Monday, October 31, 2011

717. Recurrent UTI in an old Corgi is hard to treat

Recurrent UTI in an old Corgi is hard to treat
Every dog owner and probably person will be warned about anaesthetic risks. For owners who don't want the risk, there are groomers in Singapore who find this opportunity to provide a service involving dental scaling of dogs without any anaesthesia.

Vets do not use anaesthetic on dogs unnecessary to avoid any anaesthetic risks as the high emotions of grieving of dogs dead during anaesthesia are terrible for the vet and the staff.

Since most dogs will not tolerate manual dental scaling, the groomer's assistant must grip the dog's legs tight to enforce cooperation. It is like the old days when people are held tightly by men during surgeries or given a dose of whisky. In dogs, the groomer can't sedate as the service is supposed to be no anaesthetic or sedation.

Recently I had a case of a poodle that had stopped eating for over 3 days and could not stand up. The two teenaged daughters were worried that their dog may die. The mother had taken the dog to a groomer in Sembawang pet shop to get dental scaling done. I remembered this case as the mother was running a mini-mart and I had vaccinated her dog some 3 years ago. It was a puppy then. I had the dog's blood checked, gave the IV drip and antibiotics. There was hypoglycaemia. The dog's mouth probably was very painful after enforced dental scaling by the groomer and so he would not eat. He recovered within 2 days of treatment and went home to two happy teenaged daughters and a relieved mother.

Yesterday, Oct 31, 2011, I had this 9-year-old Corgi whose lady owner was vacillating as to whether to get her dental scaling done or not. Her dog would lick at the vagina after the course of antibiotics lasting as long as one month and the urine would have blood clots or blood when all the antibiotics have been taken.

She had consulted several vets in one brand name practice for more than 10 times over the last two years after being referred to this practice by another vet who could not cure her dog's blood in the urine problem. This was because the brand name practice has all the facilities, according to the vet referring her to this practice. Ultrasound of the kidney and bladders, urine tests, urine culture and sensitivity and blood tests were done at various times over the two years. There was said to be an X-ray done but the practice said there was no record available.

But her dog would pass smelly urine with blood after a course of antibiotics prescribed by these vets. She was not happy with this situation. One vet had advised surgery of the bladder to remove "polyps" but had told her about anaesthetic risk and that the surgery was not meant to be a cure for the recurring problem of passing blood in the urine.

She phoned me to seek another opinion recently. I have the benefit of these tests. Three urine tests at different times showed struvites in the urine. The facilities or tools of the trade were used by the vets but the owner's problems were not resolved.

It was like my car's problem. My car would display "Check coolant level" and I would send the car to my usual mechanic for 4 times. The mechanics were two older men in their late 60s distinguished with snow-white hairs and specialising in the brand of car I drove. I presumed they must have the experience as their hairs were all white. I never bargained or squeezed them for discount after they service my car, as is the case with many pet owners at Toa Payoh Vets.

At the 4th time "Check coolant level," message flashed, I asked the mechanic whether he could do the job. I had to replace 2000 ml of water in 5 days after he had assured me that he had resolved my problem.

I cannot afford putting my car overnight and then encounter the same problem again. The old man pointed to some water spots on the radiator and said he knew what to do. He diagnosed the radiator cap as being damaged and therefore leaked the coolant. He said he had used pressure tests and there was no other leakage. Earlier he had put some liquid which could seal any cracks but they did not work.

Yet, I got the same problem. On the 5th time, he said he would check again. He said the 5-month-old German-made radiator was faulty and had replaced with a French-made radiator. The supplier of the German-made radiator would not provide a replacement and therefore I had to pay him $500. "The 'check coolant level' was reported within 2 months of getting the German-made radiator," I said. "I wish to speak to the distributor as he is selling faulty goods and cheating people." The old man said it was of no use. "I was referred to another mechanic down the road," I said to the old man. "You could not resolve my problem for so many times."

With the new radiator replaced, I checked the water level 5 days later. There was a need to top up 200 ml of water. So, was there a leakage or not? I have to wait and see.

My situation is similar with that of the Corgi owner as I entrusted my mechanic to resolve my problem. He recommended replacement of the radiator and some pumps and the bill came up to $7,000!

Only that she had consulted the same practice for over 10 times without resolution of her problems and I would not be surprised if she had spent $7,000 too. I did not ask her. But I could empathise with her.

I use the same guideline for sedation
A 10-kg healthy young dog - 0.4 ml domitor + 0.5 ml ketamine IV

The Corgi weighed around 14 kg but she was old. Blood tests were normal but no chest x-ray of the heart was done today as this is the usual practice. In human anaesthesia, a chest x-ray at Singapore General Hospital where I went for surgery, was mandatory.

In this Corgi, I gave 0.1 ml domitor + 0.1 ml ketamine mixed with 0. 3 ml normal saline and gave IV. This was less than 20% of the formula but the dog was sedated 80%. I used isoflurane gas to top up.

"No need," my assistant Min said when I told him to apply a tourniquet.
"Sometimes it is not needed," I said. "But I see that you have wasted a lot of time in some cases where no tourniquet was used as the blood collection or injection was not possible at the first attempt."
The dog had a tourniquet and the cephalic vein was distended. The sedatives were given.

I monitored the isoflurane gas + oxygen very carefully as the lady owner entrusted me and expected the dog to be OK. Eyelid blinking to be zero and maintenance of isoflurane was 0.5 - 1%. The dog had bilateral cataracts but I could monitor the closing of the pupil. It still took 45 minutes to complete the whole dental scaling. Solid teeth. Tartar only esp. on PM4 upper, both sides.

The owner had said, "My dog had only one anaesthesia and that was when she was spayed." I said: "That was some 6 years ago and she was healthy then. I advise an X-ray of the chest."

I collaborate with an experienced vet who did the ultrasound and X-rays. I brought the Corgi personally to discuss with him the use of the tools of the trade - the ultrasound and the X-rays and how he would interpret the results. I had wanted a contrast cystography involving injecting dyes into the dog and X-raying the kidneys and bladder to check for tumours and stones. However the cost of $500 inclusive of anaesthesia was above budget. I had to find other lower cost alternatives and in any case, there was anaesthesia which I had just performed during dental scaling in the morning.

To cut a long story short, the ultrasound showed lots of floating sandy particles inside the bladder as reported by previous vets doing the ultrasound. There was thickened bladder wall but no polyps or transitional cell carcinoma inside the bladder. "Otherwise the Doppler would show blood flowing into the mass on the inside of the bladder," the vet I collaborated with said to me. "There was zero blood flow and therefore the sandy particles were separate from any mucosa." Excellent use of the tools of the trade, I must commend him.

On X-rays, I could see radio-dense bladder indicative of struvites (as reported by urine tests by the previous vets). The owner collected urine in the morning but I had treated the dog with antibiotics 2 days ago. I wanted the X-ray to see if there were large struvite stones. There were none.

Lots of radio-dense sandy particles float inside the bladder. Could they be struvite sand or inflammatory cells?

Yet the urine test taken on the same day is negative for epithelial, white blood and red blood cells and crystals, mucus threads, yeast and bacteria.
The urine test I sent to the lab today show normal urine. Amber, clear, no nitrite, protein, glucose, ketones, urobilinogen (normal), bilirubin, blood. Urine microscopy - no white or ed blood cells, no epithelial cells, casts, crystals, bacteria, mucus threads. yeast or others.

The pH was 7.0 (5-8) and SG was 1.018 (1.0905-1.030).
Based on history, the sandy particles would be struvites or inflammatory cells.

I had to treat the dog 2 days ago as it was quite distressing for the owner. In any case, urine bacterial culture and sensitivity tests had been done by the other vets and Proteus mirabilis was found in one time. So, I did not repeat again to save the owner some money. Baytril had worked and the dog was no more passing blood in the urine while on antibiotics.

What is the next step now that the bladder is shown to be free from tumours and polyps which would cause recurrent UTI? I recommend dental scaling which was done. The next step would be SD diet for 3-4 months to acidify the urine. If this works, it will be happy days for the owner. I will use urine acidifiers and review the case in 4 weeks. Will I succeed where others fail? Only time will tell whether I can resolve the lady's pet problem of recurring UTI. This dog was well beloved as not many Singapore owners would bother to take the dog for over 10 times to treat for blood in the urine. One or two times and that's it for the old girl!

The history of the case reports from the other vets is much more important than one urine test. I would say that struvite and inflammatory cells are present.

The dog has chronic cystitis and recurrent UTI. Tumours have been ruled out as a cause. Blood test before antibiotic treatment was normal and so a other-source of infection via the blood is ruled out. This leaves struvites are a cause. The pH 7.0 is not acidic. Nor alkaline but this should be reduced to produce acidic urine to stop bacterial growth.

P.S. The dog's heart was enlarged but when I auscultated the heart, the heart sounds were normal. "Why is the heart enlarged?" the owner asked. "It may be due to old age or congenital or other reasons," I said. The dog did feel short of breath at certain times. Will update this webpage.

Updates will be at: Toa Payoh Vets webpage:

Sunday, October 30, 2011

716. Sunday's interesting case. Oct 30, 2011. $600 for a rescue dog with tick fever


I got a text message from a young lady caring for a Singapore Rescue Group's stray dog with tick fever diagnosed by Vet 1. According to her, Vet 1 said that the imizole commonly used for treatment of tick fever will be ineffective as this dog had Babesia gibsoni. Imizole is "ineffective" against Babesia gibsoni. The "effective" drugs will be the atovaquone, clindamycine and azithromycin but it will cost $1,000.

The rescue group asked her to top up the bill but she did not have the means to do so. So, she texted me for advice.

Below are some of my replies to her.

It is kind of you to do dog rescue work. There are many financial considerations.

Combination of oral atovaquone, clindamycine and azithromycin by (Vet 1) as said by you, is effective against Babesia gibsoni infections in this dog.

I will not comment further as I don't use these expensive drugs. Success rate depends on follow up, not just one injection. Blood transfusion 1.5 bags at $500/bag and hospitalisation will be more than $600 budget from the Rescue group.

Berenil is cheap but anaphylaxis according to your text. Hb at 5 is low for your affected dog, but you also need to know total RBC.

In conclusion, treatment is not cheap due to prolonged treatment and follow ups.

E-MAIL TO DR SING DATED Oct 29 (2 days ago)

Thank you very much Dr Sing. I am heading out to check on the dog this morning. If the rescue doesn't want to pay for treatment, I think I will bring the dog home to die as she doesn't like the cage...

Thanks again. Will email u soon.

Name given

The dog was sent home without the expensive treatment or imizole. The lady activist thought that the dog was "alone" at the vet clinic and she would take the dog home to die. Berenil would be available possibly 2 days later.

Coincidentally, I was following up on an English cocker spaniel, 11.5 kg with Babesia gibsoni and ehrlichia tick fever 10 days ago.

She came today for her 2nd imizole injection (0.6 ml SC today, Sunday) 10 days after the first injection (0.5 ml SC). Based on her active normal behaviour and much pinker gums, the first imizole injection had worked. Otherwise she should be dead by now.

So, should Vet 1 have given imizole to that stray dog rather than wait for the cheaper Berenil to be available later? Is imizole totally ineffective against Babesia gibsoni? I related this matter of the stray dog to the cocker spaniel and she was worried that I had not given the correct treatment.

"Will you dog be active and rushing out and have pink gums 10 days after the first injection if imizole was ineffective?" I asked her as I gave the 2nd injection today.

My thoughts are for that stray dog. I had offered to give the imizole injection and help out with supportive therapy but the lady activist was a caregiver only and could not decide as she was not the paymaster.


715. Follow up on puppy's paper training case

The puppy was paper-trained for 2 weeks and then given an extension of the confined area. Dettol was used. However, I need more info about the housing layout etc and the following are my comments:

E-MAIL TO DR SING DATED OCT 30, 2011 to me

show details 8:22 PM (7 hours ago)

Hi Dr Sing,

It was nice meeting you and Dr Vanessa when I brought my puppy for his 3rd vaccination.

The puppy has been eliminating at the correct place, i.e. the newspaper, for about 2 weeks. We let him out occasionally to a small, confined area and he has no problems going back to the newspaper to pee. However, for the past few days, he has been peeing outside the newspaper a few times even after we washed the floor with Dettol. We took it that he forgot the place the first few times, but today, the newspaper was clean and he still peed outside the newspaper. Once, when he peed on the newspaper, he sat beside the newspaper and looked guilty. Are there any possible reasons to this?

Would appreciate your advise on this matter. Thank you.



I was surprised to meet you and your mum and thank you for coming to Toa Payoh Vets.

Pl email 3 pictures of his housing layout including where you place his feed and water bowl and his sleeping bed (if any).

1. What is the pH of Dettol? Does it some ammonia urine-smell? This may cause the puppy to use the area as its toilet area and its crate as the clean den (although it has newspapers).

2. Previously, did you use Dettol?
3. Use white vinegar + water at 1 part vinegar to 3 parts water to clean the floor instead of Dettol.
4. It may be best to confine him again.
5. Pictures of the housing and other info as requested are needed.

Best wishes.


Saturday, October 29, 2011

714. Follow up on dog enucleation case - pterygium and glaucoma case

On Sat, Oct 29, 2011 at 12:14 PM,> wrote:

Dear Dr Sing,
Queenie, the 12 year old dog, is doing well. She is eating and running around. Has no problems passing motion and easing herself.
Enclosed are the pictures you asked for. I suppose her stiches come out on the 2nd of Nov (14 days)
Thanks alot

Thanks for pictures. 14 days should be OK to take out stitches. Best wishes.

Thursday, October 27, 2011

FURTD, FIV and FeLV in cats

1. Feline upper respiratory tract diseases (FURTD) are usually caused by Feline herpes virus and calicivirus in 90% of the cases in Australia's multi-cat environments. In Singapore, usually stray cats.

Sneezing, pus in both nostrils and eye discharges are the main signs.

2. FIV
Feline Immunodeficiency Virus (FIV)
Transmission is mainly by biting e.g. roaming male cats.
Clinical 4 phases
1. Acute infection - 4-6 weeks, fever, neutropenia, lymphadenopathy
2. Asymptomatic carrier state (FIV Ab positive). Most common. last months or years.
3. Chronic disease. Non-specific signs like chronic stomatitis (possible immunodeficiency cause)
4.Terminal AIDS-phase. Infections and neoplasia.

Few cats go to Phase 3 and 4.
Hard to give prognosis.

Laboratory list is typical as follows:
neutropenia, thrombocytopenia, non-regenerative anaemia (use erythropoietin)
monocyotosis and lymphocytosis
renal azotaemia
ployclonal hyperglobulinaemia

ELISA test kits. detect anti-FIV antibodies

Most cats don't develop FIV-associated disease, prognosis is generally good.
Keep cat inddors. FIV cats isolated in cattery. Good nutrition, proper sanitation and stress reduction.

Routine vaccination with inactivated vaccines

Supportive treatment. prolonged or repeated antibiotics.
Anti-viral therapy

Vaccine available. Roaming outdoor cat advised.
FIV and FeLV easily destroyed by disinfection and tranmission by fomites is unusual.
Prevent contact FIV+ to FIV-ve cats

regular deworming, clinical monitoring and preventive dental care
spay or neuter

Feline Leukaemia Virus (FeLV)
Mainly an infection of young cats cf. FIV cats older than 6 years usually. Non-specific signs like weight loss, anorexia, fever, depression.

Transmission mainly via saliva, nasal secretions during grooming, sharing of food or water sources.

Three outcomes

1. Transietn infection
2. Latency (sub-clinical)
3. Persistent viraemia.

Lympadenopathy (thymic and multicentric lymphoma most frequency associated with FeLV), ocular signs and anaemia YOUNG cats

Laboratory - non-specific
MOST common abnromality. non-regenrative
Leucoppenia, thrombocytopenia, haemolytic anaemia
Azotaemia (pre-renal or enal)
Hyperbilirubinaemia (pre-hepatic or hepatic)
ALT/AP increses
Proteinuria (secondary glomerulopathies or UTI)

ELISA antigen detection.

Other tests;
IFAT blood smears (antigen in WBC and platelets)
Virus isolation

Supportive treatment ---- control secondary infections, restore hydration with fluid therapy and nutrition. blood transfusions in anaemic cats, doxycycline for FIA. Lymphoma treated with chemotherapy.

Avoid exposure by contact.
FeLV is also a non-core vaccine,use in cats at risk e.g. cattery, outdoor, rehoming cats

712. Update: In 2008, tick fever in a Great Dane

A veterinary-client relationship of trust and respect benefits this Great Dane

"My Great Dane does not eat even his favourite curry chicken rice. He is tired and has pale eyelids for at least 2 days. Is it possible he has tick fever?" Jenny phoned me. "I removed some ticks from him recently."

She was my ex-veterinary nurse some 20 years ago and has at least 20 years of handling dogs and cats in various employment in boarding, veterinary practice, breeding and retail. She started work with animals since she was 18 years old and has hands-on experiences in dog diseases in Singapore.

Jenny continued: "The Great Dane has no appetite and sleeps a lot for the past 2 days. He looks pale in his gums. Can it be tick fever? Can you make a house-call?" the caregiver asked me.

"Jenny, if you think it is tick fever, bring the dog to the Surgery. There is no point making a house-call as it is much easier to treat him in the Surgery." I advised this busy manager of a large pet accessory warehouse retail shop in Pasir Ris.

"Can I come tonight?" the caregiver wanted to clear her administrative and paper work first.
"If you think he has tick fever, do not delay treatment," I needed no explanation that every delay permitted the blood parasites to multiply and destroy the blood cells.

"I will get a pet transport man to bring the dog down to the surgery. If it is the starting of tick fever, come down now to get the dog treated before the blood parasites multiplying in his red blood cells overwhelms and kills him," I advised.

Jenny arrived at 3 pm with an assistant. She is a gentle soft-voiced lady in her forties. I was surprised that her hair was disheveled while multiple frown lines creased her face. The 2.5-year-old male giant canine came down from Jenny's car and sauntered into the Surgery. He had never been sick and therefore had not been to the veterinary surgery for the past 2 years. He was as tall as a 12-year-old child.

Fever of 40.2C was confirmed by taking the rectal temperature. There was moderate pallor of gums and conjunctiva.

Two men carried the giant onto the table. He weighed around 80 kg.

Complete blood count needed. I/V antibiotics and amino acids given. Sent home with the i/v catheter in his vein.
Care-giver wants the dog home to treat herself

Put catheter IV inserted. 3 blood samples to be sent to the laboratory. IV dextrose saline, duphalyte and baytril IV given. Sent home with bottle of 5% dextrose saline and duphalyte on slow IV drip. Dog could still walk home. He looked normal.

Wednesday Aug 20, 2008
Not eating much. Lethargy. No news from caregiver.
Pancytopenia in blood test result - Low red, white blood cells and platelets. Based on laboratory tests, the Great Dane should not be standing and should be bleeding to death. But he could be at the start of the acute stage of Tick Fever and the parasites were just destroying his blood cells. Was there any hope for him?

Thursday Aug 21, 2008 house-call by vet
Phoned caregiver. Not really improved. Still not eating much. I told caregiver I would need to make a house-call to check and give anti-babesiosis injection. What I said was all Greek to the caregiver.

Vet needs to do a house call. The busy caregiver did not update the vet.   
Caregiver cooked liver. She gave a few bags of fluid and lots of multivitamins to the Great Dane for the past 2 days.

"Dog looks normal," his gentleman owner said. "No pallor of tick fever."
The Great Dane remembered the injections and drips at the vet and ran into the safety of his home.

The Great Dane reluctantly said goodbye to me since his caregiver asked him to do it. Given anti-babesia injection on Aug 21, 2008 before I left the Great Dane's residence. He had not recovered fully as at Aug 25, 2008. Jenny was advised to monitor his rectal temperature. She needed to buy a thermometer.
The caregiver was cooking liver. Dog ate when caregiver hand-fed bits of liver. Caregiver showed me that she had bought 0.9% Sodium Chloride from a general practitioner and 5% dextrose bag from somewhere. She would give the solutions by SC. I gave 2.6 ml Imizole SC. Duphalyte x 1 bottle to caregiver. Advised caregiver to come for more vibravet medication on completion of 7 days' course and buy a thermometer.

Friday Aug 22, 2008
Great Dane not really interested in food.
"No time to buy the thermometer," caregiver said.
"Did you check on how much water the Great Dane drink and what is the colour of his urine?" I asked.
"You know, I have been very busy updating price list of goods nowadays," she said. "I also cooked for the dog. I do not have time to monitor how much water he drinks or the colour of his pee!" The cost of goods must increase as there was a surge in food, petrol and other prices in the past week and the caregiver was responsible to get the updates done before the weekend sales. The Great Dane had to fall sick and took up a lot of her time.

"Blood tests for Babesia and Ehrlichia at the AVA would cost $200. Do you want them?" I asked the caregiver. She was hesitant about the costs involved. As I have had given the Great Dane the important treatment for the two types of parasites causing tick fever, I said, "Wait and see".

Tuesday Aug 26, 2008
"Great Dane asked to be bathed today," Jenny phoned me. "I need to come down to your surgery to get the vibravet tablets". Surprisingly the caregiver remembered as she had a lot of paperwork to do and I did expect her to forget about the medication as most owners will do. After all, the Great Dane is now eating and medication had been given for 7 days.

"When did the Great Dane recover?" I asked as I did not pester Jenny since the last call. She said she had some much paper work to do the last time I phoned her. Nowadays, a capable and intelligent hardworking employee does the work of 3 people and work never ends for the good employee.

Jenny said, "On Sunday, the Great Dane was so hungry and wolfed down his food."

"It must be due to Imizole and medication," I forgot to acknowledge caregiver's important role.

"It is due to my extra vitamins and cooking of liver for him." Jenny replied. Sometimes veterinarians look at the cause and effect of drugs rather than the acknowledgement of the care, time spent and love of the caregiver when the case is closed successfully.

Her boss came to the surgery to get vibravet for 10 more days as Jenny was busy updating the pricing of pet products. "Go and buy two thermometers," I said to the boss. "Jenny has been too busy to buy one. The thermometers can help to monitor the fever of your sick dogs." Jenny monitored the fever by feeling whether the belly of the Great Dane was hot to the hand or not. That was not a good way to do it.

It is important for the vet to follow up on suspicious tick fever cases. As there was a relationship of trust and respect, I made a house-call to give the Great Dane the anti-Babesia injection after reviewing his blood panel tests. There was no time to wait for the specific blood tests to confirm the presence of the blood parasites which may or may not be present.

This caregiver was extremely good in the nursing care of the Great Dane and a great asset to her boss. A relationship of trust and respect between the caregiver and the veterinarian is always beneficial to the pet. If there was no such relationship, I doubt I would dare to do the house-call as a follow up on the first treatment.
This case is probably an acute tick fever. Although the blood parasites were not isolated nor was a blood smear done due to financial considerations, the blood test of low blood cells and platelets is suggestive of an acute tick fever. Aggressive treatment is necessary to prevent recurrence of fever. No further treatment was requested by the owner.

As at Sep 10, 2008, the Great Dane was normal. He lived for a few more years and passed away suddenly around 2010.  

Acute Tick Fever in dogs is hard to diagnose as there are no specific signs. Lethargy, fever and loss of appetite may be the only signs. As these are non-specific symptoms, diagnosis of tick fever is often missed.

Blood parasites such as Ehrlichia canis and Babesia canis (protozoa) destroy the white and red blood cells respectively.

Haematolgy. Blood tests can be very useful in aiding the diagnosis of tick fever. In this case, the Great Dane had very low white cell, red cell and platelets. Test for Ehrlichia titres and babesia are available at the AVA (Agri-Food and Veterinary Authority) laboratory. The cost for both is around S$200.00. 5 ml blood in plain tubes is needed. However, the client did not want the blood tests done.
Subclinical Tick Fever (no signs) can exist in the dog for years. Then it becomes Chronic Tick Fever (severe anaemia, bleeding from nose, kidneys and intestines to death). Most cases of tick fever are diagnosed at the chronic stage.

Doxycycline oral tablets and Imizole (imidocarb) injection are drugs of choice for the treatment of tick fever. Avoidance of ticks by using fipronil, permethrin and amitraz are best as there is no known vaccine available.

In this case, financial considerations prevent me from following up to check the elimination of the parasites or any carrier status.

More pictures at:
Toa Payoh Vets
Report at:

711. Perineal haematoma and circum-anal tumour

Thur Oct 27, 2011
Today's cases.
A Shetland 6-month-old male had a firm lump on the right of the anus. "Perineal hernia?" I thought at first but it was not reduced in size when pushed inwards. No pain. "Suddenly appeared in the last 4 days," the young man said. So, what is it?

Zoletil 50 0.1 ml sedated lasted 5 minutes. No hyperextension of limbs. Isoflurane gas top up. Syringe out serous blood 4 ml. Incise. A capsule-like sac seen. 3/0 nylon stitched cross stitch x 1. Blood test showed no bacterial infection.

8-year-old male shih Tzu with blood in both ears. After washing, I could see a large wart in left ear and numerous tumours in right ear. "No drugs can cure this dog," I said. "Surgery is required." Ideally ear canal ablation, not just excise the warts and lumps. "Wear an e-collar," I said as the owner did not wish to have the operation on financial considerations. Ringworm generalised and a small circum-anal tumour above anus.

710. Follow up: Acute Tick fever in a young dog that went to a dog park

Thursday, Oct 20, 2011
English Cocker, Male, 2 years, 11 kg
Dog eating less. Not active. The friend suggested taking the dog to see me.
I saw small ticks all over the body. The dog had been to a dog park in Pasir Ris recently/

Very pale gums. Blood test - low haemogloblin, low RBC and low platelets. Blood smear on Giemsa stain showed Babesia gibsoni. Ehrlichia seen. 0.5 ml Imizole (imidocarb) SC given. Dosage is 0.5 ml/10 kg.

IV dextrose and baytril. Vit K1 2 ml IV. Doxycycline 5mg/kg twice a day for 21 days. 10mg/kg twice a day had been proposed by some vet books but this is 4x the standard dose. Multivitamin paste. Vit K1 tablets (1/4 tab/day).

Friday, Oct 21, 2011
Gums still pale. No appetite. Vit K1 2 ml IV and supportive therapy. However the dog barks loudly when the owner came, exhausting himself. Owner brought his liver treats. He ate one.

Blood test results before Imizole 0.5 ml SC treatment:
Liver profile= Normal
Kidney profile= Normal
*Hemoglobin- 7g/dL  [Normal range: 12-18]
*Red Blood Cells- 2.8 x10^12/L [Normal range: 5.5-8.5]
White Blood Cells- 13.2 x10^9/L [Normal range: 6-17]

*Packed Cell Volume= 0.19 [Normal range: 0.37-0.55]
Platelets= 52 [Normal range: 200-500]

*Nucleated Red Blood Cells seen [Severe demand for RBC to be release from Bone Marrow]
No platelet clump seen

Blood test results 1 day after Imizole 0.5 ml SC treatment:
Liver profile= Enzymes increased
Kidney profile= Normal
*Hemoglobin- 7g/dL [Normal range: 12-18]
*Red Blood Cells- 2.9 x10^12/L [Normal range: 5.5-8.5]
White Blood Cells- 9.6 x10^9/L [Normal range: 6-17]

Packed Cell Volume= 0.2 [Normal range: 0.37-0.55]
*Platelets= 64 [Normal range: 200-500]

No platelet clump seen but few giant platelets present
What is the importance of platelets?
a) Numbers:
The platelet count gives a general indication of the clotting ability of the blood. If the number of platelets falls below a certain critical level, spontaneous bleeding may occur. A low platelet count may indicate a problem with platelet production in the bone marrow, or may signal the presence of disease that is causing the platelets to be used up or destroyed.  An increased platelet count often reflects excitement, exertion, or an activated bone marrow. In rare cases, an extremely high platelet count may indicate there is underlying bone marrow cancer.

b) Size:
The size of a platelet is related to its age; young platelets are large and plump, and older platelets are generally smaller. This can be important if the platelet count is low; the presence of large, plump, young platelets in the blood indicates that the bone marrow is functioning well, and is responding to the need for more platelets.

c) Appearance:
 Very rarely, bizarre giant platelets, or abnormal immature platelets may be found, and these may signal the presence of an underlying bone marrow disorder or cancer

Saturday, Oct 22, 2011
The owner came, her friend and the godfather. 2-hour visit. Loud barks.
At 7 pm, the 3 visitors left. The dog panted, heart beat very fast, as if he had run a sprint. It was bad. Would he die? I should have allowed a 10-minute visit, not 120 minutes!

Connected IV - glucose 100 ml, then dextrose saline with duphalytes 500 ml. Gave lasix IV. Atropine 0.5 ml IM. By the time I went home, it was past 7 pm.

The owner was prohibited from visiting for the next few days. This dog had a keen hearing as he could hear the owner's voice at the reception area some distance away in the back of the Surgery and started barking non-stop for several minutes.

Sunday, Oct 23, 2011
Morning 10 am. Dog felt well. Barking for a while. Smelt food. Not eating. Hand fed A/D canned food and given water and electrolytes.

DAY 5.
Monday, Oct 24, 2011
IV drip. Blood looked reddish unlike bluish blood for past few days. Good news.
Passed normal stools when taken out.
DAY 6.
Tuesday, Oct 25, 2011
Deepavali. Public holiday.
Alert and standing in cage. I am relieved that the gum looks pinker. Blood test at another lab showed normal platelets but still very low Hb and RBC. I phoned owner to take the dog home at 6 pm to be nursed by owner.

DAY 7.
Wednesday, Oct 26, 2011
At home. With iron tablets and good food including egg yolk and liver.

DAY 8.
Thursday, Oct 27, 2011
At home. I phoned the owner at 6.30 pm

"My dog is very active, hungry and thirsty. I found two ticks, a grey one on her body. I put tick powder onto my bed area." One tube Advantix Spot on had been applied on Day 6. Yet he had two ticks stuck in skin. Otherwise appeared normal.
Scheduled Appointments

Friday, Oct 28, 2011

DAY 11
Sunday, Oct 30, 2011
Scheduled for next Imizole (imidocarb) injection SC. Babesia and Ehrlichia seen on 2nd blood smear on Day 6. Possibly has anaplasmosis?

DAY 12
Monday, Oct 31, 2011
Urine to be collected by the owner for urinalysis.

Acute tick fever needs regular monitoring till negative blood test results 2 weeks after the previous test but most owners don't have the time to do so.

Wednesday, October 26, 2011

709. Neoderm for 2 months thins the 6-month-old shetland dog's skin

Oct 27, 2011

I was on duty today and the young man came with a 5 kg thin Shetland with a big right perineal swelling of 4 days. Firm but not painful. Around 3 cm x 3 cm. So, what was it? A perineal hernia? No, as it cannot be pushed in. A haematoma or abscess? Likely. Zoletil 50 0.1 + 0.4 ml saline ml IV sedated the dog.

No hyperextension and therefore no need atropine unlike the Westie (pus in ears, consulted Vet 1 with no success, owner referred by an old client to me) last week when I gave him the same Zoletil 0.1 ml IV. He had stiff limbs which relaxed when I gave atropine 0.5 ml IM and gave ear irrigation. Pus and debris esp. right ear. No head-shaking 3 days after treatment

"My shetland's skin disease did not get cured," the young man of 20 years with 4 months left of National Service said. "I read in the internet that he may be suffering from demodecosis. The vet scraped his nose skin but found nothing. He gave me a Neodern cream to apply."

Two front paws near the dew claws were bald. I could see thinning of the skin and the tendons and bones below. Other parts of both the front paw look moth-bitten with hairless squares and circles. Both lower elbows ventral surface were bald.

I saw redness in skin below the front paws but not the back paws, took a hair microscopic exam and showed the young man ringworm. The other hairless area did not have ringworm as Neoderm had killed any fungus and also thinned the skin.

"My dog licks away everytime I apply Neoderm," he said of the hairless elbow and armpits.

"How long you had applied?" I asked.
"Two months," he said. I asked him to stop Neoderm as it thins the skin when used too long. Prescribed anti-fungal tablets and wash and review in 2 weeks. Should recover. Demodex unlikely.

I showed Dr Vanessa the effects of Neoderm. "This is the reason I seldom prescribe Neoderm," I said. "The owner uses it for a long time, thinning the skin."

Tuesday, October 25, 2011

708. Script for "skin disease in a dwarf hamster" video to educate pet owners

Skin Diseases In A Dwarf Hamster
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
26 October, 2011
Be Kind To Pets
Veterinary Education
Project 2010-0129

The 10-year-old caregiver asks mum many times: "Please go to the vet." Mum has no time. (Show busy Singaporean mum with two jobs at workplace if possible, taking MRT, bus etc)
Bringing Veterinary Knowledge Alive To Vet Students & Pet Owners - Sponsored by
Toa Payoh Vets ---
26 October, 2011
INTRODUCTION - hamster bites himself. More self-biting wounds - to treat or not to treat?
If not treated - consequences - cellulitis and death
10-year-old girl is worried.

MIDDLE - Picture of cage and home?
what the mother does, what the vet does, what the vet groomer does? Images show hamster has been clipped short by the groomer. Ready for bathing. How do you bathe a hamster?

Will hamster drown? Hamsters are usually given sand-bath (picture of hamster doing a sand bath) by pet owners. But now, he needs a water bath. What to do? How to bathe him? Video "How-to"
POST-BATHING - GOES HOME. Medication, bathing and new bedding. Hygiene of cage.

Check out example at: Oro-nasal fistula in the dog

CONCLUSION - Pictures of other hamsters with skin diseases to be provided by Dr Sing

Early treatment of skin diseases means
earlier recovery, lower veterinary cost and more peace of mind to your child who cares for the hamster

For more information
please visit:, +65 9668-6468, 6254-3326, e-mail

Concept by: Dr Sing Kong Yuen

Video and narration by:

NO copyrighted music or audio to be inside this video

To make an appointment: e-mail
tel: +65 9668-6469, 6254-3326
Be Kind To Pets
Veterinary Education
Project 2010-0129

Webpage at:

707. Producing the educational hamster skin disease video - comments by Dr Sing

Oct 26, 2011
I am producing a video for the AVA Responsible Pet Ownership Roadshow 2011 in Nov 2011 and time is running out. Below is my comment on the production!

Thank you for your two videos. Good hands-on work done on both videos. It is only by doing that one can learn and improve and I am glad you did that. Below are my comments.


1. Hamster video introduction. Excellent narrative of daughter and mother. It captures the attention of the viewer.

2. Sequence is not correct as your starting scene is that of a hamster with its hair already clipped. Then you show scenes with a hamster with hair. Then, hair clipped, then a hamster with hair. Correct sequence is shown in front page but I will give you a webpage address when I produce the draft.

3. The point of view is that of the little girl who is worried about her hamster with skin disease. Because she is little, she can't go to the vet by herself. So she need to ask the mother for help.

So, the introduction, middle (at least 5 messages on a hamster's skin diseases) and conclusion will be from the little girl's point of view and her actions. Did she achieve her mission?

If she fails to get her mother to act, the hamster's self biting wounds will become skin infections with pus-producing bacteria (show another hamster with cellulitis from one of my cases). By then, it will be too late.

Why did the mother act? One reason is that the examinations are on-growing. The daughter's worries distract her from studying. So she goes to the vet. "The hamster needs to be hospitalised for 3 days to be treated," I said. "That will be fine, as my daughter is having her examinations!"

The side characters are the mother, the vet (consultation by the mother, diagnosis and treatment) and the groomer (clipping coat, bathing time, bathing).

4. Try NOT to superimpose text onto the character (e.g. onto the labrador's body) as this spoil the enjoyment of viewing of the animal.

This is an example from me:
A roborovski (with hair)

e.g. narrative from little girl. Show hamster moving if you have the video before clipping the hair

CONCLUSION. The daughter phones the vet two times after bathing: "When can my hamster come home?" After bathing, on day 4 after hospitalisation, the mother brings the hamster. The 10-year-old girl is very happy.

1. "Do not use the sharp pelleted litter as bedding," I said. "Use the soft paper type". Show cage with pelleted litter usually used for cats, covering part of the floor. Show cage with paper bedding covering the whole floor.

"But the other vet said that it is best not to change the bedding as it will stress out the hamster!"

"No two vets offer the same advices," I said. "In this case, the active roborovski hamster's body could have been scratched by the sharp ends of those pellets and bacterial infection of the skin causes itchiness and scratching!"

2. "Keep the cage floor clean," I advised.

Generally, the story must flow smoothly with actions preferred. The "clock" scene needs to be removed as it does not help since the timing is still 12 o'clock every time you flash this scene. No time movement!


1. Do not superimpose text onto the body of the dog as it makes it less enjoyable to view the video.

2. Repetition of same scene. I note that ear scoping scene has been shown twice.

3. The video needs a hook which I spoke to you about. An action of the dog intensely scratching.

I have spoken to you earlier about this production.

Keep up the good work.


Try to use similar light text and black background as in the "Attack The Block"
trailer at:

Also adapt some of the stories and sounds but not copy their sounds, the story telling and the hook.

e.g. "Better call the police," the girl said
"You are better off calling the ghost-buster!"

e.g. In this hamster video narrative,you may think of above lines and replace "police" with "groomer" and "ghost-buster" with "vet"

Monday, October 24, 2011

706. Practise defensive medicine? New puppy with blood in the stools


When a new puppy has blood in the stools or vomiting/diarrhoea, the following will be the procedures at Toa Payoh Vets to provide the highest standard of care and to defend the vet in the event of litigation or complaint when the puppy dies later.

1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your epidemiological study 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. It will be a case for veterinary negligence if the parvoviral test is not 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.

Record under AMD (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.

Updates and more pictures are at: TOA PAYOH VETS WEBPAGE:

705. Post-op discharge 3 days after a breast tumour surgery

Yesterday, Oct 24, 2011, the lady owner brought her dog back as there was a "leakage" of reddish-brown fluid from the surgical wound. She had asked for advice over the phone but I told her that it would be hard to know what was happening. However the dog was eating.

"It is not possible for the dog to lick her wound," the lady said since her dog was wearing an E-collar post-operation. "I don't see my dog licking the wound when I am with her."

"I have seen cases where it has been done," I did now want to argue as most owners seem to think that the dog would lick the surgical wound in their presence. If not, then, the dog had not done it. Unless the e-collar is of a size so big, the dog can still lick its surgical wounds partly.

One of the stitches had a gap and post-op blood had leaked out. It was not serious. So, I hospitalised the dog for 3 days as she was walking at home. "Not much walking as she always lay down," the owner said.

"Any walking other than crate confinement will put tension on this long surgical wound," I said. "This is not a small 2-cm wound but more than 20-cm long. Good communication with the owner is important but sometimes it can test a vet's patience.

In this case, I had not performed the surgery. However, I had discussed in my previous article that the "walk-in" sutures and horizontal mattress sutures on the skin would have given a tighter fit to control bleeding and prevent "leaking" of plasma. As each vet has his or her own skill and style in stitching up, it is difficult to say whether the subcutaneous stitching of the tissue and then simple interrupted skin sutures did permit "leakage" as there are many factors involved in a post-operation bleeding. In this case, the whole lower part of the dog's body was wet with the reddish brown plasma and blood. I asked Min to bathe the dog as her front leg skin and elbows had yellow flakes and this has nothing to do with the surgery. The dog had not been groomed.

704. Follow up on ptergium, glaucoma and enucleation of eye dog

Yesterday, Oct 24, 2011, I phoned the lady owner to enquire about her dog after eye enucleation. She was very happy as the dog was normal.

"Any bleeding from the eye?" I asked as there was some swelling of the stitched eye socket 3 hours after removal of the eyeball. In this case, I had stitched the conjunctival (upper and lower) tissues with 2/0 absorbable. Then I stitched the eyelid margins (as shown in the picture) with 3/0 nylon. So, there were two layers to prevent bleeding out of the eye.

"Some bleeding on the first day, but nothing serious. My dog is eating. I will see you 14 days later to remove the stitches."

Post-operation bleeding is one complication in any surgery. The dog had antibiotics and painkillers (tolfedine) and has no problem as evident by her normal behaviour and good appetite.

Toa Payoh Vets webpage

Sunday, October 23, 2011

703. An old dog with a breast tumour bigger than 2 golf balls

"I went to Vet 1 as my dog was bleeding," the lady was concerned about the bleeding in her 12-year-old Shih Tzu rather than the tumours. "The vet bandaged the lump."

"Your dog has at least 4 breast tumours," I said. "How long did the biggest tumour take to grow?"

"Very fast," she said. "In the last month, it just grows so big." The tumour was the size of two golf balls. This was the left MG5 (the left caudal mammary gland, 5th gland)


1. Blood test compulsory.
Total white cell count was over 42 indicating a bacterial infection. I had the dog on IV drip and baytril overnight. Some owners object to blood tests due to financial considerations. X-ray of the chest would be preferred too but this is often not asked of the owner so as to reduce costs.

2. Surgery
Operation to be done the next day due to economic reasons. I prefer wait one week on antibiotics but there are such cases where the owner does not want to wait. Sometimes it may be better to reject such cases but compassion and the interest of the sick dog must be considered by the operating vet.

3. Pre-surgery - Zoletil
No sedation preferred. Just use isoflurane gas + oxygen.
Zoletil 0.1 ml IV although Dr Vanessa would have used Domitor. Isoflurane gas + oxygen via mask and then intubation. "Zoletil is safer in old dogs," I said. "Few vets I know use it for small animal sedation."

4. Short surgery
Only the big tumour was excised. This already took around 45 minutes. If the vet attempted to excise all, a dead dog would be the result as old dogs are very high anaesthetic risks.

In a recent on-going court case of a death of a man in his 40s who had liposuction and fat transfer to his chest, the general practitioner (GP) taking 3.5 hours for lipo-suction and transfer of fat to the chest of a man who died, I believe that the whole process of IV anaesthesia (involving topping up) took too long and lead to death. However, there were numerous perforations of the internal organs.

From what I read:
a) The expert witness mentioned about over-sedation as a cause of death as the patient did not respond even though he had numerous internal punctures.
b) The GP doctor doing the liposuction said death was due to fat embolism.
c) The GP doctor doing the IV anaesthesia (Propofol sedation given to effect iv and oxygen, but no general anaesthesia) said that the patient was alive at the end of surgery but died around half an hour later. Therefore anaesthesia was not the cause of death.
d) The autopsy report said death was due to numerous perforations of the intestines and the liver.
e) The judge was exasperated as to why the time and dosages of Propofol had not been made available before the inquest. The info was said to be in the GP's hard disk during the inquest. The case is on-going.

5. Anaesthesia
I was in charge of anaesthesia. The maintenance dose was 0.5 to 1.5% isoflurane. Towards the end of 30 minutes, I showed my assistant Min that the tongue has become white at the edges despite just 1.5%. I reduced to 0.5%. Switched off at the 2nd last stitch. The dog moved a bit. But stitching was done and the dog woke up. This was good anaesthesia. No delay in waking up and no need to use Antisedan as in the case of domitor.

6. Speed of surgery
6.1 Know your anatomy. There is the big blood vessel at around MG3 and MG4. Slow dissection and undermining is OK if you have time but old dog surgery need to be completed in less than 30 minutes for good anaesthetic outcome.

6.2 "No point having a perfect stitching and surgery if the dog dies on the operating table," I said to Dr Vanessa who started stitching up from one end intending to stitch at 0.5 cm intervals as this was her usual method. The wound was around 20 cm long. "Stitch at 1 cm intervals." I also advised stitching at the major points first e.g place 4 stitches and then continue stitching in between.

6.3 "Use walk-in sutures," I explained. But Dr Vanessa was comfortable in using subcuticular sutures to hold the subcutaneous fat together. This took much more time as skin sutures were then sutured with simple interrupted sutures. In "walk-in sutures," I would stitch the skin, then subcutaneous fat and then skin all in one movement using horizontal mattress sutures on the skin.

The whole process was completed by Dr Vanessa in around 45 minutes. Any longer would have caused death, in my opinion as the tongue was turning pale pinkish cyantotic and white at the edges.

The dog was alive and that was what the owner expected. She had come in the morning of the surgery on Day 2 to ask more questions. I had to be frank as I told her that I needed time to prepare for surgery.

In the evening the happy owner took the dog home. I write this case as a mentoring case done by me.

1. The financial considerations which were addressed yesterday.
2. The chances of survival. Hard to predict as the dog had a bacterial infection and was old at 12 years. Short surgeries make survival likely. So, the other tumours and spaying of the dog had been advised for two weeks later.
3. Whether the breast tumour is cancerous. Most likely as it grows explosively big within a month.
4. Will the tumour come back? Most likely as it is cancerous. However, the owner does not want histopathology by the lab to confirm it.

No matter how great the vet surgeon is, anaesthesia is the most important in any surgery as a dog alive is what the owner wants. Beautiful surgery is a bonus.

Toa Payoh Vets webpage is at:

Saturday, October 22, 2011

Keep Spay Surgery Simple - No subcuticular suturing

I am writing to share my over 30 years of experiences in spaying dogs and cats done by me and by other vets in Toa Payoh Vets.

I started Toa Payoh Vets in 1982 and it is 2011 now. I have seen a few cases of stitch breakdown using the method as advised by the university professors and veterinary surgery text books (Method 1).

The vet university professors since my time in 1974 when I graduated from Glasgow University and even recently in Australian Universities, advocate the following steps after removing the ovaries and uterus:

1. suture the linea alba
2. suture the subcutaneous fat to seal up dead spaces
3. suture the skin
The theory is sound and many newly graduated vets adopt this system (Method 1). Over the years, I encountered a few cases of stitch breakdown and infection in dogs and cats using Method 1 done by other vets. Or intense redness and inflammation at the surgical area.

My method does NOT use Step 2 and I have less than 1% of post-op stitch breakdown. I have no figures to substantiate my claim. I am merely sharing my experiences as I am in my retirement era, being 61 years of age.

I just hope that this knowledge may benefit the dogs and cats. In the early years of 1970 - 1980, I did not prescribe pain-killers unlike nowadays and I don't have many post-op spay problems. Times have changed. Pain-killers inclusive of antibiotics are a must.

There are many reasons for stitch breakdown but one of them is the irritating subcutaneous suture. The dog or cat keeps licking the wound or just use the hind paws to scratch it. E-collars do not help much. Soon, the unhappy owner brings in the dog or cat for review.

In private practice, the vet earns his reputation by not getting less or no post-op spay stitch breakdown as owners will compare and complain. Obviously, in other surgery like breast tumour removal, subcuticular sutures are needed to close the dead spaces. I use "walk-in" sutures. This involves suture needle going into the skin, then into the subcutaneous fat and out of the subcutaneous fat, then out of the skin on the other side. From there, I transverse, needle goes into the skin, subcutaneous fat and out from the initial side. This makes for a horizontal mattress skin suture as seen from the skin. In this method, surgical time is reduced, unlike separate subcuticular sutures of the subcutaneous fat. See case report at:

Then simple interrupted sutures of the skin as this is a usual method by many vets.

The two methods of SPAY IN THE DOG AND CAT are illustrated by real cases as follows:


1298. Subcuticular sutures have been used. The stitches under the skin hinder healing due to infections or traumatic injury from licking.
1299. Stitch breakdown and infection. Re-stitch again but no more subcuticular suturing.

1296. A spay hook enables the vet to make spay incision small in the dog and cat.
1297. Dr Sing's dog spay procedures. No subcuticular sutures.
All the years, I use absorbable PDS sutures and this means the owner does NOT need to return for stitch removal. I just use one packet of sutures. However, with Method 1, I note that some of the younger vets must use two packets and sometimes three packets in dogs that are pregnant and of bigger breeds.

I have seen cases where a vet uses 3 packets of sutures to spay a medium sized dog. This is definitely too many. One packet is chromic catgut. Two packets of absorbable monofilament. With my method, one packet of absorbable suture is sufficient for dogs up to medium size, using the spay hook.

Keep spay simple. I hope this report is of use to some practising vets. It cuts down on expenses in using more sutures and in private practice, costs keep rising as bureaucrats think of ways and means to generate income from the industry by increasing regulatory fees. Keeping spay simple and using walk-in sutures make economic sense as well as keep owners of dogs and cats happier.


4448. KPI - How long it takes to spay a female dog? 26 or 18 minutes?
4451. Surgery Audit: How long it takes to spay a female dog? 18 minutes

4438 - 4444. When do you remove the dressing or stitches after spay/neuter?
4475. Never discharge a spayed dog with a hole in the operation area
Toa Payoh Vets webpage is at:

701. Follow up on: Pterygium + Glaucoma + Haematoma in 2010, Enucleation in 2011

What is a pterygium? It is an invasive proliferative fibrovascular growth.
Excision of the pterygia was requested by the owner as the dog had difficulty seeing in the right eye and kept rubbing the right eye.

Excision was by electro-surgery under general anaesthesia. In human medicine, there are various sophisticated surgical methods used

I find that many old dogs can survive if the surgery and anaesthesia can be done under 15 minutes. Provided there is care in the anaesthesia and knowledge of emergency resuscitation. The anaesthetic time would be prolonged as there were two pterygia to be excised.

The Divine Powers above threw in an ear haematoma to be operated too. That meant a much longer anaesthetic time.

The longer the anaesthesia, the higher the chances of the old dog dying on the operating table.

This dog needed over 60 minutes of surgery. Would his cornea rupture? That would increase the anaesthetic time.

The dog did not wake up within 2 minutes at the end of anaesthesia.

An antidote (Antisedan) woke him up. He recovered smoothly on Domitor pre-anaesthetic dose, isoflurane gas maintenance and Antisedan anti-dote. He woke up quietly as if he had a good nap.

Fortunately, the mission was accomplished with excellent anaesthesia. This story had a happy ending for everyone. Further info is as follows:

In March 20, 2003, I saw a Shih Tzu puppy with a growth on the right eye for the first time. Was this a rare case of a pterygium? No. It was a Dermoid as it had hairs and was of a different colour. See: Mar 20 03. The Shih Tzu puppy has a "pterygium"?
7 years had passed since I saw the afore-mentioned Shih Tzu puppy with the Dermoid. A real case of pterygium surfaced in February 2010.

She was more knowledgeable than me in specific area affecting this very gentle X-bred dog, as she correctly stated: "My dog has a pterygium," when she first consulted me.  She requested me to excise the two bulging growths on the cornea of her dog.

The dog also had glaucoma. She was old. There was a big risk that the cornea might rupture. The bigger risk was death on the operating table as this old dog would be a high anaesthetic risk. Every old dog under anaesthesia is a big risk and deaths from anaesthesia are very unpleasant for the vet as the whole family never forgets nor forgives when the outcome is a dead body. I was very apprehensive that this well cared for and loved family member would die on the operating table as anaesthesia would take a long time to excise two pterygia. As if my worries were not sufficient, the dog also had a right ear haematoma to be operated upon. That meant that the surgery would take over an hour!

The longer the operation, the higher the chances of deaths on the operating table.

"Why do you want the pterygia removed?" I asked the determined owner.
 "My dog walked towards her left when the pterygia started to grow fast towards the centre of the cornea. She cannot see from her right eye as the pterygium had obstructed her vision." the owner said. "In addition, she keeps scratching her right eye."

"If the cornea ruptures during excision, I will have to remove the whole eyeball," I said. "Yes," the lady consented. There was this understanding and awareness of the high risk of the cornea bursting when I excise the pterygium when the intraocular pressure was very high. One pterygium was already worrisome. But this dog had two big ones.

"Have you considered enucleation (eyeball removal)?" I asked as glaucoma can be a very painful condition and treatment using eye drops must be given regularly and drug control may become ineffective over time. I don't know much about its glaucoma formation as it was treated by another vet. Glaucoma was controlled by eye drops.

"The other vet has recommended it," she said. "But my family does not want the dog to lose his eye." So enucleation was out of question.

As to what caused such a rapid growth of the pterygia in this beloved dog, it is hard to say. In people, pterygium is said to be caused by ultra-violet light exposure.

It was fortunate that the old dog survived the anaesthesia and went home. "Take good care of her glaucoma," I said to the happy lady as I discovered that the old e-collar was no more worn. I had asked whether she still had the e-collar and she said it was worn out and disposed. "That means that she must wear the e-collar all the time for many weeks and stay out of the sunlight and wind." 7 days later, I would need to review this case.

Pterygia Surgery at Toa Payoh Vets

Haematoma Surgery At Toa Payoh Vets

Toa Payoh Vets webpage and images for this article is:

In 2011, the dog's eye was enucleated. The webpage at Toa Payoh Vets is at:

Thursday, October 20, 2011

700. Follow up on paper training and stool eating puppy


Paper shredding is a common complaint in paper-training. Taping the edges is one method which you have used successfully.

Stool eating is a difficult problem to solve as the cause is usually unknown.
1. Pepper, chilli sauce and others have been added onto the stools without effect.
2. Some owners buy the "anti-stool" eating powder from the pet shops and claim effectiveness as long as the powder is eaten.
3. Others add pineapple slices onto the food and claim good results.
4. Distraction methods: Another writer advise putting a can of coins on top of the door. Hide somewhere. When the puppy eats the stools, the can of coins drop onto the floor. Personally I doubt that the puppy (as a canine with sensitive hearing) will not know that the owner is hiding somewhere.
5. Another method is to squirt water onto the puppy when he eats his stools. You need a water gun.
6. As you can see, it is extremely difficult to resolve the problem. Picking up the stools immediately (without making a fuss) seem to be another method. In this way, it is hoped that the puppy outgrows this bad habit. Otherwise he continues the habit to old age. This appears to be what you are doing.
7. My idea is to take the puppy outdoors to poop after meals but this may not be practical for you if you live in a high rise. This involves a routine as follows: Puppy completed eating. Take him outdoors to the grass. In short, take the puppy to another area (e.g. balcony has newspapers with smell of poop) to poop. This works if the puppy poops within 10 minutes after eating and the owner is free to do this consistently for 2-4 weeks.

On Thu, Oct 20, 2011 at 9:50 PM,> wrote:

Hi Dr Sing,

I hope this email finds you well.

It has been almost a week since we tried your suggestion. Newspapers (full page, spread out) are placed on the top right corner of the toilet and the puppy eliminates at the area. We are slowly trying to reduce the area of the newspaper. Attached is a picture of the toilet for your reference.

However, he has started to (in this order, not sure if it tells you anything) smell, lick and eat his stools. Soiled papers are changed almost immediately in the day, as someone is usually around to hear him running on the newspapers. One of us will wake up in the middle of the night every few hours to check on him and clear any waste, but sometimes he has already finished eating his stools. We are cautious not to disturb him when he eliminates. Pepper does not help as he eats his stools which has pepper. Is there anything we can do about this?

As the puppy loves to shred newspapers, we use masking tape and lace it white vinegar to prevent him from peeling off the tape. It works most of the time, and he does his business as usual, including eating his poop.

Once again, thanks for your advise and I hope to hear from you soon.

Best regards,
From: A
Sent: Friday, October 14, 2011 10:00 PM
To: Kong Yuen Sing
Subject: Re: paper training problems for a 3 month old poodle

Hi Dr Sing,

Appreciate your prompt reply, we are currently trying it out and will let you know how it goes. Have a nice weekend. :)

Best regards,


From: Kong Yuen Sing
Sent: Friday, October 14, 2011 7:04 AM
To: A
Subject: Re: paper training problems for a 3 month old poodle

Thank you for your detailed e-mail and the 3 images. As every puppy and owner is different in personality and training experience, the following reply may or may not be useful to you.

1. You have confused the puppy in attempting to grate-train (using the cage) and paper-train him (inside the at the same time. Puppies, like babies, are creatures of routine. One method of toilet training is needed. Either grate-training or paper training.

2. At the pet shop, the puppy has had been trained to eliminate in the grate (floor of the crate or cage). This type of grate+pee pan housing is prevalent in the Singapore pet shops as shown in the image you posted to me. The puppy wanted to eliminate on the grate but you wanted him to do on the paper and most likely paid extra attention and fuss. So, the puppy was not free to eliminate in privacy after eating as in the pet shop.

3. To make a long story short, I would propose just write about paper training as I presume this is what you want to achieve instead of writing about grate+pee pan training or both methods. The grate+pee pan method involves buying the grate + pee pan separately or the use of your existing crate.


3.1 You confine the puppy inside the toilet. Install a baby-gate. Cover the toilet floor 100% with paper. At one corner (e.g. left half, back), away from the baby gate, put a piece of paper with the puppy's urine or tissue paper with his urine smell. At the other corner (e.g. right half, front), his food and water. In the right half, place his towel, bed, or floor mat, for example. This will be his clean area.

3.2 The puppy is left there for the next 2 - 4 weeks and given privacy, not stressed out by your scoldings or presence or the presence of children and family members during eating for at least 1 hour.

3.3 The puppy can be taken out to play after he has pooped regularly and this may take a week. This is where you observe signs of elimination (squatting, turning) and put him quickly back to his toilet.

3.4 Change soiled papers frequently.
3.5 Within 7 days, you should see that the papered corner where the puppy pees and poops will be. Reduce the paper area.
3.6 If the puppy shreds the paper, you still need to persevere and do not scold or shout at him.

In conclusion, confinement for the first 2-4 weeks is the key to success in toilet training. What you do during the confinement will require your perseverance, hard work of keeping the puppy's "den" (toilet) clean.

The training is much more than what I write. The devil is in the execution. Pl let me know when you have succeeded or if you have more queries.

Best wishes.


On Thu, Oct 13, 2011 at 9:34 PM,> wrote:

Dear Dr Sing,

I would like to seek your advise with regards to paper training. Three pictures are attached for your reference; a picture of the cage he sleeps in, the toilet area with newspaper, and a view of his cage from the toilet.

I have a 3 month old male miniature poodle whom I brought home about a week ago from a pet shop. We bought him a cage and are in the process of training him to eliminate in the toilet on the newspaper. At the pet shop, he would eliminate about 15 minutes after his meal. However, he eliminates only after a few hours. For example, we will give him dinner at 7.30PM and most of the time he will not eliminate until the next morning. It is rare that he will eliminate within 2 hours. When we spot signs that he wants to eliminate when he is outside the cage, we will bring him to the toilet and coax him to eliminate, whether big or small ‘business’. Most of the time he will not do it unless he has not gone into his cage for a very long time, say a few hours. There are times when he will run to the toilet and smell the newspapers, only to run out, which we take as a hint that he wants to eliminate and put him into the toilet telling him to pee, using the same word every time. Rewards given when he does the right thing.

When we put him into the cage, he will eliminate within a few minutes or even seconds when we are not looking, and that is after we have just brought him to the toilet. The areas which he eliminates in the cage are not consistent. Even if he does not intend to eliminate, he will turn in circles and give us false alarms, as I believe he knows we will bring him out when he does that. We tried washing his entire cage with antiseptic but he still does it inside the cage. The newspapers in the toilet have traces of his pee and also a kind of liquid we bought from the pet shop to help him recognise the place.

For the first two or three days, he used to pee all over the place but after scolding him a few times and cleaning with vinegar, he has not done it since. A crate didn’t help as he peed inside it.

Are we doing something wrong? Some expressed their opinion that a pee tray would be better and the distance between the toilet and cage is too far for him, making him confused. He has not had his third vaccination so we have yet to bring him out.

Thank you very much for taking time to read this email, and also for your informative articles. Looking forward to hear from you soon!

Best regards,


699. Liposuction Death - Practice guidelines for safe sedation

Straits Times, oct 20, 2011 Pg A4
Liposuction Death - I did not cause death, says doctor

Patient: Mr Heng went to Reves Clinic in Orchard Rd on Dec 30, 2009 for a liposuction and fat-transfer operation.

Doctor 1: Dr Jim Wong did the surgery. Set up nfusion pump which administers drugs including propofol into the patient.

Doctor 2: Dr Zhu Xiu Chun @ Dr Myint Myint Kyi - monitor the patient's vital signs. Continuous oxygen supply, equipment measuring the vital signs was in place.

Said readings were within an acceptable range, no snoring or other abnormal respiratory movement to sugestg that Mr Heng' airway was disturbed. If the patient did not move much, he was quite sedated and dosage of propofol would be adjusted lower. If he moved or made sounds, after making sure that vital signs were staable, the dosage would be increased. Moderate sedation - responsive to tactile sensation.

Procedure: 12.30 pm to 3.50 pm
25 minutes after end of procedue, Dr Zhu was told there was an emergency. Mr Heng was pale and unresponsive and died.

Autopsy: >10 puncture wounds in intestines, liver

Question: Mr Heng's rep said that Mr Heng did not show any overt signs of pain because he was more than moderately sedated as multiple punctures in his internal organs from liposuction would be very painful.


1. The changes in dosage of propofol had NOT been recorded. This was unsatisfactory.
2. The patient's vital signs were recorded every 15 minutes. Every 5 minutes would be better. Vital signs include pulse rate, blood pressure, oxygen saturation

In an earlier inquest - fact finding rather than determination of who was to blame for Mr Heng's death, two experts mentioned that the patient was over-sedated.

Wednesday, October 19, 2011

698. Pterygia and glaucoma - anaesthesia in a 12-year-old dog

In Feb 2010, I operated on the old dog with two pterygia in the right eye.

The case is described at:

Yesterday, Oct 19, 2011, I operated on this 12-year-old again. She was a happy dog as he wagged her short tail, unlike some dogs that had to be dragged into the vet surgery.

The pterygia had re-grown and covered the whole eye. Despite anti-glaucoma eye drops given by the medically knowledgeable owner, the glaucoma could not be cured. Now the ptergygia had covered the whole cornea as well, nearly 100%.

"I thought you spoke to the human eye expert regarding opening a hole in the sclera to drain the high eye pressure?" I asked her the day before yesterday when the dog was admitted. She had made a special appointment to see me at 10 am as she wanted me to do her dog's operation to take out the eyeball.

"In human glaucoma surgery," she said, "a stent has to be inserted into the eye to drain off the excess fluid."

"The dog will not tolerate a stent inside her eye," I said. So she gave the usual anti-glaucoma eye drops and they worked apparently. Till the pterygia over-grew the cornea by 100%. Eyeball enucleation was the only alternative.

Now the surgery is relatively easy but the main issue is that the vet must produce a dog alive at the end of surgery. Death on the operating table is not an option. I was much apprehensive about doing anaesthesia on this old dog, much beloved by the family members.

I had operated on a 16-year-old with several large circum-anal tumours. Just as I completed removal of the tumours, the dog's tongue turned snow white. There was no hope as there must be a rupture of the blood vessel in the inside, probably the liver as the total whiteness of the tongue meant massive bleeding usually.

This dog had liver disease as evident by the blood test. I wanted to postpone the operation to a Thursday, having put the dog on antibiotics for at least a week. However, the owners had to take leave and so I operated on a Monday as scheduled earlier. As to whether delaying by 3 days would make a difference to survival, it is not possible to forecast. Anaesthesia in old dogs are high risk and I don't take such cases unless the owners and family members are well aware of the tremendous risks involved. No vet cannot be 100% successful in anaesthesia of old dogs. Deaths on the operating table are extremely emotional and so I prefer not to operate but some cases just can't live a good quality of life without surgery.

As part of coaching of my assistant Mr Min, I will record what had been done for the benefit of vet students. In vet school, the anaesthetic theories are sound and if you adopt them to the letter, you are supposed to be successful.

In practice, the health and age of the old dog make veterinary anaesthesia highly risky as this will be the case in human anaesthesia. This is what I did for this old dog.

Oct 18, 2011. The dog was admitted. The owner said the dog ate well and was normal.

1. Blood test was taken.
2. No X-ray was done to reduce costs but X-ray of the chest and ECG are done in the Singapore General Hospital when I was operated on.
3. I gave an IV dextrose saline 500 ml + duphalyte 50 ml to this dog. IV baytril given.

1. Blood test was normal for this dog. This was good news.
2. Pre-op examination. The pulse quality was poor and the pulse was barely palpable. This was bad news. Other than that the temperature and respiration were normal.
3. Sedation. This is how I coached Mr Min on the dosage of Zoletil as I asked him to learn by writing on a piece of paper the dosage calculations.

The calculation is as follows:
In the dog, the maximum Zoletil 100 is 10 mg/kg. The dog weighed 24.5 kg and would need 245 mg. Therefore the volume of Zoletil 100 (100mg/ml) should be 245/100 = 2.45 ml.

However, I was using Zoletil 50. In theory, I should give 4.90 ml IV as Zoletil 50 is half the strength of Zoletil 100. Mr Min said he understood.

I took out a 1-ml syringe and gave the dog Zoletil 50 at 0.5 ml IV. This is 10% of the calculated dose. The 12-year-old dog was unable to stand 2 minutes after the injection. For a young dog, the dosage would be ineffective.

4. Isoflurane gas by mask 10 minutes later. 5% given initially.
"Check the left eyelid blinking reflex," I told Min as he was looking at the chest movements. "When the eye white (sclera) is seen, that means the dog is in surgical anaesthesia. That means the eyeball has rolled downwards. This is such a simple method of assessing the onset of surgical anaesthesia but many vet assistants don't use this method but rely on chest movements. "When chest movements stop," I said to Min, "It is already very serious heart failure. Put your finger onto the eyelids and see whether they blink."

It takes a lot of patience to repeat instructions to new people. Life is like that. Some know it faster than others. In human general hospitals you have the specialist anaesthetist to focus on anaesthesia but for vets in most practices, the sole responsibility is the vet surgeon.

5. Intubation. When the blink reflex was gone, I intubated this dog. However, she had problem taking the isoflurane gas by tube. Her chest movements were rapid and irregularly fast. I took out the tube, put on mask again. There was some froth seen in the endotracheal tube.

6. Atropine 0.5 ml IM and Lasix 1 vial 2 ml IV were given.

7. I intubated again. The dog reacted as if the tube was irritating. It gave vomiting sounds, as if one is clearing the throat. No vomitus. Yet the dog appeared to want to vomit. So I took out the tube and gave gas by mask.
The dog struggled to get up. "Give mask at 3% isoflurane, not 5%," I said to Min who was to be focused on anaesthesia. "It will take a long time at 3% but it is safer than 5%."

The dog kept curling his tongue upwards at one stage, during mask anaesthesia. Finally he was down to be operated. I cut 2 cm at the lateral canthus, cut the conjunctiva circumference of the sclera. The eyeball collapased but was taken out. I did not pull out the globe hard as this would traumatise the optic nerve and affect the eyesight of the normal left eye. The optic nerve could not be ligated. It was cut. Bleeding was profuse. Bleeding controlled by 5 swabs after cutting the eyeball and taking it out.

Nearly 1.5 hours due to the reactions of the old dog in being anaesthesized by intubation. He had some respiratory secretions and at one time, he panted or hyperventilated for over a few minutes. There are dogs that can't be anaesthesized using intubation which is the favoured ideal method of giving gas anaesthesia as they reacted to having a tube in their trachea. Why, I don't know. It happens in very rare cases. Changing to mask resolves the problem as in this case.

By mask, it was smooth and uneventful. The dog woke up immediately after the last stitch.

10. POST-OP. Tolfedine 2.5 ml IM and SC (2 parts). Baytril tablets 3 days. Then clavulox for another 10 days. Tolfedine tablets 5 days as painkillers.

11. GOES HOME IN THE EVENING. The dog was awake within 5 minutes after end of anaesthesia. E-collar. The eyeball was swollen but no bleeding. I had put in 2 layers. 2/0 absorbable PDS to stitch up the conjunctiva (cut edges after excising the eyeball circumferentially. Then I stitch up the eyelid (excised 3 mm margin leaving 0.5 mm of medial canthus eyelid uncut). Pictures shown. What the owner wanted was a dog alive and her trust that I could deliver. It was a happy ending.

I persisted in teaching Min how to carry the big dog without bending his back. I taught Nicole the 21-year-old girl who wanted to study vet medicine the same technique. Girls must carry big dogs too if they want to be a vet and equality and respect in this veterinary world!

Tuesday, October 18, 2011

Follow up video production on the Chihuahua with oro-nasal fistual and lessons learnt

Oro-nasal fistula in an old Chihuahua - Part 2. The follow-up

show details Oct 16 (3 days ago)

I find your joint-production video much alive and interesting with 2 people narrating. It is just like a duet with two people singing. It is much more responsive and fun.

I need both of you to help me produce the follow up video on Daphne's case so that I can show at the AVA Responsible Pet Ownership 2011 talk.

1. Please do me a favour to produce the video together with .... The URL is at:
MAKE IT COME ALIVE as the dog is already dead and I have no video of her.

2. As regards music inside your video, it is a great idea. I love it. It makes me awake and alert. Not so boring. Great idea.
However, I wonder if there are copyrights issue. It is best to produce your own music or get permission from the young music-producing students (if there are any!).

3. Errors - FIV in a stray cat.
3.1 Antigens
In one slide, you say "Antibodies". Pl check. I believe it should be "antigens".

I love the red finger nails of the "Vet". It is so much interesting. Unfortunately Dr Vanessa does not paint her nails red or at all!

Best wishes. Let me know if you have questions.


show details Oct 18 (1 day ago)

Hi Dr Sing,

Thanks for your kind remarks! ... and I will be glad to produce the video for you, but we are not quite sure what a "follow-up" video is about though!

Looking forward to your reply,


1. Follow up means "what happens to the dog" since I last saw him.
The last time I saw him was the video produced by Daphne Ng. This is at:

2. The video ended with the operation done successfully. The dog goes home.

The follow up:

2.1 SEVEN DAYS LATER - mum happy. No need to clean up the non-healing wound as the infected tooth root had been extracted. Healing takes place.

2.2 SEVEN MONTHS LATER, Upper respiratory tract infection. Treated OK.
2.3 EIGHT MONTHS LATER, Dog died. What was the cause? Old age? No. It was actually a septicaemia due to pyometra.

Seriously ill. Anaemic. IV drip. No hope.
"Any bleeding recently?" I asked. The dog was not spayed and could have got an infected womb. This is called PYOMETRA.
"No," the son said.
"Yes, around 2 months ago....(see my notes) and case at:

The dog would have lived to a ripe old age if the mother had her spayed or told the son that the dog had been bleeding and contact the vet. The son is a busy marketing man and so he is not the care-giver. Unfortunately, the mother had not communicated with him about the bleeding episode which was a case of PYOMETRA. The bacteria in the infected womb continued its attack on the dog, spreading toxins and infecting other organs. When the dog came to the vet, she was at death's door.

The son was actually the one who loves this dog as shown by his actions. But he did not know the dog had a serious bleeding problem as the mum did not tell him. In retrospect, spaying this dog early would have had prevented this death. But many Singapore owners feel that it is "cruel" to spay or neuter a dog.

This is the new-age thinking but such owners need to check their dogs daily to ensure that there are no such illness or growing tumours during old age and get early vet treatment.
I need your help to create a dialogue. C... represents the vet asking questions (a rough tone). You represent the mum. C... has to represent the young man (a different tone of voice of a man of his age). This makes the story much more interesting than one person narrating.

Pl let me know if you need more info. Bye for now.