Wednesday, February 29, 2012

892. The FLUTD cat died - why?

March 1, 2012
892. The FLUTD cat died - why?
March 1, 2012

Today I had a meeting with the young couple from 9.40 am to 11.30 am as the young couple wanted answers as to why their 8-year old neutered male cat had died during treatment at Vet 2 which was associated with a veterinary surgery of Vet 1.

The cat had an inflamed penis and difficulty in peeing and in the opinion of the owners, should not have died based on this medical condition. It was a reasonable deduction and the husband had emailed me informing me of the cat's death as I had treated him in April and November 2011for Feline Lower Urinary Tract Disease (FLUTD). This case is reported in
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

Basically, XXX had a relapse of FLUTD and the couple had sent him to Vet 1 for treatment, owing to proximity of location.

Answers were wanted as Vet 2 had performed an autopsy and said that the cause of death was unknown.

"Could it be anaphylaxis or allergy to cefloxalin given together with the calcium in the IV drip?" the wife wanted to know as she had researched the internet and there was information on the adverse drug reactions using the combination, in human beings.
"It is very difficult to ascertain that the drugs had caused his death," I said as the owner had described that the cat was discharged home in a stoned state, being unable to stand or walk normally and then had pale gums and breathing difficulty in the evening. The cat was rushed to Vet 2 around midnight and he passed away despite X-rays and treatment. "Adverse drug reactions in people may not apply to the cat and vice versa."

So, what was the cause of death? The couple had spoken to the proprietor of the surgery but was no wiser. They showed me the medical records and 2 X-rays taken before death. One lateral X-ray showed black air inside the lung. The V/D X-ray showed that the lungs and chest area were opaque. It was hard to explain why.
The blood test showed a low platelet count.

Low platelet count. I discussed the case later with Dr Daniel who said that the cat have died of internal bleeding leading to or as a result of low platelet count. It was plausible. For example, traumatic injury to the lung (lung bleeding was reported in the autopsy) due to the "feisty" cat being nursed and changing of the litter, catheter and urination bag etc.

But the low platelet count by itself would not have killed this cat as I have had seen such cases of lower platelet count in toxaemia and tick fever and the dogs survived.

"In any case, an autopsy done by the same practice would not be credible as there was a conflict of interest," I said. "An independent veterinary body ought to have done the autopsy." The owner was not aware of the need for this procedure.

Vitamin C dosage The cat was given high doses of Vitamin C daily by IV during the 5-day hospitalisation. "This practice believes in high doses of Vitamin C in treatment," I said. "Whether the dosage killed this cat, it is hard to determine."

Sedation - valium and ketamine IV during hospitalisation. Would the daily IV injection to sedate the cat for ease of handling and changing of the litter cause death by cumulative dosage in an old cat that was already stressed out and frightened? I believe it would but Dr Daniel disagreed. This would account for the owner's observation that the cat could not lift up his head, that his eyes could not track finger movement and that after the 2nd day of hospitalisation, the cat looked "stoned" and could not even give a soft meow as usual.

"Why would the vet discharge a cat when he was not well?" the wife asked me.
"It could be that the cat would be better nursed at home," I said. "Since the cat was feisty (aggressive), it would be very difficult for the nurses to nurse and clean him. In the first place, this cat could have been better nursed at home. Vet 1 had proposed home nursing with the catheter inside the bladder. Struvites were reported and this would be much better to manage at home for a ferocious cat.

I can't figure out why the owner did not consult me after Vet 1's treatment was unsatisfactory in their opinion. This was what they did in April 2011 and then in November 2011. Proximity to Vet 1 was the reason given for this time-pressed couples.

"I would not go to the same car mechanic near my house if I know that he had not repaired my car to my satisfaction," I said frankly to the couple as they were the type who wanted answers to a death of the cat for knowledge and prevention and not for litigation. We could converse frankly rather than beat around the bush. "For car in bad state, it would be for safety reasons. For a pet, it could be a matter of life and death."

It was difficult to find the correct answers to this cause of death. I believe it was the cumulative effects of sedation. I could imagine that another dose of sedation was given (as stated in the records) every day as the cat showed ferocity when the litter was changed daily or frequently. There was the urinary bag attached to the catheter to be changed. Medical records stated the cat was "feisty" on two days and so sedation had to be given.

"What should we do if we have a cat?" the wife asked.

"Get a female cat," I said. "FLUTD is less likely in a female cat. For male cats or dogs with struvite urinary stones, a monthly urine test and 3-monthly X-rays for pets with struvite urinary stones is advised. But no cat owner will comply."

"Did you follow my instructions that the cat should not be given treats?" I asked. "I had recorded 'no treat' in the blood test result too." See:
http://www.kongyuensing.com/pic/20110555male-neutered-cat-house-shifting-FLUTD-urine-test-toapayohvets-singapore.jpg

The cat was given canned C/D diet after 2 months of S/D diet since April 2011 when the couple had consulted me.

"Well, 2 weeks before consulting Vet 1 in February (2012), I did give him dental treats."

"This should not be given," I said. "Struvites could be formed as a result and this lead to urination difficulty and an inflamed penis."

"The penis was inflamed because the tip of the penis had been bitten off," the wife said. "You were the one who told us in April 2011. Do you remember? You extracted the broken canine tooth as that could be the cause of irritation and injury. So his penis was diagnosed 'inflamed' by Vet 1 but it was due to the fact that he had no tip."

Owners who love their pets very well remember all treatments like elephants as their pets are family. "I remember Tobi for his hissing at me," I said. "He did not like vets. Did you give other treats as well?"

"Some love letters, as it was Chinese New Year," the wife recalled.

"Some, but not all cats and dogs with a history of struvites in their urine cannot eat other food as the problem will come back to cause peeing difficulty," I said. Her cat was one of this category. If the owner gives a strictly controlled diet, usually there is no problem.

It was a sad day and I hope that the couple had received some answers as everyone learns from experience. There is no other way. Reading widely on your pet's health problems may give insights and knowledge of what had happened to other people's pet and thereby instituting preventive measures to ensure that your pet's health is optimal. For example, dental scaling to keep the teeth and mouth free from infection, enabling the cat to eat well and without pain. Cats need to groom themselves and therefore clean teeth without periodontal diseases are more important to them as compared to the dog.

Proximity to the vet surgery is convenient but sometimes, it is best to find a vet that can handle your pet's more complex health problems. A practice that has different doctors attending to your pet may not be in the interest of your pet. However the same vet treating your pet may not be suitable and a second opinion may be needed if the outcome of treatment is not to your satisfaction.

something wrong with uploading by blogger.com in previous post - megaesophagus

I upload again

890. esophageal diverticula seen on barium meal x-ray & megaesophgus

"Barium meal X-ray may be risky," the newly graduate vet told me. "The dog may inhale it and cause aspiration pneumonia. The megaesophagus can be seen in the plain x-ray."

"Megaesophagus may be obvious to vets," I said. "But my owner is not able o visualise it in the plain X-ray. Give the dog the barium meal." The dog had been coughing frequently in the past week and for the past 3 months he was regurgitating white mucus daily and coughing too.




Proof is in the barium meal X-ray. Esophageal diverticula is an incidental finding. The white mucus could be accumulated there. Gland secretion of the esophagus? Irritation and inflammation of this cranial part of the esophagus cause coughing. Real coughing, not just attempts at retching. The sounds were similar to "kennel cough" - see my video on kennel cough in a dog.

Sunday's interesting cases - ringworm or not ringworm in a Sheltie

Sunday 26, 2012. Bright sunshine. Went to NATAS fair at Changi expo at 9.30 am to see what was available in the travel industry and new ideas on marketing. My assistant phoned to say I had an appointment at 11 am.

"Sheltie very itchy below the penis," said the gentleman. I thought it was penile trauma or inflammation of the prepuce. On seeing the dog with Dr Daniel, I saw the red circular spots and the crusted centre. "Ringworm," I said. "Had the dog been to the groomer recently?"

"2 weeks ago," the owner said.
I showed the ringworm hairs to Dr Daniel. He was not convinced saying that those could be damaged hairs, due to the dog licking the ventral area, causing inflammation and rashes.

He didn't buy into my microscopic exam of ringworm hair. Each vet has his own ideas but there are certain presentation that cannot be ignored.

"Circular rings, reddish with crusty scales in the centre," i said. These are typical presentation.

"Needs confirmation with fungal culture," he said. This is what the professors teach.
"Yes," I said. "But the owner cannot wait 2 weeks for the culture to prove it is ringworm. He wants prompt action and successful outcome."

In fact the couple had a bare patch on the dog's left shoulder area diagnosed "ringworm" by Vet 1 from Toa Payoh Vets. Since it did not resolve and the dog was still scratching, he went to Vet 2 who diagnosed demodectic mange.

"How many mites he showed you?" I asked the gentleman banker.
"One mite," he described the cigar shape.
"Well, it is possible that it is demodectic mange on that hot spot," I said. "In any case, demodectic mites are normally present in dogs, as are bacteria in our mouth. Ringworm takes more than 1 week to cure."

I did not want to defend Vet 1's "misdiagnosis" as the gentleman would not believe me. Vet 2 had cured his dog and that was results. "Yellow pimples," he said.

Tuesday, February 28, 2012

888. Megaesophagus in the older dog - treatment

Regurgitation is the presenting sign. Mistaken for "vomiting" which is a projectile action.

D/D for regurgitation
1. Esophageal obstruction. Vascular ring anomaly, stricture, foreign body, neoplasia (spirocerca lupi).
2. Motility disorders. Megaoesophagus - congential
- acquired --- primary (idiopathic)
--- secondary
Dysautonomia
3. Inflammatory. Esophagitis (secondary to protracted vomiting), caustic irriation. Hiatal hernia. Gastro-esophageal reflux.
4. Others. Diverticula, Broncho-esophageal fistula.
5. Idiopathic.


DIAGNOSIS
1. History - Other clinical signs, young or older breed, large breed
2. Physical exam - incl full neurological exam, thorough thoracic auscultation (aspsiration pneumonia, caudal lobes on X-ray)>

THORACIC X-RAY. Needs 3 views. 2 lateral + V/D. Look for aspiration pneumonia, cranial mediastinal mass, air in esophagus (one lateral without sedation as drugs can cause air in esophagus).

Contrast studies. Liquid barium using plain X-rays, evidence of strictures, vascular ring anomaly (puppies).

Food and barium dynamic studies (fluoroscopy) to assess motility of esophagus.

Other investigations to identify underlying problems.

TREATMENT depends on causes

Distemper, autonomic drugs, toxicity (lead, thallium, anti-cholilnesterase), esophigitis, systemic lupus erythematosus, hypoadrenocorticisum, thyoma, myasthenia gravis (focal, most common cause, auto-antibodies produced againt Ach receptors), polymyositis.

1. Vertical feeding - Feed from a height. Bailey's chair. 1 hour upright feeding.
2. Bethanechol or cisapride for myasthenia gravis

CASE STUDY
Use of barium meal showed esophagus enlarged in two areas, convincing the owner of the diagnosis. Plain X-ray not so clear in showing megaesophagus.
2. Dietary - canned food, meat balls. No dry food.
3. If myasthenia gravis, require anit-cholinesterase drugs and immune suppression.
bethanechol or cisapride

Monday, February 27, 2012

Follow up on guinea pig that suddenly passed blood in urine

Guinea pig, male, young, had passed blood in the urine some weeks ago. Vet 1 diagnosed UTI. Recovered after some days.

Again blood in urine. Sent to Toa Payoh Vets. Consulted me with Dr Daniel. Another recurrence of UTI? "The blood looks clean and bright red," I said. "It is unlikely to be UTI. Collect some urine for urine analysis."

How to collect urine? This is not a male dog or cat. A small male guinea pig that is much loved by his mistress who had consented to more detailed investigations rather than the usual injection and go home to wait and see. "Practise evidence-based medicine," I always advise my vets. "Feeling that it is not UTI or it is UTI is not sufficient. Feeling is not not enough". So, I had to practise what I preach and collect the urine from this little one.

Well, one must improvise as the urine must be clean and not be contaminated from faecal stools. Pictures showed.






After one day of treatment and rest, the guinea pig went home. I phoned the owner yesterday, Feb 27, 2012, around 7 days later. No more problem since going home.


FOLLOW UP ON A LITTLE GUINEA PIG'S HEALTH

Her reply on Feb 27, 2012 is as follows:

Hi Dr Sing,

The only time he's elevated to a height is when I carry him to bathe once a week. However, I have never dropped him before. He doesn't struggle at all. No one else carries him, they usually pat him when he's walking around on the floor (with supervision). When I carry him, I am seated on e floor too.

His whole cage is cleaned and wiped down with diluted vinegar or pet surface sanitizer (by byopet) at least twice a day
(morning and evening) or more.

After he got back from your clinic, he's been eating well n drinking well, a lot of hay and pellets. I feed him small portions of vegetables twice a day (either lettuce, baby carrots or cucumbers).

Thank you.

Sent from my iPhone

886. Closed pyometra email


E-MAIL TO DR SING DATED FEB 28, 2012



Hi Dr Sing


I would appreciate your advice on my dog's case.


My dog is an unspayed female Shih Tzu whose age is estimated to be around 5-6yr old(no exact age as we adopted her when she was found abandoned and in bad condition). Her weight is 3.95kg.

Her last heat ended around 30th November 2011.
She is suffering from bad case of skin problem and is drinking more water and has slimmed down. Her appetite is good with no vomiting and diarrhoea. No discharge or blood in urine observed.


I sent my dog to the vet for her skin problem and the blood test results showed elevated WBC (26.92+). As she is observed to be drinking more water coupled with elevated WBC and her unspayed status, the vet suspected it might be closed pyometra.

No X-ray or ultrasound was done due to financial concerns. Skin scrape was negative for demodex. According to the vet, blood work showed no other abnormalities. However, her T4 readings is quite low (1.3) on the normal range (1.1-4.0 UG/DL).
I can email you the blood work results once I get them scanned should you require them.

Vet prescribed Baytril 50mg tablet(1/2 tablet daily) and to recheck in 2 weeks time. She is also too skinny and vet gave Troy Nutripet gel to supplement her diet.


I am very concerned about the dangers of pyometra and would like to seek your advice. As her body is already stressed by her skin condition and her malnourished state, I am very lost.
I do not know if putting her on the antibiotics and supplementing her health in preparation for the surgery while observing for sudden changes before the next consult would be advisable? Or should I just opt for early surgery since her bloodwork suggests generally healthy organ functions.
Do you think it is possible for her to be operated by you without performing the imaging tests? What is your estimated total charges for the surgery? Please kindly advise. Thank you very much.


Best Regards
Name given




E-MAIL REPLY FROM DR SING DATED FEB 28, 2012


E-MAIL REPLY FROM DR SING DATED FEB 28, 2012

I am Dr Sing. Thank you for your email.
It is risky to diagnose closed pyometra by email without examination of the patient. I will give you my opinions based on your email report on the understanding that it is best to have an examination by me, if practical.


1. Closed pyometra occurs in a dog that has her heat period around 2-3 months ago and your dog was in this situation. She had increased white cell count and was drinking more. I presume she has weight loss over the last 2-3 months. Pl email your vet's reports and blood test results.

2. However, skin disease and poor health can also cause increased white cell count and thirst due to skin infections and itchiness. Drugs may also increase thirst or appetite if your vet had earlier treated the dog.

3. As your dog has good appetite and no vomiting, it is possible that, at the time of consultation, she does not have closed pyometra, assuming she had not been given any drug to treat her skin disease or other health problems.

QUESTIONS

3.1. Did your vet palpate the abdomen and let you know the results of his or her palpation as to whether he or she felt an enlarged uterus? Abdominal palpation is an alternative to X-rays and ultrasound and if the uterus is enlarged, it can be palpated by the vet. Closed pyometra can be confirmed just by palpation but imaging is sometimes necessary to "convince" the owner of the presence of the enlarged uterus.

3.2 Did your dog have fever at the time of consultation? What was the rectal temperature?

3.3 When did the weight loss start? Was it after November 30, 2011 or was the dog losing weight for many months?

4. In reply to your questions about spaying your dog without imaging, it is possible. My estimated charges for the operation would be around $250-$300 for a normal spay and around $500 - $600 for a pyometra spay as this takes a longer time and requires IV drip.

5. It is prudent to wait 2 weeks or longer for your dog to recover from the infection and put on weight, before any spay surgery is attempted. The skin disease should be cured first. The cause of the weight loss may be due to the start of closed pyometra if weight loss is recent.

Another blood test can be done to check the total white cell count prior to surgery, if possible.

6. Closed pyometra is sometimes difficult to diagnose when the uterus is not full of pus. Usually there is loss of appetite. Yet you said your dog has "good" appetite but is losing weight. Why? A typical Shih Tzu with good appetite at middle age should be weighing more than 3.95 kg, at around 5-6kg. Therefore, I don't think that your dog has "good appetite."

I hope the above answers your questions.

Friday, February 24, 2012

885. Veterinary Surgery Audit at Toa Payoh Vets by Dr Sing Kong Yuen

There is a need to be efficient and productive when vets operate at Toa Payoh Vets.
1. Name of file - 2012TPV Anaesthesia Record
TP Reference - 42373
Date of surgery - 24.2.12
Name of owner/representative: Mr ...

2. Patient
Name:
Age: 15 months
Weight: 5.8 kg
Temp: 38.6C
Microchip No.
3. Surgery
Procedure: Spay. Vet: Dr Sing Kong Yuen
Suture type: 2-0 Polysorb (Braided lactomer, Cutting 3/8 24 mm)
Suture packets used: One packet
Spay certificate No: 1675
4. Anaesthesia
Induction Drugs: Domitor + Ketamine IV
Dose calculation
Weight (kg)
Age
Dom
Ket
10
Young
0.4
0.5
5
Young
0.23
0.29
Given 50 %

0.1
0.15

One syringe with 0.25 ml. I added 0.15 ml normal saline = 0.4 ml IV
Top up
Isoflurane + O2 at 0.5-1
% for 21 minutes (C-B)
Isoflurane graph charting % at 5-minute intervals

Summary:
Isoflurane maintained at: 0.5 - 1.0% for 21 minutes
Route: IV
A. Time of injection of induction drug: 5.07pm
B. Time of isoflurane gas first given: 5.11pm
C. Time of isoflurane gas stopped: 5.32pm
D. Time of first skin incision: 5.17pm
E. Time of completion of skin stitching: 5.33pm
E-A = 26 minutes
E-D = 16 minutes
C-B = 21 minutes
MY AUDIT OF VETERINARY SURGERY IS BASED ON:
SURGICAL TIME TO SPAY A DOG IN THIS CASE

It took 16 minutes to spay this dog (E-D). I took 2 attempts to hook left the ovary out and had two ligatures (one transfixing and one normal) done on the uterine body. If I hook the ovary at the first attempt and ligate the uterine body once, the timing should be around 13 minutes. No bleeding seen in this case.

TIPS
The skin incision was around 1.8 cm long and the location was right, around 2 cm from the umbilical scar. The 4 legs were stretched very taut as I find this procedure much easier to hook out the left ovary. I used the scalpel to cut the ovarian ligament instead of fingers to snap it. Then I ligated the ovarian ligament area once. The dog's head was on my left. I raised the hydraulic table to suit my height as with too low the table height, I had to bend down and this would delay surgery. No swab was needed in this case. 2/0 absorbable suture x 1 packet was used. I seldom see the owner coming back for stitch removal as the stitches dissolve in 14-28 days. This saves the owner one trip and time.
5. OTHER MATTERS
Spay timing:

Skin incision: 5.17pm
Linea alba incision: 5.17pm
Left ovary hooked out: 5.19pm
Left ovarian ligament incised: 5.19pm
Left ovary clamped: 5.20pm
Left ovary ligated: 5.21pm.

Right ovary hooked out: 5.21pm
Right ovarian ligament incised: 5.22pm
Right ovary clamped: 5.22pm
Right ovary ligated: 5.23pm

Uterine body (UB) clamped: 5.24pm
UB transfixation ligature right side: 5.25pm
UB transfixation ligature left side: 5.26pm
UB 2nd ligation round UB: 5.27pm
UB incised: 5.29pm
UB checked for bleeding before putting into abdomen: 5.29pm

Linea alba stitched: 2 simple interrupted sutures: 5.29pm
Finger palpate linea alba (2 cm) for hole: 5.31pm.
Skin stitched: 5.31pm. First horizontal mattress
Isoflurane gas stopped: 5.32pm
Skin stiched: 5.32 pm. Second horizontal mattress
Uterus weight: 26 g. Owner said, not pregnant before
Spay certificate No. 1675

Dog's surgical wound bandaged, given baytril 0.6 ml and tolfedine 0.6 ml SC
E-collar. Home Baytril 50 mg x 2 (1/2 tab sid), Tolfedine 6 mg x 16 tab (4 tab sid)
6.30 pm phoned owner. Take dog home. Awake.


Website is at:
http://www.sinpets.com/F5/20120233SPAY-audit-surgical-anaesthetic-time-Singapore_ToaPayohVets.htm

884. Anaesthetic & Surgical Record for Toa Payoh Vets

The following is to monitor the productivity of veterinary anaesthesia and surgery and for instructions and review

1. Name of file
TP Reference
Date of surgery

2. Patient
Name
Age
Weight
Temperature

3. Surgery
Procedure
Vet
Spay/Neuter Certifcate No:

4. Anaesthesia
Induction Drugs
Dose calculation
Route

Isoflurane graph charting % at 5-minute intervals
Review: Isoflurane maintained at: 0.5 - 1.0% for 21 minutes


A. Time of injection of induction drug
B. Time of isoflurane gas first given
C. Time of isoflurane gas stopped
D. Time of first skin incision
E. Time of completion of skin stitching

E-A = minutes
E-D = minutes
C-B = minutes

5. OTHER MATTERS

Vet signature:


Using dog spayed by Dr Sing as an example


1. Name of file - 2012TPV Anaesthesia Record
TP Reference - 42373
Date of surgery - 24.2.12

2. Patient
Name: Jo Jo
Age: 15 months
Weight: 5.8 kg
Temp: 38.6C

3. Surgery
Procedure: Spay
Vet: Dr Sing Kong Yuen
Suture type: 2-0 Polysorb (Braided lactomer, Cutting 3/8 24 mm
Suture packets used: One packet
Spay certificate No: 1675


4. Anaesthesia
Induction Drugs: Domitor + Ketamine IV
Dose calculation
Wt Age D K
10 young 0.4ml 0.5ml
5.8 young 0.23 0.29
@50% 0.1 0.15 given = 0.26 ml. Add 0.14 normal saline = 0.4 ml IV

Isoflurane graph charting % at 5-minute intervals
Isoflurane maintained at: 0.5 - 1.0% for 21 minutes

Route: IV
A. Time of injection of induction drug: 5.07pm
B. Time of isoflurane gas first given: 5.11pm
C. Time of isoflurane gas stopped: 5.32pm
D. Time of first skin incision: 5.17pm
E. Time of completion of skin stitching: 5.33pm

E-A = 26 minutes
E-D = 16 minutes
C-B = 21 minutes



5. OTHER MATTERS
Spay timing:

Skin incision: 5.17pm
Linea alba incision: 5.17pm
Left ovary hooked out: 5.19pm
Left ovarian ligament incised: 5.19pm
Left ovary clamped: 5.20pm
Left ovary ligated: 5.21pm.

Right ovary hooked out: 5.21pm
Right ovarian ligament incised: 5.22pm
Right ovary clamped: 5.22pm
Right ovary ligated: 5.23pm

Uterine body (UB) clamped: 5.24pm
UB transfixation ligature right side: 5.25pm
UB transfixation ligature left side: 5.26pm
UB 2nd ligation round UB: 5.27pm
UB incised: 5.29pm
UB checked for bleeding before putting into abdomen: 5.29pm

Linea alba stitched: 2 simple interrupted sutures: 5.29pm
Finger palpate linea alba (2 cm) for hole: 5.31pm.
Skin stitched: 5.31pm. First horizontal mattress
Isoflurane gas stopped: 5.32pm
Skin stiched: 5.32 pm. Second horizontal mattress
Uterus weight: 26 g. Owner said, not pregnant before
Spay certificate No. 1675

Dog's surgical wound bandaged, given baytril and tolfedine SC
E-collar. Home Baytril 50 mg x 2 (1/2 tab sid), Tolfedine 6 mg x 16 tab (4 tab sid)
6.30 pm phoned owner. Take dog home. Awake.






Vet signature:

Wednesday, February 22, 2012

883. Lateral saphenous artery - Golden Retriever tumour in front of knee

The case of the old Golden Retriever with a large knee tumour.

"Your vet quoted $300 for the operation," the mother said.
"Who was the vet?" I asked as the surgery to excise this large knee tumour will take a long time, at least one hour. I had quoted $500. The owner did not want blood test or histopathology of the tumour and that would save some money. Still, $500 for the whole procedure including drugs, e-collar and post-op care was very low.

ANAESTHESIA
50% of domitor + ketamine IV according to my guidelines written previously.
The dog was old and at 50% was really knocked out. A whiff of the isoflurane gas + O2 after 5 minutes of sedation enabled intubation.

SURGERY
I demonstrated the surgery to Dr Daniel by operating together as this would not be a simple surgery as removing a tumour from the side of the body where there is a lot of skin. Here, the tumour was massive at 7 cm x 8 cm x 5 cm and if the textbook advice is to be followed, a wide resection meant insufficient skin for stitching. A wide resection is important to remove all tumour cells but an big knee wound due to insufficient skin area to close is deadly for the dog post-op as bacterial infection comes in over time.

Use marker pen to know how to excise.

BLEEDING ARTERY
There is one spurting artery of around 2 mm in diameter from the skin surface lateral to the tumour. "It is the lateral saphenous artery," Dr Daniel said. I advised a "purse-string" suture with the 2/0 absorbable and he did it. The bleeding stopped. But profuse bleeding from all other tissues continued. Swab, swab, swab, swab.

"A bi-polar electrode will be most useful," he said.
"In old dogs, the faster the surgery is done, the safer it is for this 8-year-old. I excised the tumour fast and started stitching. The bleeding continue unabated as there were numerous veins and smaller arteries. In theory, the bi-polar electrode would be used to coagulate. I could also use the coagulation electrode by switching to it from excision electrode."

"Look, the tongue and gum colour of the Golden Retriever is getting purplish," I said. In theory, it is best to stop all bleeding. This prolonged anaesthesia and the dog dies.

In practice, I stitched up the wound and used bandaging. A live patient is what the owner wants, not a clean no-bleeding surgical wound. This is the good outcome that is what text books don't teach.

You can see pictures at www.toapayohvets.com now. Will update again.

Myanmar tourism has exploded as at Feb 2012

On Feb 22, 2012, I spoke with my Myanmar travel agent partner about the latest in Myanmar tourism since the U.S has made contacts with the politicians and Aung San Sui Kyi is allowed to be in politics openly.

The following are the latest happenings in Myanmar tourism.
1. A sudden surge in tourist arrivals

2. Very difficult to find 4- and 5-star accommodation in Yangon's hotels due to the increase in businessman visitors from the Middle East and from Non-Governmental Organisations. The Middle East tourists rent the whole floor and pays 50% more, according to my partner.

3. Therefore, there is insufficient hotel rooms for tourists who want 4- and 5-star hotel. There are 2- and 3-star accommodation and they are safe, decent and clean too.

4. The administrators want to build a subway in Yangon and had approached the governments of Singapore and Japan as both have the experience.
The investors are given the land to build and both share the profits.

Monday, February 20, 2012

881. Blood in the guinea pig's urine again. Why?

"UTI" the owner said the previous vet had diagnosed UTI when her guinea pig had passed blood in the urine.

No urine test was taken by the first vet. She wanted another opinion from me.
"UTI is common," I said. "I need to ward it and do a urine collection to check the urine."

How to collect urine from a guinea pig? I remembered my sheep metabolic studies lectures in Animal Nutrition in the 3rd year. That was 4 decades ago. Improvise. I looked for a clean pan, not the usual pee pan. I found two. See images.




Will update later.
Tentative diagnosis is traumatic injury as the guinea pig still has good appetite and has not passed blood in the urine on 2nd day of hospitalisation after being treated with medication.

Image from link from toapayoh vets as blogger.com seems to have some problems in layout when images are posted directly to it.






880. Sunday's interesting cases at Toa Payoh Vets

Feb 19, 2012
Bright sunshine day

CASE 1.
"My guinea pig has UTI. He passes blood in his urine," the young lady's GP carrier had two large spots of blood spread onto the white tissue paper. "He had passed blood before and recovered after antibiotics," she had the GP treated by 2 vets elsewhere a few weeks ago. The GP of one year old had excellent appetite and was bright.

"Was urine collected for analysis?" I asked as I shared the case with Dr Daniel. Seldom do vets collect urine from a GP. It is just not the thing to do. I mean, how do you collect urine from a 500g GP? Male dogs can be catheterised to collect urine. But a GP?
"No," she said.
"A urine analysis is most important," I said. "I need to ward the GP for 2 days to observe and collect urine."
How to do it? I used two clean plastic tray covers under the grated floor. See image.
Fresh red blood. Bright red as if there was some bleeding internally inside the bladder. Or kidney? More passed. I wondered if the GP would bleed to death.

1. UTI? That's the primary diagnosis. The other vets had diagnosed UTI and so the owner assumed UTI.
2. Certain types of food causing reddish blood. But this was pure red blood.
3. Coagulopathy? Dr Daniel suggested.

The GP passed more than 10 ml of blood. I collected 1.5 ml from the tray and sent to the lab.

URINE ANALYSIS
Blood+++. pH=9.0. Negative for bacteria, crystals, WBC.

The GP did not pass blood after 24 hours. He ate only fresh apples and vegetables.

Saturday, February 18, 2012

Update on the Chihuahua had "died" article

876. The Chihuahua had "died"

Yesterday, Tuesday Feb, I did an unusual Chihuahua spay cum teaching session to Dr Daniel in the afternoon. In the evening, the mother phoned Dr Daniel and said the Chihuahua had died. I was shocked and very sad. However, the Chihuahua had given birth to 2 dead 52-day-old pups.

Today at 10 am, she phoned me to ask whether she should continue feeding egg yolk to the same Chihuahua. "Hold on," I said as I went to ask Dr Daniel as to what was happening. "She said the dog had died."

I asked the mother. "Oh, the dog was dying. She fainted but I could see her breathing. After 2 hours in this position, the dog woke up and is now OK."
This was incredible as I could not understand why the dog had died. Her death was on my mind this morning. She did have a cyanotic tongue on picture taking. She was taken home 2 hours after my surgery and Dr Daniel had checked she was OK.

BACKGROUND
Tuesday Feb 14, 2012 (Valentine's Day)
Home breeder Mr Lim phoned me to ask about Caesarean cost. I had charged $250-$300/Caesarean for breeders some 7 years ago and that was how he knew me as I was in the breeder Caesarean section business doing over 100 dystocias.

"The fees were too low," I had stopped servicing the breeders some 4 years ago. "It should be around $800 - $1,000."

VET 1 TREATMENT. Mr Lim was in Malaysia and so he sent his mum to Vet 1, a vet to get an IV drip first as his mum said the dam was dying since giving birth to two dead pups discovered on Monday morning. Now, it was Tuesday 1 pm and many hours had passed.

Vet 1 also did a blood test and ultrasounds. Possibly two dead fetus according to the ultrasound. I palpated the abdomen. There was a small firm lump of 8 cm x 8 cm which would be just the uterine body as a pup would be 2x larger. In any case, the mum said there were dead pups and so Caesarean was needed. But Mr Lim had instructed that I did it, and so the mum and daughter carried the Chihuahua and the IV drip bottle of 5% glucose saline, ultrasound and blood test from Vet 1 to my Surgery.

Home breeders want the least cost Caesarean sections and he just wanted Vet 1 to give the dog an IV drip first before sending to me. But he had the ultrasound and blood test. It was more costly now.

I spoke to Mr Lim by phone and advised spaying as the dog is 6 years old and had difficulty giving birth now. Mr Lim agreed and so I used this case as a demonstration of how I did a spay on a pregnant Chihuahua to Dr Daniel who had joined the Surgery after his recent graduation.

There was milk in the glands and so it was a surprise that Mr Lim said the pups born premature were 50-52 days. But he is a professional experienced home breeder and so I would accept his calculation.

The dog was severely dehydrated. She was extremely weak as she had not been treated by any vet after her premature births of 2 pups. Therefore Vet 1 had given the glucose saline drip as instructed by Mr Lim. It is a mystery as to why Mr Lim phoned me to perform a Caesarean section for his dog as I had not seen him for over 4 years after I had given up on providing $250-Caesarean section to the Pasir Ris dog breeders as I was barely making ends meet and had no time for pet owners unlike now.











5057 - 5066. How to operate on a very weak Chihuahua after 2 premature births
The ultrasound report from Vet 1 indicated one or two dead fetuses. This is where X-rays would be more useful as the skeletal features of the fetuses would be visible. Or there could be a mis-interpretation of the ultrasound by Vet 1. Abdominal palpation by me did not reveal any hard lump of dead pups. Yet, there was the ultrasound report from a "brand-name" veterinary practice stating the existence of one or two dead fetuses. I advised a spay. The dam went home 2 hours after the spay and two hours later, the mum had phoned Dr Daniel saying that the dog had "died." The next morning, I answered the phone and she asked whether she should feed the dog "egg yolk" or not.

So, this was an unusual case of a Chihuahua that had not really died and had been operated for some 10 minutes without the need of isoflurane anaesthesia, indicating that she was near death's door. Normal dogs and any person will need the anaesthetic gas as they will feel the pain of tying the ovarian ligaments, clamping and incisions.

She had a bottle of IV glucose saline before and after Caesarean section. As at Feb 19, 2012 as I write this report, she is OK. Chihuahuas are very fragile dogs and when stressed out or hypoglycaemia, many don't recover despite treatment. So, anaesthesia can be fatal in such situations. In this case, the vet has to make a judgment as to whether to operate or not. If the dog dies when a Caesarean section is requested due to dystocias, the vet is to be blamed for not operating. If the vet operates and the dog dies, the vet is also blamed sometimes. It is best to give the IV drip of glucose and antibiotics for some 15 minutes before surgery and get the whole surgery from start to finish in less than 15 minutes.




In this case, 19 minutes were taken but that was as fast as I could do as the dog did struggle when she woke up in the last part of surgery - ligating the uterine body. So there was a delay as she was given low doses of isoflurane at 1% and I stopped surgery for a while. Do not attempt to give 5% isoflurane in such situations as that could be fatal.

Updated webpage and more images at:
http://www.sinpets.com/dogs/20120232emergency-casaerean-section-chihuahua-Singapore_ToaPayohVets.htm

878. Follow up on Chinese New Year 2nd day's cases

Feb 19, 2012. Time flies. I have written a follow-up on the interesting cases I saw on Chinese New Year 2nd day on Jan 24, 2012. The webpage and images are at:

http://www.sinpets.com/F5/20120231chinese-new-year-2nd-day-vet-cases-Singapore_ToaPayohVets.htm



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.




5052 - 5055. A stray cat's serious fight wounds. I got a video produced by Nicole and this is at:
How to clean a badly wounded cat's paw wound, demonstrated by Dr Sing Kong Yuen
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. Dental work advised.
UPDATE: Feb 19, 2012. The owner did not return for review.
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?"









4990 - 4999. Abscess caused by two maxillary molar teeth. High fever. Anaesthesia to extract the two loose right maxillary molars was very risky. IV drips, antibiotics and anti-fever 24 hours first  
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.

UPDATE: Feb 19, 2012. The owner did not return for review of the right cheek wound. I presume it had closed by granulation as it would be too big to stitch up. I suspect this case is due to a flesh-eating bacterial infection as it is not typical of a malar abscess.

3. Persian cat of a son who is studying overseas. F, 13 years, not spayed. EMACIATED. Drooling. 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.





5067 - 5071.
LPGS - lymphocytic plasmacytic gingivitis stomatitis in an old cat

UPDATE: Feb 19, 2012. To my surprise, the mother reported that the Persian cat was back to normal, eating and putting on weight. Her son, studying in Australia was happy as this was his cat. LPGS (lymphocytic plasmacytic gingivitis stomatitis) is diagnosed by biopsy of the ulcerated oral tissues, but this would cost the owner more money.






Therefore, I did not practise defensive medicine as I did not insist on getting this test done as the signs and symptoms were quite clear. The causes of LPGS are varied as there is no one cause known. It included stress, viral and bacterial infections (FIV, feline leukemia, feline calcivirus, Bartonella henselae bacteria, genetic predisposition, sensitivity of gums to bacterial plaque by provoking the aggressive inflammatory response sending large amounts of lymphocytes and plasma cells (two types of white blood cells) into the gums and oral tissues).

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."
UPDATE: Feb 19, 2012. The guinea pig started eating but died "suddenly" around 3 weeks after my treatment. The owner requested an autopsy. The stomach was full. The lungs were infected and the chest had a lot of blood tinged fluid, causing great difficulty in breathing and death.

Guinea pig not eating for weeks


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 to check the hamster's lungs. 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.
UPDATE: Feb 19, 2012. The owner did not return for review.
In conclusion, on this Chinese New Year 2nd day, January 24, 2012, I had a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.



The updated webpage and images are at:

http://www.sinpets.com/F5/20120231chinese-new-year-2nd-day-vet-cases-Singapore_ToaPayohVets.htm

Tuesday, February 14, 2012

Guinea pig couldn't breathe. Autopsy.

The young girl who brought the guinea pig on 2nd day of Chinese New Year is a medical undergraduate for not eating for some weeks. She had consulted Vet 1 earlier and was given antibiotics but the pet still had no appetite. I anaesthesized it and clipped the overgrown lower premolar and molar teeth which had arched over the tongue.

She texted me today, February 14, 2011, at 7.30am for an urgent appointment as her GP was not breathing well. When I saw her at 9 am at the Surgery, the GP had just died.

"Why?" she said the GP had been eating on his own since she ordered the Critical Care from online petshop that delivered on the 7th day of CNY. The GP was hand fed and was eating well till yesterday, around 21 days after the teeth were clipped.

"An autopsy will give some answers," I said. She wanted one done and I asked Dr Daniel to do it with me. Significant autopsy findings were:

1. Stomach was full of Critical care mashed food and so the GP was really eating.
2. Gas in the large intestines could be normal and food seen in the caecum.
3. Some greenish mashed food inside the mouth. Could be after death.
4. Trachea was very clean, so no inhaled food from hand feeding.
5. Lungs severely congested.
6. Massive hydrothorax (reddish fluid splashed out) and this would cause respiratory distress and death.
7. Left lung had white fibrinous adhesions on the posterior lobes. The GP was not a healthy one and had pneumonia some months ago and had recovered, the owner said.
8. Heart had fibrinous pericarditis as the pericardium seemed to have small yellow nodules (abscesses?)

The young girl asked me what was the cause of sudden difficulty in breathing and death. "Hydrothorax is the cause and may be associated with cardio-respiratory infections in the past," I said. "The GP could have weakened immune system as he was not eating for many weeks."

"Is his sickness infectious to the other GP?" the girl asked me. The other GP was fat and ate well. She had just disinfected the crate. But I asked her to do again esp. water bottles and feed bowls.

CHEEK TEETH
I checked the cheek teeth as I had clipped the bottom premolars and molars under general anaesthesia around 21 days ago. I present the image for the benefit of GP owners and GP anatomy for vet students. The guinea pig has 20 teeth. The dental formula is I1,PM1,M3.




VETS TO NOTE
Many cases of the rabbit and guinea pig not eating are due to malocclusion. However, the teeth involved may be the inside premolars and molars, usually the bottom ones in the guinea pig. The overgrown teeth arch over the tongue and cause ulceration on the other side. Palpate the top of the premolars and molars with your finger to feel the sharp edges of malocclusion if possible or under anaesthesia. It is easier to do in the racehorse, but the principle of palpation is the same.

Wrap the guinea pig or rabbit in a towel and use a buccal separator to open the mouth for inspection. I used isoflurane gas anaesthesia for a few seconds to permit me to do the job of clipping the teeth. It is difficult to clip the teeth without anaesthesia as the tongue is in the way and may be accidentally cut.

Guinea pigs, hamsters and rabbits are not the favourite patients of many vets and there are some any internet postings from non-vet experts in the above-mentioned pets cursing the veterinarian for being incompetent and ignorant. Pass the case to other vets if you are not keen on treating such creatures rather than just give antibiotics for inappetance.

GUINEA PIG OWNERS
Check the mouth esp. the inner teeth weekly. Feel the cheek for painful reaction indicating an oral ulcer or abscess. Weigh your guinea pig weekly and if it is losing weight, consult your vet and ask for the teeth to be checked.





UPDATES will be at:

http://www.sinpets.com/F5/20120230guinea-pig-malocclusion-anorexia-inappetance-Singapore_ToaPayohVets.htm

876. Chihuahua had "died"

Yesterday, Tuesday Feb, I did an unuusual Chihuahua spay cum teaching session to Dr Daniel in the afternoon. In the evening, the mother phoned Dr Daniel and said the Chihuahua had died. I was shocked and very sad. However, the Chihuahua had given birth to 2 dead 52-day-old pups.

Today at 10 am, she phoned me to ask whether she should continue feeding egg yolk to the same Chihuahua. "Hold on," I said as I went to ask Dr Daniel as to what was happening. "She said the dog had died."

I asked the mother. "Oh, the dog was dying. She fainted but I could see her breathing. After 2 hours in this position, the dog woke up and is now OK."
This was incredible as I could not understand why the dog had died. Her death was on my mind this morning. She did have a cyantoic tongue on picture taking. She was taken home 2 hours after my surgery and Dr Daniel had checked she was OK.

BACKGROUND
Tuesday Feb 14, 2012
Home breeder Mr Lim phoned me to ask about Caesarean cost. I had charged $250-$300/Caesarean for breeders some 7 years ago and that was how he knew me as I was in the breeder Caesarean section business doing over 100 dystocias.

"The fees were too low," I had stopped servicing the breeders some 4 years ago. "It should be around $800 - $1,000."

VET 1 TREATMENT. Mr Lim was in Malaysia and so he sent his mum to Vet 1, a vet to get an IV drip first as his mum said the dam was dying since giving birth to two dead pups discovered on Monday morning. Now, it was Tuesday 1 pm and many hours had passed.

Vet 1 also did a blood test and ultrasounds. Possibly two dead fetus according to the ultrasound. I palpated the abdomen. There was a small firm lump of 8 cm x 8 cm which would be just the uterine body as a pup would be 2x larger. In any case, the mum said there were dead pups and so Caesarean was needed. But Mr Lim had instructed that I did it, and so the mum and daughter carried the Chihuahua and the IV drip bottle of 5% glucose saline, ultrasound and blood test from Vet 1 to my Surgery.

Home breeders want the least cost Caesarean sections and he just wanted Vet 1 to give the dog an IV drip first before sending to me. But he had the ultrasound and blood test. It was more costly now.

I spoke to Mr Lim by phone and advised spaying as the dog is 6 years old and had difficulty giving birth now. Mr Lim agreed and so I used this case as a demonstration of how I did a spay on a pregnant chihuahua to Dr Daniel. There was milk in the glands and so it was a surprise that Mr Lim said the pups born premature were 50-52 days. But he is a professional experienced home breeder and so I would accept his calculation.

The dog was severely dehydrated.

Sunday, February 12, 2012

875. Sunday's interesting cases

Sunday, Feb 12, 2012

Bright sunny day. Two vets, excluding me are needed on Sunday to reduce waiting time to less than 15 minutes per client. Some cases like dental scaling takes around 30 minutes and if there is one vet, the clients who come later can complain of waiting over 2 hours. I had an early meeting with Dr Daniel, Mr Min and Mr Lim (intern) in the consultation room to discuss about work attitudes, behaviour, stock inventory, anaesthetic records, case records, surgical processes, efficiency and productivity, wastage of resources and time and consistency to enable my vision of Toa Payoh Vets to be the top 5 practices in Singapore. I asked Mr Lim to take minutes of this first meeting. Clients are younger and much more sophisticated as you can see from the cases described below.

Case 1
Golden Retriever's toe fracture as the wife had stepped on him. Review. Much less swollen. Still lame. I showed Dr Daniel how I would handle this case as I would have done in a racehorse. Outside the clinic, trotting and walking. He was limping but we knew which leg. Got X-rays. Cost the owners a bit of money.

"How's your daughter's guinea pig?" I enquired as I had clipped its overgrown cheek teeth and it was not eating for the next day. Vet 1 had treated it earlier with some injections but the GP was still not eating and had lost weight. I had the GP under anaesthesia to check the mouth and the cheek teeth were overgrown. So, this was the problem as the GP had become very thin by then.

"The GP is OK now. Eating," the wife said. "My daughter is a medical undergraduate. She ordered the emergency mixture via the internet and it cost a lot of money."

"I did advise her to go to a pet shop that specialises in GP and rabbits and will have it. In any case, how do you know it is expensive?"

Mum said: "I paid $50.00 for the goods delivered on the same day."

The internet is now what young adults do. I don't stock the mixture as there are not many cases of GP or rabbits. I had advised her to hand-fed the mashed up pellets and also the medication 6X/day in small amounts and also electrolytes. But she wanted prompt results of return to feeding and ordered the emergency mixture. It ended well for the GP. This case illustrates the importance of checking the cheek teeth and not just the front teeth. A similar case in a rabbit recently had been written in www.toapayohets.com

Case 2.
I did not expect any early birds as this was Sunday. Suddenly 2 young ladies came in at 10 am with an Italian Greyhound, 4 years, excellent bodily condition, and wanted dental scaling done. "Has the dog eaten?" I asked. "It may vomit out the food during anaesthesia or sedation."

"At 9am," one lady said. "Just a small amount. When I phoned for appointment yesterday, nobody told me not to feed the dog before surgery."
"I will do it at 4 pm, sufficient time to let the food pass through," I said.
"We live in Tampines," the lady said. This would take some time to go back and forth, at least 30 minutes.

To be practical, I got the dog done with Dr Daniel Sing, mentoring him by showing how I would do it. No problem using 50% of calculated dom and ket combination ination and isoflurane gas. Dog did not vomit. Went home to a happy lady after one hour.

Case 3
An elderly man came in specifically to see me to get his 8-year-old Jack Russell dental work. No dental done before. Dog was given same as the Italian Greyhound. But older. This is a higher risk. As before, I mentored Dr Daniel Sing. He had his own ideas from his professors and this is to be expected of young graduates. Full of theories and latest knowledge of vet medicine and that is good as you can see from one case of the sheltie with nasal discharge and the excellent X-rays taken.

However, the dog stopped breathing, according to Min. I was out a while but came back within 10 seconds, according to Dr Daniel in review of this case later. No time to test his theories. I know what the professors would have taught about injecting the emergency adrenalin etc. Time is of the essence.

I did cardiac massage, blew air into the lungs by cutting the tightly tied endotracheal tube to both jaws (I don't tie this way but the professors would have taught this is the correct way, in normal situations, correctly). "Give Antisedan inj IV" I said. Dog revived and was OK. Alert as a guard dog standing up. "Propofol to continue anaesthesia," Dr Daniel said as there was two teeth left to be scaled and the dog could bite.

"No more IV in this case as the dog's heart may stop," I said. "Just isoflurane gas by mask and it will take a longer time." The dog was treated.

P.S Propofol seems to be a favourite of recent Murdoch Univ trained vet graduates and is used much in the University. But I don't use propofol and there is no need for it as there are other alternatives available. New graduates must adapt to the workplace rather than replicating or using what they have seen being used by their professors.

A practice has to manage cost so as to provide the cheapest competitive veterinary services. It cannot stock similar drugs as they do expire and led to a high wastage of resources and money.

Friday, February 10, 2012

Follow up by vet - the persistent coughing shih tzu

Yesterday, Friday, Feb 10, 2012, the owner brought the Shih Tzu for review as I had phoned him to enquire about the dog's coughing of white mucus.

"Eats a lot, poop a lot. Pee a lot," the owner said to me. "Is his coughing infectious to other dogs or the children?"

"No," I said. "The blood test is normal and the dog is more active and has no fever."

No weight gain for the past 7 days. "The tongue ulcer on the tip is still there," the owner said as the dog prevented me from checking the tonsils for several trials of opening his mouth. "The dog eats dry food as he likes it," I said. "This may have caused the big tongue ulcer, 1.0 x 0.8 cm from healing, Give canned food for the next 4 weeks, if possible."

The submandibular and popliteal lymph nodes were reduced in size by around 20%. I asked the owner to feel the nodes. The axillary lymph nodes were not palpable. He would be checking the size of the nodes.

Urine test had indicated high serum urea and bacteria in the urine.

I palpated the throat. The dog retched and coughed white mucus onto the table and then the floor. The man took my tissue paper to wipe away the white mucus.

"My dog vomits when he drinks a bit of water, two teaspoonfuls per meal," the owner said and had complied with my advice to feed small amounts 5x/day. "Now, he throws up around 5X/day, but previously it was 10 times or more."

After my treatment last week, the dog threw up once per day. So, the problem has not been resolved.

A follow up is important. So, what's the problem? Pleural effusion of the lungs and enlarged heart. How about stomach gas. "We need to X-ray the stomach/gullet area if this problem persists," I said.

872. TOILET TRAINING - The 3rd dog shows he is the boss - urine marking

EMAIL TO DR SING DATED FEB 10, 2012
...singnet.com.sg

Dear Dr,



I really need your advice how I can train my schnauzer. I have a total of 3 dogs, this schnauzer give me the most problem and seem to be not learning. He was the last to come in to my house. At the moment he is already 3 years old and I really not sure can I still toilet train him. As I have try many way to ask him to go and pee but always love to give surprise.



Both my other 2 dog are well toilet train and do it at the right place. The schnauzer really give me a problem. When I ask all the dogs to pees they will go to the toilet and pee. Normally my other 2 dogs will go in to pee first. The schnauzer will only go to pee after both dog have pee and try to pee over my other 2 dog pee. This is not a problem with him.



He always love to any how pee near to the door and other part in the kitchen for no reason. He will just pee a little bit here and there. I am not sure is he trying to get my attentions. Even he know it is wrong to do it he still do it. He seem to love to just pee a little to cover the 2 dog pees and have his own pee outside the toilet. I try to catch him in the act but was not successful. Normally after feeding I will try to get him to the toilet. But he will not do it even I spent 30 mins trying to get him to do it in the toilet. The moment. I leave him go to my room 5-10 minutes time when I am out he will pee near to the door or at the wrong sport. Any solutions which I can house break his bad habits.



Please help me and give suggestion. I am totally lost.



Regards,



EMAIL REPLY FROM DR SING DATED FEB 11, 2012



Kong Yuen Sing



5:51 PM (16 hours ago)














to Edwin, bcc: me, bcc: daniel, bcc: jasonxll










I am Dr Sing from www.toapayohvets.com. Thank you for your email.
It will be difficult to house-train the Schnauzer as he is 3 years old, not a puppy. He is urine-marking (pee over the other 2 dog's pee and elsewhere) to make sure that the other 2 dogs know he is the boss.

Some suggestions:
1. Neuter him soon.
2. After neuter, start house-training by confinement to one area or room for 2-6 weeks, if you have any space. Or use crate-training and take him out every 3-4 hour to pee. Basically same training as for puppies as described in toapayohvets.com, puppy house toilet training webpages.
3. Firm commands in house-training with rewards on success.

With best wishes.

Thursday, February 9, 2012

871. An e-mail to Dr Sing about a cat

Feb 10, 2012. Veterinary medicine is a diverse topic. Feedbacks are valuable but most are complaints. This is one feedback that was surprising to me.

EMAIL TO DR SING DATED FEB 9, 2012
Dear Dr Sing

A belated Happy Lunar New Year to you. I trust this email finds you in good health and standing. Its been quite some time since our male cat Tobi was treated at your wonderful practice. Unfortunately our beloved Tobi has passed away on Saturday, 4 February 2012.

Just a bit of history. Tobi was admitted to your care on 24 April 2011. His case is listed in your website under cat cases-UTI -1st FLUTD.The cat can't pee again dated 12 June 2011. Shortly after his discharge, we moved into our new home. Tobi recovered well as there were no territorial cats and stress was kept to a minimum. He was maintained strictly on Hill's C/D wet food.

However, sometime from October 2011, he seemed to be licking his private area again though not as frequently as when he had UTI , he was also peeing normally with good volume. His disposition and general health was very good. This continued until February 2012 when we noticed his urine volume seemed to have lessened somewhat and his penis appeared to be inflamed. We brought him to a vet(shall not mention the company name) who gave him an injection of antibiotics and anti-inflammation and discharged. Two days later, it did not seem to get better, we brought him back to the vet again, a blood test was performed with several struvite crystals detected. The vet advised us that a similar injection could be given or a catheter could be inserted. We chose the injections as we were trying to avoid Tobi being warded as it may be more stressful. In order to give the injections, Tobi had to be put under G.A. as he was putting up such a struggle. Anyway it was done and he went home.

Yet again two days he was still having difficulty peeing, this time we opted to bring him to another branch (this branch was 24 hrs with larger facilities). Tobi was sedated, warded with a catheter inserted and put on a drip via a Y-site. He was also given daily IV feeds with Cephalexin and calcium, diazepam amongst others. He seemed fairly alright the first two days, it was only on the 3rd day that we noticed he appeared rather "subdued", quiet, not he's normal fiesty self. By the 4th day ,he was lying down the whole time and didnt seemed to respond to us. We attributed this to possible lethargy and medication. The next day, his blood tests were normal and after a cursory examination he was declared fit for discharge despite the fact that by now he could not even stand up or move, we bascially had to carry him into his carrier to be brought home. We reached home in the mid afternoon and put him in the room, again we had to carry him out of the carrier. From the time we reached home right until 10 pm, Tobi condition just deteriorated, once in while he would sort of jerk himself to another area in the room, Im not sure how he did this as he was immobile from the front quarters, his eyes could not track movement, he was drooling brown liquid and had raspy breathing. We took him back to the 24 hr branch at around 10.30 and the vet on duty arrived about 15 mins later,another blood test was conducted plus a chest x-ray, all looked normal, tests for leukemia and FIV was also done, clear as well. At about 11.30am, Tobi convulsed, expelled fluid and stopped breathing, we had opted for DNR. An immediate autospy was done, organs again were all fine. Nobody seems to have an answer for his death.

Needless to say, we are extremely saddened as well as puzzled by his sudden demise, more so when he was brought in for what ought to be a routine treatment for am inflamed penis. Instead five days later, we are having to cremate him. We have since search everywhere for anything information that might explain his sudden death. From what we found, we suspect, of course this may speculative at best, but it appears to be anaphylactic shock ( the question is what was the cause). Again we suspect it could he may have been allergic to one or more of the medications prescibed via the IV drip. Admittedly there could be numerous other possible causes. However we feel it seems to fit the symptoms Tobi displayed - pale gums, immobility, drooling, low temperature, increased heart rate.

We are not ones to assign blame or find fault. Nonetheless, suffice to say we are disappointed with the level of monitoring at the vetirinarian branch Tobi was in. We are well aware that cats are notorious for masking pain and discomfort but honestly to discharge a cat that can't even stand on its feet! It would be like a doctor discharging a patient who can't walk and asking him to go home. While Tobi's blood tests looked fine, a more thorougly physical examination would have raised one or more red flags. From the time of his passing, not one person from the vet had called to offer their condolences or at least offer some theory as to Tobi's death. It's as if that there was no obvious cause, so nobody can be bothered about it.

My wife and I are still coping with his passing but we are doing well. I just thought that since you treated Tobi twice and did such a wonderful job each time, we would like to let you know what has happened since then.

Thank you for taking time to read this long email. Meanwhile, we wish you all the best in your practice and your great care towards all animals, big and small.

P.S. we would have like to gone back to you but the distance was a bit prohibitive. Anyway we thought it would be just a routine treatment but......

Best Wishes & Regards
Name of young couple


EMAIL REPLY FROM DR SING DATED FEB 10, 2012

Hi

I thank you for your compliments and good wishes.

1. You mentioned "a blood test was performed with several struvite crystals detected"? Is it a urine test?
2. What is DNR?
3. Was an X-ray done?
4. Was a urine test done?

Please accept my condolences for the passing away of Tobi. Pl phone me if you have any queries about Tobi as it is easier to discuss on phone than by writing emails.

With best wishes for both of you.

Wednesday, February 8, 2012

870. A 12-year-old Jack Russell coughs fresh blood for last 2 days

This case illustrates the importance of using relevant evidence-based medicine to provide a standard of veterinary care affordable and expected by the sophisticated younger generation of Singaporeans. This google generation knows much more than the baby-boomer generation and wants answers quickly as to what is the cause of the problem with their sick pet. Not more than one visit will be the best as Singaporeans are time-pressed.

Yesterday morning, I was the vet on duty. A young man came with his 12-year-old Jack Russell which was in excellent body condition. "He coughs blood in the last two days."

The dog's gums were slightly pale. Rat bait poisoning? Unlikely as the dog was supervised when outdoors and there were no rat baits used in the apartment. This was a much loved dog as he would try and attack the newspaper delivery man every morning but not his family members and the family's friends. He was a puppy when the young man was in Primary 5 or Primary 6 and now 12 years or more had flown by.

"Is he a scavenger?" I asked as the Jack Russell started coughing when I palpated his throat from the larynx downwards. The dog coughed and retched. Fresh red blood with white mucous came out from his mouth onto the floor of the consultation room.

"Yes, he swallows any food he would find in the house." the young man asked me for tissue to clear the mess.

"Is he like my son's Bichon who waits for some chairs not pushed inside the dining table to jump onto the table to eat the chicken bones?"

"Yes, yes, he is like that!" the man said.
"As the throat is so painful, it is possible that there is a chicken bone poking the throat and causing coughing and bleeding. I will need to X-ray the throat, lungs and stomach area."

The owner must be given the advice and if he does not want the X-rays, this must be recorded in the case sheet. He wanted the X-rays and complete blood test.

"My dog had a fierce cancerous lump removed from his neck skin at another vet clinic," the owner said to me. He phoned the vet and they faxed over the report in the afternoon. It was a sebaceous gland carcinoma which had grown red and fast on the dog's lower neck 2 years ago. The skin in that neck area was hairless but no recurrence of tumour was seen.

So, was this a case of chicken bone trauma or not? I got the X-rays done. "Pleural effusion," commented two vets as the X-ray of the lung showed radio-opacity instead of black spaces as for normal lungs. Based on clinical signs and the history of a cancer as well as diffuse nodules seen on the X-ray, I advised the owner that it was most likely metastases of cancer cells to the lungs. Bronchoscopy and lung biopsy could be done but this would add to the cost.

The owner decided on euthanasia and was present when I administered the injection. It was sadness in the evening but he was satisfied with the evidence-based medicine done. If the vet had just given some injections and drips without advising X-ray, this coughing of blood would continue and the owner would become much unhappy with another visit. Therefore, the vet must know what to do in a case of coughing blood. In retrospect, this dog had been coughing for the past year but had not coughed blood till the last 2 days.

Blood test revealed an increase in total white cell count suggesting a bacterial infection, red blood cells and haemoglobin in the lowest range of normal values, suggesting blood loss probably from the lung bleeding. I explained the findings to the owner. He had to decide what to do further.

The diagnosis of tumours in the lung due to metastases from the sebaceous gland carcinoma is quite possible. Veterinary costs need to be minimal so I did not suggest bronchoscopy and lung biopsy to confirm the lung tumours as this would prolong suffering in this dog. Coughing of fresh blood is very likely from the lungs as the amount was much more and persistent.

869. Update: Miniature Schnauzer with recurrent urolithiasis


Recurrent urolithiasis
1. First time - calcium oxalate stones
2. Second time (now) - struvite stones

If the owner is careful and listen to veterinary advice, this case can be prevented using dietary management (prescription diet), monthly urine testing and 3-monthly X-ray of the bladder.

However, most Singaporean dog owners don't bother with the monthly urine testing and X-ray though some do come for the prescription diet.

In one male Miniature Schnauzer dog that I mentored a vet in his first urinary bladder operation of his vet clinic assistant's dog (see Toa Payoh Vets - Dogs - Urinary problems), this dog is fed commercial dry dog food which is less expensive than prescription diet, there is NO recurrence even a few years after surgery. The clinic assistant does not bother with all these advices of monthly urine tests and 3-monthly X-rays!

Website with updates and pictures at:
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm

Importance of stone analysis - Calcium phosphate urinary stones at recurrence

In my review of this recurrent urolithiasis, for the benefit of dog owners, the vet did not perform a stone analysis in the first cystotomy done 12 months ago. This was probably due to the owner's instructions to reduce costs. In the recurrent case, operated by at Toa Payoh Vets by Dr Vanessa, I insisted on a stone analysis. The results were as follows as this ought to be done to know the type of stones present and hence a preventive program using prescription diet or other ways to manage and prevent recurrence.

12.1.12 At Vet 1
after midnight emergency


Shih Tzu, Male, 8 years old



BLOOD TEST
URINE TEST
X-RAY
WBC high 24.48 (5.5 -17)
Neutrophils 82%, L=3.6%, Mono = 12.9%
Absolute High for Neutrophils, Monocytes, Basophils, Platelets, BUN, ALKP.
Dysuria urine pH = 7.2, USG 1.015




3.1.12 at Toa Payoh Vets

SURGERY
URINE TEST
STONE ANALYSIS: Calcium Phosphate.


Urine pH 7.0, USG 1.012
Protein 2+, Blood 4+, WBC 468 RBC 25, Bacteria 3+, Crystals Nil.

Do proper planning before surgery to save on manpower time and resources and to reduce length of anaesthesia, ensuring better survival outcome for old dogs.
No crystals in the urine do not mean no urinary stones inside the bladder or kidneys
Negative for oxalate, urate, magnesium, cystine, ammonia, bicarbonate.
In conclusion, most Singaporean pet owners don't bother with prescription diets, monthly urine tests and 3-monthly X-ray to detect small urinary stones which can be flushed out using urohydropropulsion and thereby saving on surgery and higher costs. However, it is THE DUTY of the veterinary surgeon to record in the case sheet that such advices have had been offered to the owner to prevent misunderstanding when there is a recurrence.

Younger Singaporeans may be much more sophisticated and educated and may understand the need for such preventive tests. But many Singaporeans are time-pressed. Till the dog can't pee or pass blood and then they may consult the vet. I hope this review will provide some information to owners who wants more information on prevention as I do know of some owners who would just euthanase the dog when there is a recurrence.


Website updates and images:
http://www.sinpets.com/dogs/20120219recurrent-urolithiasis-urinary-stones-toa-payoh-vets_Singapore_ToaPayohVets.htm

Tuesday, February 7, 2012

866. Pug needs dry S/D

Today, I phoned owner of a pug to follow up on the pug's fits and why she still needed S/D cans for past few months. The pug has this urinary tract infection if fed home-cooked or other foods.

"SD diet cannot be given for more than 3 months," I advised. "You need to change to CD". I ordered dry CD for her as it is more economical. She had ordered SD diet from a vet in Toa Payoh and when she came, she was told no S/D dry. I made an investigation. S/D dry is not available from the supplier and the vet had not updated her. All vets are to record orders in a book from now.

As the vet in charge, I need to get feedback and this is one such feedback when I followed up with the owner. She had not wanted to "complain" about this lack of service from my associate vet who had promised to order the S/D for her and she came but was told none available.

PUG Male, 3 years
26.1.11 dysuria

23.8.11 Urine test. pH =5 (5-8), SG=1.016 (1.005-1.030.) Nitrite +ve, Bacteria 3+

10.9.11 Urine test pH =8 (5-8), SG=1.029 (1.005-1.030.) Nitrite +ve,
Protein 3+, Ketones trace, Blood 4+, Bacteria 3+. WBC >2250, RBC >2250
Crystals Triple phosphate 2+.
S/D advised.

17.10.11 Urine test. pH =6.5 (5-8), SG=1.006 (1.005-1.030.) Nitrite -ve, Bacteria Nil. Blood trace, WBC 20, RBC 3. Crystals Nil. To acidify urine.

9.9.11 Fits April and Sep 2011. Blood in urine. Follow up today Feb 8, 2012. "One fit episode, no point consulting the vet," she said. I said I was phoning regarding the S/D diet being fed for some time.

10.9.11 Blood test Total WBC high 22 (6-17). N=84% L=7%.
17.10.11 Blood test Total WBC normal but N=10%, L=22%, Monocytes=53%, Basophil =14%. Chronic infection/inflammation likely.

865. Calcium phosphate urinary stones - Xhih Tzu

Review of one case
Shih Tzu, Male, 8 years old
12.12.10 Dysuria urine pH = 7.2, USG 1.015



12.1.12 At Vet 1 emergency
WBC high 24.48 (5.5 -17)
Neutrophils 82%, L=3.6%, Mono = 12.9%
Absolute High for Neu, Mono, Baso, Plt, BUN, ALKP.

13.1.12
Urine pH 7.0, USG 1.012
Protein 2+, Blood 4+, WBC 468 RBC 25, Bacteria 3+, Crystals Nil
STONE ANALYSIS: Calcium Phosphate.
Negative for oxalate, urate, magnesiu, cystine, ammonia, bicarbonate

Monday, February 6, 2012

864. Performance counts - no repeat consultations

Sheltie, F, 8 years. Copious purulent nasal discharge on left nostril. There might be slight discharge from right nostril.

Feb 7, 2012 visit today. Case handled by Dr Daniel Sing with me. I did mentoring as I have to ensure that service is done efficiently and up to my standard."

It is Feb 7, 2012 now. The 2nd visit was on Jan 7, 2012. Vet 1 had extracted 9 teeth again. But bad breath still remained as I checked the mouth and noted that the gum of M2 on right upper jaw was inflamed. The tooth appeared shaky but I could not confirm it.

What to do with this case? I took over as the man wanted results.

1. Nasal swab for bacteria and fungus. culture and antibiotic sensistivity test.
2. X-ray of nasal area and lung to check for tumours, abscess or infections.
3. Extraction of the loose teeth as bad breath still persisted.

"This is my 3rd visit for the same problem," the owner said. "I want the vet to be pro-active.
The 3-rooted molar on the right upper jaw was shaky and I extracted it within a few seconds. There could be bacteria entering the nasal passages on the right side causing daily mucus production and pus and right nostril discharge. Altogether I extracted 7 teeth.

Will have to wait and see as persistent nasal discharge is hard to treat if it is caused by fungus and/or infected tumours.

An unusual case: Calcium oxalate stones, then struvite stones 4 months later

This case illustrates the importance of doing urine analysis for urinary stone cases. Sometimes, some vets may not do it to reduce veterinary costs for the owner. This is not good practice unless the owner rejected this test.



FIRST REPORT - SEP 2011 - Calcium oxalate urinary stones
http://www.sinpets.com/F6/20110920retrograde-hydrouropropulsion-singapore_ToaPayohVets.htm. The owner decided to feed just home-cooked food after the surgery.

SECOND REPORT - FEB 2012 - Struvite urinary stones despite giving "home-cooked food".
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm

862. Sunday's interesting case - rabbit eye tearing

Sunday Feb 5, 2012

Bright sunshine. Dr Daniel Sing started his first Sunday of working life after graduation. As a mentor of my associate vets, I was present in this case as in other cases of associate vets. Trust and audit are my management style to ensure a high standard of veterinary care at Toa Payoh Vets and that is why I do intrude into the consultation of my associate vets now and then and review their case sheets. There is no short cuts to be successful in work and life. "Associate vets in Toa Payoh Vets must adopt a consistency in the treatment of similar processes and system to ensure good clinical outcomes," I said to Dr Daniel Sing and Dr Vanessa Lin.

Without a system or standard operating procedure, each vet does his own treatment and may miss out on certain steps. For example, in urolithiasis, a failure to send urine for analysis or stone for analysis unless the client objects to this steps due to economic reasons. So, this is why I am around in some consultations of associate vets.

On this fine Sunday, Dr Daniel had a rabbit which had tearing eyes. A large bald area below the weepy eye. He touched the lower part of this hairless area. I did so too. The rabbit reacted by moving away its face. Abscess or tooth pain?

I got a fluorescein strip from the box and Dr Daniel stained the cornea. Show, not tell is the best in veterinary practice. The rabbit had an eye corneal ulcer as evident by the green 11 o'clock to 2 o'clock stain. So there is an ulcer? What next? New vets tend to relate a list of differential diagnosis to the client, as this is what the vet professors teach them.





5008 - 5009. Corneal ulceration in a rabbit. What is the cure? This is more important than why? The primary cause was two ingrowing cheek teeth on the right side. Isoflurane anaesthesia was necessary to open the mouth as the rabbit was very nervous when the vet tried to open its mouth.
To me, this is OK but some clients just have little time and just want to know what's wrong and the solution. Since this rabbit had an "on-off" eye tearing in the past few weeks and felt pain at the lower maxillary cheek area, Dr Daniel diagnosed teeth problem.

I advised warding the rabbit for one or two days. On the next day, to get the rabbit anaesthesized to check the mouth.

Monday, Jan 6, 2012
Dr Daniel used isoflurane gas mask to anaesthesize the rabbit. Min helped. I was around to pull out the tongue. Inside the left cheek, food and two long curved teeth of around 1.5 cm long were stuck and causing pain. Dr Daniel used the forceps to pull out the two teeth and two broken fragments. I took some images. I quickly irrigate below the 3rd eyelid with 5 ml of clean water as Dr Daniel everted the 3rd eyelid, just in case debris had gone inside it.

The rabbit should feel better now. Will observe on Tuesday and update. Rabbit should be able to go home. "This rabbit eats only pellets", said the gentleman owner. "No hay." He had gone home to bring the rabbit pellets.

Show not tell is the best advice for a vet in private practice. In this case, it was not possible to show the anaesthesia but there were two bone fragments and images to show the owner to give him evidence of what happened and what was done to ensure a good clinical outcome. I don't expect any tearing. On the surface, this appears to be a case of eye corneal injury as there is green fluorescein staining. Veterinary medicine can be challenging. Rabbits can't talk and owners can't tell what's wrong. Therefore, it is up to the vet to palpate (pain in the teeth area) thoroughly and in this case, the primary diagnosis would be ingrowing cheek teeth causing facial pain and irritation and eye rubbing to relieve the pain. A hypothesis. If the rabbit has recovered within 2 weeks, then my hypothesis is correct.

No need to spend money X-raying as visual inspection under anaesthesia using gas mask and isoflurane and oxygen is the method of choice and cheaper. "SC anaesthetic drug injection can be used but not necessary as the gas method is safer and the rabbit wakes up fast," I said.

The cause of tearing of the eye would be due to the rabbit rubbing its facial area to relieve tooth pain of the right teeth cutting into its right cheek, not corneal injury. "This rabbit has to be separated from the other rabbit for some time," I advised the owner. "This is to prevent the other rabbit from grooming or licking its eye." The owner said: "It is difficult to do so." Well, vets should advise but it is up to the owner to accept it.

Updates and more images at:
http://www.sinpets.com/F6/20120217cheek-teeth-ingrown-rabbit-eye-tearing-toa-payoh-vets_Singapore_ToaPayohVets.htm

861. Review of recurrent urolithiasis in an 8-year-old lMini Schnauzer

History
Miniature Schnauzer, Male, 8 years
9.3 kg 39.3C

15.9.12 Dysuria >7 days. Eats dry food.
Urethral obstruction. Catheter relieved obstruction.

15.9.12 URINE ANALYSIS
pH=7 (5-8), SG 1.030 (1.005 - 1.030)
Protein +, Blood 4+, WBC 504, RBC 1440, Bacteria +, Crystals Nil

X-ray

BLOOD TEST
Urea = 7 (4.2 - 6.3)
Creatinine = 61 (89-177)
WBC = 13.6 (6-17) with neutrophils 93% absolute 12.6, lymphocytes 6.5%, absolute 0.88
No hypercalcaemia

STONE ANALYSIS - multiple fragmented uroliths. CANINE CALCIUM OXLATE
Calcium oxalaate monohydrate 100% stone 5% shell
Calcium oxalate dihydrate 95% shell

16.9.12 Cystotomy. Urinary stones removed by Vet 1


RECURRENT UROLITHIASIS
3.2.12
8.2 KG 38.4c
Dysuria. Fed home-cooked food.


3.2.12 URINE ANALYSIS
pH=9 (5-8), SG 1.025 (1.005 - 1.030)
Protein 2+, Blood 4+, WBC 0, RBC >2250, Bacteria +, Crystals Triple phosphate +, Amorphous phosphate 3+

STONE ANALYSIS - Sent stones to the lab

Owner did not want blood test
X-rays - 15 stones seen. bladder and behind os penis. see image.

CONCLUSION
This is not a recurrent case of calcium oxalate urinary stones as the 2nd episode showed struvite stone formation.

MANAGING Calcium Oxalate Urolith prevention - do urinalysis and X-rays.
If urine SG >1.020 give canned food or add water to food
If urine pH <6.5, consider diets that produce less acidic urine eg. u/d or use urinary alkalinizers eg. K citrate If urine pH>6.5, USG <1.020, no crystals, repeat urinalysis monthly, then every 3-6 montyhs.
Repeat X-ray every 6-12 months to detect urolith recurrence early.
Repeat urine test and X-rays if signs - haematuria, pollakiuria, dysuria recur.

STRUVITE stones are clinically insignificantg if no urinary tract infection as bacteria forming urease are rquired for struvite urolith formation in dogs.

UROLITHS
1. Voiding urohydropropulsio9n if small uroliths
2. No clinical signs of blood in urine etc, leave stones alone.
3. With persistent signs, remove uroliths
4. Send for stone analysis.

For calcium oxalate prevention,
1. Diets promoting urine pH <6.59 were at highest risk
2. Avoid risk factors like hypercalciuria due to hypercalcemia, metabolic acidosis, high sodium consumption and Vit D excess.
3. Feed canned foods and/or add more water to food so that urine pH is consistently <6.5
4. Consider hydrocholorothiazide (2mg/kg q 12 hr) with highly recurrent urolithaisais in dogs without hypercalcemia.
5. Consider potassium citrate (75mg/kg q 12-24 hr) if urine pH is consistently <6.5