Sunday, March 11, 2012

901. Hamster stitches may not dissolve if they are nylon

E-MAIL REPLY TO DR SING DATED MAR 11, 2011

On Sat, Mar 10, 2012 at 9:57 PM, ...gmail.com> wrote:

Hi,
A few weeks ago I brought in my hamster (Bob) to get a tumor removed but I'm a bit concerned how the stitches have not dissolved. I have been giving him the medicine he was subscribed, though unfortunately last week (or the week before?) one of them spilt by accident. How long does it usually take for them to dissolve, because on your website I saw it was supposed to be 4-7 days but it's already been much more then that.
I'm not sure if this is the correct email for these kind of inquires, but please feel free to correct me if I am mistaken.
Thank you and regards,
-Name of Owner

E-MAIL REPLY FROM DR SING DATED MAR 11, 2011



Pl bring hamster to the clinic for check up. Stitches should dissolve in 14-28 days if they are absorbable ones. Your hamster's stitches may be nylon and need to be removed by the vet as they don't dissolve by themselves.

Saturday, March 10, 2012

900. The guinea pig passes "blood" in the urine. Review and follow up

FIRST CONSULTATION WITH DR SING ON FEB 19, 2012

The young lady had consulted Vet 1 about her young guinea pig passing blood in the urine. Vet 1 had done the ultrasound and other tests which the young lady had not kept any records. The blood in the urine came again after a few weeks and she consulted me.


"Was a urine test done by Vet 1?" I asked. According to her, it was not done. A urine test is important when the complaint is "blood in the urine". It can tell many things as guinea pigs and rabbits may pass "blood-coloured urine" due to dietary causes. However the owner sees the reddish urine and thinks her pet is passing blood in the urine.

How to take urine from a guinea pig? For expediency, the vet usually gives the antibiotics, suspecting Urinary Tract Infection (UTI) and that would be the end of it. However Vet 1 apparently did many tests including ultrasound and had cost the owner a bundle. When the guinea pig passed "blood" in the urine again, she came to me for a second opinion.

In private practice, the clinical outcome is important. Otherwise, the owner just go to another vet as in this case.

Passing "blood" in the urine. Real blood. I used evidence-based medicine to diagnose this case. I hospitalised the guinea pig. As he was peeing "blood" in large amounts, I was fortunate to capture his urine and sent it to the laboratory for a proper analysis. My method is described in the images below.

5072 - 5075. 2nd time, the young guinea pig passes blood in the urine. Owner wants an answer. Practise evidence-based medicine by doing urine analysis & X-rays



Collect urine for testing. I used a clean plastic tray cover under the grating and a sterile syringe to collect the freshly passed urine. In this case, the guinea pig passes lots of urine and immediately. So I was fortunate enough to collect a relatively clean sample. He also pooped and this showed he was in good health. Weigh the guinea pig always. His weight was 500 g.

The next day of hospitalisation, the urine was no more bloody. I collected the urine in a syringe to show it to the owner and for this report. I did not test this urine to save costs for the owner.



The 2 X-rays showed some radio-opaque material inside the large intestines. Two views of X-rays are best as one view (lateral view) may not give a mis-diagnosis of the material as being inside the bladder.
The laboratory test showed "blood ++++" in the urine but no bacteria or white cells indicative of an infection. So, in this case, I was able to provide evidence to show the owner that her guinea pig was actually passing blood in the urine.




Practise evidence-based medicine. That is the way to earn the owner's trust. I also did 2 x-rays of the guinea pig's abdomen. There was some radio-opaque crescent material in the intestines. Could this be the "metallic" rust or some radio-dense chewing of the guinea pig? This guinea pig loves gnawing at everything and Dr Daniel was of the opinion that he had chewed some toxic matter.

(Later, in one photo below sent to me on Feb 27, 2012, you can see that the guinea pig was standing in a cage that is actually rusting)




SECOND CONSULTATION WITH DR SING VIA E-MAIL ON FEB 27, 2012

Other than that, please be careful about over-use of disinfectants and chew blocks that may have chemicals inside the wood. Toxins to the kidneys due to chewing of blocks and fence may also damage the kidney and cause blood in the urine.


On Mon, Feb 27, 2012 at 12:59 PM, ...@gmail.com> wrote:

He loves standing this way and the plastic screen is placed before the fence. However, what I noticed is that he's just grabbing the top edge to stand now. (You can see in the photo that the fencing was really rusty and the plastic fencing was used by the owner to prevent him from gnawing it. Later, I guessed that the young lady went to buy a new replacement fencing as the other photo showed white fencing (see photo below).

THIRD CONSULTATION WITH DR SING ON SUNDAY, MAR 4, 2012

Haematuria. "The guinea pig passes blood in the urine again yesterday," the young lady messaged Dr Daniel and came to the surgery. Yet, the carrier's absorbent litter showed just yellowish brown urine but the owner confirmed that real red blood had been passed at home.

"There are many causes," Dr Daniel enumerated UTI, stones that were not visible on X-rays, tumours. What to do? Go for a 3rd opinion? "You were supposed to be the 2nd opinion," she said.

So what was the cause of bleeding in the urine? Bladder or kidney problem? Hard to say. We did not actually see the "bloody urine" as the guinea pig came without having passed blood in the urine in his carrier.

"An exploratory laparotomy would be highly risky," Dr Daniel advised. The guinea pig was now 650 g compared to the earlier visit some 10 days ago.

I gave the following advices:
1. Feed the guinea pig organic vegetables, fruits and hay for one month.
2. No treats and pellets.
3. Feed the medication as before.

"How about dried raisins?" the lady asked. "They are his favourite."
"No raisins too."

Could raisins be the cause since the guinea pig had recovered the next day when hospitalised at Toa Payoh Vets and fed only vegetables and apple? Not a drop of blood. He went home and the cage was screened to prevent him climbing and chewing the wires (pictures given by owner).


Photo (left) is the photo of his new enclosure. You can see that instead of wiring, its the blue plastic on all 3 sides within the enclosure.


In the Photo, you can see that the blue piece is before the wiring. Also, you can see the small rubber tubing (fish tank cleaning rubber tubing, sliced along an edge) that I have just added to cover the top-most horizontal wires. I noticed that he doesn't bite this material.
In the Photo, it shows the clear plastic sheet on his enclosure door. It is also placed before the wiring, from Bean's perspective when he is in the enclosure.

Noted the possible toxins from the cleaning items, chew toys and cage wirings.




Thank you!
Regards,
Name of owner


I will wait and see whether the guinea pig is OK. "Blood" in the urine may not be actual blood this 3rd time. The urine could be "discoloured" urine due to the raisins and diet. To save the owner vet expenses, I did not advise more urine testing and sent the guinea pig home on antibiotics and pred medication for the next 7 days. Three days later, I texted her and was told that the guinea pig did not pass blood in the urine. Then on March 9, 2012, I got the phone message below:

FOURTH CONSULTATION WITH DR SING VIA E-MAIL ON MAR 9, 2012

Hi,

I just gave B.B a tablespoon of pellets as his weight is 500gm now. He stopped eating the veggies that he usually likes. I tried apples, carrots, romaine lettuce, butterhead lettuce and cucumbers, all to no avail. He just ignores them or just take a few bites. His consumption of hay has also gone down.

He's not peeing blood and since the protein content in his pellets aren't high, I reintroduced it. He went straight to eat it and seems to be happier. For the past few days, he's been going to the pellet bowl and looking into it even though it was empty.

Sent from my iPhone

REPLY FROM DR SING, MAR 9, 2012

Monitor n record amount n type of food  daily.  Wait n see.

Comments: It seems that the guinea pig has not passed "blood-coloured" urine since March 4, after replacing the rusty fencing (as seen in an email picture from the owner) and not giving raisins. Only time will tell whether the guinea pig will be fully recovered. The interesting aspect of this case is that there is no way the vet can know that the guinea pig had gnawed on the rusty fencing till the picture was received. So, could the rusty fencing be the cause of "blood in the urine? Rust could damage the kidneys and cause bleeding. This is one possible cause.

It is really difficult for a vet to diagnose this case if the vet does not do urine analysis and speculate that it is always a urinary tract infection. The guinea pig is a valuable family member to the younger generation and it is imperative that a correct diagnosis be made and in this case, urinalysis is mandatory. There is no point doing ultrasound and other scanning when the urinalysis can provide clues and is much less expensive and more useful. But guinea pigs don't pee a lot and it is extremely difficult to collect the urine. Therefore, hospitalise the patient!




NOTES:
http://www.sinpets.com/F6/20120238guinea-pig-haematuria-singapore_ToaPayohVets.htm
gives the latest updates and pictures.

Wednesday, March 7, 2012

899. A dog care-giver's rage

On Tuesday, March 2, 2012, a dog care-giver was mouthing profanities for over an hour, repeating "can't ni lao boo chi bye". He was stout and had a broad face with bulging eyes that could frighten the weak-hearted.

He brought in a Spitz that had died. Caesarean and spay were done by Dr Jason on Saturday.

Monday, March 5, 2012

898. Sunday's interesting cases: The guinea pig passes blood in the urine for the 3rd time

Sunday Mar 4, 2012

Case 1. Haematuria. "The guinea pig passes blood in the urine again yesterday," the young lady messaged Dr Daniel and came to the surgery. Yet, the carrier's absorbent litter showed just yellowish brown urine but the owner confirmed that real red blood had been passed at home.

"There are many causes," Dr Daniel enumerated UTI, stones that were not visible on X-rays, tumours. What to do? Go for a 3rd opinion? "You were supposed to be the 2nd opinion," she said.

So what was the cause of bleeding in the urine? Bladder or kidney problem? Hard to say. An exploratory laparotomy would be highly risky. The guinea pig was now 650 g compared to the earlier visit some 10 days ago.

I gave the following advices:
1. Feed the guinea pig organic vegetables, fruits and hay for one month.
2. No treats and pellets.
3. Feed the medication as before.

"How about dried raisins?" the lady asked. "They are his favourite."
"No raisins too."

Could raisins be the cause since the guinea pig had recovered the next day when hospitalised at Toa Payoh Vets and fed only vegetables and apple? Not a drop of blood. He went home and the cage was screened to prevent him climbing and chewing the wires (pictures given by owner).

Will wait and see.



EARLIER CONSULTATION ON FEB 27, 2012

Other than that, please be careful about over-use of disinfectants and chew blocks that may have chemicals inside the wood. Toxins to the kidneys due to chewing of blocks and fence may also damage the kidney and cause blood in the urine.


On Mon, Feb 27, 2012 at 12:59 PM, ...@gmail.com> wrote:

He loves standing this way and the plastic screen is placed before the fence. However, what I noticed is that he's just grabbing the top edge to stand now.

EARLIER CONSULTATION ON FEB 28, 2012



Hi,


Photo 2 is the photo of his new enclosure. You can see that instead of wiring, its the blue plastic on all 3 sides within the enclosure.


In Photo, you can see that the blue piece is before the wiring. Also, you can see the small rubber tubing (fish tank cleaning rubber tubing, sliced along an edge) that I have just added to cover the top-most horizontal wires. I noticed that he doesn't bite this material.


In Photo 1, it shows the clear plastic sheet on his enclosure door. It is also placed before the wiring, from Bean's perspective when he is in the enclosure.


Noted the possible toxins from the cleaning items, chew toys and cage wirings.


Thank you!


Regards,
Name of owner

---------------------------------------------------------------------------
Case 2. Vaccination. Westie with lots of pus in both ears came for vaccination. I was surprised that he had recovered 90%. Some black specks in his spinal area whereas previously the whole area was tar black. "Ear canals are clean," I said as I taught Dr Daniel that I would smell the cotton tip after inserting into the ear canal. Most vets don't do it. Smell is a good indicator of ear canal health. I pressed the sides of the ears firmly. No pain. A bit more firmly on both ears. The dog gave a slight yelp. Overall, the ears were clean and had no more pus. I was surprised. The medication was working for this old dog obsessed with ear scratching for many months. The dog had ear irrigation twice and was OK now.

"Dental scaling is needed," the lady owner in her late 40s said. "When did your dog eat breakfast?" I asked. "Always at 6.30 am." Since I did not want the owner to come again, I advised dental scaling at 3 pm, using domitor and ketamine IV. No vomiting. All OK.

Case 3. Meeting with Mr Min, Dr Vanessa and Dr Daniel.
"There is a lot of administration that the lay staff like Mr Lim and Nicole had to do," I said to the 3 of them. "They loved to help out Dr Vanessa in consultation and surgery but they neglected to complete their project." They took a lot longer time to complete the project and they do take days off now and then. Therefore I had advised that they be advised to focus on their work.

"Technical aspect is just one aspect of veterinary medicine," I said to Dr Vanessa. "There is the administration side and the other aspects to support the vets. The vets must discourage idle gossip that lay staff love. They are paid to do a job but they prefer to see practice. That is not what I pay them to do."

I hope the vets have a better understanding that veterinary medicine is much more than just diagnosis and treatment. Lots of paperwork, taxation and other legal submission to the authorities, stock checking and control, payment and sterilisation, cleaning etc.

Case 4. Maltese with blood clot inside the eye, in front of the iris.
Mr Min suggested that the torch-light be shone from 6 o'clock upwards. Sure enough, the young couple could see pinkish blood clot inside the eye in front of the pupil. The dog had been rubbing its eye hard.

A durian seed undetected by X-ray and ultrasound

I shared with Daniel the owner's spending $3,000 for a durian seed inside her dog, at Vet 1. "A barium meal will have detected the durian seed," he said.

She had consulted me as her dog had vomited and would rather not have the blood tests, the X-rays and other tests as she had spent a lot of money at Vet 1. Conservative IV drip with medication for 24 hours warding at Toa Payoh Vets, resolved her problem. No durian seed this time as I palpated nothing inside the stomach. The lady wanted to show me a photo of the durian seed in her handphone, the seed removed by Vet 1 under exploratory laparotomy but could not find it.

895. An excellent article and surgery on megaesophagus & "vertical feeding"

The link is as follows:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC340085/

In practice, it will be most expensive for an owner to get all the tests done to determine the cause and the surgery. In my case, the owner was not keen on more tests.

"Vertical feeding," I asked Dr Gladys what it meant as stated in her University book. I was glad to see her now graduated and practising as last year, I met her in Perth and she was in her 5th year, studying very hard.

This was after we had taken the X-ray with barium meal to show the megaesophagus to the owner as he was not much convinced with the plain radiograph.

"Feed like a human being, being upright," she said.
"You mean, the dog should stand up and eat and drink?" I asked. Lucky for me she had the patience.
"Use a Bailey's chair," she replied.

Well, Bailey's chair are mentioned in the internet on megaesophagus nowadays and therefore is no secret.

It is actually a toddler's dining chair where you confine the toddler.
"It is not practical," the owner told me when I advised him to make one Bailey chair. "I don't expect my dog to sit in it for more than 5 minutes.

The theory is that gravity enables the dog that is fed soft food seated in a Bailey's chair to get the food into the stomach. The dog must sit in it for some time and this may not be to the dog's liking.

The dog had lymphoma and FNA (fine needle aspirate) done on the popliteal and cervical lymph nodes by Dr Gladys and Dr Daniel indicated abnormal cells. A lab test was recommended.

"The owner is more interested in the cure than in knowing that his dog had what type of lymphoma," I said to Dr Daniel. "Such test need money and the owner just wanted to cure the dog of regurgitation and the tongue ulcer. Will such test help? I will say not. So, in practice, economics play a big part unlike in the academic world of the Vet School."


UPDATE AND PICTURES WILL BE AT:
http://www.sinpets.com/dogs/20120237megaesophagus-vertical-feeding-dog-singapore_ToaPayohVets.htm

Saturday, March 3, 2012

893. Sophisticated Singaporean pet owners

Yesterday, Friday, I had a meeting with Mr Min, Dr Vanessa and Dr Daniel, seated facing them in the small consultation room, at around 11.30 am when Dr V came to work. The topics covered were:

1. Trend of better educated younger clientele.

"Nowadays, Singapore clients are better informed, esp. on specific diseases as they research the internet," I said. "Therefore, the vet must be able to provide additional value and know the answers to resolve their problem. Clients already know some answers.

For example, megaesophagus in the dog. The diagnosis is easy. Give me 3 solutions or treatments," I asked Dr Vanessa. I continued as clients were waiting outside: "Vets can see the megaesophagus on the plain chest X-ray, but don't expect the owner to see it. That is why I had a barium meal done on the shih tzu so that the owner can really see the dilated esophagus. In fact, there was an esophageal diverticula in the front part of the esophagus.

Dr Gladys had warned that the dog could get aspiration pneumonia if he was given the barium meal," I looked at Dr Daniel who was present during the X-ray. "But this test had to be done and the risk taken. Now, the owner is satisfied with knowing what cause regurgitation in his dog for the past 3 months. As to the cure, that's another matter. Get the diagnosis accurately in a manner that the owner can relate to. Not just showing some area on the plain X-ray and expecting the owner to be convinced as that was not possible in this case earlier."

I read out a text message from a young girl whose rabbit had just given birth to 2 kits. "She's very knowledgeable," I said to Dr Daniel who had diagnosed pregnancy after palpation of a soft abdominal lump and predicted one rabbit.

I had said that "X-rays are necessary to confirm how many babu rabbits were there or whether it was a hairball as diagnosed by the young girl who had earlier texted me to say her 5-month-old rabbit was not eating and drinking.

I had asked: "When did you see the rabbit being mated by the 6-month-old male?". She said: "2 weeks ago."

She asked whether she ought to X-ray and I said it was not necessary. "Just separate from the male, keep her in a quiet place, feed her the fiberplex to move her bowel since the stool pellets are harder and syringe her with electrolytes. She came all the way from Tampenis and it was good that she had good news from her text message 3 days after consulting me.

2. Be meticulous in recording.
Proper and accurate recording ofsurgical procedures, hospitalisation records and anaesthetic records. "All vets will be responsible for their own records," I said. "When there is litigation, such records will be evidence of professionalism or lack of care," I said. "If you want to continue working as a vet, you have to be aware of the trend towards a litigious society and the many regulations of the veterinary authority. Such as the requirement to submit rabies and microchip records monthly. I cited examples of disciplinary enquiries of the liposuction death case where the anaesthetist record was said to be "doctored" and the acupuncturist who prescribed drugs but failed to keep proper and accurate records.

"There are more newspaper complaints and litigation in the medical profession nowadays," I said to the two young vets. "It is best to learn from the failings of others. Unless you want to be suspended or struck off for negligence or for not providing a reasonable standard of care. In the old days, there was not so much need to keep detailed records of anaesthesia and surgery. But times have changed and it is best to be up to date on trends and regulations."

"You two younger vets have at least 30 years of practice to look forward. It will be bad to be suspended or become infamous in litigation. Unfortunately, as a licensee, my name will be dragged in too in such circumstances."

Much more had been said by me than I can record. It is not easy to be a vet or doctor nowadays and so one must be careful. Very careful.