3-year-old Pug with difficulty urinating

INTERESTING CASES ON WEDNESDAY JAN 26, 2011


I asked intern, Michelle to write down the following rather than being an observer. She has just completed her A levels and is waiting for the A-level results and wants to study vet medicine. So, I spent some time on this case with her to make vet medicine alive for her when I am free as she does not really benefit from case studies as she is not in Vet course yet.

The Pug had a complaint as follows:
Not able to pee normally for past 2 days. "But he pees normally at one big lot yesterday," the lady who loves pugs wanted to consult me as she had a black pug seen by me some 18 years ago. The black pug had passed away from old age and she never had such problems for the 3 pugs she had. Now, this pug that does not look like a "pug" because he had a longer body and not broad chested had dysuria (difficulty in urination). He had been operated on by an expensive vet one year ago ($2,000 for the whole urinary stone surgery case etc).

"The vet removed the kidney stones," the lady told me but had no medical records from the vet.

"Are you sure it is kidney stones?" I asked her as she was satisfied that the dog had recovered and that was what mattered. The dog had been on S/D diet for one month and C/D diet for 3 months. Then only home-cooked food for the last 8 months. Dysuria occurred 2 days ago. So she consulted me as she surfed the internet.

I was in charge of this case working closely with my associate Dr Vanessa Lin.

PALPATION OF BLADDER, URINE TEST AND BLOOD TEST
1. Empty bladder. So, I asked the owner to let me keep the dog till his bladder is full and I can collect urine for analysis of urinary stones and crystals as well as other tests. There is no point catheterisation at this stage to collect urine as the bladder was emptied recently. Blood was taken. An IV drip was given to get some urine produced.

2. URETHRAL OBSTRUCTION
Dr Vanessa told me that the catheter could not be passed through for more than 10 cm, i.e.. beyond the os penis. I advised X-ray and a spasmogesic injection to be given to relax the bladder muscles. She gave the spasmogesic injection and did the X-ray before 5 pm. She used a smaller hard-catheter and could get the urine out (around 20 ml in a collection bottle) for laboratory analysis.

I checked the pug at 6 pm with the owner who came to visit. The pug was put on the floor. He was very happy. He lifted his leg and peed around 20 ml of dark brown urine. The nurse matron apologised but I said it was OK and a common incident. The intern mopped away the urine.

The following is Michelle's case report is as follows:

3) Pug with difficulty urinating

Catheter could not go through; obstruction in the urinary tract; small bladder stone detected using x-ray

Urinated at 6.30pm; dipstick test:

pH 7.0

WBC 1.00+

Blood ±

Colour of urine: orange-yellow

Protein 2.00+

Specific gravity: 1.015


"The dipstick results are not as accurate as urine analysis," I told Michelle. "The urine test report will be in tomorrow and compare the results."

ADVICE FROM DR SING
Each vet has his or her own method of treatment. For me, the diagnosis is urethral obstruction behind the os penis (based on catherisation mainly). "The X-ray showed some opaque sand behind the os penis," I said to the owner. "What happens is that it causes pain and so the dog has dysuria. After the pain subsided, the sand particles go back to the bladder and so the dog could pee a large amount of urine at one go. Till the next episode."

"What is the treatment?" the lady asked me. "The dog can't be peeing with difficulty now and then."

"Be patient," I said. I advised a low dose of prednisolone and let Dr Vanessa Lin know about this approach. Pred brings down inflammation and let the sand particles be passed out. This is my rationale for the treatment but each vet will have his or her own approach.

Antibiotics for the next 2 days. The dog would drink water and urohydropropulsion can be used to flush out the sand particles. This would be tried first before another bladder surgery which the owner was not keen to do. This case may not need the bladder surgery but the owner must be patient for dietary and medical treatment. This is where many owners want fast results. Bladder surgery would resolve the problem fast but there is the owner's wish not to have it. It would not cost her $2,000 but economics do play a great part for the owner.

This is Day 1. The pug had passed urine at 6.30 pm with some difficulty (leg held up for more than 60 seconds). Will wait and see.

Dr Vanessa phoned the previous vet and was told that the urinary stone removed was 95% struvite. As every urinary case is different and every vet has his or her approach, my management of this case may differ from that of my associate vet. The urinary pH on dipstick is 7.0. So, a vet could argue that the urine is not alkaline. Struvites stone form in alkaline ph but a pH 7.0 on urine dipstick shows neutral pH.

Dietary and medical management, instead of surgery may be possible. Will update when urine test pH and crystal results come in today.

313. Exporting dogs to Australia (continued)

1. E-MAIL TO DR SING DATED JAN 13, 2011

Hello Dr Sing,

I just brought my pets to a Malaysian government clinic to get samples
of their blood.

At first, I was told that I could do the RNATT at this Shah Alam clinic
but when I called the second time to confirm, the person on the phone
told me it is not possible.

I was told people usually send the blood serum to the UK for testing
because it is cheaper and also because Australia does not approve of any
lab in Malaysia.

I sent an email to the AQIS department of Australia to find out where I
could send my dog's blood serum for testing and they gave me this
address in Singapore!

Veterinary Laboratory Branch
Animal & Plant Health Inspection Division
Primary Production Department
Central Veterinary Laboratory
13 Jalan Seranggong Kechil
Singapore
Telephone: 46 1867 4000
Fax: 46 1830 9162

Have you heard of this laboratory in Singapore? I will call them next
week to find out more about them and whether I can take my dog's blood
serum to them for testing.

If you look at the Australian rates for the Ehrlichiosis, Brucellosis,
Leptospirosis and Leishmaniosis tests, it is quite a rip off and I hope
I can get my tests done in Singapore.

http://www.csiro.au/resources/ps7p.html

Sincerely,
XXX


COPY OF REPLY FROM AUSTRALIA TO XXX



Dear XXX,



Thank you for your email regarding approved laboratories in Malaysia.



Unfortunately AQIS has not approved any laboratories in Malaysia and we
recommend sending the blood samples to one of the following:



Veterinary Laboratory Branch

Animal & Plant Health Inspection Division

Primary Production Department

Central Veterinary Laboratory

13 Jalan Seranggong Kechil

Singapore

Telephone: 46 1867 4000

Fax: 46 1830 9162



Alternatively, you can send samples to the Australian Animal Health
Laboratory (AAHL) at:



Dr Stephen Prowse

Acting Director, AAHL

CSIRO Livestock Industries

Australian Animal Health Laboratory

Private Bag 24

Geelong VIC 3220

Australia

Phone: +61 3 5227 5000

Fax: +61 3 5227 5555

E-mail: _AAHL-Reception@csiro.au _

Web:http://www.csiro.au/places/aahl.html

Web page for import/ export blood
testing:http://www.csiro.au/services/ps62.html



Please contact AAHL regarding the box to store your pets' serum in.



I hope this is of assistance,



*Sarah Nash*

*Live Animal Imports
Australian Quarantine and Inspection Service – AQIS
Biosecurity Services Group - BSG
Department of Agriculture, Fisheries & Forestry – DAFF*

Phone: +61 2 6272 4454
Fax: +61 2 6272 3110
Email:animalimp@aqis.gov.au



*From:XXX
*Sent:* Wednesday, 12 January 2011 1:36 AM
*To:* DAFF Public Relations
*Subject:* Ehrlichiosis, External Parasites , Brucellosis, Leptospirosis
and Leishmaniosis Tests - A message from the DAFF website feedback form


*Subject*: Ehrlichiosis, External Parasites , Brucellosis,
Leptospirosis and Leishmaniosis Tests

*Page*:
http://www.daff.gov.au/aqis/cat-dogs/countries/cat4/info-pack-4#12

*Comments*: Good day, I will be importing a dog from Malaysia to
Australia some time this year. Could you let me know the exact
laboratory that I need to send my dog's blood serum for the
Ehrlichiosis, External Parasites , Brucellosis, Leptospirosis and
Leishmaniosis tests? I was at a government vet yesterday to collect
blood samples from my dog so that I can send them to a lab in the UK for
the RNATT test. According to the vet's assistant, it seems like Malaysia
does not have the facilities to do the required tests. I was also told
that I need to purchase a special box to store my pets' serum when I
send them to Australia for testing. I would appreciate it if someone
could point in me in the right direction even though I have to wait
about 150 more days before I can take my pets into Australia. Sincerely,



E-MAIL REPLY FROM DR SING DATED JAN 14, 2011

Lab in Singapore is an approved lab. It is a government lab and therefore trusted by the Australian government. You need to find out exactly what this lab needs and whether they will accept your blood samples from Malaysia.

Also, proper storage conditions and sampling are needed to be done. Otherwise you waste money sending blood samples which are rejected as being "not suitable for testing".


E-MAIL FROM XXX TO DR SING DATED JAN 25, 2011


I have about 140 days before I can move my pets to Australia because
they only accept animals with a valid RNATT result, 150 days from the
date of the blood sample.

I hope the Singapore lab will be easier to deal with.

E-MAIL REPLY FROM DR SING DATED JAN 25, 2011

Lab in Singapore is an approved lab. It is a government lab and therefore trusted by the Australian government. You need to find out exactly what this lab needs and whether they will accept your blood samples from Malaysia.

Also, proper storage conditions and sampling are needed to be done. Otherwise you waste money sending blood samples which are rejected as being "not suitable for testing".

312. Exporting dogs to Australia from Singapore/Malaysia

There are many procedures needed to export dogs to Australia as evident from the following difficulties encountered by a dog lover:


Hello Dr Sing,

I just brought my pets to a Malaysian government clinic to get samples
of their blood.

At first, I was told that I could do the RNATT at this Shah Alam clinic
but when I called the second time to confirm, the person on the phone
told me it is not possible.

I was told people usually send the blood serum to the UK for testing
because it is cheaper and also because Australia does not approve of any
lab in Malaysia.

I sent an email to the AQIS department of Australia to find out where I
could send my dog's blood serum for testing and they gave me this
address in Singapore!

Veterinary Laboratory Branch
Animal & Plant Health Inspection Division
Primary Production Department
Central Veterinary Laboratory
13 Jalan Seranggong Kechil
Singapore
Telephone: 46 1867 4000
Fax: 46 1830 9162

Have you heard of this laboratory in Singapore? I will call them next
week to find out more about them and whether I can take my dog's blood
serum to them for testing.

If you look at the Australian rates for the Ehrlichiosis, Brucellosis,
Leptospirosis and Leishmaniosis tests, it is quite a rip off and I hope
I can get my tests done in Singapore.

http://www.csiro.au/resources/ps7p.html

Sincerely,

311. Be hands on and learn from mistakes in video production

On Fri Jan 21, 2011, I was happy to meet the ex-intern who completed her first year of vet studies at Sydney Univ. She had done a video of pyometra for me and so she did contribute to the company and that was good.

She presented me a "Soo Kee" jewellery paper bag with a yellow ribbon. So I thought I must have got a present of diamonds or gold.
"Can I open it?" I asked her. "Thank you for the jewellery".
"The bag is nice and so I used it. It is nouggats from Australia."
I was just jesting with her.


"Did you score high distinctions in all subjects?" I asked.
"No," she said. "There are so many topics to study and learn."
"I hope you don't have to re-sit papers," I said.
"No," she replied.
"That's good. It seems to me that a student whose parents save and sacrifice their personal pleasures to send a child overseas should not fail in exams. What topics will you be studying in 2nd year?"
"I have not checked the syllabus," she smiled.
It would be new subjects and I am sure she would be doing well.
"Well, don't spend too much time on online farmville, as I noted from your Facebook," I said. "Time is better spent doing some reading or acquiring new skills like improving your video skills with better software. The one you did for me was using plain software which could not be used to vary font size or change font types."
She would be doing another video educational project for me. "Do it," I said. "There will be mistakes made. This hands-on experience makes you learn and be better at documentary production. There is no other way to learn except to do it."

310. 24-hour service by a competitor

Wed Jan 20, 2011

I got a phone call from the 72-year-old man. He said: "You got big competition. A new vet opens 24 hours. Did you read the Straits Times today - half a page of advertisement?"

"No, I did not read the newspapers," I said. "There will always be competition," I said. "Younger vets open their own. There are more than 40 vet practices in Singapore now."

Much success depends on whether the vet can provide satisfactory outcomes to the owners at affordabale prices. There is a vet who tereats high end clients and difficult eye and spinal cases. He is said to be quite busy.

A painter is angry at the vet

The painter introduced herself when she saw me taking pictures of lotus flowers as I practised my photography of flowers and compostion. She lamented that she had not brought her camera. I offered to let her take some pictures and would send them to her in a CD later.

As she discovered that I am a vet, she started to say: "My vet is money-faced (or some expressions to that effect). She ought to have put the cat to sleep. All white gums. My cat was dying. He had the human equivalent of HIV. It is called FIV. Yet my vet went on a rescue mission and charged me a lot of money."

"How old is the cat? Did you tell her to put the cat to sleep?" I asked.
"4 years old. The vet should know that there was no hope in FIV. I don't buy animals. I adopt them. Now, this cat was already diagnosed as having FIV."
"Did you really instruct her not to treat but put the cat to sleep as there was no hope?"
"I did."
"How much were you charged?"
"$500."
I asked: "What does it include?"
"Treatment and some form of cremation."
"The charges are reasonable to me," I said.


Her point was that no treatment ought to be given. Just advise euthanasia. Or let her know the total costs of survival treatment.
For cats with poor prognosis, I would normally be brutally frank about the economics of treatment. In this case, the painter suffered an allergic reaction (numb lips etc) and was warded in the human hospital. She phoned this vet about antibiotics given to the cat. She thought it was tetracycline and was then not sure.

"So difficult to extract info from her," she complained. Fortunately she survived.

Last week, an aunty of a niece with a young guinea pig passing blood phoned me to say I ought to advise euthanasia. "I can see that the guinea pig is brain dead similar to what happens to people." The guinea pig had recovered from the bloody diarrhoea and was at home on medication and electrolytes. The niece was to nurse it and was told that the prognosis was very poor. Yet, the aunty interferred by saying that I should advise the niece to get rid of this guinea pig as it had no chances of survival. It is hard to say in this case as this guinea pig was young. As vets, we try to save lives. "Put to sleep" advices are not to be given lightly. Except in recurring FIV cases in cats. Talk about costs to the owner.

Giving back to society

Tues Jan 18, 2011

I was surprised that this successful Myanmar accountant of around 40 years of age gave back to his community by building a school in a very remote rural area 4 hours by car, boat and motor-bike from Yangon. He donated some $30,000 to build the school.

I asked for pictures and he showed me the primary school. The school desks would be of antique value. They were wooden and I believed I saw them some 50 years ago in Singapore when I started Primary School!

There are other Myanmar doing their bit for fund raising but this is the first one who does build a school and maintains it. He showed me a picture of a golden plaque in memory of a Japanese man who built another school nearby. This Japanese man is around my age of 60 years but has passed away.

After building, the school will be handed to the Ministry of Education. "How do you know money and things donated to the school is really given to the children?" I asked him.

"The volunteers bring themselves and give directly."
"Who are the volunteers?" I asked.
"They are the people in the movie industry," he said.
In March, I will be arranging a trip to this place to help out or donate educational materials.

Any readers interested, please e-mail judy@designtravelpl.com

307. Hamster loses weight after abscess treatment - email advices

E-MAIL TO DR SING DATED JAN 19, 2011

Good morning!

I have a worrying situation here.. :(

My 19 months Syrian had his abscesses drained out on Sunday ( 16 Jan ). The vet at Vet XXX discovered some dry blood on his upper chest. When they press it, there are pus. So they drained it out and put some gel on it so that bacteria will not go in the wound. The funny thing is that my hamster stay alone.I dont understand how he can get hurt coz when i checked the website, it was stated that "abscesses occur when a bite, scratch or wound become infected". Maybe he hurt himself while running around freely in my living room when I give him playtime?? I never know... :(

Anyway, the vet drained the pus off and I have been going to the vet since Mon daily to have his wound clean up. I also have been giving him benepac (probiotic ) and a drop of baytril daily.

The problem is his weight was 164g on 9 Jan 2011 and it dropped to 154g on 16 Jan 2011 ! yesterday, I weight him and he is 153g !! I am so worry about his weight lost...
Other then that, he is fine. He still play on this wheel, climbing the cage etc....

I noticed that he is not eating much. He is on soft diet ( such as mashed sweet potatoes, eggs, coconuts , organic baby cereal etc ) since June 2010 as he doesnt have his upper teeth ( which required me to bring him to the vet at least once 7-10 days for his teeth trimming too.. haiz...

What shall I do? Is he in pain and that's why he doesnt have any appetite?

Thank you.

Yours sincerely
Name of Owner

EMAIL REPLY FROM DR SING DATED JAN 19, 2011

Weight loss is serious if it continues. If the hamster is not having good appetite after abscess drainage, there may still be residual abscess and bacterial infections. As each vet has his or her own method of treatment of abscesses and I have NOT seen the hamster and therefore is speculating that the infection is still there. Depending on the size and extent, some large abscesses need more than one surgical drainage.

You may need to give his hamster pellets and seeds and electrolytes (mashed food) and syringe feed every 2 hours 6x/day in small amounts for the next few days. Review with your vet again your concern. Diagnosis and advice by e-mail is never good nor accurate.

306, Divine play on the vet? puppy eyelid granulomas

If you believe in Divine Powers playing fun and games with vets, this case must surely be one of them.

The puppy was purchased with no obvious eyelid growths. Then the puppy started rubbing her eyes all day long as 3 large eyelid growths appear. Why? There is no rational explanation. Tearing stained the left lower eyelid.

Electro-excision is the cure. As the puppy is a high anaesthetic risk, two vets prescribe eye drops. Vets seldom do anaesthesia in puppies, not even once a week, as there are usually no indications. The same applies to Toa Payoh Vets and I am sure for the other 40 veterinary practices.

But these eye drops would not reduce the large inflamed granulomas and will not resolve the puppy's problem of itchy eyelids and continuous scratching. A puppy in distress worries the owner as a puppy can easily die if not treated. What to do?

"Give an eye ointment and ask her to come back one month later," my assistant suggested. I said: "The lady had seen two vets and had got an eye drop. This growths need to be cut off. Preferably by electro-excision. However, the puppy may die under anaesthesia and then we get a big problem. Some owners demand compensation. New puppy deaths are extremely emotional and unpleasant."

I did not further stress the lady by requiring her to sign the consent form for anaesthesia as I noted that she had many questions with no answers from the vet. Why did the eyelid growths occur? What is the cause? Will a new eye drop work? What is the best drug? Why is the paw itchy? For the paw itchiness, I could tell her the cause was ringworm. Will the itchiness disappear with this Surolan ear drops given by Vet 2?

So, I used electro-surgery, a bit of Zoletil IV and isoflurane gas to excise 3 eyelid granulomas (histological confirmation). Then 7 days later, the owner returned. "The puppy is still scratching the eye (despite wearing an e-collar). I found a tick in the face." Therefore the tick must be from the vet. It was likely but it is hard to prove its origins. So I said: "It is possible that the tick came from the grooming as the puppy was clipped bald all over."









"What to do with the open wound? One stitch had come off," the owner pointed to the medial canthus (see picture). The correct method would be to re-stitch under anaesthesia. But that would mean another risk to be taken. Eye drops again? It would not help. I noted a 4th eyelid swelling on the upper eyelid to the right of the previous one. "There is a 4th eyelid growth," I said. "It is best to remove it as it may be the cause of eye rubbing."

This time, I just gave isoflurane gas and excised the big granuloma. Stitching should be from muscle to upper eyelid edge rather than lower eyelid edge to upper eyelid edge to prevent ectropion. The puppy went home with no complaints for the next 10 days. I hope all would be well.

Through my 30 years of small animal practice, I had not encountered this problem in such a young puppy. So, was it Divine play? It is hard to say. I doubt other vets all over the world encounter such a problem. The eyelid granulomas appear some days after purchase, as if by magic.

The 72-year-old man didn't give a damn about Datuks.

Ben is a 72-year-old man and had been in the pharmaceutical business for a very long time. He met an Indonesian Chinese who was very poor but is now worth over $700 million.

This contact bought a Singapore hotel for $35 million. "He just paid $4.5million for a Singapore apartment," Ben said to me as I picked him up from his house to visit the hotel to have lunch with the General Manager. "Everybody talked to him with respect, addressing him as Datuk but I don't give a damn," he said to me.

I had asked Ben whether he could refer a hotel with 30 rooms for 60 people from Myanmar performing in Singapore on Feb 3 and 4 (Chinese New Year). So he recommended this hotel which is 3-star and therefore affordable. At the same time, he would introduce me to the GM and all senior officers there. "The owner is my friend," he said. "Very smart and suspicious. He thought I was getting a commission or fooling around when I told him about 30 rooms requested by you."

"When people are so rich, they have to be suspicious. Everybody wants their money." The man had money embezzled by his staff before. If they have to remain rich, they have to be smart too.

At the lunch meeting, the GM of the hotel was very friendly. "Did the boss call about my request for 30 rooms?" Ben asked him. "Yes," he said. This showed that a rich business man can be rich because he personally is on top of things. 

Ben said: "He picked the furniture for the hotel by buying them himself." In this way, nobody could cheat him. No wonder he is rich. How did he become rich? Producing medicine in a factory in Indonesia. As for Ben, he sells raw materials to him and so is just comfortable.

"Do you want to attend the AA seminar on what to do when your car has an accident," Ben asked me. I should be less brutally honest but I said: "Don't waste my time!" Ben was shocked. "Well," I said. "If it was a fashion model show, I will go. What is there to learn from AA about car accidents?"

Ben was also not pleased with me when he declared to everyone at lunch that he bought two bags of rice and eggs (banned by the AVA, he pointed to me as if I was AVA vet controlling the import of food from overseas) from Johor. He said: "People say Johor is dangerous. Robbery. But I have not encountered any incident."

"Do you drive a Mercedes to Johor?" I asked him. 

"So you say to everyone that I have no Mercedes," Ben replied. "That I can't afford a Mercedes?"
"You say so yourself," I said. "I am sure you can afford a Mercedes. But it is a very common car in Singapore. I think you will own a Bentley like S.L Liem who was a big racehorse owner in Singapore many years ago when I was a horse vet. His driver drove him to the Turf Club in a Bentley or some rare luxury car."

Ben corrected me and gave the proper name of this rich Indonesian Chinese. It was a fun lunch. The GM was a very busy man with hotel occupancy 100%. "A 3-star hotel is affordable for many people, he said. "There are not many in Singapore as demand exceeds supply. So, no 30 rooms for you now. A 4-star is neither here nor there as its rates are unaffordable for this niche of tourist. Yet its standard not as high as 5-star." He recommended that I open a one-stop spa. Well, it was a good lunch. The GM would not permit me to pay for it. The 72-year-old man got me a free parking ticket from the hotel's sales manager as I had parked in the hotel.

"Use my card first," he said to me. He had an old card which I told him would have an expiry limit. He would not believe me. So I used his card. "Card expired," the machine said. The hotel guard came over, over-rode the machine and we left. I had told him so. He was born in 1932 and disliked all new technologies like facebook, blog, newer phone models. I can't blame him. There is so much to learn.