Sunday, June 3, 2012

1014. Sunday Jun 3, 2012's interesting cases

Sunday June 3, 2012
2.30 pm to 5pm

Yesterday, Saturday morning and today Sunday afternoon, I presented myself at Toa Payoh Vets to do my "trust and audit" veterinary work. This is an important part of management of a veterinary practice as veterinary performance counts in the sustainablility of the business. Referrals come from good performance and good clinical and surgical outcomes from all the 4 vets at Toa Payoh Vets. My duty is to ensure a consistent and high standard of performance and so I do my unannounced "trust and audit" checks and mentorship.

On this Sunday afternoon, I was surprised to see a familiar black and white Corgi with cataract eyes coming in for a check up and vaccination. Corgis are rather rare in my practice and a Black and White one is rarer compared to the brown ones. I can remember this case distinctly as its case file is quite thick due to much veterinary investigations that had to be done.

"You don't work on Sunday afternoons," the slim lady owner said to me.

"No," I said. "I came to do my checks on the staff and cases. How's the Corgi now? Any more smelly urine passed?"

A bit of history. This Corgi had been having urinary tract infections for the past year or more. After a course of antibiotics, the dog would recover. Then, the infection comes again. This interesting emotional case is reported at:

So, on this fine Sunday afternoon, I happened to be at the Surgery and see this Corgi again. She had lost some weight, around 1 kg and looked quite neat and majestic. She had come in for a check up, vaccination and pro-heart vaccination and Dr Vanessa would be in charge.
"When did you stop the S/D diet?" the lady said that S/D was too expensive.
"Around 2 months ago," she replied.

"S/D diet is specially formulated for cases of urinary struvite-stones and so it is more expensive. How long was she eating the canned S/D diet?"

"3 months," she replied. "Now she is on a holistic dry food."
"What is the name of the dry food?" I asked.
She did not remember.
"What is the colour of her urine?" I asked. "You are supposed to get her urine checked every 2 to 3 monthly for urinary tract infection and stones." But most owners don't do that till the dog has a urinary problem.
"Is she still passing smelly urine?" I asked. "Like ammonia?"

"No," she said. "No other vet had asked me about the smell of urine, except you."
Smelly urine is one topic vets don't ask, I guess that the vet professors never emphasize on smell during the lectures.
"Any difficulty in passing urine?"
"No more," the lady said. "Well, occasionally. I am seldom at home when she pees. She pees twice a day and sometimes when she pees on the 3rd time, there is a smell. But no more problem. She drinks more now."
"That's good news," I said. "She drinks more because she does not have to worry about painful urination as in the past months for over one year. I guess dogs with urinary tract infection may figure out that the less they drink, the less they need to pee as urination is painful."

The dog was checked by Dr Vanessa. I examined the dog too. There was some redness in her vulval mucosa and inguinal area.

"Any vulval licking?" I asked.
"Sometimes but not often as before"
I palpated the dog's bladder since this was her original source of problem. An empty bladder. There was a small walnut-sized lump of the bladder. The Corgi suddenly yelped as if it was painful but did not bite me. She was 9 years old and would bite and so I had to be careful as I was just bitten on the right forefinger tip guinea pig with the punk hair between the ears when I examined his mouth.

The dog had a blood test and was vaccinated. I made sure that the owner had a urine-collection bottle to send in the urine for testing during the week. Most owners don't do it but it is good for the dog with a long history of 2 years of urinary tract infection. The dog is in excellent condition. A bit of left forepaw itchiness for which Dr Vanessa prescribed a cream.

This is the type of challenging cases that need a lot of investigation and time. If the dog is treated by several weeks as was done in the previous 2 years, it was difficult to come to a satisfactory resolution of the old dog's urinary tract infections which recur after antibiotics.  Bladder tumours were once diagnosed but with a good ultrasound of the bladder, as seen by Dr Daniel when he had not yet graduated, this case was diagnosed as not having bladder tumour but just bladder "sand".

When the urine sample was analysed, there was no crystals, no bacteria, no white cells. Negative crystals do not mean there was no struvite crystals which had been diagnosed by one of the vets during the past 2 years. In this case, the effects of treatment with the S/D diet and the resolution of her urinary tract infections for the past 2 months confirmed that this beloved spayed female 9-year-old Corgi had a urinary tract infection due to struvites stones inside her bladder.

Ideally, she should have her urine tested every 2-3 months since she had 2 years of urinary tract infections, but no Singapore owner will do that.  Till there is a problem! Singaporeans are time-pressed but dogs are families and so there is great emotions involved when the vet cannot resolve a chronic urinary tract infection as in this case.


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