1045. Example of a veterinary report

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

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

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



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



Date of Veterinary Surgery Report: Jun 22, 2012

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



Case seen on May 14, 2012 by Dr Daniel Sing

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



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



3. General Examination: Abdominal pain



4. Tests done & significant findings of tests:

4.1 Blood tests

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

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



4.2 Urine tests

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



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



4.3 Histopathology: Moderately differentiated adenocarcinoma



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



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



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



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

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



Signature of Veterinary Surgeon: Dr Sing K Y

Date of this report: Jun 22, 2012



Attached and owner has acknowledged receipt:

Blood tests given to owner: No

Urine tests given to owner: No

X-rays given to owner: No

Ultrasound report given to owner: Not Done.

Histopathology report given to owner: No

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

Others given to owner: NA



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

Ear Scope: NA

Skin scraping: NA

Opthalmoscopy: NA

Urinary stone analysis report: NA

Others: NA



Comments by Dr Sing K Y

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



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



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



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



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

tpvets_logo.jpg (2726 bytes)5301.

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



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