog's mouth to expose the back teeth full of tartar. "Give an IV drip plus antibiotic IV before dental work," I advised. There was a need for blood test and an anaesthetic consent form. However, the blood test would add up the cost and so this was not done. A general examination would do. Domitor 0.1 ml and isoflurane gas. 3 teeth extracted by Dr Vanessa.

The dog went home to a happy mother with two daughters on Chinese New Year's eve. Many of such cases need dental work but can get frightened by warnings about deaths from anaesthesia from the vet. Obviously the vet has to cover himself by getting the consent form signed as this is an old dog and could die. Hospital doctors do the same too. In this case, no consent form was asked to be signed. Careful anaesthesia resulted in a happy outcome for this dog. Old dogs seldom die from dental work if there is careful anaesthesia and no chatting between the vet and the assistant. Focus on the patient and in my 30 years of experience, I can be confident that the old dog will not die on the operating table as the anaesthesia duration is very short if the vet prepares and knows what to do efficiently and productively.

832. Tonsillitis in an old dog

E-MAIL TO DR SING DATED JAN 21, 2012

Dear Dr. Sing,

Patient Ref. No. ... (... (Silkie, 8.5 yrs old))

We were at your clinic last Sunday (15 Jan).

I'd like to have a better understanding regarding B's lump at his throat:

On 11 Dec 2011 after his dental scaling (during which you checked on his throat), we were told that the tip of his epiglottis was red. Antibiotics prescribed, to be reviewed.
15 Jan 2012 review: we were told there is a lump at his left tonsil (right tonsil could not be seen as Bowie was struggling too much). I forgot to ask, what about the redness at tip of epiglottis?

Your advice was to put him on antibiotics first and to review again in 1-2 months' time. As B is such a nervous dog, he'll be sedated for a proper diagnosis for his next review. You said that if it is indeed a lump, the tonsil/s will be removed. Is tonsil/s removal the only treatment option, even though the lump may be benign? Without tonsil/s, wouldn't he be more susceptible to virus infection in the future? What if the lump is a cyst or an abscess?

Your reply via e-mail will be greatly appreciated, Dr. Sing. Thank you!

PHONE REPLY FROM DR SING
It is best to speak by phone as email replies can be misinterpreted. Questions can be answered immediately and clarification can be made immediately too.

In this case, tonsil removal is advised in case the tonsil is a growing malignant tonsillar carcinoma as the dog is old. The red lump of the is around 0.5 cm x 0.5 cm and visible. An aspiration biopsy can also be done in this case to check whether the tonsil is an abscess, cyst or cancerous. Sedation will be needed and anaesthetic risks are always there.

It is worrisome for the owner. The vet's duty is to inform the owner of the presence of the tonsillar growth. Excision or biopsy depends on the economics and malignancy or otherwise of the growth.

I have an image of an 8-year-old Chihuahua with tonsillitis and will post it later. 13 teeth were extracted.

831. The Shih Tzu has reccurent urolithiasis. 13 calcium phosphate stones

Chinese New Year Eve 4.56pm
Jan 22, 2012

PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.

It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.

The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.

DIAGNOSIS: Calcium phosphate urolithiasis

CASE MANAGEMENT AT TOA PAYOH VETS

14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.

8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.

13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.

Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.

X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.

TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.

2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.

4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.

HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).

REFERENCE: The 5-min veterinary consult - Tiley Smith

1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.

2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder

OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.

PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.

INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D

FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.

TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet

A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm

B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.

Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)

BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)

Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.

Saturday, January 21, 2012

830. Sunday's Jan 22, 2012 interesting case (Chinese New Year's Eve)

Sunday, bright. sunny. Most vet practices close in the afternoon as there would be no clients. Toa Payoh Vets open till 5 pm. In the afternoon, no clients as at 3 pm when I am writing this report on a new client whose poodle, male, neutered, vomited blood yesterday and vomtied without blood today.

General exam was normal.
ABDOMINAL PALPATION
The dog arched his back when his ant aabdomen was palpated. "Hunched" said the lady owner. Mild pain in the liver, kidney, gastric area. The lady owner said: "Hunch back."

HISTORY
Since young, the dog had been vomiting every 1-2 months. Usually threw up without food. Vet 1 said nothing was wrong. I proposed X-ray or ultrasound after the Chinese New Year. For the time being, put on antibioitcs for 10 days.

TREATMENT
1. Dextrose saine 500 ml IV drip + anti-spasmogesic + antibiotic. Goes home later.

ADVICES
My hypothesis. Most likely the dog had been eating outside objects on the grass when walked by the domestic worker during the evening. Domestic workers meet their friends when they walk the dog and so it was possible that the dog gets fed some food or had gone onto the grass to eat anything . It is hard to say.

Blood test, X-ray and ultrasound can be done a few days later if vomiting continues. Cost is nto a problem with this owner. I said: "It is also possible that this dog has a small gastric foreign body that can't be vomited out nor passed through the intestines and so the dog vomits 1-2 monthly due to gastric inflammation and irritation by the movement of this foreign body and bacterial infection of the stomach (gastric mucosa)."

RIGHT EYE TEARING AND ITCHY
Swollen eyelids of the right eye due to rubbing. "Fluorescein eye stain is useful to check whether the eye cornea has ulcers or not," I put the fluroescein strip under the upper eyelid of both eyes. "Can you see the green stain on the cornea?" I shone the white light tangentially at the the right eye. "Yes," the lady owner said; "Green patches in the central cornea and at 12 o'clock and 2 o'clock. What is an ulcer?" she asked me as she could not understand. "It is a wound like the skin that has been cut, you will get a skin ulcer. A broken surface." She understood and translated it into Mandarin. I don't know how to translate ulcers in Mandarin. I must learn Mandarin as there are more Chinese Nationals nowadays and many Singaporeans speak Mandarin!

3 EMERGENCY CASES
1. One year old, female, Corgi, itchy back, wet areas. Their Vet is off, but the dog is still v. itchy. "Very good appetite after Shincort inj by Vet 1," the owner said. Wife and young son came. I advised clipping all bald just as Dr V wanted to clip just the back half. "There may be other areas and it is best to get hairs grow together." Owner said he saw "flea dirt," although Vet 1 saw a tick. A flea bite allergy not controlled by Vet 1's Shin cort injection?

2. Westie now not eating again. Wanted to see Dr Vanessa.

3. A dog with loose teeth or bad teeth. Made an appointment. Saw Dr Jason Teo yesterday.