Tuesday, March 31, 2015

Rembering Lee Kuan Yew









Sunday, March 29, 2015

1157. STORY. The meowing cat. Kidney disease FLUTD cat passes blood in the urine - follow up

A challenging medical case. On March 17, 2015, the cat came to me for a 2nd opinion. He had bladder obstruction and had been treated by the other vet for around 4 days before discharge. But the cat was not eating and had blood in the urine. I got X-rays done after palpating much enlarged painful kidneys of 3-6X normal and seeing the inflamed red prepuce of this 1-year-old male, not neutered cat much loved by the family for his vocalisation.




He would meow to greet people unlike the dumb sterilised cats in the apartment.  He meowed as if saying "good morning" when he recovered after 2 days of in-patient. So I could understand how much he was loved. He looked good and I sent him home.

However, the owner could not feed him or syringe him. He came back with ulcers in his tongue, right lip commissure and right upper gum. I suspected he was forced fed and suffered traumatic ulcerations. So he would rather die than be forced fed by the owner. Severe dehydration and recumbent. Low body temperature or hypothermia. Poor pulse volume.

I thought he would die soon on this date of admission - Mar 24, 2015. I gave him 250 ml of SC fluids with all the multivitamins and amino acids and antibiotics per day for 2 days and did not expect him to revive.

But he bounced back to life after 2 days of in-patient treatment when he meowed again on the 3rd day. The owner did not want him home and wanted another 2 days for him in Toa Payoh Vets. He recuperated and meowed whenever he saw the staff. Such a lovely behaviour. Much as if he appreciated being visited. So he went home on Mar 26, 2015.




No bad news till Mar 29, 2015 when the owner said he had passed blood in the urine.  


Mar 30, 2015

"My cat is eating and drinking a lot, but he passes blood in the urine!"   the owner phoned today.

Advised:
1. Stop medication
2. Urine test
3. Switch to dry Renal within 3 days.

The cat has not fully recovered from kidney disease. He went home 2 days ago, meowing and eating a bit of his canned food. Alert. But the owner phoned to say he is passing blood in the urine. A urine test was done on
---------------------------------------------------------------------------
Mar 30, 2015
pH 6.5, SG 1.025, Protein 2+, Blood 4+, White blood cells >2250, Red blood cells >2250. Bacteria Nil. Casts and crystals Nil.


Compare to the previous 2 urine tests.

Mar 24, 2015
pH 6.5, SG 1.019, Protein 3+, Blood 4+, White blood cells >2250, Red blood cells >2250. Bacteria 2+. Casts and crystals Nil.

Mar 17, 2015 (first consult at Toa Payoh Vets)
pH 6.5, SG 1.025, Protein 3+, Blood 4+, White blood cells 1791, Red blood cells >2250. Bacteria 2+, Casts and crystals Nil. Spermatozoa +, Ketones Trace.

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Mar 17, 2015 URINE CULTURE
Amoxycillin+Clavulanic Acid, Cefuroxime, Nitrofurantoin, Ampicillin+Sulbactam, Ampicilin --- Resistant

Cipofloxacin, Gentamicin, Cotrimoxazole, Fosfomycin  --- Susceptible. 
The first vet had prescribed amoxycillin + clavulanic which is commonly given to cats in Singapore.

CONCLUSION
The cat is eating and drinking, but the kidneys have not recovered fully. There is no bacteria in the urine in the 3rd test on Mar 30, 2015.  He was not "passing blood in the urine" from March 19 to Mar 29 after a change of antibiotics and 2 days of inpatient treatment.

But on Mar 29, the owner phoned me to say he was passing blood in the urine. Will the cat get kidney failure again?

This FLUTD plus kidney infection is a complex case to resolve.


Bulying in guinea pigs

Mar 30, 2015
FEEDBACK FROM GUINEA PIG OWNER

Dear Dr Sing

Just to let you know that Mochi is doing well so far after the UTI & diarrhea last month. In fact, she still had blood in her urine after the second visit for diarrhea. I suspected it may be bladder stones so I continued to monitor for a while. Then one day, I discovered some transparent jelly like substance in the litter box...bladder stones? Subsequently no more blood in the urine which brought much relief to me. 

After that couple of weeks of isolation from Mocha, Mochi was so afraid of her when I tried to put them back in the same cage. They were so tensed & nervous that I had to assemble another cage for Mochi. Now they seem happy having their own space.

Mochi used to bully Mocha so Mocha is now more relaxed being alone. Previously, Mochi competed with Mocha for food, water & litter box. She's happy to have everything to herself at present.

Last visit, I promised to send you info on how I assembled the cage for my guinea pigs. Please refer to attachment.

Best regards


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Guinea pigs do compete for dominance and space like people. Bullying is quite common but the owner is not aware of it. 


 

1155. Sunday Mar 29, 2015 Remembering Lee Kuan Yew

I closed Toa Payoh Vets in the rainy afternoon so that the staff can watch the State Funeral possession of Mr Lee Kuan Yew and listen to the 10 eulogies. I feel great sadness as he had done alot for the ordinary Singaporean esp. with undergraduate scholarships given on merit, rather than on favouritism.  In this way, the poor can better themselves if they excel academically.   

Saturday, March 28, 2015

1154. A stray cat trapper in Singapore

Mar 27, 2015

I met a cat activist, a lady in her late 40s,  bringing in stray cats for sterilisation at James Tan Vet Centre. She was washing the metallic cat traps outside. Her black car was a SUV. The seat was packed with carriers, dry cat food and  cat traps.  

"I would have liked to buy a bigger commercial vehicle," she said. "But I don't have a company to register this van."
"You don't need a private limited company to do it," I said. "You can register a sole proprietorship."
"The ROC (Register of Companies) will close it down as I don't make profits."


"I don't think the government will close a private company that is not making profits annually," I said.

"It can be quite costly for the feeders if there is more than one stray cat," she said. She was a volunteer who would trap stray cats if the feeders agree to pay for the petrol costs, sterilisation and hospitalisation fees at the Vet Centre. The Cat Welfare Society had approved her project.

"Over the years, there have been many stray cats trapped and sterilised," I said. "How come there are still stray cats still breeding? " I don't see more than one stray cats in the Toa Payoh housing estates, the hawker centres and the public parks. Some town councils even employ pest controllers to cull them and at one time, the government AVA was active in doing it."

"There are people who dump their pregnant cats," she said.
"How do you know these cats are not really stray cat?"
"They are not feral cats as they behave, being friendly to people," she replied.
"Where do you she find such cats?" I asked.
"In the Kim Chuan industrial parks. I place food inside the cat traps. They are hungry and so enter the traps."

"I notice you have only one type of dry cat food and one colour," I said. "Instead of the multi-coloured pellets."

"Those multi-coloured pellets are too high in salt," she said. "These light brown ones are better." 
"What brand is it?" I asked.
"SAVA brand. You can buy them from any pet shop "
"Where are they made?" I enquired.
"From Thailand. They are good enough for the strays."

She had her career but spent rime trapping stray cats for sterilisation and release if the cat feeders are willing to pay for the costs. .
  . 

Friday, March 27, 2015

A guinea pig has sudden onset bloat - clostridial infections?

This 4-year-old male guinea pig was OK the day before but overnight, became lethargic and would not eat. The owner consulted me. I noted a large abdominal distension, esp. the left side. There was gas inside the bloated stomach. The guinea pig was hypothermic at 36C and the gums were pale and cyanotic. I got the X-rays done and released the gas using a 23G needle and 10ml syringe to suck out. The guinea pig felt better. 

The stomach deflated. SC drips plus baytril antibiotics did not help. Around 2 hours later, he passed away.  Toxins from Clostridial bacteria could have killed him. Gastric volvulus or distension was present. The prognosis was poor.  No more hay for the other guinea pig which was still OK and eating the same hay.

Bubbles in the abdomen indicate that the intestines had lost blood supply and leak gas into the abdomen. The guinea pig died from septicaemic shock as Clostridial bacteria is highly pathogenic. No post-mortem or bacterial culture was done. 







Thursday, March 26, 2015

Empathy in medicine

Educating For Empathy - Journal of General Internal Medicine 2006.

Empathy in doctors significantly influences patient satisfaction, adherence to medical recommendations, clinical outcomes and professional satisfaction. Frequency of medical errors among doctors decrease as the empathy levels increase


1151. Video on annual health screening for a 10-year-old Shih Tzu

This trim fair lady loves her female, spayed 10-year-old dog very much as she will present her dog yearly for the vaccination. She had made an appointment today after receiving my vaccination reminder card.

This time she requested a blood test. I was surprised that she was well informed.
As for the dental scaling, she said: "I am worried about anaesthesia. Maybe another time."
The back teeth were full of tartar but the teeth were still strong and solid. When I opened the dog's mouth wider, she gasped although the shy Shih Tzu with clear corneas did not flinch a bit.

 "It is necessary to check for mouth ulcers and tumours," I explained to her.


Normally, some of my vets just give the vaccination and general examination or just the vaccination owing to the owner's financial cost constraints.  So no blood and urine tests were done or advised by my vets.

I did a health check video for the benefit of the younger dog owners. The dog was a good patient. The overall experience was eventful as more and more dark brown anal sac oil kept discharging as I expressed the anal sacs. Yet the dog did not bite her backside. The tell-tale sign was just some hair loss and skin irritation at the end of the tail. The ear canals were dirty and need cleaning.

This was a happy interaction for the vet, the dog and the lady dog owner on this Friday morning.

Wednesday, March 25, 2015

A 7-year-old Pom coughs non-stop - x-rays

Chihuahua, F, 6 years.
No respiratory distress. X-rays of normal heart and lungs for comparison with the Pom case below.



Pom, F, 7 years
Acute respiratory distress
Non-stop coughing
The first vet had taken a 2nd X-ray 7 days ago when the dog started coughing again and prescribed medication. He did not think it was a heart problem.

Yet the dog's coughing got worst and became continuous during the past week. The owner consulted me.  No X-rays were taken by me.


No heart murmurs. Irregular heart beats.
What is the problem? Any cure?

X RAYS FROM THE FIRST VET







ANALYSIS - COMPARISON WITH X RAYS OF 2 OTHER DOGS
VENTRAL-DORSAL VIEWS OF X-RAYS



7-year-old Pom with continuous coughing. Pulmonary edema (cloudy lungs).
The right and left ventricles are enlarged when you compare to the normal heart of the Chihuahua. No heart murmurs. Irregular heart beats.  
As a Mar 27, 2015, the dog no longer coughs, being given heart medication

Compare that to the 6-year-old Chihuahua with no heart problem. Clear lungs (black)


Compare to a 1-year-old Pom with right-sided heart enlargement, coughed blood and panting



No cardiogram or another X-ray were done during consultation at Toa Payoh Vets,owing to cost constraints.



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ANALYSIS - COMPARISON WITH X RAYS OF 2 OTHER DOGS
LATERAL VIEWS OF X-RAYS

7-year-old Pom with continuous coughing. The heart looks normal.  This X-ray by the first vet was taken around 7 days before the non-stop coughing presented itself.  I did not have any X-rays taken to lower medical costs for the owner. 




A 6-year-old Chihuahua with a normal heart and lungs


A 1-year-old Pom with right-sided heart enlargement








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ANOTHER CASE OF COUGHING AND PANTING in a Pom seen by me in 2009.
POM, F, 1 year old.















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A CHIHUAHUA WITH NO PANTING OR HEART PROBLEMS FOR REFERENCE







1149. Singapore: A safe and prosperous haven

"I am not a free lance tour guide," the girl with the deep set sad eyes said. "I am a part-time tour guide."  She was on duty at the travel agency office, just like a car salesman but this was the first time I saw her, despite over 10 visits to this office.   

"What is your target sales?" I asked.

"150," she has no problem getting 150 people to go on tours since she is an "old bird". She said she would be on duty this coming Sunday March 29, 2015 at Marina Bay Sands as she was required to be present. But with the passing of Mr Lee Kuan Yew on March 23, the travel fair was cancelled.

It is Mr Lee's transformation of Singapore from a swamp land to a First World Country with almost full employment, making Singapore a safe and prosperous haven in churning waters that this lady can work part-time. 

The older generation would worry about losing a full-time job and getting another. Here, she could work part-time for this agency and also for other agencies whenever she likes. There is a labour crunch due to the full employment, unlike countries like Greece with 25% unemployment.

1148. Skin diseases: White skin spots or patches in a dog or cat

Skin cells called melanocytes produce pigment giving the skin its colour. If melanocytes disappear or is not produced or produced less, the skin loses its colour. "White spots appear".

In people, the causes are:
1. Pityriasis versicolor (white spot disases), body and limbs, mild itchiness. The acids secreted by yeasts - Malassezia, inhibit melanocytes from making melanin. Selenium sulphide solution and clotrimazole cream are common treatments.  Oral anti-fungal medication for severe cases. Recovery of normal skin pigmentation may take many months.

2.   Vitiligo is a skin disordr. Melanocytes are destroyed. The skin is usually completely white and clearly demarcated from the surrounding normal skin.

3. Idiopathic guttate hypomelanosis are 2-4 mm flat pale spots on the face, arms and legs. Extnesive and chronic sun exposure causing skin damage.

4. Post-inflammatory hypopigmentation - previous skin injury. Pigment temporary disappear.  After vaccination or injection in the dog or cat.

5. Chronic arsenic poisoning. Rare cases where contaminated well water or traditional Chinese medicines containing arsenic is consumed for a long time.

6. Hypopigmented mycosis fungoides is a form of skin cancer. White patches on the body. Uncommon.  Slow progress

Skin colour may take several months to recover after successful treatment.

In Toa Payoh Vets, the number one skin disease in dogs is ringworm which is curable.

Tuesday, March 24, 2015

Was the neutered father guinea pig responsible for 2 babies?

Mar 24, 2015

The pair of guinea pigs gave birth to 1 male and 1 female on   before the sire was neutered.

Parents  about 1 year old.
Sep 3, 2014   dam gave birth to a male and a female. F1 generation
Oct 7, 2014   sire was neutered by Dr Daniel
Feb 13, 2015  dam gave birth to 2 males. F2 generation.
Was the neutered sire the father? The Korean lady asked me.  Dr Daniel said that the neutered sire should be separated from the dam for 3 months after neuter.

Guinea pigs mature at 3 months of age.
Gestation period 59 - 73 days or 2 months.





Dec 3, 2014  F1 male will mature from 3 months and will mate with the mother.
Feb 13, 2015 (2 months' gestation, mating on Dec 13, 2014 by F1 son).
So the neutered father was NOT responsible.  









1146. Pug with folliculitis

Mar 24, 2015
Review of the pug. 9 days. Still has inflamed skin. Appeared spreading.
Ringworm +ve some hairs
Skin scrapings 3 areas - no mites seen.
Allergy?  Plastic biting of handles of mum's bedframe - allergic on chin and face.

Saturday, March 21, 2015

1145. Sunday morning smiles on Mar 22, 2015 at 7.30 am

Sunday Mar 22, 2015

I went to the public fitness park at 6 am and at 7.30 am to exercise. I usually discipline myself to do it once, to exercise to keep fit this year. Bright cloudy morning.


As I walked out, the slim Myanmar maid, around late 20s, in bright red T-shirt, longer blue floral white shorts with two ties at the lower side and pony-tail was washing the bright red Porsche. She smiled nowadays when I said good morning or hello to her. This bright red Porsche alone would cost around $300,000 and her salary, assuming $500/month would mean 50 years of being a domestic worker to earn this amount. I hope she would save up and buy land in her village to better her life. Maids work to support their aging parents and siblings in Myanmar.


At the fitness park, I was surprised to meet this lady who walks her 11-year-old Golden Retriever every day. I met her some weeks ago when I walked to the subway to catch a train to work on a Saturday morning. Her dog was trying to sniff me out and she restrained him. "Are you from Grand  Spring condo?" I asked.  "No, I am from Rose Flower Gardens," she replied. "I was wearing long pants to work when we met some months ago," I said. "So, you will not recognise me. You walk to this neighbourhood too?"

"My dog gets bored walking the same route," the Golden Retriever was dragging her away.
"More likely you will get bored," I could not imagine a dog being bored when taken out in the morning to exercise. "How do you prevent tick infestations of your dog?"
"I spray an organic repellant on his body and paws and so this dog does not have ticks," she said.
"Do you use spot-on insecticide between the shoulders, e.g. Frontline?" I asked.
"Yes, I use it once a month."

"Be careful that you do not get poisoned with the daily spray as you will have inhaled it," I advised. "Even if it is organic, it is still poison!". Many Singaporeans do not bother to look into the medical side effects of multiple pills popped into their mouths including glucosamine and DMSO, anti-perspirant sprays and monthly hair dyes to look younger.

Assuming that a spray is organic, it will be safe for the health of the person and the dog. But long-term use will cause poisoinng of the body system.  

The lady smiled and her dog dragged her off.  Walking every day seemed to have reduced her weight since I saw her more than 2 months ago and she looked happier. She smiled as she left. 

There was another older lady who walked her Golden Retriever along the roads. She also carried pieces of newspapers to scoop up the poo. The dog stopped suddenly as if he wanted to poop and so she got the newspapers ready to place. I stopped walking so as not to distract the dog. Alas, the dog did not do it. She appeared embarassed and I asked: "How many times does he poo a day?"
"Twice," she replied as the dog dragged her off.

In my neighbourhood, I saw a light brown with black soft top, probably an Audi 2-door with a bicycle attached behind the boot, driving out. An older woman walked the road to exercise. A young couple put the golf sets in their car to golf. A Caucasian expatriate with helmet cycling. One man was jogging. An older man with knees bandaged walked past me, avoiding eye contact.

On this Sunday morning in a peaceful country, most of my neighbours are sleeping late and miss the beauty of dawn breaking, the birds chirping and the coolness of the early morning. For the past years, I did not exercise, as is typical of most Singaporeans. Work and raising a family took precedence. There must be time to smell the roses in Singapore when there is peace.   








  

Friday, March 20, 2015

Myanmar Stories: A Myanmar maid learns the basic of computers

Mar 18, 2015

At Khin Khin's employment agency, I met a Myanmarese maid from Pathein. Her employer had asked her to go home since the replacement maid will arrive soon. After 4 years bringing up a child and looking after the household, she did not want to renew her contract. Yet she had not completed her computer course yet and this course would start in 2 weeks' time.

Finding a new employer may be difficult. Her pay was $480. "I have an employer willing to pay $550," the agent said.  Her old employer had permitted her 2 Sundays off and she enrolled for this computer course. Her English is much better. Will she be able to find a new employer? 

Thursday, March 19, 2015

Paper training a new puppy (video)

An elderly couple bought a 3-month-old Chihuahua for a 3rd vaccination.
They have an old Silkie who is paper-trained. I enquired how they would train this new puppy. The Silkie may pee anywhere if the new puppy can do it and so it is important to confine the puppy early.

Video is produced.
1. No confinement.
2. Sometimes the new puppy will pee on the newspapers, meant for the Silkie in the kitchen. Most times anywhere in the apartment.  
3. The Silkie is paper trained by beating by the son, many years ago. Negative reinforcement training.



The couple did not want the 4 fences as they are too big. Buying a crate and paper training inside the crate is my proposal. See video.


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CONFINEMENT  2-8 WEEKS.
1. Crate + newspapers
2. Playpen + newspapers
3. Playpen + grate
4. Crate

Urine smell

2-4 months best. Older rebellious.

Indoor and outdoor.

Patience, Perseverance and Regression.

1142. How to stay healthy? Do your research.

Mar 20, 2015

My neighbouring tenant who sells parts to plumbers, electricians is 66 years old. I saw him cutting out tablets (3 types)  and putting them into pill containers for 7 days. Every 5 months, the government doctor will prescribe him the same medicine

SIMvastatin 20 mg  2 tablets at night
ENALApril 20 mg 1 tab 2x/day
Sunvasc Amlodipine besylate 7 mg
Hypernol Atenolol 100 mg




"I don't see the same polyclinic doctor," he told me. "Each doctor will have his or her differing opinions. In the end, they prescribe me 5 months' supply of these pills! I go back every 5 months for a check up and get the same medication."

4 years ago, he went to a private specialist at Mount Elizabeth as somebody referred him to the doctor.
 
"4 nights in a single room, looking out of the window, here and there," he recounted. "I was not even sick.I asked to be discharged. Every visit from the doctor cost me $300. One month's drugs cost me $3,000.  The total hospitalisation bill came to $21,000. "

The nurse told him to ask for half a month's supply. "That was $1,500 and later, she advised me to get $750 supply. I just cannot afford the fees and went to a private general practitioner who charged me around $200 for the drugs."

Now the polyclinic doctor charges him around $30.

Does he really need the drugs? "My blood pressure is only 140," he said. "Yet the doctors prescribe me drugs to control my high blood pressure."

His blood pressure and cholesterol levels needed to be checked every 5 months.  Too many years of various types of medication may harm the kidneys and livers leading to kidney or liver failure. It is best that he gets the medical reports and get the reports interpreted from a family doctor. The polyclinic doctor comes and goes and he never has a family doctor who can follow up with his "chronic diseases."







Wednesday, March 18, 2015

1141. Two cases. 1. Pyometra - vomit and "bloody" diarrhoea. 2. Hyperestrogenism - Swollen vulval area

A young lady's 10-year-old Cocker Spaniel had vomiting and bloody diarrhoea for around one week.
"There is a smell of blood," I said. "The blood test showed low red cell count and haemoglobin. The white cells increased showing bacterial infection. The platelets are low, showing septicaermia. The signs are not good."

I advised inpatient for 2 days with IV drips. Tests for Giardia, coronavirus and parvovirus were negative.

The lady wanted her dog back on the same day. At home, the dog continued vomiting and passing bloody stools. "She is having her heat period now," she said. The next day, the dog passed away at home when I called.

This could be a case of closed pyometra with "heat" being observed by the lady on the day before the dog died.

The dog reacted wanting to bite me when I palpated her lower abdomen. She was overweight and so I could not feel the distended uterus. Septicaemia would result in vomiting and diarrhoea. However, the lady did not want the dog to be warded and this is the owner's wish.

This death could be prevented if the dog had been spayed at a young age. But many owners prefer not to spay their female dogs. The illness and death stressed this young lady considerably. It affected me too as I would like all pyometra dogs to live.

However, I could not operate as this dog was unfit for surgery. Blood transfusion would be costly and there was some financial concerns in this case.  Prevention by spaying the dog would have been much cheaper but many owners do not expect their female dogs to suffer from pyometra.


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Mar 19, 2015.
Another case of suspected pyometra today. The 4-year-old Shih Tzu licked her vulval area till it became 10X larger than normal (video). Some female dogs are very clean and would lick off every small drop of vaginal discharge till the vulval area became much swollen, as in this dog. Another possibility is hyper-estrogenism.

The owner confirmed that this dog was very clean. She had fuzzy memory of the onset of the last heat. "Maybe November," she said.
"When was the earlier heat?" I asked.
"May," she said.
"So it is March now," I replied. "However, not all dogs come on heat exactly 6 monthly."

Antibiotics now. Spaying 2 months later is advised.

BLOOD TEST
2 abnormal results
Blood glucose  12.1  (3.9-6.0)
Monocytes 18.3% (3-10),  Absolute  1.94 (0.15 - 1.35)








1140. Pyometra in a Miniature Schnauzer

Thursday, March 19, 2015

The 6-year-old Miniature Schnauzer just could not stand up during the last 2 days before pyometra surgery.
"He could stand up when I carried him," the owner came on the 2nd day. The dog was recumbent and not active.
Blood test showed blood bacterial infection

Two days of IV drips and antibiotics. No immediate operation as survival rate will be very low. Owners expect miracles.

On Mar 18, 2015, he was operated by Dr Daniel. Thick dark brown pus (video).
Today, Mar 19, 2015, 11.15am, he was back to normal self (sitting up) see video and should have a good chance of survival. (Video).



Monday, March 16, 2015

** 1138. A 1.5-year-old cat has kidney failuare - nephritis & proteinuria. Had FLUTD 10 days ago.

10 days ago, the 1.5-year-old male, not neutered cat had obstructed bladder. A vet had relieved the blocked bladder after hospitalising the cat for 5 days. Now, the cat "cannot walk" and has throat pain.

The other vet's history showed the cat had septicaemia and kidney disorder (high creatinine).   The cat is very thin, at 4.1 kg now and hypothermic. The cat had dropped around 1 kg of bodyweight since 10 days ago.  The cat still peed blood but had no blocked bladder. 

X-rays showed enlarged kidneys. .

The first vet had  prescribed resistant antibiotics. When the cat was lame 4 days ago, the vet prescribed Tramadol 50 mg (1/6 twice a day for one week.).

But the cat was peeing blood.
Urine tests showed protein 3+, bacteria, blood, and white cells, spermatozoa + (cat is not neutered).

The vet had discharged the cat after 5 days of inpatient treatment. He prescribed clavamox 62.5 mg 1 table two times per day and Danzen once a day. The clavamox is usually given orally to cats by most vets in Singapore. In this case, it was ineffective based on the antibiotic sensitivity test (see below).

Hence the cat still passed blood in the urine for the last 10 days, became weaker and the inflamed penile area was really painful. So, the cat could not walk properly. The penile area was still inflamed and enlarged (see x-rays). The kidneys became more inflamed and hence palpable as 3X enlarged. The kidneys were damaged as protein is found in the urine test.

No blood test was done again to reduce medical costs. The first vet had done blood test showing septicaemia and kidney disorders.


BACTERIAL CULTURE AND SENSITIVITY TEST
At this stage, I did a bacterial culture and sensitivity test. Sometimes, there is the cost considerations and the test is not routinely done.


Bacterial culture of urine - showed Enterobacter aerogenes bacteria  resistant to amoxycillin+clavulanic acid (clavulox, clavamox), cefuroxime, nitrofurantoin, ampicillin + sulbactam and ampicillin.
It was sensitive to ciprofloxacin, gentamicin, cotrimoxazole, fosfomycin.


KIDNEY FAILURE means that the kidneys is unable to remove waste products from the blood. The kidneys have not stopped working and making urine. Early clinical signs are increased thirst and urination. Advanced kidney failure cause uraemia and signs include loss of appetite,vomiting, diarrhoea, very bad breath and ulcers in the mouth.

A high blood urea nitrogen (BUN) and creatinine levels mean kidney failure. 


TREATMENT
Thin lethargic, dehydrated.
In patient 2 days.
1. Diuresis.  At least 200 ml of sucutaneous fluids twic a day are given to "flush out" the kidneys. The flushing process is called diuresis is used to stimulate the kidney cells to function again. If enough kidney cells are functional, diuresis "restart" the kidneys. Replacement of various electrolytes  esp. potassium must be done. Proper low protein nutrition and drugs to control vomiting and diarrhoa.


2. A low protein diet to decrese the work load on the kidneys.
3. A phosphate binder to prevent phosphorous accumulating in the blood.
4. Fluids subcutaeously given at home. Not done in this case..
5. A drug to regulate the parathyroid gland and calcium levels.
6. A drug to stimulate the bone marrow to produce new red blood cells if the cat is anaemic.  
Baytril and drips.


MAR 24, 2015 FOLLOW UP - (7 DAYS AFTER CONSULTATION AT TOA PAYOH VETS).
1. No more blood in the urine since my treatment on Mar 17, 2015 (10 days after treatment by first vet).
2. Cat needs to be hand fed.
3. Cat does not poop.
Admitted: Wt 3.5 kg. Lost 600g since 7 days ago as the cat did not eat.
Temp 35.1 C compared to 36.7C 7 days ago. Severe dehydration. R lip commissure abscess, R gum ulcers behind R U canine tooth, central tongue ulcer. Rehydrate. Check FIV, FeLV but these were negative.  Poor prognosis.

Need to order only Royal Canin Dry Food for kidneys (no pork). The Royal Canin canned food and the Science diet K/D can and dry has pork.


4 cats in the household. This cat was the new introduction but had been with the other 3 cats for 15 months.

CAUSE OF FLUTD

The vet had diagnosed FLUTD (Feline Lower Urinary Tract Infection). However, the vet's blood tests showed septicaemia and kidney infections. This means that this cat has a much more serious illness than the ordinary FLUTD cases where, after relieving the bladder obstruction through catherisation, the cat bounces back and starts eating.

The owner had changed Fancy Feast to Pro Nature dry food 3-4 days before the bladder obstruction. There was no Fancy Feast available.  A change of diet suddenly may cause FLUTD leading to bladder obstruction. The other 3 cats were not affected. The husband could not recall till I asked him to recall and he confirmed that there was a change of brand of dry cat food. The vet had recorded this in his case sheet.

With kidney pain, the cat cannot walk normally. I felt an enlarged kidney but no pain. This is because the vet had prescribed oral Tramadol for the last 2 days. 









Urine test showed bacterial infection of the bladder. After 2 days of inpatient treatment with drips and medication, the kidneys have reduced in size by 50%. The cat can sit up and ate a bit of the other vet's prescribed diet for struvites. He could sit up and meowed.

The owner confined him at home, away from the other 3 cats and hand feed 6X/day, mixing Fancy Feast with prescribed Royal Canin Renal diet. Water is available freely.

FOLLOW UP ON APRIL 23, 2015
The cat is back to normal health and eating Royal Canine Renal Diet. The Science Diet K/D contains pork and so cannot be given on religious grounds.

FOLLOW UP ON MAY 12, 2015
The cat was back to normal. The daughter brought him in for neutering. "I thought your father likes him as a non-neutered cat as he responds to his attention," I said. She wanted him neutered to prevent any pregancies. So, he was neutered. His kidneys were no longer painful. I presumed he had recovered. No blood or urine tests were done to save on medical costs.  

Monday, March 9, 2015

1137. The dwarf hamster led an active life after surgery

March 10, 2015.

An early phone call from the worried lady. "There is a big hole under my hamster's right armpit," she announced. "Should I see you at the Clinic?"

The dwarf hamster had a big SC lump excised by Dr Daniel 5 days ago. The hamster climbed up and down 4 levels, a luxurious type of housing. The stitch broke down and now, I advised secondary healing. No point re-stitching.

1135. Unbelievable story: Multiple Myeloma - 4 years to live

March 9, 2015

"I googled the internet," the senior citizen said. "The life expectancy of multiple myeloma patients is around 4 years. Now, it is 10 years. When I was diagnosed, I hoped for 3 months to settle my personal matters.  I developed kidney failure, with creatinine over 1000. I was shivering and had lost considerable weight. My skin was red and I looked terrible.

"A friend suggested that I pray and after my prayer, my body was at peace and I recovered. Not fully but I surpassed the life expectancy of 4 years. "

I was glad for him. I had met a relative of this senior citizen just 1 day ago at an Association lunch. She said that he lived so long because he could afford expensive drugs.  A woman with the same diagnosis died after 3 years.

So, was it the faith or the expensive drugs that prolonged his life? He had his belief now.


Thursday, March 5, 2015

1134. Unbelieveable story: 15th day of Chinese New Year

Mar 5, 2015.

15th day of Chinese New Year is significant for traditionalist as it is the last day. I was invited to a family function to celebrate.

I had known the family for over 10 years and was once the family vet. When the Golden Retriever had lymphoma, there was a need for almost daily house call IV drip and attention as the owner did not want chemotherapy and the dog passed away after a few months. There was much emotional distress and the mistress consulted other vets. It took more than 2 years for the mistress to recover and invite me to her new year celebrations in December 2013.

In December 31, 2013, I celebrated the end of the year with the family on the invitation of the mistress. There was a strange incident in that everybody not residing in the house, except my wife and I left before 12 midnight.  The mistress did her annual prayers and prophesized that "those who stayed behind to welcome the New Year would prosper in 2014." I had rented a car for some months and the car number plate appeared first prize in the next 4D draw.   I had documented this incident with evidence of my car number plate and the 4D results. A $10 bet would give me $20,000 prize. The family members and I had small bets on this car number on the last draw before this prophecy. There was no wining. So we did not follow up. I do not bet 4Ds and so would not have pounced on the prophecy. If not, I would put $100 and win  $200,000.

In December 31, 2014, everybody stayed to welcome the New Year and I told the mistress that there would be no chance of winning 4D. She told me she did win first prize 1559 in Wed Feb 18, 2015 4-D draw. But it was famine for me and the other family members as we punted on our own numbers without a good outcome.      

This evening of the 15th day of the Chinese New Year, the moon was orange against the deep blue evening sky as I drove along Braddell Road to the house at 7.30 pm. My camera was not near me and so I missed a great shot of orange against moderately deep blue sky.  The orange is that of lighter Mandarin oranges. The blue is that of the pinafore of the Convent of Holy Infant Jesus student.

The dinner table was filled with food. I was surprised that the brother of the mistress told me he had suffered a stroke earlier but now had recovered much. He was the one who left without welcoming the New Year.

"I don't think it is stroke, but my family would not agree with me" the mistress suddenly declared to me at the dining table. "A man with stroke would be quiet. He was behaving like a very strong man. Two men (her brother in law and her employee) could not restrain him."
The two witnesses present nodded their heads in silence.
"Do you mean that he was possessed by spirits?" I asked.
This was surprisingly to me.  I don't know whether men who has stroke would exhibit super strength.

The brother had left before welcoming the New Year and suffered a "stroke" one month later. In the New Year, the family had a ritual of prayers for health and prosperity and he left early. So, he was not blessed by Providence.

One must be a believer to come to this conclusion.  In that year, the day after her prophecy that those who stayed behind to welcome the New Year would get prosperous, the first prize of the 4D draw was my rental car on the first draw after the New Year after the annual prayers.  I had recorded this episode in another story earlier.

Tuesday, March 3, 2015

1133. The male cat had urethral obstruction 7 years ago - kidney failure now?

On July 8, 2013, a grey male neutered 12-year-old cat had difficulty in urination for 2 days. I palpated the bladder. It was not swollen and so there was no urethral obstruction. 7 years ago, he had urethral obstruction and was catheterised by a vet and had recovered. He was fed dry food mainly and BURP canned food since 4 months ago.

I gave antibiotics. I advised dental work and change to feline C/D diet.


Then in Feb 4, 2014, he had dysuria again for one day. He lost appetite. He meowed a lot after urination and so the owner brought him to see me. The bladder was painful on palpation but was not distended to omuch. No vomiting or drinking or peeing excessively. Blood test showed a higher level of urea 14.8 (7.2-10.8) and creatinine 177 (71-160). Platelets were low at 238 (300-800).

I gave dextrose saline SC, irrigated the bladder with saline, gave antibiotics and Vit K1. X-rays showed a swollen left kidney (tumour or swelling?).

I phoned 2 days later and the grey cat was back to normal. He could control his bladder.

No news from the lady owner till today Mar 2, 2015, asking about the price of dry food, Prescription Diet K/D and wanting to buy feline C/D.


In November 2014, she had consulted another vet. The cat had started to vomit prior to boarding him for 2.5 weeks from Sep to Oct 2014. He vomited more often and became thinner. So, she consulted the other vet who took a blood test which showed slightly elevated urea and creatinine levels.

He prescribed K/D.
"How long did it take the cat to recover from vomiting?" I asked the working lady in her late 40s. She had rushed back from work to buy the food.

"he took 2-3 weeks to recover from vomiting and now had put on some weight. No more vomiting. I just wanted to stock up the dry K/D and buy 2 cans of feline K/D."

The cat was fed another brand of dry food and BURP in the past but now she switched to dry K/D.

"My cat prefers the wet food nowadays," she said when we met today.
"I did advise dental work as the gums will be painful when the cat eats dry food."
"Too old," she said the cat would be 15 years old in Dec this year and so no point spending money on dental. 

The cat would be on one tablespoon of K/D canned, canned BURP with low salt day and night and dry food K/D available. The cat did not have abnormal drinking.

It is a cat's destiny as to whether he has dentistry to relieve his tooth ache. Just like people as to where we live and earn a living. One client told me his friend's 11-year-old girl was missing for the past 3 days after going to the cinema in a country outside Singapore.   

This cat may not have kidney disease as there are no signs of drinking excessively.

If the cat had dental work 2 years ago to extract the rotten loose teeth, he would have a better quality of life but cat owners do not want to incur medical costs. A cat can live a longer life if his diet and health is monitored closely together with your vet.  Vomiting and weight loss are signs of poor health, not necessary kidney disease as the cat does not drink a lot of water. It could just be bacterial infections from the rotten teeth and a simple dental work by the vet would have made this cat much more lively.       



Monday, March 2, 2015

1132. The Golden Retriever's hind leg keeps swinging

Mar 2, 2015  7.07pm  Bishan library

This 5-year-old male neutered Golden Retriever was very itchy. "I couldn't sleep since he had been scratching the whole night, waking me up! That was why I phoned you to see him this morning."


The dog had been itchy in 2012 and I had resolved the problem and so the working lady owner came back to me for diagnosis and treatment.

"Do you remember this dog? He exploded anal sac oil straight into Dr Daniel and onto the walls of the consultation room!"

"Yes," I had recorded this incident in the case sheet. I cannot remember every dog's explosive anal sacs as this was not the only one. For the past 4 years, the anal sacs had filled up and nobody had expressed them.  So, they were time bombs of foul-smelly oil, spreading bad odours in the consultation room. This scent makes you want appreciate perfumes.

"Did you express the anal sac weekly or before bathing?" I asked the sun-tanned lady.
"No, no, but I sent him to the groomer every 2 months and this famous pet shop charges expensively. They groom the dog, clean the ears and express the anal sacs"
"How much?"
"$160 for every visit, but as Chinese New Year was in Feb 19, I did not send him to the groomer. I put some ear drops bought from the shop and did the ear cleaning myself! But my dog gets more and more itchy every day. His hind leg will swing back and forth in mid-air (see video).

The dog's ears were relatively clean but were painful to my touch. I could elicit the hind leg motions whenever I touched the lower ear area. So, this was a case of ear pain causing this behavior. The dog had to bite his backside and back legs to relieve the continual itchiness. The whole right back was very red as well.

Was this a case of allergy to the commercial ear wash? I had the skin and hairs checked for ringworm and demodectic mites. Ringworm was present in those red inflamed backside but no demodectic mites from 4 skin scrapings.

I got the dog sedated and the coat clipped bald. The ears were thoroughly irrigated.

"The hair will take 6 months to grow," she lamented.
"3 months if there is no more skin infections or itchy skin," I told her. This dog had chronic anal sacculitis and skin infections and so the coat was sparse.