Saturday, June 30, 2012

Sunday Jul 1, 2012 interesting cases

Jul 1, 2012

1. Pekinese with right eye ulcer. Owners had run out of eye drops. Around 10 days since tarsorrhapy done by Dr Daniel.

Eyelid stitches removed. Dr Daniel used fluorescein eye stain. NO more staining indicating ulcer had healed. I took some images of pre- and post-injury corneal ulceration. I wil use this as a case study for video production. Excellent surgical outcome in this case. This was because the owner's mother knew how to care for this dog. The eyelids did not have any discharge or dirt on Day 12 when I saw him as contrasted to other dogs with similar problems and being cared for at home.

2. Foul-smelling "decomposed dog" case Shih Tzu had been warded here for 15 days. No more bad smell. Main problem is an intense ventral contact dermatitis. Dog just had to scratch belly -- traumatic injury and smells. Will follow up. 

History. Shih Tzu, Male, Born Sep 2004.

Seen other vets in Dec 5, 2009, Apr 16 10, May 10, 10, Aug 6 10, Oct 31 10, Apr 5, 11, Jul 10 11. 
Wanted to send dog to SPCA if I can't cure this "smell like dead dog" lower half of body. "The decomposed dog smell comes back 2nd day after bathing," the serious gentleman told me. "Not all skin diseases in the Shih Tzu are curable," I said to him. "Hospitalise the dog for a few days and let me observe him." The dog had a full coat with no hair loss. Some scales drop off from the lower belly and chest areas which were inflamed. I expressed the anal sacs.

They were filled with dark brown oil and very smelly. The flies appeared from nowhere and landed on this oil when I took the tissue with the oil for photography outside the Surgery. "Can't be the anal sac oil causing this smell," the owner disagreed with my findings and the fact that the flies were so interested in this anal sac oil. Normally, flies don't come at all. My hypothesis was that the oil might have licked out and stained the dog with the smell of dead flesh. The owner was not convinced as he said the groomer and the other vets had expressed the glands. Well, I had the pictures of the flies but it was poinless to show him since he had discounted this as a cause.

I smelt the dog's body on Day 3 of hospitalisation with medication given and skin washes done. There was a faint oily smell but not the decomposed meat smell. "Not that smelly," I said to the owner. But I observed that the dog's lower body was very red. As if the dog had rubbed it or more likely scratched it vigorously. The inflamed neck and groin was seen on and off. So, this was the problem. My hypothesis is that the dog just could not help scratching the lower body, due to conditioned reflexes. He had been scratching it for months as it was a way to relieve the itchiness. Some anal oil would have contaminated this traumatised skin and made the skin much more itchy and infected. So, 2 days after bathing, the rancid dead flesh smell came back.

Altogether, I hospitalised the dog for 14 days. "How much it will cost me?" the owner asked. "Not much," I said. "Since there is no surgery done." After 14 days of medication and washing, I sent the dog home with instructions that he wear a shirt to protect his lower chest and groin. The owner did that and on July 9, 2012, I phoned him. He was very happy as the dog did not smell anymore. Before sending the dog home, I expressed the anal sac. Another lot of dark brown anal oil came out.

This dog was not sent to the SPCA now and should live a normal life much loved by this serious gentleman. Dogs with skin diseases are sent to the SPCA to be put to sleep usually. Skin diseases in Shih Tzus are more common than in other breeds, in my practice experience. It is possible that the busy and time-pressed Singapore owners don't have time to do the daily brushing and grooming. This leads to skin infections and continuous itchiness. Many of these skin disease cases need reviews and strict compliance with medication prescribed. But this owner said that his dog passed blood in the stools when the other vets prescribed oral medication and so he did not do it. He did see 7 vets in 7 times as the vet practice has different vets on duty at times he went.   
     
UPDATE:
Yesterday, July 9, 2012,  I phoned the owner to find out the fate of this Shih Tzu.  He said: "No smell,"
"Did you buy the shirt for him to wear?" I asked. "Yes," he sounded quite happy. I hope this Shih Tzu's anal sacs don't produce more of the stinking oil again. I doubt the owner will come for review when there was no apparent skin problems!  





1059. Carnaissal tooth abscess, bone cyst or tumour?

I am reviewing the following case at Toa Payoh Vets on Sunday Jul 1, 2012 at 9.11 am as this time is peaceful, being located aways from lots of residents.



The 12-year-old Golden Retriever had a big hard lump on the right face, below the eye, in the position of a carnaissal tooth abscess fistula. At first sight, I diagnosed a carnaissal tooth abscess as this is the most common location and problem in older dogs that do not have any dental work done in 12 years! Dr Daniel said it could be a bone cyst or tumour.

As the owner did not want any X-ray to be done, Dr Daniel extracted the right maxillary 4th premolar.

I noted that the roots are shrivelled and blackened but I was not present during the dental work. According to Dr Daniel, this would not be a carnaissal tooth abscess. "I have seen two cases of bone cysts in Australia" he was doing internship then.

"Did you see the bone cyst in a similar location, below the eye?" I clarified with him later.
"Not in this location but bone cyst can occur in anywhere as a hard swelling from the bone. Bone cyst is a differential diagnosis."

"I have seen none in my past 30 years of practice," I said.

99% of my cases are small breeds as over 80% of Singaporeans live in apartments and so Golden Retrievers are uncommon patients and so I have not seen one with carnaissal tooth abscess in this breed.

So, is this a case of a carnaissal tooth abscess or not? The owner did not want histopathology or biopsy but agreed to X-rays after the tooth extraction. I have cropped the X-rays to focus on the relevant areas and to scrutinise them. What do you think?     








X-ray after extraction of the maxillary PM4 showed a large dense globular lump (Y). It is hard to say whether it is a bone cyst, bone tumour or encapsulated abscess of the root of the carnaissal tooth.

MY HYPOTHESIS
Due to its unique location, I would say this hard lump is associated with the carnaissal tooth infection going on for many years. This dog did not have dental work for the last 12 years and the tooth root had rotted away sending bacteria into this area, infecting the bone. The reaction is a hard lump which the owner noticed recently. The dog was still "eating" and the owner consulted us for the lump.

FOLLOW UP
 

1058. Medical negligence - failure to examine the baby's eyes

Sunday Jul 1, 2012

Blue skies, white clouds. I came to the Surgery at 8am and took some pictures of the yellow flowers and lime against the bright morning sun. My air-conditioning lady neighbour had planted them on the flower lots separating the car parking lots and cared for them well. I managed to take a picture of a butterfly and a solitary busy bee. There was a small bird with a yellow neck seen for a short while. Taking flower images with a working Sunday bee in bright morning sun make them look better.
MEDICAL NEGLIGENCE - FAILURE TO EXAMINE THE BABY'S EYES

Earlier, I read a Straits Time report about a 52-year-old paedectrician having to settle with a parent whose 12-year-old child's eyes (one blind and one in poor visual health) were not examined by him 12 years ago.

I always emphasized to Drs Vanessa and Daniel that certain procedures must be done and recorded. If the pet owner does not want the procedures, this must be written on the case file. Failing to perform certain procedures will lead to "medical negligence" litigation. They are to write "AMA" - procedures informed but not wanted to be done.

As each vet or doctor has his or her own sensibility and responsibility, it is up to the licensee to ensure that best practices are followed. For example, in a haematuria case, urine analysis is mandatory. No excuses. If the dog dies subsequently, a failure to get the urine analysed opens the vet to medical negligence litigation. As simple as that. It takes a lot of patience to ensure that the clinic is well managed so as to minimise litigation.   

Thursday, June 28, 2012

1057. How to succeed in the wedding photography business

Jun 28, 2012
National Library Board
Professional Photographer   www.professionalphotographer.co.uk  Feb 2012
THE BUSINESS - New Series - "What recession..." Kevin Mullins Pg 73

His plan was to double the bookings year on year to a comfortable level.
In his first professional year in 2009, he shot 15 weddings. In 2010, 33 and in 2011 doubled again to 58 weddings. In 2009, the standard wedding rate was 800 pounds. In 2011, over 2000 pounds. Success affected his personal and social life.

Success factors:

1. USE STATISTICS TO YOUR ADVANTAGE
Every enquiry made in a preadsheet and keep track of enquiries even for dates he is not available.
Can see whether the referral came from (website, oral etc), the venue, date of wedding and importantly the date of enquiry.
*From statistics, he checked his business practices e.g. venues, busiest periods for enquiries is in Jan and Feb. 2nd spike inend of summer. Plan for 2011.
 *statistics gave him a profit per hour per wedding. assess whether worth sacrificing 6 days a week and lot of his social and personal life.
*do not really want to increase his fees a lot. Decided to spend less time to make the same amount of money per wedding.

Three moves that changed his business for the better:
1. Move to a time-based fee
2. No more pre-wedding shots (taking up lots of evenings and Sundays) for wedding packages.
3. Reduce the amount of editing per wedding

2. TRIM YOUR SERVICES*His brand is a photojournalistic wedding photographic style, so it does not lend to pre-wedding shots (which is stationary, like taking pictures in Taiwan).
*if do pre-wedding shots, should charge for time spent in the package prices and do it at times suitable to his business and his family.
*reduce number of imagaes from 400to 200 to clients. So he saved many hours a week time in editing output
*got new tools in his workflow e.g. Photo Mechanic - another article.

3. CHARGE FOR OVERTIME WORK
*He noted that he rarely leave a wedding on time. He usually worked on a "bridal prep" to "first dance" basis. (Singapore does not usually have "first dance"). He found that in 2010 he spent 60 hours after the "first dance" unpaid.
*now he charges overtime (like caterers, DJ, drivers etc)


4. KNOW YOUR CAPACITY LIMIT
*58 weddings are too much to shoot and edit as he has no personal life. In 2012, he capped bookings at 30 in his diary.

5. USE FORUMS AND SUPPORT GROUPS FOR TRAINING
*
The SWPP is great for mentoring, support and access to great photographers
*frequently use a photography forum called IPPN  (www.ippn.co.uk) - very helpful.
*learning all the time as idustry is tough. He knows that he must be on top of the business side of things to be successful.  

Conclusion. Keep track of your business through metrics and accounting (including workflow and marketing), a lot of hard work and beautiful photography, have a faithful and honest work ethic, business will grow.

www.kevinmullinsphotography.co.uk
www.twitter.com/kevin_mullins



The above factors apply to the business of veterinary practices too esp. using metrics and proper accounting, hard work and do beautiful surgery (good surgical outcomes, no infections).
Today, I read that a "bogus vet" in Singapore was to be fined $42,000 for doing stray cat sterilisations in her Bishan apartment. She was a veterinary nurse working for a veterinary clinic. The Cat Welfare Society alerted the clinic that they had received invoices with two different types of clinic stamps. She gave $5.00 commission to the transport man for every cat brought to her and was using the clinic's invoices.

Wednesday, June 27, 2012

1056. KPI and follow-up: Open Pyometra chihuahua

On Jun 15, 2012, the breeder's Chihuahua that had been adopted by a couple was spayed after 24 hours of IV drip and antibiotics.
12 days later, the owner complained about some bloody discharge from the dog's vagina.
"Is she eating normally?" I asked. "Yes," he replied. "Some cases of pyometra do have small amounts of bloody discharge some days after operation," I prescribed him antibiotics.

Today, I review the June 14 blood test result. Total WCC 14.4 (6-17) was normal. N59%, L21%, M15%, E2%, B3%.   Platelets wee lower at 175 (200-500). Platelet clumping noted. However, the dog is normal and the high monocytes (M) and low platelets did not adversely affect this dog.


USING STATISTICS TO LOOK AT MY BUSINESS PRACTICE - TIME SPENT/DOG SPAYED BY THE VET. IN THIS CASE, THE VET IS MYSELF.

HOW LONG IT TAKES TO SPAY AN OPEN PYOMETRA CHIHUAHUA?
Date of surgery: Jun 15, 2012
Vet: Dr Sing Kong Yuen
Procedures: Spay and dental scaling
Chihuahua, F, 9 years old, 2.2 kg, 37.2C.
No. of packets used: 2. Type: Polysorb absorbable 2/0 and 3/0
Dom + Ket at 25%    0.02 + 0.03 ml IV

1.  A:  IV inj Dom + Ket    10.07 am
2.  B:  Isoflurane gas first given  10.09am
3.  C:  Isoflurane gas Stopped: 10.51am (spay and then dental work)
4.  D: First skin incision: 10.18 am
5.  E: Skin stitched: 10.44 am

E-D = 26 minutesE-A = 37 minutesA small breed dog or cat spay should be completed (E-D) in less than 20 minutes and (E-A) should be less than 30 minutes. For pyometra as in the above dog, the time taken is longer as the womb is filled with pus and extra care and longer skin incision are needed during surgery.






I am still doing a trust and audit check on my vets to make sure that the time spent/spay is not too long due to lack of planning and inefficiency or idle chatting. Employees love to chat and that is part of human nature. However, no chats should be done during surgery as there must be focus on the patient's life.

Proper accounting must be done to ensure that the business can survive in this harsh economic environment.



1055. Update on article: Be Kind & Brave - Adopt a Stray

PROMOTING THE ADOPTION OF STRAY CATS


My latest image "Be Kind & Brave" was inspired by a Singaporean couple who adopted a cat from the Cat Welfare Society. "Adopt a female cat," I advised since the 7-year-old male cat had signs of FLUTD and had passed away during treatment at a veterinary practice, causing much distress and sadness to the wife.





Compared to my older image in 2003, I have improved my photographic skills and have got a better lens! Both cats were photographed outside the Toa Payoh Vets with the wall as the background. I prefer the 2003 image as it seems more dynamic.



It is quite difficult to think of captions. Both cats were sterilised by me. The male cat in 2003 was brought in by a cat activist to be neutered and left ear tip snipped. After that, he was put back to the streets. Over the years, pest control firms appeared to net the stray cats and so in 2012, you seldom see stray cats at eating places in the wet market.



However the other "Be Kind & Brave" cat in 2012 has a very good home and is well loved. There was no need to snip her left ear tip unlike community cats without homes. Her spay operation is shown below. She is OK and back to normal now.



I hope that in the next 3 years, Singapore will permit cats to be housed in the HDB apartments so that they need not be "illegal" in public housing.



A pretty stray cat from the Cat Welfare Society was adopted and came to Toa Payoh Vets for general examination and later on, vaccinations.



She grows up fast. She caterwauls and is the loud screams disturb the neighbours. I spayed her around the 10th day from the onset of caterwauling.









Her owner wanted a complete blood test and FIV screening to check her health status. Blood test shows low platelet count which was worrisome. FIV test was negative. As at Jun 28, 2012, the cat is in excellent health and is very active, being much loved by a Singaporean couple.





TIPS TO EXCEL IN VETERINARY MEDICINE AND SURGERY



Young vets are advised to learn the skills of digital photography such that they can produce excellent veterinary images. By illustrating reports of cases seen with attractive pictures, the vet improves his or her veterinary knowledge and diagnosis.



There are many distractions in Singapore such as the many online shows and TV programs to watch. If young vets want to be great vets, they need to sacrifice their spare time to do practical research and write up case studies. In doing this, the vet reflects on his or her handling of the case and gets better at treatment of similar cases. Good clinical and surgical outcomes are produced and the vet builds up a good reputation over the years as referrals from happy clients come from distant parts of Singapore. They come not because the vet is "cheap", but because he or she can resolve the owner's pet problems fast.



IMAGES ARE AT:
http://www.toapayohvets.com/sinpets/20120615digital_photography_stray_cat_adoption_singapore-ToaPayohVets.htm

Tuesday, June 26, 2012

1054. Adopted stray cat with low platelet count

TOA PAYOH VETS ARTICLE AT:
 http://www.toapayohvets.com/sinpets/20120615digital_photography_stray_cat_adoption_singapore-ToaPayohVets.htm

The owners wanted a complete blood test of the adopted cat that was to be spayed on the same day. She was caterwauling 11 days ago. There was a weight loss and I was told she was fed a Barf diet. I advised against spay surgery to be on the safe side. The wife wanted it. The ovarian vessels were much congested due to the heat period and needed extra care in ligation.
The cat took around 2 days to recover but this is the normal situation after spay. Now the cat is very active as I read from the email below.

BLOOD TEST
Jun 8, 12
TP 41855
Cat Welfare Society Adopted cat around 1 year old, female.

Significant findings blood test (jugular vein)
Total WCC 5.3 (5.5-19.5)
N 63%, L28%, M 4%, E6%, B0.1%
Plateltes 38 (300-800)
No platelet clumps seen. Large platelets present.

As to why the platelets are low, it is hard to know the cause. Clinically, the cat was active and the surgical outcome is excellent as the cat has no complications (bleeding and infection) after spay and is active. So, this low platelet count is one of the mysteries of veterinary medicine.

UPDATE JUN 27, 12. However, the cat is OK. One dangling stitch is still present 19 DAYS after spay on Jun 8, 12. But the is not bothered. I advised they will dissolve in 2-4 weeks' time, so no need to come to me for stitch removal. I use polysorb absorbable sutures 3/0 and did 2 horizontal mattress sutures. As the cat would not permit a focused image to be emailed to me, I don't know whether it is the stitch or not. In any case, all dissolvable stitches in the skin drop off from 14-28 days after surgery.


I am keeping the emails for reference and will reply if I have more info.


E-MAIL TO DR SING DATED JUN 27, 2012
Dear Dr Sing

Thank you for the care and advice concerning Sofi. As spoken yesterday, she has healed and recovered exceptionally well. The stiches are still visible though she shows no discomfort and does not lick the site at all. Please find the links below for 1) Barf and 2) Wellness

1) BARF - http://barfsingapore.com.sg/

This appears to be a well balanced and species approraite diet for cats though we are a little concerned about the possibility of contamination and exposure given the transportation process from Australia to Singapore. Going back to Sofi's blood test which indicated low platelets, we also wonder whether it could possibly be toxoplasmosis from eating the raw food, this is just speculation of course, the low platelet count could be due to a variety of reasons. Since the operation, we have stopped feeding her BARF completely.

2) WELLNESS - http://www.wellnesspetfood.com/recipes.aspx?pet=cat&ft=2

We are currently feeding her the canned chicken version. She consumes a can in about one and a half days with a little water added in every meal. In addition to the canned food, she also receives about a spoonful of Wellness Core kibbles daily. This is more to add variety and give her something to chew on.

We would be happy eto hear your thoughts on the pet food and anything else you have to say.
Best Regards



TOA PAYOH VETS ARTICLE AT:
http://www.toapayohvets.com/sinpets/20120615digital_photography_stray_cat_adoption_singapore-ToaPayohVets.htm

Monday, June 25, 2012

1053. SOP: A dog with closed pyometra

A FEMALE DOG WITH CLOSED PYOMETRA - STANDARD OPERATING PROCEDURES (SOP) AT TOA PAYOH VETS 
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore When an older female dog has pus in the vaginal discharge or is suspected of having closed pyometra, the following will be the procedures at Toa Payoh Vets to provide the highest standard of care. This SOP defend the vet during allegations of negligence litigation or complaint if the dog dies later.
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore
1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your estrus onset and duration to determine whether parvovirus is a likely cause.

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

3. DETAILED EXAMINATION. Parvoviral test, blood test (haematology or complete blood test), stool test. There may be a case for veterinary negligence if the parvoviral test has not been done.

4. TREATMENT. According to symptoms. IV, SC or oral fluid therapy depending on situation. Antispasmodic, antibiotics, multivitamins, protein drip, Vit K1 when necessary. Times and amounts given will be recorded.

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 puppy. Such phone calls must be recorded in the medical case files.
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore
new puppy purchased has loose stools, now has blood in stools for 2 days, toapayohvets, singapore 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 WEBPAGE:
http://www.sinpets.com/dogs/20111036puppy-blood-in-stools-diarrhoea-vomiting-singapore-toapayohvets.htm

Sunday, June 24, 2012

1051. Sunday Jun 25 12's interesting cases

Sunday Jun 25, 12 was a bright sunny morning. It was my nephew's wedding and it was the day my car's malfunction (battery warning sign) meant I had no car.

INTERESTING CASES
1. Rabbit with backside licking.
New client. The Hongkong mum and two pre-teen daughters living in Singapore wanted to consult Dr Vanessa.

I was at the counter service making sure that all clients get served within 5 minutes of waiting as there was a complaint of having to wait over an hour for one of my vets by a guinea pig owner whose guinea pig has eye ulcer in one eye and now had another eye ulcer.

Referrals from a pet shop as the owner of the rabbit had been twice to Vet 1 near her place but could not get resolved. Referrals are important but resolving the problem of the rabbit is more important. "Otherwise the owner will have to go to the 4th vet," I said to my vet. It is as simple as that. I would monitor this case.

2. Emaciate Bischon has no more hard "durian seed" in the abdomen compared to 2 days ago. The owner did not want any blood test and X-ray. I showed her how to feel the durian seed as the dog was skin and bones. She said she had paid $2000 at another vet for her dog treatment and would not want any test.  I gave the IV drip for past 2 days. Today, I palpated the abdomen and there was no more hard mass. The dog had passed hard greenish stools thick as the biggest German sausage. Will be sent home on Monday.


3. Eye ulcers are emergencies
One home-maker with a small daughter noticed that her Shih Tzu's eye was tearing and half-closed. She phoned her husband to abort his golf tournament. I handled the case and use the fluorescein eye stain test. The ulcer is obvious and my vets don't feel it necessary to do the test. I have to get them to change their mindset and adopt a SOP or treatment protocol.

"Eye stain of a bright green means a recent ulcer," I told my vets. "The other parts of the cornea with no obvious ulceration will show a lighter green as in this case." I showed the image to my vets. It is hard to change mindsets as most vets don't feel the need to demonstrate the presence of corneal ulcers. After all, it is obvious as the eye is itchy, watery and inflamed. This type of thinking is not based on evidence-based medicine. The picture of this case showed a deep central ulcer with other keratitis from central area upwards. Could this be due to the baby daughter pulling the dog's tail or scratching the dog's eye? She was with the grandma. "Nobody knows how the injury is caused," I said. "It is best not to upset the caregiver. As the eye injury is within 24 hours and the cornea is not perforated, chances of healing with tarsorrhaphy are good."  




4. Syrian hamster with scabs and crusts on face and spinal area. Probably scabies but hard to find the mites on microscopic exam. Given ivomec inj. Warded 4 days to get the scabs peeled out, otherwise, they irritate the hamster (84 g, lost weight for Syrian). Mother and Primary 6 daughter came to bring the hamster home today. She is very current on newspapers as I mentioned that females are very good at studies and work if they are motivated. "Like the two IT ladies mentioned in the Straits Times corruption cases. They can close deals but the way it was done was not the way." She knew what I was talking about but not her mum. She said: "Mum does not know." The hamster's skin needed to be treated properly at home and I would see it in 2 weeks' time.

5. Instant diagnosis. "A malar abscess" I told Dr Daniel when a Golden Retriever came in with a swelling below the eye.
"He needs an X-ray to see whether there is any tooth root fracture," Dr Daniel said.
"For economic reasons, the X-rays and blood tests are not wanted," I replied. So, we would give the IV drip and antibiotics and operate the next day.


6. "Dead dog smell" Shih Tzu looks better and scratches its lower body much less. I smelled the body as it is the only way to confirm the owner's complaint "dead dog decomposed smell."  Dry eyes. Under treatment. Bathed.

7. American cocker paw maggot wound finally closing. >30 maggots. "The exposed toe nail needs to be cut off," I said to the owner and Dr Daniel. Otherwise, it is irritating and painful."

8. The Beagle with the bladder cancer came in for dental work and ear irrigation under anaesthesia. He was quite active but I noted he has difficulty peeing in the morning when let out today (Monday 10 am). He would lift his leg against the tree trunk and not a drop of urine passed out. He had peed in his crate overnight though. Needs his anti-fits medication or his body will tremble.


9. Young Schnauzer still has nasal discharge and sneezing (cold?). Vet 1 was consulted and recommended "saline into the nose." This is unconventional treatment and so I don't know why. Conventional treatment by Dr Daniel. I phoned on Monday 11 am and the lady said the dog was not sneezing. Each vet has his or her way of treatment but in the end, the good clinical outcome counts. This is the reality of life.

Saturday, June 23, 2012

1051. Urethral catherisation in the female dog

I manage to find my article written in 2011.


http://www.sinpets.com/dogs/201006260catheterisation-female-urethra-dog-Singapore-ToaPayohVets.htm


In male dogs, every vet knows where to insert the urethral catheter, but in the female dog, it is very common to incorrectly insert the catheter in the clitoral fossa if the vet does not know the anatomy of the female urinary system! So, I am attaching an illustration for reference.





An X-ray of a Miniature Schnauzer that has urethral catherisation. Digital palpation and insertion of a soft catheter was done by Vet 1 as I had referred the owner to her. I was in Hong Kong at that time and the dog had difficulty peeing after passing out some stones. Did the dog owner agree to Vet 1 removing the urinary stones? No.

"Why?" I asked Vet 1 later when I returned to Singapore. She was willing to spay and remove the urinary stones at one surgery whereas I did not want to do two-in-one as I don't increase my anaesthetic and surgical risk by doing a prolonged surgical procedure.



She did not know the reason. "Is it the cost?" I asked her.



"No," she said. "The owners were agreeable to do the two surgeries when they consulted me."



First X-ray shows numerous stones. Advice to remove the bladder stones not taken up as the owners wanted a spay to be included at one surgery, i.e. 2-in-one operation.
Subsequently, second X-ray with urethral catherisation. I checked out this X-ray 24 hours before the spay
PHOTOS ARE IN TOA PAYOH VETS' WEBSITE


Vet 1's boss tries to send image to me via his Blackberry phone.



Owner shows me the 5 stones peed out

Spayed by me

"How much did you quote?"



"The usual rates," she would not give me the actual figure. A fuzzy reply.



"Did you do it immediately?" I asked.



"No, it was a Saturday and the cost would be much higher. I hospitalised the cat. They took back the cat on Sunday."



"Did you follow up?" I asked.



"Yes, but there was nobody answering the phone." This is a good vet as many vets don't do follow up.



"I am sure it is the cost," I said.



"No," she replied. "They had agreed to the surgery."



Other than cost, what could it be? Preference for a veteran?

Later the husband came to me to get the dog spayed. The husband would not give me the reason as to why they did not accept the combined surgery as that was what they wanted. A fuzzy reply saying that the dog could pee after the catherisation. Besides the dog could pass out the 5 stones. So, they did not want to operate. The husband asked: "Vet 1 says the bladder will rupture if I don't remove the bladder stones as they will increase in size. Is it correct?"

"The bladder will rupture if the urine can't flow out for a long time," I said. "The stones will irritate the bladder causing bleeding. As to whether the stones will rupture the bladder by themselves, I don't think they will as they are not sharp." It is a difference of opinion. Some vets will not agree with me.

The dog still has the 3 stones and apparently had no blood in the urine. I did not advise further as this would be like high-pressure selling. The husband had associated feeding 2 cans of S/D diet with the passing out of 5 stones (see image) and got another 6 cans. I had advised 1-3 months feeding of S/D diet for struvite stone dissolution but that means more than 6 cans!

Knowing the reasons of the client is important to improve the standard of care and service. If the vet does not bother to ask, the answers will never be known and the standard of care cannot be improved.

UPDATE: As at Jun 25, 2012, no complaints of blood in the urine. I have not phoned yet as it seems to be "pestering" if the owner has decided not to operate. The spay op was OK otherwise I would have heard from the owner. Since the stitches were dissolvable, I did not see the dog post-op to remove the stitches.
The first report of this case is at:

http://www.sinpets.com/dogs/20120246bladder-stone-spay-packaged-deal-singapore_ToaPayohVets.htm

Cat with rectal prolapse

I presume you are a veterinary foundation. You can use the image in its original form with "toapayohvets.com" in it. Best wishes.






On Sat, Jun 23, 2012 at 9:45 AM, Hannah Lieberman wrote:



Wow, thank you for getting back to me so quickly. That's exactly the one I want. It's very clear.



If we wind up using it, I will absolutely give you credit as requested. I will also send you the link to the finished product.



Oh jeez - I just re-read what I had written. I'm sorry. What I meant to say was that we don't treat rectal prolapses. Because we get so many requests, and because the general public doesn't typically understand what is happening with their pets, I am making lists of what we do and what we don't do, and trying to provide photographic examples for everything on both lists. The rectal prolapse is something that falls under surgeries we don't do. (Sadly.) I hope that doesn't change the status of your permission.



I'm attaching the requested image. Thank you again.





Sincerely,

Hannah Lieberman

Mobile Clinic Director

The Sam Simon Foundation



Use your tools of the trade - opthalmoscope

Yesterday, Friday, Jun 22, 12, I allocated cases to Dr V and Dr D so that waiting times don't drag on as most Singaporean pet owners hate to wait at the Surgery. This is a common trait and many vets and doctors at Clinics don't realise that trait. So, I install this system.

The new client went to Dr V.

"I just want a second opinion," the lady in her 40s said to me. "My vet (many years of experience and consulted by this owner for around past 20 years) said my dog's blindness is due to brain problem and not cataracts. He said there is no cure. MRI may detect where the problem occurs in the brain."

I went into the consultation room to particpate.  After fluorescein stain showed negative corneal ulcers. The dog banged his head when he walked and so there was blindness in both eyes.

WHAT TO DO?
"Did your vet do an eye check with this opthalmoscope?" I asked the lady who came with her brother-in-law whom I mistook for her husband.

"No," she said. I guess her regular vet finds that it is not necessary to use the opthalmoscope or there are other reasons as each vet approaches a consultation differently from others.


NOTES: This may be a case of SARD
Sudden acquired retinal degeneration (SARD)
Bilateral. Middle aged. Older dogs females predisposed. All breeds affected.
Complete blindness
Cause unknown
No treatment
Bilateral absence of the menace and dazzle response
Resting mydriasis
Retina degeneration
Hyper-reflectivity of tapetum
Vascular attenuation
Differential diagnosis:  Central (neurologic) blindness or peptic neuritis
Test: Electroretinogram


This case is a female Maltese, 8 years old, completely blind. Will wait for blood test report. From the opthalmoscopy, I saw in both eyes, the lower half of the fundus being very shiny reddish brown (hyper-reflectivity) like semi-circles. The upper half is greyish white with bigger blood vessels (Vascular attenuation) seen. The optic disc appears swollen (oedematous) - optic neuritis?

Follow up: Rabbit with large cheek abscess





E-MAIL TO DR SING DATED Jun 19, 2012
Dear Dr Sing,

here are the photos of Huihui and Ban Ban's most recent photos. No 18 is to let you see how they are housed currently, normally no partition only cos Huihui needs to be separated from Banban currently.

Thanks a lot for helping explain many things to us also and all the advice and recommendations.

Just to inform you that Huihui has started eating the pellets slowly and had drank at least 10mls of apple juice.


E-MAIL TO DR SING DATED Jun 24, 2012

I want to ask when should I stop pumping in the chlorohexidine wash into his face as the hole actually closes up every morning and evening and I have to poke through the sealed hole each time I wash..... The swelling has gone down considerably but the area around the hole is quite hard so I am not sure if there's anything wrong. I am not sure if there is still any pus inside although I thought I see some whitish stuff inside. His appetite has gone back to normal and his speed of eating has returned to normal. He also started to lick me after each treatment, which I considered as a good sign as he hasn't did that since the swelling started. He has also regained his energy, running and jumping up and down his toilet, standing up frequently to beg for treats/pats. So can you please advise me if I should continued poking through the hole to wash or just leave the hole to closed up?

Sorry for the long letter but I thought I should let you know how he is doing


E-MAIL FROM DR SING DATED Jun 24, 2012

I am glad to see one of your two rabbits after over 5 years. I am still checking my website the original picture taken when I neuter and spay your two rabbits.

You have written an excellent post-op nursing report. Good detailed report from the owner is very rare and is useful as a follow-up on the operation (lancing of the abscess done by Dr Vanessa before the X-ray as advised by me).

You need to flush out as much pus from deep inside the abscess and therefore continue irrigation till you don't see any "white" pus inside the cavity.

1. From the X-rays, the abscess from the elongated impacted molar is very deep and molar tooth extraction should be the solution to prevent recurrence of the abscess. However, this procedure is not so easy in a rabbit compared to the dog and cat.

2. The rabbit needs to be checked for molar spurs every 4 weekly. Trimming of the spurs to the gum line may be necessary in malocclusion.
3. Make an appointment next Sunday morning July 1, 2012 to check on the molars and the abscess. I am in the midst of writing a case report of your rabbit X-ray. It takes lots of time to do it. Best wishes.

Friday, June 22, 2012

1047. Permission to use image of cat with rectal prolapse

On Sat, Jun 23, 2012 at 5:52 AM, Hannah Lieberman wrote:


Hi there,

I run a non-profit foundation mobile veterinary clinic that we take to low-income neighborhoods in Los Angeles, CA three days a week to perform veterinary surgeries on pets belonging to low-income residents. All services are completely free.


I am currently building a new website, and including photos of ailments that we're able to treat in our clinic. Since we treat rectal prolapses, I'd like to include a picture of one.

I really like the picture of the cat with the rectal prolapse you have your website, and would like to include it on ours. May we get permission to do that, please?

E-MAIL REPLY FROM DR SING DATED JUN 23, 2012
I am Dr Sing from Toa Payoh Vets. Which picture hyperlink is that? Please let me know.


You can use the picture of the cat with rectal prolapse if you use it without deleting "toapayohvets.com" acknowledgement. Good luck.



1046. Closed Pyometra - blood tests and x-rays

Golden Retriever, Female, 10 years

Not eating for 4 days. Lethargy. No fever.

History: Polydipsia & Polyuria

1.  Blood test:
Total WCC = 38 (6-17). N86%, L4%, M9%, E1%, B0%

2. X-rays: Uterine horns filled with pus
3. Ultrasound: Pus seen in both uterine horns. Cervix is closed.

Diagnosis: Closed pyometra

Surgery: 1 hour. Spayed.

Outcome: Good. Dog is back to normal.

High total white cell count and history indicated closed pyometra. X-rays and ultrasound are useful to confirm pus in the uterus.

1045. Example of a veterinary report


From Jun 23, 2012, all veterinary surgeries will be recorded in the following format:

http://www.bekindtopets.com/animals/20120613veterinary-report-format-adenocarcinomasingapore-ToaPayohVets.htm


\

From Jun 23, 2012, all vets at Toa Payoh Vets will record the veterinary surgeries done in the following format and e-mail to Dr Sing. This e-mail will be stored in the "cloud". An example is given below:



Veterinary surgery report - excision of bladder adenocarcinoma on May 14, 2012 & follow up 38 days later on Jun 21, 2012



Date of Veterinary Surgery Report: Jun 22, 2012

Name of Veterinary Surgeon: Dr Sing Kong Yuen & Dr Daniel Sing



Case seen on May 14, 2012 by Dr Daniel Sing

1. History & Complaint: TP 43355, (Name of Dog), Beagle M, 13 years, attended by Dr Daniel Sing



2. Presenting Sign & Symptoms: Incontinent with bloody urine dripping all over the floor and passing blood clots for > 4 weeks. Haematuria + Anaemia



3. General Examination: Abdominal pain



4. Tests done & significant findings of tests:

4.1 Blood tests

May 10, 12. RBC low 5.1 (5.5-8.5), Total WCC 12.4 (6-17), N 75%, L12%, M7%, E5%,B1%

Jun 21, 12. RBC 5.6 (5.5-8.5), Total WCC 12.1 (6-17), N 77%, L16%, M7%, E0%,B1%



4.2 Urine tests

May 10, 12. pH 5, SG 1.005, Protein 3+, Ketones 1+, Blood 4+, WBC 90, RBC>2250, Bacteria 3+



Jun 21, 12 pH 7, SG 1.008, Protein 1+, Ketones -ve, Blood 3+, WBC 48, RBC 351, Bacteria 3+



4.3 Histopathology: Moderately differentiated adenocarcinoma



5. X-rays: Radio-dense "stones" seen in bladder area.



6. Anaesthesia: May 15, 12. Body weight: 16 kg. At 50%, Dom 0.32, Ket 0.4 ml IV. Isoflurane gas maintenance. Surgery time: 2 hours. Polysorb absorbable sutures 2/0 x 3 packets, 3/0 x 1 packet



7. Surgery: May 15, 12. Excision of hard gritty tumour, 1.8cm x 1.5cm x 0.5 cm, near the neck of the tumour. Sent for histopathology. Operating surgeon: Dr Sing K Y. Assisted by: Dr Daniel Sing



Follow-up dates: May 22, 12 7.35 pm, Dr Sing K Y phoned owner. No response.

Jun 22, 12, Dr Daniel Sing informed owner of the 2nd blood and urine test results



Signature of Veterinary Surgeon: Dr Sing K Y

Date of this report: Jun 22, 2012



Attached and owner has acknowledged receipt:

Blood tests given to owner: No

Urine tests given to owner: No

X-rays given to owner: No

Ultrasound report given to owner: Not Done.

Histopathology report given to owner: No

Sterilisation Certificate No. .... given to owner: NA

Others given to owner: NA



Anaesthetic & Surgical Record No. ........(Form is not printed yet).

Ear Scope: NA

Skin scraping: NA

Opthalmoscopy: NA

Urinary stone analysis report: NA

Others: NA



Comments by Dr Sing K Y

Another two attempts to phone the owners were not successful. On Jun 21, 12, the owners came with the complaint of painful left hip and re-stocking of anti-seizure medication which must be given daily to prevent seizures. Jun 21, 12 was 38 days after the surgery.



Outcome of surgery: Good. On Jun 21, 12, the couple is very happy that the dog is active and no longer drips dark brown blood and passes blood clots everywhere. They said the urine is clear and has no blood. The dog is able to control his bladder during the daytime but not at night. The dog weighed 15 kg compared to 16 kg during first visit but is putting on weight. Bladder palpation by Dr Sing elicited a painful whine from the Beagle. The bladder was around the size of the tennis ball. Catherisation by Dr Daniel Sing did not produce urine. The wife came later in the afternoon with a bottle of urine collected directly from the dog.



Results: This 2nd urine test indicated UTI and demonstrated the presence of blood. The lab reports will be given to the owner at the next visit.



2nd urine test: Jun 21, 12 pH 7, SG 1.008, Protein 1+, Ketones -ve, Blood 3+, WBC 48, RBC 351, Bacteria 3+



baldder adenocarcinoma seen during surgery. beagle, male, 13 yearsCase report at Toa Payoh Vets:

tpvets_logo.jpg (2726 bytes)5301.

Trust & Audit in a Case of an old Beagle with fits and bladder cancer



http://www.sinpets.com/dogs/20120440veterinary-audit-cystotomy-carcinoma-bladder-toapayohvets-singapore_ToaPayohVets.htm


1044. Veterinary surgery report will be recorded for every surgical case in the following format

A veterinary report will be recorded for every surgical case with the following format and filed on the discharge of the pet:

Date of Veterinary Surgery Report:
Name of Veterinary Surgeon


1. History & Complaint
2. Presenting Sign & Symptoms
3. General Examination
4. Tests done & significant findings of tests
5. Diagnosis - tentative and confirmed
6. Treatment
7. Anaesthetics, Surgical procedures, Sutures & No. of packets used (Record No. )
dates
8. Date admitted: Date discharged:
9. Clinical outcome 3 & 14 days or later - Follow-up dates:

Signature of Veterinary Surgeon
Date of this report

Attached and owner has acknowledged receipt:
Blood tests given to owner
Urine tests given to owner
X-rays given to owner
Ultrasound report given to owner
Histopathology report
Sterilisation Certificate No. given to owner
Others given to owner
Anaesthetic & Surgical Record No. ....................
Ear Scope
Skin scraping
Opthalmoscopy
Urinary stone analysis report
Others

Comments by Dr Sing K Y

Wednesday, June 20, 2012

1043. The cat bit his tongue - need for thorough exam of the mouth

Two cats fought on the ledge of the 7th storey HDB flat. Both fell at 10 pm yesterday. The stray cat died. The home cat came for treatment as she has blood stained chin.

Simple case. A horizontal lacerated wound. Stitched up 3/0 nylon for chin lacerated wound. 5/0 nylon for tongue vertically lacerated wound (lower and upper area) . I advised nylon instead of dissolvable as the area was infected due to trauma and cat fight.

After the surgery, I took some pictures and saw the lice running around the face. Also tartar in the teeth of this 3 year old cat. I phoned the owner to advise dental scaling and he said OK. During scaling, the vet noted a big laceration of the tongue. The owner was phoned to give permission to stitch up. I advised 5/0 nylon and 3 simple interrupted stitches on top and 2 below the tongue surface.

Always examine the whole mouth from end to end as vet medicine springs surprises.

1042. Failure to keep a proper record: $5,000 fine for senior cardiothoracic surgeon

Straits Times Jun 20, 2012
I showed the article to Dr Daniel and Dr Vanessa to illustrate the importance of meticulous recording to protect against litigation.

The cardiothoracic surgeon of the National Heart Centre was fined $5,000 by the Singapore Medical Council. He was censured and to give an undertaking that he would not repeat the clincial error and pay the cost of the legal proceedings.

What he did not do:

1. Failed to keep a proper record of his discussion with a patient's operation. Fined $5,000 for professional misconduct.
2. Failed to note the patient's consent to the operation (lobectomy).
3. Needed to maintain a higher standard as a senior doctor of 22 years so as to be a role model for junior doctors.

The Committee said that keeping proper medical records is part of patient treatment and these records avoid disputes between doctor and patient. The patient had given his informed consent but the surgeon had not recorded the informed consent given in this case. This is different from not obtaining informed consent.

FOR VETS
1. Patient to sign the informed consent form
2. Vet must record in writing that the patient has given informed consent (time, date).

The practice is usually to get the informed consent form signed by the pet owner.

      

1041. Follow up: Beagle with bladder cancer (adenocarcinoma)

Today, June 21, 2012 I was surprised to see the Beagle, Male, 14 years old so alert and able to control his urination (in the daytime). It was a great joy to see the happy couple as I did not expect this old dog to survive the 2-hour surgery to remove his bladder cancer. But here he was today at 10.30 am with the happiest client. They had made an appointment with Dr Daniel who is their vet surgeon. I come to Toa Payoh Vets for the past 10 days at 9 am and so am able to manage my "trust and audit" of the associate vets.

The complaint was that the dog cried when the wife wipe the left hind hip area after bathing. As for the bladder, there was no complaint now. No more leakage of urine with blood. I checked the op area. The dissolvable stitches had fallen off. The lower part of the body was stained yellow and the owner confirmed that he could not control his bladder when he sleeps.
HISTORY
Beagle, Male, 14 years. Haematuria and urinary incontinence. 
May 13, 12. Blood in the urine. Can't control the bladder at all. X-ray of bladder done but not so clear. I thought there were sharp stones. Blood and urine tests done.  Case report written.
May 14, 12. I removed most of the bladder tumour near the neck of the bladder in with Dr Daniel assisting. A 2-hour surgery. Histopathology of bladder tumour: a moderately differentiated adenocarcinoma.
May 16, 12. Went home.
May 17, 12. Paraparesis. He had bolted from his confined space at home and a luggage fell on his back!

CONSULTATION ON June 21, 12 for painful left hip area. Dr Daniel extended left hip. The dog wanted to move away and yelped. There could be arthritis of the left hip as he had difficulty getting up immediately. 

I was more interested in his bladder. "He looks younger," I said and had some pictures taken of him. A 14-year old looking like a younger Beagle. I palpated his bladder while he was standing on the consultation table. I could  feel a bladder the size of an orange. Yet when Dr Daniel and Min went to collect urine

"No more drinking lots of water like before," the husband said. "Now he drinks around l litre, not 1.5 litres or more."


1040. Executing my vision to be top 5 vet practice in Singapore

Yesterday, June 20, 2012, I stopped consultations and had another talk with Dr Vanessa and Dr Daniel seated opposite me to the left and right respectively, in the consultation room at around 12 noon. I know it is extremely difficult to get vets to buy into my vision to make Toa Payoh Vets a top 5 veterinary practice in Singapore.

It is always difficult in any business for the leader to execute a vision because each employee or associate vet has his or her own agendas.

1. "First Impression Counts," I said to Dr Daniel. "If a vet can be bothered to shave, it gives the impression that he can't be bothered to take good care of the customer's pets." I looked at Dr Vanessa's feet and said to Dr Daniel: "Wearing flip-flops and clogs to work is not permitted and a vet had done this in Toa Payoh Vets for some months."

2. My.hints and advices are ignored. "If vets don't accept hints to change their mindset to improve their standard of care, I will be frank. If vets bring down Toa Payoh Vets to the bottom 5 practice in Singapore, I will not hesitate to fire them. Simple as that. I will just close down the practice when I am unable to work. I don't believe in passing the practice to the next generation. I don't believe in leaving my legacy to the next generation. Dr Daniel will have to earn his stripes.

3. Practise evidence-based medicine and know what to do. For example, the rabbit came in with a jaw abscess and there was no advice from the vet to get an X-rays done to check the extent and location of the impacted and infected roots of the cheek teeth. This will not be tolerated by me. In this case, the owner was very knowledgeable about medical practices and was agreeable to the X-ray being done. But the associate vet did not even mention this. This should not be happening again nowadays when litigation and complaints are getting more common.
4. There are around 50 vet practices in Singapore. Why should the client come to Toa Payoh Vets if the practitioners are mediocre and cannot produce excellent clinical outcomes?

It is very hard to execute a vision to be top 5. Failure of associate vets to adopt best practices need to be monitored. Associate vets who don't meet my standards to implement my vision will have to go. It is no more open a practice and clients will come as in 20 years ago. A practice must be sustainable and not losing money over the years as operational costs keep escalating while fees are kept low due to competition. It is quite easy to lose money if the vets are not of a high standard to perform and so it will be better that they work elsewhere.

5. Working in a corporation. Employee and associate vets may feel they are independent contractors and don't take instructions from the licensee. In real life, the licensee is held accountable and if associate vets dress what they like and bring disrepute to the practice, it is best to fire them and just be a small surgery with good referrals and profitability rather than be a multi-doctor practice.  

 




1040. Follow up: Rabbit's hyphaema. Bleeding inside the eye.

Jun 20, 12
It is a rare case of bleeding in the rabbit's eye.
BEFORE TREATMENT




2 DAYS AFTER TREATMENT
FOLLOW UP ON JUNE 20, 2012
Thanks for the trouble to give me the feedback today to say that the rabbit's eye is now normal and that the bleeding has disappeared 3-4 days after going home. Much appreciated.


1039. Follow up: Hypoglycaemia & Atypical lymhphocytes

June 20, 2012
"The Jack Russell X is normal now," the wife came in for more antibiotics for the urinary tract infection and was most happy. "I consulted a lady who can communicate with my dog. She graduated from overseas. My dog told her he is going soon when I ask whether my dog should take chemotherapy."

"I am open-minded," I said. "Your dog is on prednisolone which is a form of chemotherapy without the toxic side effects and so he is feeling much better now.".

1038. Follow-up: Pyometra Chihuahua

Jun 20, 2012

Phoned owner today. Excellent news.
Today is Day 6 after pyometra surgery to remove infectd womb on Junb 14, 2012

Eating well, everything OK, quite active.

The husband said: "Drinking a lot of water the last 2 days, but otherwise OK."
On Jun 17, complained of "bleeding" from operation, see image. I said it was due to the e-collar traumatising the right side of the surgical area but the owners insisted that the dog never did it.
"The dog does not do the scratching in front of the owner," I said. "The owner cannot be watching over the dog for 24 hours every minute of the day."

DAY OF SURGERY (Upper image)

2 DAYS AFTER SURGERY (Lower image)





I gave a very low dose of pred and the inflammation subsided satisfactory.

RETROSPECT
I should not have sent the dog home on the same day as surgery as pyometra is a big surgery. However, this dog ate and wagged her tail in the evening at 6 pm when I asked Dr Daniel to take her out for some sunshine, observation and photography. 



At home, she must have walked around and felt the itch and pain and used her e-collar to rub the surgical area. The e-collar reached the right flank and the sharp edge also nicked and lacerated the base of the nipple sharply. It is hard for the owners to believe what I said as they said the dog never attempted to do it (in their presence).

1037. BE KIND AND BRAVE - ADOPT A STRAY

PROMOTING ADOPTION OF STRAYS
2012. My latest image inspired by a couple who adopted a cat from the Cat Welfare Society. "Adopt a female cat," I advised since the male cat had FLUTD and passed away during treatment at a veterinary practice, causing much sadness to the wife.

Compared to my older image in 2003. It is quite difficult to think of captions. Both cats were sterilised by me.

Tuesday, June 19, 2012

1036. Follow up: Constipated cat on Jun 19, 12

On Tue, Jun 19, 2012 at 4:13 PM, Mr Dong Liu <dong.liu@uqconnect.edu.au> wrote:
Dear Dr Sing,

I was reading your blog post 1033 Fecal impaction of the cat, I was just wondering how did you manage to pass the catheter into the cat? Did you use general anesthesia or Domitor on the patient?

Regards,
XXX


E-MAIL REPLY FROM DR SING DATE JUN 20, 12


This case was performed by Dr Daniel Sing. The cat wxxxas not aggressive and so no sedation and anaesthetic was used when the urethral catheter was inserted gently. The cat was very timid and did not mind.

In this case, there was a tube of enema given a few days earlier and two hard stools had passed out. Also, the oral laxative oil had been given and the cat had passed into the colon but no stools were passed.
The cat was X-rayed before the urethral catheterisation (2 images). They showed faecal impaction of the whole colon.


After the urethral catheter enema using normal saline of 70 ml by Dr Daniel, the cat passed another hard faecal tablet the next day.

June 20, 2012 TODAY
10.30 am. The owner phoned to say 5 hard faecal pellets had been passed out. He was quite happy. "My cat vomited as he pooped," he said. "Quite a lot of stools." That was good news. He will come with the cat tomorrow.   
MY DISCUSSION WITH A SENIOR VET ON JUN 18, 12

1. He said digital extraction of the stools. I clarified as this seemed to be drastic and traumatic.
He said to use forceps to pull out the stools.

2. I had done colonstomy to remove all the hard stools in one old cat with similar impacted stools in the whole large intestine. The cat was OK. In this case, the senior vet said no need to do such surgery. Use forceps to pull out the impacted faeces will do.

3. Such impacted faecal cases are not common compared to difficulty in passing urine.

1035. Medical negligence of 2 embryologists

Straits Times Jun 20, 12  A2
IVF mix-up: mum seeks damages

In a medical negligence suit, it is not only the practising doctor or vet that is liable for damages as the following case shows:
1. Thomson Fertility Centre (TFC) waived all hospital and docotrs' charges
2. Thomson Medical was fined the maximum of $20,000 for failing to ensure suitable practices were followed
3. The woman who alleged negligence had a baby with a stranger's semen insgead of her husband's sued Thomson Medical, Thomson Fertility Clinic and 2 embryologists for special damages of $750,000
4. She wants the court to assess the amount of general damages.
5. Legal fees must be paid by the company and this could amount to $100,000 in protracted trials.

As TFC had admitted clinical error, the court will decide a "fair outcome" for all parties as regards the quantum of compensation

In conclusion, the licensee or key appointment holder and the Practice can be sued for damages, not just employee doctors or vets who performed the procedure. Therefore, strict monitoring and management of the employee or associates vets are necessary to prevent possible litigation and that includes "trust and audit" procedures to be done by the licensee regularly.

1034. Westie's skin diseases - atopic dermatitis

This case was successfully treated by me, in the owner's opinion. It is not easy to treat all skin diseases

Monday, June 18, 2012

1033. Follow up: Faecal impaction of the cat

June 19, 2012

Yesterday, X-rays were done. A 70-ml normal saline enema via the whole dog's cathether was gently squirted into the colon. When blocked, squirted saline and push catheter in.  So, the whole length of the catheter was passed in. An enema and oil laxative was given. Today, the owner phoned Dr Daniel to say one very hard stool had been passed by the cat this morning.

"Should feed canned food," I advised. The cat would eat only dry food. The cat ate a bit and vomited the oil. Wait and see.

1032. Follow up: Monday Jun 18, 2012 JRX leukaemia

Trembling, recumbent on Thursday June 14, 12
Not eating for 5 days. Intensive IV fluid including amino acids, Vit K1
Went back on Saturday with poor prognosis of acute leukaemia. The shivering was attribute to a very low blood glucose from the blood test.

I phoned up on Monday Jun 18, 12

"The dog is good," the caregiver maid said. "He eats and drinks. No shivering. He does not want me to carry him downstairs to pee. He will walk to the lift and then walk on the ground floor." This dog will never pees inside the apartment. I was surprised at his rapid recovery considering that he was shaking all over his body 4 days ago.

Sunday, June 17, 2012

1031. Sunday Jun 17, 12 interesting cases

Sunday Jun 17, 12

1. A Shih Tzu with the "decomposed corpse" smell

Yesterday was a Saturday. I came to the Surgery by bus and subway and reached at 9 am to help Mr Min and get feedback. Dr Vanessa was on duty to my surprise. A phone call came in and the owner said: "Are you Dr Sing?"

I said yes. "I want to send my Shih Tzu to the SPCA as I can't stand his decomposing smell anymore. 2 or 3 days after bathing, the odour of rotten flesh comes from his lower body. The top half of his body has no smell. I had consulted other vets and your vet (name given) 4 times but there is the same foul smell in the whole apartment. I prefer not to send him to the SPCA if you can resolve his body odour."

"Have I treated this dog before?" I asked.
"No," he said. I asked the owner to leave the dog overnight as I would be off duty. Then, on Sunday today, I had a good check up of this dog.

SIGNIFICANT FINDINGS
Shih Tzu, Male, Neutered, 8 years old, 8.2 kg.

1. Ventral part of the body has been shaved. It is inflamed and has some flakes. I smelled the ventral areea. A faint vinegar smell but no stinking rotten flesh smell.  When I told the owner about this, he said: "I had bathed the dog recently. But the whole bedroom will be full of rotten flesh smell after a few days."

2. Right anal sac was full of dark grey oily graunules. Left anal sac had some too. When I put the tissue paper with this oil, onto a table, outside the surgery for photography, at least two flies and one insect buzzed in excitely. No foul smell.

HISTORY AT TOA PAYOH VETS
Dec 09  skin problem
May 10  buy medicine for skin problem
Aug 10 buy medicine for skin problem
Oct 10  skin esp. ventral region.
Apr 11  skin, anal sac rupture
Jul 11  buy medicine for skin problem 
Jun 17, 12 Phoned Dr Sing. I told him to bring reports of another vet he saw "2 months ago" and to write what has happend to the dog during the past years.

HISTORY AT OTHER VET PRACTICE
Feb & Mar 12  Consulted another practice, according to reports presented by the owner.
Vomited and had bloody diarrhoea when he took 3 types of medication and so the owner stopped them.

LETTER FROM OWNER
The main point of the detailed letter is that the dog uses his hind legs to scratch the lower part of his body and makes some noise as if in pain. The foul smell comes after the first day of shower.

SIGNIFICANT FINDING TODAY
Ventral dermatitis with redness and scales. Ringworm +ve. Check for yeast.
Anal sac full of dark brown anal oil.



 

Friday, June 15, 2012

1030. Consistent professional advice for struvite UTI


http://www.bekindtopets.com/dogs/20120614veterinary-database-UTI_singapore-ToaPayohVets.htm






From Jun 23, 2012, all vets at Toa Payoh Vets will practise evidence-based medicine. In cases of urinary tract infection, urethral obstruction and urinary stone removal, urine test is the minimal test to be done.



Blood test, X-rays, ultrasound, urinary stone analysis (in urinary stone removal) should be advised and recorded that advices have been given. These tests (esp. urinary stone analysis) should be done, whenever relevant and possible unless the owner has economic reasons for not wanting tests done. An example is given below:

Friday, June 15, 2012

1030. Consistent professional advice for struvite UTI



I have spoken to Dr V and Dr D regarding the need to give a consistent advice on the management of struvite UTI in dogs. Many Singaporean owners check the internet and are more sophisticated than in the old days.



A case is illustrated:

Case of the female Shetland, one year old. Dr Daniel's case

Jun 10, 2012. Complaint of blood in the urine for 2-3 months.

X-ray of bladder advised but not accepted



Urine test



pH 9.0 (5-8)

SG 1.026 (1.005-1.030)

Protein +

Blood trace

WBC 30

RBC 10

Bacteria 2+

Triple phosphate occasional



Tentative diagnosis should be UTI with struvites. Dietary management, acidification of the urine and antibiotics should be the treatment, not just antibiotics.



Follow-up urine test in 4 weeks is the minimum. X-rays of the bladder will be preferred. Most owners don't bother with follow-up. It is important.



Note: Triple phosphates are "struvites".

Toa Payoh Vets' Dog Spay's Key Performance Indicators

129. Follow up: The female Schnauzer peed out 5 urinary stones

HISTORY
The female Miniature Schnauzer peed blood in the urine. Urine test showed struvite crystals. X-ray showed several bladder stones. The owners wanted spay and urinary stone removal at the same time. I did not agree to this as the anaesthetic and surgical risk would be higher. So nothing was done.  When I was in Hong Kong on May 25, 2012, I received a phone call from the husband. The dog had difficulty peeing and was lethargic. I referred him to another vet who took an X-ray and was willing to do spay and urinary stone removal at the same time. Since it was Saturday, the fees would be higher. On Sunday, the owners took the dog back. No news from them. Around June 11, 2012, the owner asked me to spay the dog first. The following is a follow-up on the spay.
E-MAIL TO DR SING DATED Jun 13, 2012

Hi Dr. Sing,

Attached is a picture of the bladder stones passed out together with the urine by XXX.
The stones started to show up 2 days after putting her on the *S/D diet prescribed by you.
The largest of the five stones came out on 24 May 2012 (Thursday). That was the day before she had difficulty to urinate and we sent her to your referred vet.

Thanks.


*2 cans of S/D diet were purchased by the owner although a 30-days' supply was advised. They felt that the dog might not eat the diet.

E-MAIL FROM DR SING DATED JUN 14, 2012
Hi

Thank you for your email and pictures.
How is XXX recovering from the spay? When she starts eating normally?

E-MAIL TO DR SING DATED Jun 16, 2012
Hi Dr. Sing
Thank you for your concern. XXX is recovering well as if nothing had happened and she is eating well, except that I noticed a red patch (about 2cm in dia) forming on her skin close to the incision point.

I am quite curious to see mytwo male dogs are getting very excited and trying persistently to climb on her these few days but she doesn't seem to be on heat. Any idea why they are behaving this way ?


E-MAIL FROM DR SING DATED JUN 16, 2012
Thank you for your email.The red patch may be due to the dog licking. Did your dog wear an e-collar? As for the male dogs being interested in her, she appeared to be on heat based on my observation of enlarged ovaries during the spay. You said her last heat was 4 months ago butit could be 5-6 months ago and so the dog came onto heat. So the male dogs would still be interested as spaying does not immediately stop the female dog from being attractive to male dogs.

You got 6 cans of S/D diet for her. Please note that the recommendation is to give S/D diet daily for 1-3 months if you wish to dissolve the struvite stones. The remaining 3 bigger stones may not dissolve even on S/D diet is given as recommended and surgical removal may be the option if there is persistent blood in the urine.

Best wishes.

1028. The rabbit keeps rubbing his right eye for 2 weeks

Today Jun 15, 2012 Friday, I was at the Surgery the whole day from 9am onwards. This is the 3rd day I took the feeder bus and subway train and feeder bus to Toa Payoh Vets as I used to drive over the past years. It is a form of exercise and an experience to appreciate life, the morning sun and the heartlanders going to work. It is humid and sweaty but that is living.

I did my trust and audit cases of the associate vets. One of these cases involved eye problems in the rabbit. Many rabbits seem to have eye problems and some vets may not be keen on treating them. I assessed how my vets treat such cases in the "trust and audit" checks. I got the dwarf rabbit into the consultation room and did the examination together with Dr Vanessa.
"You don't need to be a licensed vet if you just prescribe eye drops for "eye cases," I said to Dr Vanessa. "Any owner can buy eye drops and treat themselves if the vet just prescribe eye drops!"


The young couple came with a male 2-month-old Netherland dwarf rabbit with a red itchy right eye and a red nose. "We went to Vet 1," the fair trim lady said. "But my rabbit is still scratching his right eye."
"What did Vet 1 do?" I asked.
"He gave eye drops. We have used up the eye drops now. But the rabbit is still scratching!"
"Your rabbit may have an eye ulcer," I said.

EYE EXAMINATION
1. White light shone onto the cornea. Nothing. The cornea was as clear and transparent.
2. "Use the fluorescein eye stain," I said to Dr Vanessa. "It will stain the ulcer. This should be standard operating procedure but many vets don't do it. Just prescribe eye drops and send the rabbit home."
3. As the rabbit was frisky, I advised a gas anaesthetic by mask. Surprisingly, a green stain from 11 to 1 o'clock showed up the corneal ulcer. I asked the couple to go into the op room to see the ulcer.
CAUSE OF THE ULCERATION
The owner did not know. "Do you have hanging balls with sharp hay inside?" I asked. "The hay may have injured the eye."

"We have the ball with hay stuck inside, on the cage floor" the couple said.
TREATMENT
2 WAYS
1. Conservative. Irrigation of the 3rd eyelid. Subcon injection and e-collar. Cage rest in a dark place for around 30 days.
2. Stitching up the upper and lower eyelid. This would be my choice as the healing of the ulcer is much faster. But there is a lot of nursing.

As the young couple will be unable to do the nursing, I did the conservative way. I asked my assistant Min to give them an old carrier as they have been taking the rabbit in an open basket. The rabbit may suddenly jump up and fall and fracture his leg or back.

CONCLUSION
Solving the owner's problem should be the best practice. Otherwise the owner just go to another practice.





1027. Follow up: Acute lymphoblastic leukaemia. Whole body shivering 12-year-old Jack Russell X

Acute lymphoblastic leukaemia - low RBC, low WBC, low platelets
Prognosis is poor. Vincristine and prednisolone advised. Remission does occur.


COMPARED TO 3 MONTHS AGO. Blood in the urine. Recovered 2 days after antibiotics.

BLOOD TEST
Date 27 Mar 2012
Glucose 4.1  (3.9 - 6)
Liver ALT 6.2  (<59)
AST 56  (<81)
Urea 8.0  (4.2 - 6.3)
Creatinine 85 (89-177)

Hb 16.3 (12-18)
Red Cell Count 6.5 (5.5-8.5)
Total WCC 10.7 (6-17)
N=75%, L=10%, M=12%, E=0%, B=2.3%, Atypical Lymphocytes - None
PCV 0.45 (0.37 - 0.55)
Platelets 487 (200-500)
Platelet clumping noted. Large platelets present. Occasional nucleated RBC seen.


URINE TEST. I had discussed this in another article earlier.

TREATMENT - CHEMOTHERAPY
A bone marrow biopsy is needed. Every treatment is around $1,000 and 6 treatments





Thursday, June 14, 2012

1026. Spaying a breeder's Chihuahua with pyometra

June 15, 2012

The "Voice For Dogs" refered the owners who adopted a breeder's Chihuahua to Toa Payoh Vets. All teeth encrusted with tartar. Pus dripped from the vulva.

"What's the age? She is very thin, at 2.2 kg" I said.
"We don't know," the couple said.
"When's the last heat? 2 months ago?"
"April 14, 12"
I diagnosed open pyometra and advised spay the next day, after IV drip and treatment. The dog's temperature was 37.2 deg C.

ANAESTHESIA
Dom + Ket at 25% (0.02 ml + 0.03 ml) as the dog is old and thin. A bit of isoflurane gas. Intubated. Maintained at 1-2%. Swollen uterine horns 1.5 cm in diameter.
Ovarian fat very fragile. Ligated and both broke loss. Bleeding seen.


A: Induction Drugs injected IV at 25% calculated dosage: 10.07am
B: Isoflurane gas first given: 10.09am
C: Isoflurane gas stopped: 10.51 am
D: First skin incision: 10.18 am
E: Last stitch: 10.44 am
E-D = 26 minutes.
Swollen uterus was seen easily and hooked out.
Dental scaling and extraction after that.

Complication: Bleeding. The ovarian fat was "watery". The suture ligation broke in both. Some bleeding. Owner was told of the risks of bleeding.

BLOOD TEST RESULTS
Normal.
Total WCC 14.4 (6-17).
N=59%, L=21%,M=15%, E=2%, B=3%
Total RBC 6.9 (5.5 - 8.5). Hb 16.6 (12-18).
This case illustrates the high risk (bleeding) of operating a thin, old Chihuahua with pyometra. It was not recommended to delay surgery as the pus was toxic. Pyometra can be diagnosed based on history of estrus 2 months ago and vaginal discharge of pus. Blood tests, ultrasound, X-rays add up to the costs but are usually necessary. In this case, the total WCC was still normal though vet books say that WCC will be increased in pyometra..







1025. The Schnauzer pees 5 urinary stones

TRUST AND AUDIT CASE STUDY on Jun 14, 2012 by Dr Sing at 6.50 pm at Toa Payoh Vets

An interesting case

XXX, Miniature Schanzuyer, Female, 5 years

May 3, 12. Dr Daniel's case. Haematuria (end stream) and stranguria,  increased frequent urination. Diet brown rice and dry dog food.

May 7, 12  X-ray & urine test. S/D diet given 2 cans. Antibiotics.
>5 urinary stones. Advised surgery to remove stones and diet change to low protein diet*.



The couple spoke to me as I was the original vet who had treated the dog earlier. They wanted spay and urinary stone removal in one surgery. I advised against doing two major surgeries in one in case of complications from infections, bleeding, death due to prolonged procedure. I did not want to do it. The couple left. No news from the couple.

May 25, 12. I was in Hong Kong and got a phone call saying the dog could not pee at all. She had passed out 5 urinary stones but was now in distress. I referred to another vet practice. Vet 1 x-rayed and catheterised and the dog could pass urine. It was a Saturday and she had said that fees,  would be higher, but Vet 1 could do spay and urinary stone removal. The owners were willing but since the fees would be higher on a Saturday, she advised another day. On Sunday, the dog was peeing and was OK. The owners decided against the operation.







"Could it be the high fees quoted?" I asked Vet 1. "How much did you quote?" She did not reply.

Jun 12, 12. I spayed the dog as requested. No urinary stone removal as requested. History from owner today. No haematuria since May 26, 12 after treatment by Vet 1 on May 25, 2012. The husband showed me 5 urinary stones that had been peed after the dog took 2 cans of S/D diet. I palpated the empty bladder. A hard mass of around 1.5x1 cm in size indicating that the 3 stones were still inside the bladder. Advised S/D diet for one month.  The owners wanted only 6 cans.  Previously, the owner wanted only 2 cans in case the dog does not eat the food.


Weighed 4.8 kg on Jun 12, 12. Had lost weight as her weight was 5.1 kg on May 3, 2012. The 5 stones could be sent for analysis to confirm struvites but due to economic reasons, I did not advise.

SPAY. Ovaries enlarged 8 mm x 8 mm x 6 mm. On heat? The owner said the dog was on heat 4 months ago.
4.8 kg
10.28 am  Dom 0.19 ml + Ket 0.24 ml IV
10.33 am - 11 am Isoflurane gas
10.40 am Skin incision - 11.07 am Last stitch = 27 minutes
2/0 absorbable x 1 pac
11.20 am - Antisedan 02 ml IM wakes up the dog.


URINE TEST MAY 7, 12

Significant results
pH  7 (5-8)   
SG 1.026  (1.005-1.030)
Nitrite Positive (Negative)
Protein 3+ (Negative)
Blood 4+ (Negative)
White blood cells 558
Red blood cells  >2250
Bacteria +
Crystals  Triple phosphate occasional


CONCLUSION.
1. The owners asked me whether Vet's 1 advice that the stones will rupture the bladder if not removed by surgery is correct. "Unlikely to do so," I said. "They are not that large. But they will irritate the bladder causing infections. "
2. Will S/D diet dissolve the remaining 3 big stones? "Not likely as they are large." I said.
So, presently, the status is that the stones are still there. Some dogs do not need stone removal but in this case, removal and prevention using prescription diet are the best course of action. The problem here is that the owner does not want to feed the S/D diet for at least one month as he took only 6 cans of S/D diet.
















Jun 14, 12 Meeting

*In theory, lower protein, less ammonia produced, less likely to form struvite stones. My contention is what "low protein diet" means and what is the % of protein that constitutes "low protein" diet in practice? What practical advice should the vet give to the owner?

My meeting with the vets at Toa Payoh Vets today regarding consistent advice in a struvite case. The advice should be consistent from all vets at Toa Payoh Vets. Some owners may not want X-rays. In urine test, once there are 3 factors - alkaline pH, bacteria and struvite crystals, the recommendation should be a prescription diet like S/D diet or equivalent for 1 month and switch to C/D diet for 3 months to dissolve the stones


E-mail from owner dated Jun 13, 2012

Hi Dr. Sing,


attached is a picture of the bladder stones passed out together with the urine by XXX

The stones started to show up 2 days after putting her on the (S/D( diet prescribed by you.

The largest of the five stones came out on 24 May 2012. That was the day before she had difficulty to urinate and we sent her to your referred vet.