Sunday, July 29, 2012

Sunday 29 Jul 2012 afternoon cases

1. Dog with dead grey skin below throat of 20 cent area. Some pain. Could it be due to penetration by hard dog bone treats? Few days only.  The owner was flying and would be back tomorrow. Large area of cellulitis. conservative treatment. IV drip first and blood test.

2. Owner phoned wanting to de-mat the cat under sedation. A man here told him that there are 2 types of sedation. One without recovery and one with recovery. The former type is safer. I was surprised. "Much depends on the cat's health like heart, liver and kidney problems," I said. If the cat is not healthy, both types may kill the cat.

3. Beagle, 13 years old follow up on high liver enzymes by Dr Vanessa. Had vomiting and diarrhoea last visit. I insisted on IV drip with medication and to bring the dog home with the drip as the young lady did not want hospitalisation. IV drip gives direct effect. The dog recovered the next 2 days. "Just giving an injection and some medication to give at home will not work," i said to the father. "The intestines are  not well and so there wil be more bloody diarhoea overnight and unhappy owner having to clean up the mess."  As to the request for liver supplementation, I educated the young lady to take another blood test to check the status of the liver health rather than getting supplements. "For all you know, the liver was damaged due to an infectious organism at that time and has now recovered. The monocytes were 36% last time while the normal should be around <5%. So there was a chronic infection somewhere. The blood test showed "degenerative changes in the blood cells" too indicating something toxic at that time. A blood test was agreed upon by her father.

4. "Thank you for your help," the woman with red eyes said to me after her 18-year-old shih tzu was euthanased as I had interrupted Dr Vanessa to treat her case first as an emergency of a suffering crying old dog. "I wonder whether I should have her anal tumour removed when it was very small." Earlier she had wanted a house-call to euthanase the dog but we could not spare a vet to do it on a busy Sunday.

"When was that?" I asked. 
"2 years ago."
"Did you neuter the dog as the male hormones encourage the growth of this circum-anal tumour?" I asked.
"No," she said. "The tumour just exploded and grew large only in the last few weeks."
"The other vets would not advise operation as the dog was very old and high anaesthetic risk," I explained.  "This dog has a long life."
"My female dog has been spayed and is 18 years old and alive. I didn't neuter the male."

I checked the recent blood test results:
Only significant changes were in the differential blood count with N=83% (60-70) and L = 8% (12-30) and M=1% (3-10). But total WBC was normal at 8.8 (6-17). 

In conclusion, it is still best to neuter your dog and to get small anal tumours in male dogs removed by your vet when it is very small, even if the dog is "old".

Saturday, July 28, 2012

Jul 29, 2012 Sunday's interesting cases

July 29, 2012
Arrived at 8.30 am. Bright sunshine Sunday.

1. Poodle spay came in at 10 am.  I told the owners that they could pick up the dog at 12 noon.
I prepared D+K, for this 3.5 kg dog.
D+K at 50% IV sufficient to intubate when done at the 4th minute after injection. Dr Daniel to spay.

2. Lady intern from stat board wanted to do internship as she wanted to become a vet. Had an Arts degree, AVA does not give vet scholarship to older graduates and the cost was prohibitive. "Be proactive and positive," I said. "Nobody can predict the future.

3. A Tampenis client of Dr Vanessa came to get some medicine and cream for his dog treated successfully for skin disease in Nov 2011. He wanted the tablets and the cream. When I advised that we don't sell tablets, he was furious as he could "buy from other vet clinics." So, he left in his taxi.

4. Dr Vanessa's 3 clients came in a bunch. So it is barking dogs. As it is a personalised service, her clients must wait. We have other vets but they want her.

5. You treated my Schnauzer with bloodied ears and pus flung onto Mr Saw last time," the lady selling rabbit health products said to me. "So I come back as the ears are giving me problems again." That was 3 days ago. I warded the 12-year old dog for ear irrigation and dental work. This morning I checked the oily ears. Much better. Took some pic. Will write up this case later.

Jul 29, 2012 Sunday's interesting cases

July 29, 2012
Arrived at 8.30 am. Bright sunshine Sunday.

1. Poodle spay came in at 10 am.  I told the owners that they could pick up the dog at 12 noon.
I prepared D+K, for this 3.5 kg dog.
D+K at 50% IV sufficient to intubate when done at the 4th minute after injection. Dr Daniel to spay.

2. Lady intern from stat board wanted to do internship as she wanted to become a vet. Had an Arts degree, AVA does not give vet scholarship to older graduates and the cost was prohibitive. "Be proactive and positive," I said. "Nobody can predict the future.

3. A Tampenis client of Dr Vanessa came to get some medicine and cream for his dog treated successfully for skin disease in Nov 2011. He wanted the tablets and the cream. When I advised that we don't sell tablets, he was furious as he could "buy from other vet clinics." So, he left in his taxi.

4. Dr Vanessa's 3 clients came in a bunch. So it is barking dogs. As it is a personalised service, her clients must wait. We have other vets but they want her.

5. You treated my Schnauzer with bloodied ears and pus flung onto Mr Saw last time," the lady selling rabbit health products said to me. "So I come back as the ears are giving me problems again." That was 3 days ago. I warded the 12-year old dog for ear irrigation and dental work. This morning I checked the oily ears. Much better. Took some pic

1814. Struvite stone treatment - Dr Daniel Sing

Thursday, July 26, 2012

1813. Two vets not punctual.

The lab with epulis waited for Dr Daniel and another poodle owner waited for Dr Vanessa as they did not turn up early. That is not a good practice to come late.

1812. Epulis - Vet 1 advised no need surgery, not malignant

Friday, July 27, 2012

Today, I left home at 7.19 am, missed the feeder bus and walked to the Yio Chu Kang subway as the next bus will be 9 min. A breezy bright morning with sunshine and blue skies. I reached Toa Payoh subway at 7.50 am and walked to Toa Payoh Vets reaching at 8.41 am. A slow walk for exercise. Quite breezy but still sweating at the end.

A father and son came with a Labrador, Male, 12 years, bleeding from a large gum tumour. He had consulted "3 vets" but they did not advise surgical excision.

According to Vet 1's medical report- biopsy of gingival mass which was a fibromatous epulis of periodontal origin. According to the owner, Vet 1 did not advise surgical excision as it was "generally benign". Neither did another 2 vets from the same practice. The lump grew and grew and started to bleed at times. He was bleeding spots of blood outside the surgery at 9.15 am when the owners came. I asked them to wait as Dr Daniel was not here yet. More bleeding.

I decided to take over the surgical case as this is an old dog. Should be 14 years as he was stated 12 years in 2009 in Vet 1's record.

Blood test by Dr Daniel showed normal results except slightly below the low range of RBC and PCV

Domitor + Ketamine at 25% instead of 50% as the dog is really old.
Electro-excision is OK at this dosage if not delayed. Needed some isoflurane gas. Also for dental scaling. Strong teeth.

Implemented new anaesthetic recording system.
Today I used my first Anaesthesia & surgery record No. 151.

27.7.12, Lab Retriever, Male, 12 years, 36.3 kg, 39.1C
A   *Inj Domitor (0.4 ml) +K (0.5ml) IV at 25% calculated dose   10.06 am
B   Isoflurane gas first given                          10.18 am for dental scaling. Good teeth.
C   Isoflurane gas stopped                              10.51 am. End of dental scaling
D   Electro-excision of epulis started               10.10 am
E   End of excision                                         10.18 am
Antisedan IV to reverse domitor                      11.02 am. Dog wakes up in 1 minute

In 2009, Vet 1 said half the jaw had to be cut off, so the owner did not want surgery. Another of the 3 vets said that since the epulis was not cancerous as checked by biopsy, there was no need to remove it. But this epulis grew to twice the size and blood dripped from this tumour whenever it was injured, soiling the floor.

He did some internet surfing and consulted Toa Payoh Vets' Dr Daniel as 2nd opinion.
As the dog is old, I took over the case as I had more experience and could perform a shorter surgery, minimising risks of death on the op table.  The likely reason that the other 3 vets didn't recommend surgery would be that the dog is old and they don't want to
bear the high risk of anaesthetic death ruining their reputation.

I took 8 minutes to excise the epulis 2x2x1.5 cm under Domitor and Ketamine at 25%. A vet must be quick and know what to do during surgery, as the analgesia would wear off 8 minutes after injection. The dog started to move around the 8th minute. The incisor tooth might be entombed but I did not think of slicing the epulis to check and gave it to the owner. The owner threw it away.  Isoflurane and intubation were done for dental scaling. Solid teeth in general except for the tartar and plaque. The dog was given carrots and apples and had good food.

electro-excision of a gigantic epulis
tpvets_logo.jpg (2726 bytes)5508 -5517. A gigantic epulis
Control of bleeding. Electro-excised more of the periodontal ligament inside the hole. I used cotton to plug the hole after removal of the epulis to stop bleeding. The bleeding was profuse but stopped after 5 minutes of plugging with cotton.

UPDATE  July 30, 2012  12.50pm. 3 days post surgery, I phoned the owner to ask about the health status of his dog.

"On the first day at home, he was not able to walk on his left hind leg and we had to carry him outdoors for him to pee," he said. This dog has a left hind pain before surgery, possibly a bad hip. "However, today he could go to the lift himself."

"Has he got a good appetite?" I asked.

"He is eating soft food and wants to eat more. He has no problem eating."

"You can continue your usual dry food and others now," I said. "Is he more active?"

"I can see that he is overall well," the gentleman thanked me for following up. It was good to know that this old dog is OK. It is not guaranteed that all old dogs operated by me survive anaesthesia and so surgery must be short to lessen any risk of death.

Oral tumours are best removed when they are small in size, even though they may not be cancerous. This is because they cause oral pain as they ulcerated and become infected. They interfere with the joy of eating too as an ulcerated infected mouth is very painful. has some problems displaying the width of the page.
Toa Payoh Vets webpage is:

Wednesday, July 25, 2012

1811. Blood test of closed pyometra CKC 4 years

The size of the womb is bigger than the German sausages sold in the gourmet supermarket as you can see from the images. Packed bursting with pus. I showed dog with PUO, JJ's owner, the difference in blood test of a bacterial infected dog.

"The blood test showed low RBC, HCT and Hb and normal MCHC.

Total WCC 127 (6-17). Neutrophils at 95% indicating a raging bacterial infection and a serious poor prognosis of death.
The platelets were low at 11  (normal 200-500) - likely to bleed internally to death.
The lab report said: "the blood cells show degenerative changes? age/transport. several abnormal seens seen. No platelet clumps."

On clinical grounds, this dog was having septicaemia and the owner must be informed early prior to surgery of the high probability of death on the op table. Failure to do so would be negligent of the vet. I phoned the owner to tell him. The dog was operated by dr Daniel and is OK now. She is young and so has a better chance of survival. No x-rays were wanted.

1810. PUO - Pyrexia of Unknown Origin in a hiding Maltese

Today is Wednesday. On Sunday, the young couple from Bukit Panjang brought a 4-year-old male neutered Maltese to consult me. Late in the night, the dog suddenly went to a corner to hide. "He was restless and reluctant to walk," the young lady said. "He panted but could walk."

So the owner took him to an emergency clinic on that Saturday. Tramadol and meloxicam inj and SC drip were given.
Fever was present. She was told to monitor the breathing closely and keep JJ in a cool place and ensure access to water and to see her regular vet the next day. The owner was worried about tick fever as she had plucked out a fat mother tick 2 weeks ago from the dog. Also the dog is not on anti-tick spot on medication but never had tick problems.

The first blood test taken on Jul 21, 2012 at 8.54 pm showed high RBC, HCT and Hb and low MCHC.  Other results were normal.

On Sunday morning, I saw the dog at 10 am. The dog still had fever at 40C.  "The high RBC and Hb is a concern. I need another blood test to check," I asked for permission as the lady thought that the dog was dehydrated. Clients are much more sophisticated with the internet nowadays.

Other than fever, JJ had some pain on his back spinal area. He gave a soft "ha" when I pressed the spinal area between T7-13 and this effect could be reproduced as the owner could hear it too. "Did the vet check on this?" I asked. "Yes," she said. "She did it in a different way." No abdominal pain could be found but the dog was already given painkillers yesterday.

"There is some pain, now muffled by the use of Tramadol and meloxicalm painkiller injections given yesterday," I said. "Did the dog fall on his back?"

The dog could have tripped. For the pat 4 years, he hoped over the concrete bar to go inside the toilet for around 5x/day. Over 4 years, this would be over 6,000 hops and punishing to the spinal column. Pain --- panting --- leads to "fever".

July 22, 2012  10 am
The second blood test showed normal RBC, HCT and Hb and MCHC. "RBC, HCT and Hb" are on the higher side of the normal range," I explained. "MCHC was on the lower side of the normal range. " Other results were normal.

"The bad news is that the liver enzymes are high  ALt 219( normal <59) and AST 196 (<81)," I said. "There could be hepatitis just starting and so the total WCC did not go up. However, the neutrophils are 77% as compared to 56% from the first vet. It is possible that there is a bacterial infection just starting. Since the first vet did not do this test, it would not be known if there was abnormal liver function."

So was this a case of heptititis causing fever? The owner consulted me on Tuesday as the dog was dragging his left hind feet but otherwise energetic and happy and eating. No fever but then he was on anti-fever medication. "The first vet used the hind legs to collect blood," I showed the lady the bruised black area around the hocks. Some vets like to collect blood from the back legs but usually no problem in walking."
Today, Wednesday, I phoned the owner at 5 pm. JJ was ok.

Advised toilet ramp and attention to paw licking. Wear booties? The owner didn't like the idea. I suggested a short-term use of anti-inflam and also trimming and washing the paws.

Conclusion. Cause of liver disorder and hepatitis? Hard to say. The dog was not vaccinated. He was walked daily outdoors by the mum and could have picked up an infection. He could have got infected in the liver from unhealthy dog treats. So, it is difficult to come to a conclusion. LD diet was given for 2 weeks for the liver and we have to wait and see.  

1809. Vets to write down follow-up tel calls to owners

Sometimes the husband gets the calls and don't communicate with the wife, as in the case of the CKC with closed pyometra. I phoned the husband a few times as his tel is on the case card. The dog was hospitalised 5 days. On the 4th day, the wife phoned the clinic and told me that nobody ever informed her about the health of her dog operated by Dr Daniel Sing. The dog was in good condition.. This was surprising as I had spoken to her husband who knew the seriousness of the case based on blood test with total WCC hitting the roof. 

Another owner of a jack russell that vomited phoned and told me that Dr Vanessa had not informed him of the blood test result. But Dr Vanessa said she had. It was her word against the owners.

So, nowadays, all vets will write down date and time of informing the owner in the case file, to avoid misunderstanding. Such feedback is valuable to improve our services and that is why I do answer phone calls to know the ground level.  

Complaints about long waiting time and not be seen at the appointed time are another issue that have to be resolved.

1809. Toa Payoh Vets Anaesthsia & Surgery Record

Today the printer came with the books. Each of the 4 vets here will be having his own book to record % of isoflurane gas used, time taken, sutures, tranquilisers used. This record will be used in cases of complaints/litigation and each vet will be accountable for his recording.

These records will serve as a check and audit for 'controlled drug' usage and shown to the authorities when needed. Such records are necessary to ensure good management in vet surgery and anaesthesia and it is the responsibility of the licensee vet. For the vets, it means meticulous recording is required and serves as a good defence in cases of litigation/investigation.

1808. Cambodia Khmao Project

Dear Dr Sing.

Some information about myself and The Khmao Project.

I moved to Cambodia 3 years ago and instantly recognised the plight of animals here, it is extremely difficult not too, regardless of your education and background.

Being a developing country, Cambodia is still coming to terms with genocide, war, widespread corruption and heartbreaking poverty.

Animals in Cambodia that do not have financial value (livestock having monetary value) are not considered companion animals or pets, as they are in western cultures.

They merely exist, and have to fend for themselves for food, shelter, health wise.

Cambodia, being a buddhist country, also does not believe in desexing or an interruption to "the natural order"..therefore euthanasia is also against their beliefs.
Everyday here, you are confronted with neglect on such a massive scale. Hence the need for an animal welfare project here in Siem Reap.

There are Khmer "vets" here, but their level of training is very minimal (if any), this is of great concern, when they can advertise themselves as Veterinarians

The only other western vet is 6 hours away..not great in the case of an emergency!

I also have access to a laboratory at a western run hospital, where I can take various pathology samples in for analysis then I send the results to a vet friend in Australia for diagnosis and a treatment plan. This has proven to be invaluable!

All of the female desexings I refer to Phnom Penh (the capital-6 hours away).

I am lucky that the French vet in Phnom Penh supplies me with antibiotics etc..but these items can prove quite costly as they are imported from France. Obviously the cheaper alternative are available here in Cambodia, but mostly these items are not of great quality,(also are "copy medications, non generic) and have been stored in the correct manner and therefore lose their effectiveness. I try to go to Bangkok as much as possible, (to source anesthetics in particular) but sometimes this is difficult.

About The Khmao Project...

The project is in its infancy stages at the moment. Currently we are treating a small amount of local/stray dogs and cats for various conditions, offering vaccinations, general health care and re homing them to expats once they are healthy.

The plan is to (once we have the appropriate funding) to open a facility with a veterinary clinic,(proceeds of this go back into the project) kennels to house stray dogs and cats, offer desexing, vaccinations, health care. Eventually we would like to have a mobile clinic to go out to the various provinces in Cambodia and continue to offer free treatment to Cambodians.
Obviously once we have the facilities etc we will be asking for volunteer vets from overseas to come and donate their time. We will also be employing local Khmer staff and training them in animal care and husbandry. Eventually we would also like to offer further sustainable training for Cambodian vets by western trained veterinarians.

This is a massive task and we are hoping to be able to achieve this.
If there are ANY items in the future that you would be able to would be greatly appreciated!

Please feel free to contact me if you have any queries or questions. Hoping soon to face our Facebook page up and running so we can keep you up to date The Khmao Project, if you wish.

Katie Beattie V.N

1808. Too risky pyometra surgery

On Tue, Jul 24, 2012 at 2:17 PM, Jan Cavan wrote:

Hi Dr Yuen,
I was researching about Pyometra and came across your blog. I really need your help. I'm very desperate.

My dog has pyometra, but the vet does not recommend surgery for the following reasons. If they ever perform surgery (when she gets better), they won't do it without injectable anesthesia/complete sedation. But based on your blog, gaseous anesthesia is actually okay to use too.

1. her age (she will be 13 years old this December)
2. she has kidney problems (creatinine was 5.0, gone down to 2.0 after some medication, but is now back up to 13)
3. she is anemic

But I believe that 2 and 3 above are caused by pyometra. Right now, she is taking:
1. antibiotics for pyometra
2. Nefrotec to make her urinate and release the toxins
3. Red Cell for some iron supplement
4. She is currently in IV fluids to rehydrate her as she appears to be dehydrated

I am in California and my dog is in Cebu, Philippines with my parents. I wish I could fly her out to Singapore so you can maybe help her out, but that is no longer an option at this point since we need to make decisions immediately as my dog is getting weaker. I would actually also fly you to Cebu to perform the surgery and we rent out a veterinary clinic's equipment here. If that is something you would consider, please let me know as soon as you can. It's 11PM here and I might sign off soon. If this is something you would consider, would you be able to please contact my parents? The Philippines and Singapore have the same timezones.
I understand that you may not be like the usual emails that you get, but I'm really, really, very desperate right now. My initial plan was to postpone surgery until she recovers so I can bring her to CA with me. But now, I am desperate. I really, really, really need your help. I am a complete wreck.
Looking forward to hear from you.

There will be other vets in Philippines that can operate on pyometra using gaseous isoflurane anaesthesia and IV drips. You need to find them, esp. those in bigger practices and hospitals, maybe in the city? Your country is large, unlike Singapore and there will be more vets who can do the surgery. You may need to drive the dog to the particular vet or vet school.

I am sure there will be one vet who will do it but it may be too far from your place.
However, gaseous anaethesia is NOT a guarantee that your dog will survive the surgery or post-surgery and you need to understand and give the informed consent you have to give to the vet.
Best wishes.

Sunday, July 22, 2012

1807. Wanting to be rich

My advice to a Filipino vet from a middle-income family. She couldnt' find a vet tech job or a waitress job in Singapore on a recent visit. She had sprained her shoulders and back and left limb having been a medical transcriptist for past 7 years as it paid S$1,000/mth compared to vet job and wanted to do some work without typing. Singapore has tightened its rules and so approvals are very difficult.

 Hello Dr. Sing,

Eileen here...I just want to express my utmost gratitude for all your words of wisdom yesterday. Maybe I still need time to do a bit of internalizing to figure out what I really want to do. You are right, I really am confused about what career move I should make. I have booked a ticket going back to the Philippines to clear my head and get a better perspective. Thank you so much for the chance of experience. Learning is quite priceless.


Thank you and good luck. Life is never easy for most people who want to be rich. There must be a passion and a compassion in such person and lots of personal sacrifices (health, personal, friends, family) if they want to be really rich. 

1086. sunday July 22, 12 interesting cases

July 22, 12
Bright sunshine, blue skies, white clouds
6 pm

1. Maltese with fever last night. Saw Vet 1 and given treatment. Blood test showed unusual high RBC and Hb. So, unlikely to be tick fever. "Sudden onset, not wanting to move yesterday evening" was the clue. I palpated spinal area inT7 - 13 area. Dog was already on pain killers from Vet 1 but responded with a soft "ha ha " sound which I could reproduced to let the young lady owners hear. As to the cause of fever 40C today at 10 am, I suspected there could be extreme pain and panting - increasing body temp but why increase in RB  C and HB? Gave IV drip and tolfedine and to observe. "Must I come back on Monday?" the young lady asked. "No need if the dog is active and eating." I said. "Continue with anti-fever and other medication. I will check the blood." A case of PUO? Pyrexia of unknown origin.

2. Golden Retriever with the most smelly neck. Can't stand this smell. Cellulitis.  "Must we complete 10 days of medication?" the lady asked me. "Yes," I said. "The stinking smell is due to a flesh-eating bacteria and 3 days will not be sufficient." "Need antiseptic daily?" she asked. "Yes, use the wash." "Any cream?" she asked. "No need." I said.

3. Roborskvi with backside cellulitis. Lady owner could not cure it. On 29 Jun 2012, one of  the two siblings was treated by Dr Daniel for similar backside wound and had healed after 5 days of hospitalisation. Owner asked to separate the siblings but she put them together again. "What happened to the other hamster?" I asked. "He drowned." "How?" I asked as she was living in a Toa Payoh HDB flat. "He fell into the hole," she said. "What hole?" I was shocked. "The hole where my washing machine pipe discharged the water."  Now, this sibling's backside had got bad and needed hospitalisation. 

3. Chihuahua spayed 5 days ago with pyometra came at last minute. "Dog was licking the side of the spay wound causing a reddish patch to the side. Why?. Also a blood spot on my cushion," the lady owner said. "Is this normal?"
"This is normal in that residual blood get passed out after spay from pyometra, but is not serious. Is the dog active and eating?"
"Very well," she said. "Probably plaster is irritating," I checked the spay wound and removed the plaster. No inflammation on wound, so that was ok. Gave injection and sent the dog home. No need plaster. 

4. Shih Tzu with both ear pinnae inflamed. "Came at 3.30pm, now it is nearly 6 pm", the lady said to me. I had done the eye ulcer tarsorrhapy on one eye and Dr V had done the other. Both eyes are OK but she said ear problem came soon after wearing the e-collar. She had the dog spayed at another practice. The vet said ears were dirty and prescribed ear drops of 2 bottles. Now the ears are itchy.  She preferred Dr V and had to wait. Personalised services are like that, otherwise the clients will be assigned to me or Dr Daniel Sing if they can't wait. "Ear problems are common in Shih Tzu," she was so busy that she has no time for the dog and would not want hospitalisation. So she was waiting for ear irrigation. I sedated the dog first and told Dr V about it, so she could save some time. It was already 6 pm and the client from Changi had to pick up her daughter from the enrichment lessons somewhere.  

5. A young cat vomited food half an hour or more after eating 4 x in the past 4 months. Losing weight compared to the other cat. Both fed separately.

Is this a case of some foreign bodies inside the stomach or a stomach diverticula? The couple wanted immediate X-rays and blood test and I referred them to another vet with complete facilities but who does not work on Sunday.    

Thursday, July 19, 2012

1085. Blood tests and X-rays in the diagnosis of pyometra in dogs

Recent history of estrus, clinical signs  and abdominal swelling and pain on palpation may be sufficient. However, blood tests give an indication of the health status and the anaethetic risks using evidence-based medicine in case the dog dies during or after surgery.

Both female dogs around 4 years old.

Date: Jul 16, 2012
CKC with closed pyometra
Estrus said to be less than 1 month ago.
Goes home 5 days after surgery as she needed IV drips. Wagged tail on Day 3.
Womb looks about to rupture. It was extremely swollen and has petechial haemorrahges. See images
However good news. Went home.

Hb 11.6 (12-18)
RBC  4.9  (5.5-8.5)
Platelets 11 (200-500)
PCV 0.34 (0.37-0.55)
Total WCC  127 (6-17)
Blood cells show degenerative changes ? age/transport. Several abnormal cells seen. No platelet clumps seen.

NOTES: Actually degenerative cells due to toxins of bacterial infection in the uterus.
Compare to chihuahua with open pyometra

SGOT/AST 117 (<81)
Urea 36 (4.2-6.3)
Creatinine 174 (89-177) - normal
No X-ray though advised.

Chihuahua. Consulted vet early when dog was not eating and was lethargic but discharge of pus from vagina for around 10 days.
Goes home 3 days after surgery as she was more alert than the CKC, growling all the time.

X-ray showed enlarged uterus (arrows compared to image of uterus) but some vets may not agree with me.

Hb 17 (12-18)
RBC 7.2 (5.5-8.5)
Platelets 208 (200-500)
PCV 0.49 (0.37-0.55)
Total WCC 6.2 (6-17) N=75%

SGOT/AST  115 (<81)
Urea 3.7 (4.2-6.3)
Creatinine 53 (89-177)

Wednesday, July 18, 2012

1083. The internet connections open the door....

"I went to the internet and typed "Singapore Vets," the gentleman told me yesterday, July 18, 2012 as he and his wife came to take the chihuahua home at 4 pm. "I skipped church as I saw that my dog did not want to eat her breakfast and was sleepy. The internet showed Toa Payoh Vets being open on Sundays and the opening hours and so I came to your surgery. Normally my wife goes to another vet in Ang Mo Kio but she was overseas on that Sunday." 

I told them that the dog was operated by Dr Daniel Sing who had not minded discharging the dog after surgery. But I had intervened and strongly advised the gentleman to hospitalise her for 3 days as pyometra is a serious illness and the daily temperature needed to be monitored at Toa Payoh Vets. There could be stitch breakdown due to the dog jumping at home and unhappiness in having to re-stitch. At least 2 days of hospitalisation and also not to wait till the wife return from the UK to see the dog before surgery as pyometra is life-threatening. I advised that the dog returned home when the wife came back from overseas and this meant 3 days of hospitalisation which was good for this fierce chihuahua who growls whenever she sees me. She remembered me palpating her swollen abdomen for the enlarged uterus to confirm pyometra (without X-ray or blood test if the owner didn't want the tests). It caused her pain and she never forgave me.

The dog was visited by the family including the adult daughter and her friend during the past 3 days.

The wife has her favourite vet and so this would be the last time I see the dog as the wife is the one in charge of the chihuahua's health.

The internet has opened the door for Dr Daniel Sing to gain a new client. Can he retain the loyalty of the client? A good surgical outcome helps but there is more to make the connections with a new client.

As for me, I have made the connections because the wife asked for my name and then for my name card. Dr Daniel was in Bangkok at this time, otherwise he would be present.

The internet connects open the door. Will Dr Daniel be able to connect with this new client? The veterinary professors have not taught him how to do it as this is not their main job.

Tuesday, July 17, 2012

1082. Connect with the client - The Power of Prayer

I have no doubt that the story as narrated by a friend I have known for over 30 years is true though I did not witness it. So I advised Dr Daniel to communicate with him by talking about the "power of prayer". But he did do it.

The story was that one day, a New Zealander couple came to this friend's cafe for breakfast. The husband was in a wheel chair and had been paralysed a long time. So he would use the stick to get up and hopped with his wife's support. My friend asked permission to pray for the husband's recovery. Permission was granted. At the end of the prayer, the husband stood up and then threw away his stick as he could walk normally. I guessed Dr Daniel found it hard to believe in the power of prayer and did not mention this to my friend who had brought in a Golden Retriever with muzzle inflammation for treatment. This dog was seen twice by Vet 1 near his place but had not responded. He wanted a second opinion.

I asked Dr Daniel to follow up 3 days after our treatment. It is always excellent service to follow up. He phoned but there was no response. My friend phoned me later and said: "I can see some hairs growing in the muzzle skin. I guess it is recovering."

So I told Dr Daniel. "Do you think it is the power of prayer?" I asked him. I doubt that my friend prayed for the dog to recover in this case and I did not ask him as it sounds too frivolous. Dr Daniel still would not believe in the New Zealander story. "Well, you connect to a client not just on dog skin disease," I said. "It is on topics that interest him. By the way, he narrated another episode of healing. A woman was paralysed and could not even walk. She recovered after he prayed for her..."  Dr Daniel rolled his eyes and would not talk further.

1082. Update: Imizole was effective against Babesia gibsoni in this stray dog

Oct 30, 2011

On Friday, Oct 28, 2011, 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 consulted by the Group. According to her, Vet 1 said that the imizole commonly used for treatment of tick fever would be ineffective as this dog had Babesia gibsoni.

As imizole is "ineffective" against Babesia gibsoni, Vet 1 wanted to use the "3 effective" drugs atovaquone, clindamycine and azithromycin. However, it would cost the Rescue Group $1,000. Berenil was cheaper but might cause anaphylaxic shock and in any case there was no stock at that time.  

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 and alternative options.

Below are my replies to her.

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

Combination of atovaquone, clindamycine and azithromycin by (required by Vet 1) as said by you, is claimed by Vet 1 to be effective against Babesia gibsoni infections in this dog. Vet 1 had said that imizole is ineffective against Babesia gibsoni.

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, anti-tick fever 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.
A Cocker Spaniel has tick fever in 2011 is the case report. 
Shoreline stainless steel vet operating table can rust if the vet does not bother to maintain it. toapayohvets, singapore
Day 1 to Day 5 of tick fever
She came today (Sunday Oct 30, 2011) for her 2nd imizole injection (0.6 ml SC today) 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 the story of the stray dog with tick fever to the cocker spaniel and she was worried that I had not given the correct treatment.

Day 1 ---> imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets
imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets  
Day 4 & 5 ---> imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets  
Day 4 & 5 ---> imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets
Day 4 & 5 ---> imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets
Day 10 ---> imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets imizole injection, tick fever, babesia gibsoni, canis, ehrlichia, dog, singapore, toapayohvets
"Will you dog be active and rushing out to play and have pink gums 10 days after the first injection if imizole was ineffective?" I asked her as I gave the 2nd injection today. As the dog still had ticks attached to her head and spinal area, I asked: "Does your dog go under the bed?". She said "Yes, my dog likes to sleep under the bed." I said: "Ticks may be present on the under part of the bed and attaches to the dog. Advantix should work as this spot-on was given 10 days ago when the dog came in. Give another dose in 4 days." I wanted to prescribe the anti-tick wash but did not as I asked her to use the Advantix and the dog had not many ticks. 

My thoughts on this fine Sunday morning were for that stray dog and the caregiver who was a student. The young Singaporeans prefer to text and on Saturday, Oct 29, 2011, 2.53 pm,  I got the following:

"Dr Sing, I brought the dog home as they could not do anything for her. Rescue opted to try Berenil but can't get for a few days so we are waiting. She is very weak. I think she may be dying. How much is one shot of imizole? Do u think it is worth a try? If not too expensive, I don't mind trying myself. What else can we do for her in the meantime?  
I phoned her on Saturday and told her to bring the dog for the imizole injection on Saturday at 9.30 am. But she said that the transport was not available. In any case, the Berenil may be available on Monday and the dog was still alive.  So I hope that this dog had the Berenil treatment soon. 

As for the English Cocker Spaniel, as at Nov 3, 2011, the dog is normal. "Except that she tires easily," the owner said to me. She submitted a urine sample for testing. The values were normal. The urine SG was high, at 1.041 (range should be 1.005 -1.030), pH was 7.0 and struvite crystals were present. "Could it be the high liver I am feeding?" the lady asked me. "Should I stop feeding the liver?" She was also feeding iron supplements and all the good home-cooked food. "Since your dog tires easily, she has not fully recovered her normal red cell amount," I said. "The high urine SG is unusual. It shows that the kidneys can concentrate the urine well but what causes it is hard to say."  I may need to have another urine test 2 weeks later. 

Nov 3, 2011, as I update this report, I had been thinking about the high urine SG. My hypothesis is that the destruction of so many red and white blood cells damaged by the Babesia and Ehrlichia organisms during the past 14 days would have contributed to a large amount of protein damage for the past few days. The kidneys are normal and have to work hard to excrete the urea. This resulted in a high urine SG. There may be a high blood urea but I did not take a blood sample when the urine sample was sent.

Since the kidneys and bladder were normal, there was no proteinuria during urinalysis. Is this hypothesis sound? These are the types of questions the professor may ask in a case study during the final exam of the 5th year vet student. I remembered my "viva" or "oral exam" on a case study during my final year by my Professor of Vet Medicine and an external examiner and I presume Murdoch vet students still get this oral test.

A reply or hypothesis may not be possible for a vet student so much burdened with 5 years of vet knowledge memorised to pass the Final examination in November 2011 if the Professor of Vet Medicine asked about the high SG during the oral test!   

Earlier report: A Cocker Spaniel has tick fever in 2011 or


Update on animal activist's help of a tick fever rescue dog

The Rescue Group's vet had said that imizole would not be effective against Babesia gibsoni and advised a triple-drug combination costing $1,000. The rescue group wanted this activist to pay $600 to top up the $600 budget from the rescue group. The activist sought my advice by text and there was some delays as the Rescue Group's vet said that Berenil would be available as a cheap alternative in a few days' time. So the activist waited. But no Berenil. The activist was pro-active and posted online for help. A donor responded and would pay for treatment by the donor's vet. It seems that this rescue dog will survive the tick fever and that is good news for her and for anyone.

The following is her reply to my follow-up on her rescue dog's status



Its been a busy few days.

The Berenil is discontinued in Singapore already, and the rescue people told me I have to pay myself or let her die. We brought her home on Saturday and on Sunday she was having difficulty breathing and could not stand up. I posted her pictures online and a very kind stranger offered to pay for her treatment on the condition that we go to her vet. ... is being treated at (Name of vet practice given) as requested by the donor.

Her red count had dropped even further, and her platelets dropped to only 12. She stayed there for 2 nights and they gave her lots of supportive fluid therapy, erythropoietin and used steroids to stop the hemolysis. She perked up very well and is now resting at home. We will repeat her blood count on Friday and give her Imizole on Saturday if all goes well. For now she is on pred, metronidazole, Doxycycline and some other supplements. I was also force-feeding her Hill's a/d several times a day. As of this morning she was willingly eating herself! I think things are looking up and Dr ... thinks she will survive. I hope the Imizole works to cure the infection.
I'm sorry we were not able to take her to you. I have great faith in your clinic, but unfortunately the money is not mine! :(

Thank you so much for your concern, you are very kind..
Btw, she's not my dog! We are just fostering her and hopefully will find her a home.



I thank you for being proactive in helping the stray dog. The vet is doing a great job and I am quite sure imizole will be effective. Best wishes.

I met the young undergraduate activist in May 2012. The above-mentioned stray dog was treated by the sponsored vet and is well. Based on this anecdote, imizole was effective against Babesia gibsoni infections in a stray dog.

Updates will be at webpage:

1081. Tick fever in a great dane, cocker spaniel and a samoyed video production

July 18, 2012  5.15 am

I am trying to get an educational video produced high-lighting the diagnosis and treatment on the 3 cases of tick fever in Singapore,

for the vet students studying hard in their little rooms. The cases are at:

A lot of time is needed to summarise and compare the significant points of the 3 cases

Monday, July 16, 2012

1080. Veterinary leadership

Managing a practice seems easy to the outsider. I have 3 associate vets. I can sleep late and come to office whenever I wish. This is the wrong perception of outsiders. This is because employees start to slacken as the boss is seldom around. If the boss does not bother or become a womaniser as in some successful employment agencies I know, the whole business goes down the drain.

From Monday to Friday and some Saturdays, I leave home at 7.30 am, take a feeder bus to the subway, then another feeder bus or walk to Toa Payoh Vets.  On weekends and public holidays, I drive and reach the surgery before 9 am.

1. I man the phone calls in the morning and get complaints or feedback on services provided by associate vets. It is better to receive negative feedback so that we can improve. One of them is long waiting time, as long as two hours in one case. I had spoken to my associate that waiting time should be less than 15 minutes in general.

2. Coming back for stitch removal after spay or neuter. I told my associate vets that this need to return must be stopped as we use dissolvable stitches. I don't ask the patients to come back in 10-14 days after surgery but my associates do. So, there is an inconsistency in services from the same company.

3. No offer of chair for client during one-on-one consultation. I simply grab a chair for the client when I see my associate vet not doing this despite my advice. Mindsets of the young ones are hard to change as they are brought up in a different affluent culture. But excellent services retains customers and the associate vets should be aware of this. We get more new customers but where are the old ones?" I asked them

1079. Love what you do - Singapore vet graduates are fortunate to get employment easily

Yesterday Jul 16, 2012, I interviewed a Filipino vet who had 7 years of medical transcription experience and was looking for a vet technician job in Singapore. She sent 100 resumes and phone various practices and received negative replies. Now she has 8 days left to look for a job. She was referred to me by my friend, Khin Khin, a licensed employment agent dealing mainly with Myanmar applicants. Lately she got walk-in Filipino and Indian prospects too.

Now, it is extremely difficult to find an employer. The ratio of 4 Singaporean to 1 foreign worker has been increased to 5:1 and the salaries have been increased much more since July 1, 2012. So many organisations just can't employ foreigners as they don't have this ratio.

She came to Toa Payoh Vets at 9.15 am as Khin Khin had asked her to be punctual at 9.30 am. Punctuality is important for anybody and creates a good impression.   

"Why did you leave out your personal particulars like citizenship, home address?" I asked. "By doing this, you make the interviewer do more work to ask you."

"My friend in the event management company in Singapore told me not to include these info," she said. "I will be discriminated if I do it."

"It is better that the employer knows what nationality you are and if there is no need for Filipinos, you will have been better off, saving time."

I reviewed her veterinary degree. The surname on the degree is different from the passport name. She had an affidavit to say that there was a mistake in the spelling. "This creates a bad impression that you don't bother to ensure accuracy," I explained to her. "MOM officers will check the surname and reject any application immediately."

She said she needed to spend time to get this rectified.
"Why didn't you work in a veterinary practice instead of medical transcription for a US hospital for 7 years?" I read her letter of appointment. "You just don't have the necessary small animal experience."

"Medical transcription pays me more," she mentioned this was S$1,000 per month with 12 hours of her efforts daily. Now she has shoulder ache and pain in her left thigh (sciatica?) and so was looking for a job that would not involve typing.

"My father was not happy when I told him I would be working as a waitress in Singapore," she knew that vet technician jobs are hard to find as she had spoken to her counterparts in vet practices and she was not in desperate need of money since her family was well to do.

"It is the timing and the referral from your friends in the vet practices rather than emailing," I said I do get several such emails.

It is so difficult for her to work in vet surgeries in the Philippines as the pay is low. New Singaporean vet graduates are so fortunate as all can get to work in veterinary practices or the government. Yet there are so many vet graduates in other countries who can't do what they love.


Sunday, July 15, 2012

1078. Uplifting Service - 2012 Ron Kaufman

Saw the book at the library. Good tips to create value for customers through action.

Chapter 16. Pg 164. Building your service recovery system is useful - stories of recovery are collected and service providers rewarded.
How can this be applied to Toa Payoh Vets?

Skin disease cases - recurring or from another practice
If the vet in Toa Payoh Vets can successful resolve the dog's skin problems.
This means using evidence-based medicine (skin scrapings of 5 sites, not just one site, swabs, microscopic exam) and follow up 3 days later and 2 weeks later. Very few vets bother to do it. Very few owners bother to return for review 2 weeks later. A system to document skin disease treatment?

Recovering an existing customer is usually less expensive than acquiring a new one.
1.  If the vet promses to phone back later, the vet must do it. This is one complaint I receive when I man the phone calls.

Other matters
1.  Waiting more than 2 hours despite making appointments. A rare complaint but this should be attended to. There must be a monitoring system by me. Now, waiting times are limited to 15 minutes per person.

Saturday, July 14, 2012

1077. Sunday Jul 15, 2012 interesting cases

Sunday Jul 15, 2012 interesting cases

Bright sunshine, blue skies

1. Case 1. New client. 3-year-old plump femal echihuahua suddenly lethargic and not eating. Black green diarrhoea.
"I saw whitish discharge yesterday," the 70-year-old man said.
"Is it from the anus or from the vagina?" I asked.
"Can't tell,"
"When was the dog's last heat?" I asked.
"Last 4 weeks, small amounts of blood unlike the first heat."
"It is not normal for a healthy to have small amounts of bleeding and for 4 weeks," I palpated a swollen anterior abdomen. The dog growled in response.
"Most likely a closed pyometra," I said. "An infection of the womb. Blood test and X-rays will be taken and an IV drip with antibiotics to be given today."

2. Case 2. 5-year-old male rabbit with rapid breathing and not eating.
"He had never fully recovered since 2 months ago," the young lady said.
"With this type of fast nose breathing, the rabbit is suffering from a serious lung infection usually," I said. "He is unlikely to live for a few days. Any change of hay and is it dusty?" I asked as the rabbit showed signs of pneumonia. The owner did not want any blood test or X-ray. So treatment would be symptomatic and the rabbit warded for one day. The rabbit passed away soon and the owner was informed promptly. No complaints as she was informed of the poor prognosis.

3. Review of Shih Tzu with vomiting and diarrhoea. Came in yesterday Saturday while Dr Daniel was on leave. He was neutered by Dr Daniel but his surgery area was not infected. For such serious vomiting cases, I warded the dog for 24 hours, gave the  IV drip, antibiotics and anti-spasmogesic. Blood test. Vomited once but no diarrhoea due to treatment. Dr Daniel will call the owner as this is his case and responsibility to provide a good customer service. Very painful throat (forced feeding of medication) when I palpated it and bit me as the dog hated oral medication and bit the owner. Dog went home.
4. Review of poodle with intense facial itch. Dorsal elbows blackened skin. Had horizontal ear canal resection done by me some weeks ago and was OK. "Allergy?" It is hard to say. Warded and horizontal ear canal cleaned. No demodectic mange mites seen on microscopic exam of elbow skin but it does not mean there is none. Allergy to various things is a possibility, like dog treats.  

5. A young French couple with a 3-year-old boy came to buy a kitten or dog like the tea-cup yorkshire. "We don't sell them as we are a vet surgery," I said. I checked my Samsung laptop for the phone number of a pet shop that sells kittens and puppies but stopped when a rabbit owner came in. I resumed later and asked them to phone the Holland branch of Pets Station. "Best not to buy a tea-cup yorkshire," I said. "It is hard to take care when you have a small boy."

This is "creating value" to a prospective client as it will be easier to tell him to go look for the phone number himself. The husband shook my hand.

Friday, July 13, 2012

1076. Golden Retriever keeps panting every day

GR, Male, 7 years started panting. Treated by Vet 1, but panting came back again after 7 days of medication. Owner did not want blood test again.

I checked the Vet 1's report. Liver and spleen enlarged.

"Unable to do CBC as the machine cannot read the blood."

However, he did a blood smear (RBC NAD, large reactive lymphocytes 3+) and rectal palpation (enlarged prostate both sides). He did blood biochemistry - NAD
Recorded panting could be due to anaemia
Diagnosis: Acute lymphoblastic leukaemia? prostatitis/BPH
Treatment: Tardak inj. and usual medication.

MY BLOOD TEST done without charging the owner

Total WBC 91 (6-17)
Marked luekocytosis with many abnormal cells seen. No platelet clumps seen.
RBC and Hb low --- anaemia
PCV 0.28, MCF low, MCHC low. Platelets low 196 (200-500)

What's the cause of this high WBC? Due to economic problems, the owner did not want any testing.
Could this be a case of tick fever?  So far, the dog is still panting but is at home as the ladies do not want euthanasia.

Glucose 3.4  (3.9-6)
Hb 10.5 (12-18)
RBC 5.0 (5.5-8.5)
Platelets 196 (200-500)
PCV 0.28 (0.37-0.55)
Total WCC 91 (6-17)
N= can't do

There is a marked leucocytosis with many abnormal cells seen. No platelet clumps.

Two blood tests showed similar leucocytosis. As to the cause, it is hard to say.
SGPT/ALT   122 (<59)
SGOT/AST  792  (<81)
Urea 7.6 (4.2 - 6.3)
Creatinine  132  (89-177)

Dog was euthanased on Jul 17, 2012 as he had deteriorated in health.

1075. Tick fever in Singapore dogs from the drug supplier and in a Westie

Saturday 11.35 am

I spoke to the drug supplier of anti-tick fever medication. He said that the bottle costs around $200 and he does not stock it anymore. "Sudden demand for the drug," he said. "Then no demand. I have lost money." I asked him which months of the year were there more tick fever cases, but he could not say.

I ordered another bottle by indent and he said it would arrive in August.

Dr Jason Teo's dachshund had tick fever recently while he was in Australia, he told me today.
"In many cases, no fever," I said to him.
"Yes, my dog did not have fever. I did 4 blood tests."
"Usually, only anaemia will be the finding," I said.

He could tick fever confirmed by the lab and so now I asked him to use the medicine at correct dose. "Not over the recommended dose," I said. "It can be lethal."
I will see how his dog responds.

A few days ago, I met the "Huggies" girl whose Westie had tick fever and had recovered after treatment and blood transfusion. I remember Huggies. "How many diapers per day for the new born baby to one year old ," I asked. "You were not born when I became a father some 30 years ago."
"8 diapers/day for 6 months."
"How much it would total up?" I asked.

Her dog kept having small ticks every day and so she phoned me for the solution? I advised a tick dip, putting the Westie inside a bath tub. "Wear an e-collar for next few days. Vaccum the flooring or keep the dog in a confined room." Easier said than done. The dog had "hot spots" in the belly and around the neck. So I advised careful use of the tick wash and total clipping of the coat. Eye ointment to protect the eyes during tick dip and antibiotics for the hot spots.

"Baby ticks of small dots come from the floor cracks and surroundings and also from the coat," I said to her. They can't be seen till they reach a certain size. That is why I recommend total clipping of the entire body including the face."

I don't know whether she clipped her dog bald or not. So far, no news from her.    

Tuesday, July 10, 2012

1074. SOP: Tick fever in a Samoyed

Tuesday July 10, 2012, I had a discussion with Video producer Nicole, Dr Daniel, Dr Vanessa and Intern Siti, a 4th year student from Serdang Vet about the diagnosis and treatment of tick fever in dogs, using a real case example referred to me recently but died within 4 hours of arrival. Siti is to present this case in her 5th year and so she was writing up the case. I gave her a day to write the case but she could not do it.

What is tick fever?
What body systems are affected?
When do clinical signs appear from the start of infection?
What should be done to diagnose tick fever is suspected? 

The vet had 3 differential diagnosis - pyometra, tick fever and liver failure. His medication indicated that he was treating for liver failure and had given the owner a poor prognosis.

What is most important question to ask in the history if tick fever is to be diagnosed?

What laboratory tests must be done?

What signficant aspects of the tests must the vet look for?

What is the cause of death in this Samoyed?
An autopsy would be needed but the owner would not want it.
Possible causes:
1. Kidney failure according to one senior vet, based on the 2nd blood test.

AMA - Against medical advice. The vet did record in his case file that the owner did not want a tick-vector test to be done. The vet has given his advice but it is up to the owner to accept his advice as the owner pays for the test.

Follow-up. The vet recorded that he did phone the owner 3 days after treatment. That is good practice, but the owner denied having received any call.
Medical negligence - The burden of proof is on the owner. Was this vet negligent? My answer is no.  

1073. FLUTD and constipation in a cat

Hi Dr Sing, My name is Gary from Vancouver Canada, I really appreciate your blog and it gives me a lot of in depth on animal's medical problems.

I am not sure if you would accept inquiry from general public on Internet, but I would like to give it a try and see if you can drop me a quick notes.

I have a 19 month British shorthair cat. He is male, neutered. As I have learned the hard way, male cats are prong to FLUTD.

Two months ago, he was completely blocked. I took him to local vet here. They unblocked him and put him on prescription diet Hill's S/D for about a month.

He was peeing fine, but the flow was never that strong after catheteration. The doctor prescribe him with some medicine which helps relieve of urethra and it helped him for about a week.

We took him back to the vet for the follow up. He did urine test and found no crystal or inflammation. But around that time, my cat started to dribble during peeing. Doctor did a physical test on his bladder and found it was not big. Therefore we went home and put him on Hill's C/D and monitoring his peeing status. (we gave him more water in the wet foods to increase his water intake)

A week has passed by, he still dribbles. He usually goes into bathroom two to three times and each time takes a long time, it sometimes takes up to 5 minutes, I see urine pass through constantly, but again, it dribbles, not a stream.

We decided to take him to another vet today. This new doctor said his bladder is big, and need to do x-ray and catherteration again. We went ahead with it.

As we discussed about the result of the x-ray, doctor mentioned that he also has constipation problem.

This leads to several of my questions.

1. Ever since my cat got blocked the first time, we fed him prescription diet dry and wet foods with additional water in the wet foods. Why would he get re-blocked and suffer from constipation? I would assume the water intake is enough and it should resolve urethral obstruction and constipation problem

2. what is your opinion on raw foods and all wet foods for cat? From what I read online, it could resolve FLUTD and constipation problem.

3. Would prescription diet such as Hill's c/d and s/d cause constipation? or if doctor prescribe diet to address constipation issue, will it cause future FLUTD again?

4. what is the best diet you would recommend for my cat who suffer from both constipation and FLUTD caused by urethral obstruction?

Thank you in advance for your help. I really hope I can hear back from you. I am just a desperate cat lover who is at loss and seeking help everywhere.

Thank you again and appreciate your time.


Reply Forward

Gary Chen

2:12 AM (4 hours ago)

to me


On Tue, Jul 10, 2012 at 10:05 AM,> wrote:

Thank you for your email. It is extremely difficult to know what causes FLUTD in a male neutered cat. Before answering your questions, I would like to know the following:

1. Results of urinary analysis and X-ray images taken by your two vets will be very useful.

1.1 Did the first vet's urine test show struvite crystals?

1.2 What does the second vet's urine results show? Do you have the results?

1.3 Any blood test results?

2. What type of cat litter you are using and how often you change the litter?

3. Any other cats in the house?

4. Any new events or pets like dogs introduced recently?

5. Constipation. You will know better whether your cat is constipated if you are the one cleaning up his litter. Is he constipated?

Can you provide the info?


Hi Dr. Sing

Thanks for your reply. I am so glad that I can hear from you for 2nd opinion.

I will try my best to answer 1st set of question at this moment, if it's not thorough enough, I will get info my my vet.

1. 1 First vet's first urine test at the time of obstruction, show struvite crystals, therefore he gave him Hill's S/D. After a month on S/D, we went back for 2nd urine test, and the result was negative. but my cat, Maoru, wasn't peeing smoothly

1.2 Maoru is still with the 2nd vet, we will know result of the urine test today or tomorrow

1.3 Blood test was done by first vet, but I could not remember the result. I will have to find out for you

2. Maoru uses human toilet bowl instead of litter box, and we flush right after he uses toilet almost every time.

3. We just lost the other cat last Thursday due to breath arrest.

4. During first obstruction, there was no environment change, but I suspect constipation was a long term issue. Second obstruction slowly getting developed two weeks ago, and we lost our other cat last Thursday

5. yes, He is constipated. he's very inconsistent and irregular. He sometimes goes daily, then we worry less, but he could go every two days or sometimes goes into the third day. His X-ray yesterday did show a lot of feces in his body.