Tuesday, February 26, 2013
Sunday, February 24, 2013
1394. Follow up. Sunday. Cat with bladder stone
Sunday Feb 24, 2013
6.23 pm Yishun public library to type this report
Communications post-op is most important. The cat owner phoned me twice and left his name and phone number. My receptionist reminded me to phone him after my consultations. I was kept busy with the owners of a cat from an American couple regarding removal of the claws, a rat with nasal swelling on the right and a large skin lump on its back and a rabbit from Woodlands for "spay" from a Malay family who had stated incorrectly the gender. Two big terrapins came yesterday for Dr Jason Teo - one would not eat and the other one had puffy eyes and I had them cleaned and given eye drops and bask in the bright morning sunshine. I had to supervise a new vet technician as Mr Min would be moving on to better future after having worked two years with me, increasing his value to the new employer as an experienced vet technician.
Back to the cat with the bladder stones was operated on Thursday, 3 days ago. The owner phoned me yesterday and today to provide me feedback and that was important.
"My cat did not vomit after eating food. He drank a lot, around 375 ml of water and peed a lot," he said. "He laid on his urine and so his surgical wound is very red."
"It is good news that he pees a lot," I said. "This shows that his bladder is normal." I tried not to joke that this showed that his bladder was not leaking after my surgery.
"What should I do to the red area of his wound?" the owner asked.
"It is very difficult for me to know what you are describing," I said. "Was the cat licking the wound since you did mention about taking off the e-collar?"
"No, he is still wearing the e-collar."
Since the owner was working, I suggested that he changed the plaster covering the wound and replace with a new square one. "It could be the blood clot from the skin after stitching," I said. Will wait and see.
It seems that the cat with the renal impairment based on blood tests taken by Vet 2 on Wednesday (4 days ago) is doing well. He did not vomit his food. I asked the owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet yesterday. He has a good maid and with home care, this cat should thrive.
Before I forget, the Thursday surgery in brief is as follows:
ANAESTHESIA
5 kg bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one syringe. Isoflurane gas top up was necessary for a short while. Rectal temperature was 36.8 C after sedation as the cat was angry and we could not want to antagonise him more.
SURGERY to remove bladder stones seen on X-rays taken by Vet 2.
1. Catherise the bladder
2. Withdraw urine for urine analysis
3. Inflate bladder with 40 ml normal saline so that it is palpable.
4. Incise skin and linea alba.
5. Press out the distended bladder.
6. Incise at apex of 8 mm as I know the stone was around this diameter.
7. I insert an artery forceps to grab and take out the stone without making too big a bladder incision.
8. My assistant Min pumps in more normal saline as I closed the wound for a while.
9. 3 small pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and blood.
10. More irrigation of the bladder.
11. I stitched the mucosa 3/0 absorbable - inverting layer
12. I stitched the serosa similarly - another inverting laye.
13. To check leakage, I asked Min to pump in more saline via the catheter to inflate the bladder. No leakage.
14. I put the bladder back into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0 nylon).
14. I put the bladder back.
15. Post-op baytril and tolfedine
16. Cat goes home in the evening as the cat was quite ferocious and nursing at home would be better as the cat would be hand-fed food (K/D) and medication.
Friday - Day 1 after surgery. I phoned the cat owner.
"Vomiting one hour after food and medication," the owner reported as he had given medication on the evening of the surgery. I advised not giving the tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by hand.
Saturday - Day 2 after surgery.
Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due to the high BUN kidney disorders," I said. "That would account for vomiting. Feed less amounts"
Sunday - Day 3 after surgery.
Feedback in above paragraphs. Will need to summarise all later,
Discovered and borrowed two thick books published in 2012 and 2013 from Yishun library.
1. Web Marketing All-in-one for Dummies. 8 books in one.
2. Social Media Marketing All-in-one for Dummies. 9 books in one.
Thick as a bible. No wonder most doctors and vets give them a miss.
6.23 pm Yishun public library to type this report
Communications post-op is most important. The cat owner phoned me twice and left his name and phone number. My receptionist reminded me to phone him after my consultations. I was kept busy with the owners of a cat from an American couple regarding removal of the claws, a rat with nasal swelling on the right and a large skin lump on its back and a rabbit from Woodlands for "spay" from a Malay family who had stated incorrectly the gender. Two big terrapins came yesterday for Dr Jason Teo - one would not eat and the other one had puffy eyes and I had them cleaned and given eye drops and bask in the bright morning sunshine. I had to supervise a new vet technician as Mr Min would be moving on to better future after having worked two years with me, increasing his value to the new employer as an experienced vet technician.
Back to the cat with the bladder stones was operated on Thursday, 3 days ago. The owner phoned me yesterday and today to provide me feedback and that was important.
"My cat did not vomit after eating food. He drank a lot, around 375 ml of water and peed a lot," he said. "He laid on his urine and so his surgical wound is very red."
"It is good news that he pees a lot," I said. "This shows that his bladder is normal." I tried not to joke that this showed that his bladder was not leaking after my surgery.
"What should I do to the red area of his wound?" the owner asked.
"It is very difficult for me to know what you are describing," I said. "Was the cat licking the wound since you did mention about taking off the e-collar?"
"No, he is still wearing the e-collar."
Since the owner was working, I suggested that he changed the plaster covering the wound and replace with a new square one. "It could be the blood clot from the skin after stitching," I said. Will wait and see.
It seems that the cat with the renal impairment based on blood tests taken by Vet 2 on Wednesday (4 days ago) is doing well. He did not vomit his food. I asked the owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet yesterday. He has a good maid and with home care, this cat should thrive.
Before I forget, the Thursday surgery in brief is as follows:
ANAESTHESIA
5 kg bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one syringe. Isoflurane gas top up was necessary for a short while. Rectal temperature was 36.8 C after sedation as the cat was angry and we could not want to antagonise him more.
SURGERY to remove bladder stones seen on X-rays taken by Vet 2.
1. Catherise the bladder
2. Withdraw urine for urine analysis
3. Inflate bladder with 40 ml normal saline so that it is palpable.
4. Incise skin and linea alba.
5. Press out the distended bladder.
6. Incise at apex of 8 mm as I know the stone was around this diameter.
7. I insert an artery forceps to grab and take out the stone without making too big a bladder incision.
8. My assistant Min pumps in more normal saline as I closed the wound for a while.
9. 3 small pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and blood.
10. More irrigation of the bladder.
11. I stitched the mucosa 3/0 absorbable - inverting layer
12. I stitched the serosa similarly - another inverting laye.
13. To check leakage, I asked Min to pump in more saline via the catheter to inflate the bladder. No leakage.
14. I put the bladder back into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0 nylon).
14. I put the bladder back.
15. Post-op baytril and tolfedine
16. Cat goes home in the evening as the cat was quite ferocious and nursing at home would be better as the cat would be hand-fed food (K/D) and medication.
Friday - Day 1 after surgery. I phoned the cat owner.
"Vomiting one hour after food and medication," the owner reported as he had given medication on the evening of the surgery. I advised not giving the tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by hand.
Saturday - Day 2 after surgery.
Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due to the high BUN kidney disorders," I said. "That would account for vomiting. Feed less amounts"
Sunday - Day 3 after surgery.
Feedback in above paragraphs. Will need to summarise all later,
Discovered and borrowed two thick books published in 2012 and 2013 from Yishun library.
1. Web Marketing All-in-one for Dummies. 8 books in one.
2. Social Media Marketing All-in-one for Dummies. 9 books in one.
Thick as a bible. No wonder most doctors and vets give them a miss.
1303. Bladder stone in a 7-year-old cat
Wednesday Feb 20, 2013
"Can you operate today?" the owner of this 7-year-old with a disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me by his vet friend working in Biopolis. I had asked him how he came to know about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is about to open in Singapore.
"I can operate today, but you may have a dead cat at the end of surgery," I showed him the high total white cell count and neutrophils of the cat's blood test taken earlier in the day. "These data showed that the cat has a generalised blood infection of bacteria and is not in a good health state to be under anaesthesia and surgery. He may die on the operating table."
"But Vet 2 told me that my cat is suffering from a serious kidney failure. She said I should operate soon and any delay will result in death." Vet 2's blood test result show BUN as "---", creatinine and phosphorus as exceedingly high. This indicated an acute renal failure.
"It is best to stabilise this cat first," I had read the medical reports and viewed the X-ray. "Was there any antibiotic injection given to the cat? Any fluid therapy? Any urine test? Any fever?"
"I don't think so," the gentleman is typical of the increasingly educated and well informed pet owners in Singapore putting vets on their toes as he would have done his internet research on his pet's urolithiasis with one click of the mouse. "Otherwise my bill will have this item charged. Vet 2 did say that the cat was slightly dehydrated"
The cat was now furious and the owner could not handle him. I did not want to provoke this frightened cat further as the cat would go crazy and very aggressive. I asked the owner to hold and talk to him while I gave the Baytril antibiotic injection SC. I assessed that this cat would not need the fluid therapy as he was drinking and peeing. Only that he was not eating for a few days and the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked him to return again if the cat had not recovered but Vet 1 closed on Wednesday and so he remembered Vet 2's colleague whom he had seen before. Vet 2 told him that she was not sufficiently experienced to operate and her colleague's surgical bookings were full house. So he had to find another vet and that was where his vet friend referred him to me. I don't know this vet friend and so it was a surprise.
The operation would be done the next day. Weighing the cat, taking the rectal temperature and giving SC drip would be out of question as the cat was quite fed up with Vet 2's blood taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had managed well. I presumed she X-rayed first, otherwise it would be very difficult to restrain this little tiger.
Thursday Feb 21, 2013
The main worry was the possibility of death under anaesthesia as this cat was just not fit for surgery based on Vet 2's blood test of a severe kidney disorder. I would say it would be acute nephritis but this cat had no history of vomiting. Would this cat die on the operating table? This was one of those hot potatos vets prefer not to handle as death may result in bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to operate myself under such negative conditions of impending death of a cat. Ideally, the cat should wait 3 or more days before surgery. But the owner was much worried and the kidney disorder may worsen to severe vomiting and death owing to delays. The kidney enzymes were exceedingly high. To wait would be risky as a cat in deteriorating health would die anyway.
So, I was holding the hot potato one way or another. To operate or to wait more than one day.
What safe anaesthesia to give? This is hard to say.
"Can you operate today?" the owner of this 7-year-old with a disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me by his vet friend working in Biopolis. I had asked him how he came to know about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is about to open in Singapore.
"I can operate today, but you may have a dead cat at the end of surgery," I showed him the high total white cell count and neutrophils of the cat's blood test taken earlier in the day. "These data showed that the cat has a generalised blood infection of bacteria and is not in a good health state to be under anaesthesia and surgery. He may die on the operating table."
"But Vet 2 told me that my cat is suffering from a serious kidney failure. She said I should operate soon and any delay will result in death." Vet 2's blood test result show BUN as "---", creatinine and phosphorus as exceedingly high. This indicated an acute renal failure.
"It is best to stabilise this cat first," I had read the medical reports and viewed the X-ray. "Was there any antibiotic injection given to the cat? Any fluid therapy? Any urine test? Any fever?"
"I don't think so," the gentleman is typical of the increasingly educated and well informed pet owners in Singapore putting vets on their toes as he would have done his internet research on his pet's urolithiasis with one click of the mouse. "Otherwise my bill will have this item charged. Vet 2 did say that the cat was slightly dehydrated"
The cat was now furious and the owner could not handle him. I did not want to provoke this frightened cat further as the cat would go crazy and very aggressive. I asked the owner to hold and talk to him while I gave the Baytril antibiotic injection SC. I assessed that this cat would not need the fluid therapy as he was drinking and peeing. Only that he was not eating for a few days and the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked him to return again if the cat had not recovered but Vet 1 closed on Wednesday and so he remembered Vet 2's colleague whom he had seen before. Vet 2 told him that she was not sufficiently experienced to operate and her colleague's surgical bookings were full house. So he had to find another vet and that was where his vet friend referred him to me. I don't know this vet friend and so it was a surprise.
The operation would be done the next day. Weighing the cat, taking the rectal temperature and giving SC drip would be out of question as the cat was quite fed up with Vet 2's blood taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had managed well. I presumed she X-rayed first, otherwise it would be very difficult to restrain this little tiger.
Thursday Feb 21, 2013
The main worry was the possibility of death under anaesthesia as this cat was just not fit for surgery based on Vet 2's blood test of a severe kidney disorder. I would say it would be acute nephritis but this cat had no history of vomiting. Would this cat die on the operating table? This was one of those hot potatos vets prefer not to handle as death may result in bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to operate myself under such negative conditions of impending death of a cat. Ideally, the cat should wait 3 or more days before surgery. But the owner was much worried and the kidney disorder may worsen to severe vomiting and death owing to delays. The kidney enzymes were exceedingly high. To wait would be risky as a cat in deteriorating health would die anyway.
So, I was holding the hot potato one way or another. To operate or to wait more than one day.
What safe anaesthesia to give? This is hard to say.
Friday, February 22, 2013
1301. Update on recurring urate or oxalate urolithiasis
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Wednesday, February 20, 2013
1300. Audit & Trust case follow up: Recurring urolithiasis - Cocker Spaniel
Wed Feb 20, 2013
A review of the case operated by Dr Vanessa twice for oxalate bladder stones in May 2011 and September 2012. I audited the case and on Sep 26, 2012, I asked Dr Vanessa as to what follow up she had done to prevent a 3rd recurrence. She said she had advised U/D and had sms the caclcium oxalate stone analysis results. Many owners will just ignore the advices till another recurrence and another operation or euthanasia of the poor old dog. I took the trouble to write to the owners to let them know the preventive measures as I don't want a recurrence too, although recurrence is in the interest of the practice. An extra effort had to be made to follow up and vets usually don't have the time to do the hard sell of prescription diets in the interest of the canine patient.
The father came to buy 12 cans of U/D again for the cocker spaniel, male, 11 years old today. "How's the dog?" I asked him as he had been feeding this U/D since Oct 5, 2012 when he bought 3 cans and came whenever he ran out of the stock. Seldom do I encounter such a disciplined owner as many Singaporean owners tend to forget about feeding the relevant diet to prevent bladder stone recurrence.
"His body condition is much better compared to previous times when he sheds hair all the time and has dry skin flakes," the father surprised me with this feedback. "I thought it was normal for dogs to shed hairs."
"How do you know this dog sheds hairs previously?" I asked. "Does he drink lots of water?"
"Hairs scatter all over the floor of the apartment and so this shows he has been losing hair. He drinks water too."
This was good news but it is too early to tell whether the dog will have recurrence of bladder stones. The 2nd episode occurred 16 months after the first cystotomy operation to remove the stones. It is only 5 months after the 2nd cystotomy.
From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd oepration, he fed cheap canned food and meat and yet the stones recurred. Now, he is satisfied with the U/D.
PREVENTION MONITORING IS NOT DONE.
Many owners don't know that urine tests and X-rays are still necessary as part of the prevention of recurring urolithiasis as typical in this case. Feeding of prescription diet is just one aspect. Monitoring should be 1-2 months for the first 6 months and thereafter, if negative results, 2-4 monthly. Very rarely do any Singaporean dog owner comply with this advice and there is not much the vet can do.
Monitoring and urine tests which show small stones can easily be treated with a process called urohydropropulsion in which the catheter is inserted into the bladder and the small stones are sucked out easily. These stones are anlaysed in case they are of different composition.
This case shows that the education of the dog owner with recurring urolithiasis is an uphill task and there are so many family members involved. Who in the family will have time to do the 1-2 monthly monitoring? The young ones are busy with their work and personalised life. The older members may not have the motivation to spare the time to get the dog tested.
Today, I reminded the father that he has to send the urine for analysis of crystals. He said: "Yes, you have given me the bottle to collect the urine." There is not much I can do. Urine test will monitor the urine pH, bacteria and other results as well as urine crystals and monthly urine tests will be more economical than another surgery. But Singaporeans seem to be time-pressed and so that is the culture.
P.S Urine tests. Absence of oxalate crystals in the urine doee not mean no oxalate stones as can be seen in the 2 urine tests taken prior to bladder stone removal surgery as follows:
May 24, 2011 Urine pH 7.0, SG 1.028, Blood 4+, WBC 10, RBC >2250, Bacteria 3+, Crystals Calcium oxalate occasional
Aug 28, 2012 Urine pH 7.0, SG 1.029, Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals Nil
From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd oepration, he fed cheap canned food and meat and yet the stones recurred.
A review of the case operated by Dr Vanessa twice for oxalate bladder stones in May 2011 and September 2012. I audited the case and on Sep 26, 2012, I asked Dr Vanessa as to what follow up she had done to prevent a 3rd recurrence. She said she had advised U/D and had sms the caclcium oxalate stone analysis results. Many owners will just ignore the advices till another recurrence and another operation or euthanasia of the poor old dog. I took the trouble to write to the owners to let them know the preventive measures as I don't want a recurrence too, although recurrence is in the interest of the practice. An extra effort had to be made to follow up and vets usually don't have the time to do the hard sell of prescription diets in the interest of the canine patient.
The father came to buy 12 cans of U/D again for the cocker spaniel, male, 11 years old today. "How's the dog?" I asked him as he had been feeding this U/D since Oct 5, 2012 when he bought 3 cans and came whenever he ran out of the stock. Seldom do I encounter such a disciplined owner as many Singaporean owners tend to forget about feeding the relevant diet to prevent bladder stone recurrence.
"His body condition is much better compared to previous times when he sheds hair all the time and has dry skin flakes," the father surprised me with this feedback. "I thought it was normal for dogs to shed hairs."
"How do you know this dog sheds hairs previously?" I asked. "Does he drink lots of water?"
"Hairs scatter all over the floor of the apartment and so this shows he has been losing hair. He drinks water too."
This was good news but it is too early to tell whether the dog will have recurrence of bladder stones. The 2nd episode occurred 16 months after the first cystotomy operation to remove the stones. It is only 5 months after the 2nd cystotomy.
From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd oepration, he fed cheap canned food and meat and yet the stones recurred. Now, he is satisfied with the U/D.
PREVENTION MONITORING IS NOT DONE.
Many owners don't know that urine tests and X-rays are still necessary as part of the prevention of recurring urolithiasis as typical in this case. Feeding of prescription diet is just one aspect. Monitoring should be 1-2 months for the first 6 months and thereafter, if negative results, 2-4 monthly. Very rarely do any Singaporean dog owner comply with this advice and there is not much the vet can do.
Monitoring and urine tests which show small stones can easily be treated with a process called urohydropropulsion in which the catheter is inserted into the bladder and the small stones are sucked out easily. These stones are anlaysed in case they are of different composition.
This case shows that the education of the dog owner with recurring urolithiasis is an uphill task and there are so many family members involved. Who in the family will have time to do the 1-2 monthly monitoring? The young ones are busy with their work and personalised life. The older members may not have the motivation to spare the time to get the dog tested.
Today, I reminded the father that he has to send the urine for analysis of crystals. He said: "Yes, you have given me the bottle to collect the urine." There is not much I can do. Urine test will monitor the urine pH, bacteria and other results as well as urine crystals and monthly urine tests will be more economical than another surgery. But Singaporeans seem to be time-pressed and so that is the culture.
P.S Urine tests. Absence of oxalate crystals in the urine doee not mean no oxalate stones as can be seen in the 2 urine tests taken prior to bladder stone removal surgery as follows:
May 24, 2011 Urine pH 7.0, SG 1.028, Blood 4+, WBC 10, RBC >2250, Bacteria 3+, Crystals Calcium oxalate occasional
Aug 28, 2012 Urine pH 7.0, SG 1.029, Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals Nil
From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd oepration, he fed cheap canned food and meat and yet the stones recurred.
1299. Email advices on toilet training
------------------------------------------------------------------------------------
On Wed, Feb 13, 2013 at 1:20 PM, E@yahoo.com.sg> wrote:
EMAIL REPLY FROM DR SING DATED FEB 16, 2013
Hi, I need your advice.I have a toy poodle, she is spayed and can pee on tray 100%. But when she was 3 years old, I brought home a mini poodle puppy.Since then she refuse to pee on the same tray. I put another tray in another room, she pee on the new tray some times. And rest of the times, she pee on the floor around the tray that the new dog pee.I cant grab her to put her on the tray as she is very aggressive, and growl and bite.I have tried to give her more attention, and also tried to beat her, but she just get worseWhat should I do?Thanks first
EMAIL REPLY FROM DR SING DATED FEB 16, 2013
From: Kong Yuen Sing <99pups@gmail.com>;
To: E@yahoo.com.sg>;
Subject: Re: Need help
Sent: Sat, Feb 16, 2013 11:55:32 PM
Thank you for your email. It is not easy to give advice in your situation of two poodles competing for your attention. Have you tried "positive reinforcement" method of treats and praises for performance? Or the clicker method?
1. Spend time with the old poodle.
2. When she pees on the tray, give her treats and/or praises or bring her for exerciseThis depends which motivates her.
3. Use the old tray which has her urine smell. What happened to it?
4. Neutralise the urine smell on the floor.
5. Confine to small area again as in puppy toilet training.
6. Spay her if relevant.
7. Many weeks and months of positive reinforcement training may be needed to change the behaviour as the dog is an adult and not a puppy with ease of training.
8. Ensure she has no urinary tract infection - check with your vet. Urine test.
9. There may be a need to separate both poodles for some time and to wash your hands when you handle the younger poodle before handling the older one.
10. Pee trays may NEED to be washed frequently if your old poodle is a cleanliness freak and this may be one reason she will not pee on the pee pan but outside the perimeter..
11. Use the commercial pee pads to absorb the urine as a different approach and trial?
The above are some of my suggestions and I don't know whether they will work. Best wishes.
------------------------------------------------------------
On Tue, Feb 19, 2013 at 8:29 PM, E..yahoo.com.sg> wrote:
Hi sorry, need to add. My old poodle is aggressive. Its tough to grab her to bring her to the tray like she was a puppy as she growl n bite. Would you recommend a behavorist to resolve tos aggression?
Sent from Yahoo! Mail on Android
There must be a reason for her aggressive. See your vet for medical problems or a behaviorist.
EMAIL REPLY FROM DR SING DATED FEB 20, 2013
Tuesday, February 19, 2013
1298. The "lau hong" Scottish Terrier
Since adoption in Nov 2011, this Scottish Terrier of 2 years 4 months, male dog had been farting almost daily. I reviewed his case records as he had been to see us for 7 times. The first time was Nov 2011 when he had vomited. In April 2012 he vomited and in Feb 2013 I was the vet attending to his vomiting again. This dog was described as a "habitual scavenger" by my associate. He would eat any food, eat the wooden stair case, lick any floor, drink his own urine and ate his own stools when he was young.
"I call him the 'lau hong' dog", the gentleman owner laughed when I spoke to him by phone on Feb 18, 2013, two days after treatment for vomiting 3 times and telling him that the dog's intestines were full of gas. A state of flatulence which had existed for over 2 weeks, he had said on Feb 16, 2013.
"Does he pass smelly gas?" I asked.
"I don't know as I don't smell it specifically."
"The smell of the gas will let us know what sort of bacteria and damage to the intestines occur," I explained.
"Sometimes, it is smelly. He keeps farting daily."
To the owner, this behaviour is normal. It is actually not normal. He consented to a blood test as he did not want one earlier nor an X-ray. Economics play a big role in heartlander practice.
Blood test revealed a lower than normal white cell count 5.2 (normal 6-17). Elevated PCV at 0.64 would give rise o an increase in RBC 9.4 (5.5-8.5) and haemoglobin 22 (12-18). The liver enzymes SGPT/ALT 119 (<59 0.19="" 10.7="" 472="" acid="" and="" br="" creatinine="" high="" normal.="" sgot="" so="" urea="" uric="" was="" were="">
What do the blood test tell me?
One blood test may not be reliable. It seems there is liver disorder and reduced white cell count. Was there a virus? The dog did not have his yearly vaccination.
What caused so much gas production in the intestines?
"I call him the 'lau hong' dog", the gentleman owner laughed when I spoke to him by phone on Feb 18, 2013, two days after treatment for vomiting 3 times and telling him that the dog's intestines were full of gas. A state of flatulence which had existed for over 2 weeks, he had said on Feb 16, 2013.
"Does he pass smelly gas?" I asked.
"I don't know as I don't smell it specifically."
"The smell of the gas will let us know what sort of bacteria and damage to the intestines occur," I explained.
"Sometimes, it is smelly. He keeps farting daily."
To the owner, this behaviour is normal. It is actually not normal. He consented to a blood test as he did not want one earlier nor an X-ray. Economics play a big role in heartlander practice.
Blood test revealed a lower than normal white cell count 5.2 (normal 6-17). Elevated PCV at 0.64 would give rise o an increase in RBC 9.4 (5.5-8.5) and haemoglobin 22 (12-18). The liver enzymes SGPT/ALT 119 (<59 0.19="" 10.7="" 472="" acid="" and="" br="" creatinine="" high="" normal.="" sgot="" so="" urea="" uric="" was="" were="">
What do the blood test tell me?
One blood test may not be reliable. It seems there is liver disorder and reduced white cell count. Was there a virus? The dog did not have his yearly vaccination.
What caused so much gas production in the intestines?
1297. Resection of a cancerous tumour in a Syrian hamster
On Valentine's Day, Dr Daniel and I operated to remove a huge blackened skin lump of 1.3 x 1.3 x 0.5 cm from the left shoulder of the 2-year-old Syrian hamster.
The ideal way in dogs would be to resect the skin of 1 cm away from the edge of the skin tumour according to the vet book to cut off any spreading cancer cells.
A Syrian hamster's shoulder area is so small. This is not practical as the wound would be so big that the stitching of the wound will not be possible.
In this hamster, the tumour was cut off. The owner did not want it to be sent to the lab for histology. It looked much like a cancerous tumour. Toa Payoh Vets would send it for confirmation.
Test showed it was malignant.
Hamster skin growths need to be removed by the vet when they are small as there is the danger of spreading and insufficient skin to cut off and to stitch up after resection.
Also anaesthesia by gas to top up as the surgery and stitching took some time. How much of gas to give by mask? This is a judgment of the vet.
"Insufficient," Dr Daniel said as he stitched up the wound after I took off the mask after giving a few seconds of 5% isoflurane and the hamster moved a bit.
"Every vet can operate on any size of large skin tumours in the hamster," I told him. "The only difference is which vet can operate such that the hamster survives at the end of the operation." 5% isoflurane is very potent to a hamster. 2 or 3 seconds of smell will do to top up Zoletil sedation which was need in this type of large tumour removal surgery. The hamster had 5 drops Zoletil 50 IM but was still not fully sedated. Hence the isoflurane gas top up. This is where the judgment of the vet comes in. A second more may just kill the hamster unlike that in the dog.
Hence there is a layman's belief that hamsters die on the operating table easily and many vets prefer not to operate but give medication for tumour cases. Medication never works. Anaesthesia may kill. So, many hamster owners wait and wait till there is no choice but to operate. By that time, as in this case, the tumour is massive and not all cancerous cells can be taken out.
I warn the owner that the tumour may recur again as it was not possible to make a big cut and to have sufficient skin to stitch up. The lab report indicated the resection margin had tumour cells and so I expected the tumour to recur.
The ideal way in dogs would be to resect the skin of 1 cm away from the edge of the skin tumour according to the vet book to cut off any spreading cancer cells.
A Syrian hamster's shoulder area is so small. This is not practical as the wound would be so big that the stitching of the wound will not be possible.
In this hamster, the tumour was cut off. The owner did not want it to be sent to the lab for histology. It looked much like a cancerous tumour. Toa Payoh Vets would send it for confirmation.
Test showed it was malignant.
Hamster skin growths need to be removed by the vet when they are small as there is the danger of spreading and insufficient skin to cut off and to stitch up after resection.
Also anaesthesia by gas to top up as the surgery and stitching took some time. How much of gas to give by mask? This is a judgment of the vet.
"Insufficient," Dr Daniel said as he stitched up the wound after I took off the mask after giving a few seconds of 5% isoflurane and the hamster moved a bit.
"Every vet can operate on any size of large skin tumours in the hamster," I told him. "The only difference is which vet can operate such that the hamster survives at the end of the operation." 5% isoflurane is very potent to a hamster. 2 or 3 seconds of smell will do to top up Zoletil sedation which was need in this type of large tumour removal surgery. The hamster had 5 drops Zoletil 50 IM but was still not fully sedated. Hence the isoflurane gas top up. This is where the judgment of the vet comes in. A second more may just kill the hamster unlike that in the dog.
Hence there is a layman's belief that hamsters die on the operating table easily and many vets prefer not to operate but give medication for tumour cases. Medication never works. Anaesthesia may kill. So, many hamster owners wait and wait till there is no choice but to operate. By that time, as in this case, the tumour is massive and not all cancerous cells can be taken out.
I warn the owner that the tumour may recur again as it was not possible to make a big cut and to have sufficient skin to stitch up. The lab report indicated the resection margin had tumour cells and so I expected the tumour to recur.
1296. Blank CD of digital X-ray
Yesterday, Feb 18, 2013 I brought a Jack Russell to a clinic for X-ray. The owner brought the dog in saying to Dr Daniel and I: "I heard a crutch....crutch...crutch...sound and this dog was under my car. If his injuries are too severe, put him to sleep."
"The dog must have slept under the car," I said.
"My SUV car has a high floor and he could be running under the wheels."
The dog was standing but limping on the right hind limb. Dr Daniel put the dog his left side on the examination table and gently palpated the right foot and lower limb. There was no pain reaction. I was beside him and so I flexed the right hip. The dog yelped. So there was intense pain and some swelling in the hip area.
Dr Daniel said: "There are muscle tremors in the right hip area" meaning that the car trauma would be in that area rather than the foot.
Was there a hip fracture? However, the dog looked
I had known this gentleman for over 20 years and though he can well afford any veterinary expenses, I know sometimes he will not want to pay and so I said: "If you want to want to save money, wait till tomorrow while we give the pain-killers." He was undecided. If the dog has a serious injury, then he would euthanase her.
So Dr Daniel decided on 3 X-rays - the abdomen one view and the hips 2 views. The storm clouds were gathering this afternoon. But I took the dog inside the crate to this clinic for the X-rays. The male vet was busy talking to a client and I said hello to him. Another vet attended to another client who wanted to borrow the "wheel chair" for his paralysed lame dog. The principal vet was busy consulting with clients. It seemed to be a bustling clinic in this stormy afternoon with a government department warning of flash floods.
So, I did not bother them. After the X-ray, I waited a while for the drizzle to stop and read a Pets' Magazine. A slim frontline girl in light yellow uniform asked me whether I wanted an umbrella. I said yes and she gave me one. I took the dog out. Another staff (a volunteer) in greyish blue uniform was behind me and helped to open my car door so I could put the dog crate in. Service from the front-line staff was excellent in this clinic. As there was a "We reserve the right not to serve you" notice on the lower front of the receptionist table, I did not make any conversation with the staff. In case of misunderstanding? Actually they were too busy to make idle conversation too. Once I got into the car, the storm clouds burst.
On returning to Toa Payoh Vets, Intern Ms Toh came out to take the crate and the CD of the X-ray. "This CD is blank," Dr Daniel said to me. I was much amazed as this had not happened before. How did it happen? I don't know. Dr Daniel phoned the clinic to ask for the email copy. I answered the phone when the clinic called. The staff manning the phone said: "You will have to wait a while for us to email to Dr Daniel. The vets are busy."
Cock ups do happen in the service industry. It is one of those surprises in life. This must be a rare occurrence.
"The dog must have slept under the car," I said.
"My SUV car has a high floor and he could be running under the wheels."
The dog was standing but limping on the right hind limb. Dr Daniel put the dog his left side on the examination table and gently palpated the right foot and lower limb. There was no pain reaction. I was beside him and so I flexed the right hip. The dog yelped. So there was intense pain and some swelling in the hip area.
Dr Daniel said: "There are muscle tremors in the right hip area" meaning that the car trauma would be in that area rather than the foot.
Was there a hip fracture? However, the dog looked
I had known this gentleman for over 20 years and though he can well afford any veterinary expenses, I know sometimes he will not want to pay and so I said: "If you want to want to save money, wait till tomorrow while we give the pain-killers." He was undecided. If the dog has a serious injury, then he would euthanase her.
So Dr Daniel decided on 3 X-rays - the abdomen one view and the hips 2 views. The storm clouds were gathering this afternoon. But I took the dog inside the crate to this clinic for the X-rays. The male vet was busy talking to a client and I said hello to him. Another vet attended to another client who wanted to borrow the "wheel chair" for his paralysed lame dog. The principal vet was busy consulting with clients. It seemed to be a bustling clinic in this stormy afternoon with a government department warning of flash floods.
So, I did not bother them. After the X-ray, I waited a while for the drizzle to stop and read a Pets' Magazine. A slim frontline girl in light yellow uniform asked me whether I wanted an umbrella. I said yes and she gave me one. I took the dog out. Another staff (a volunteer) in greyish blue uniform was behind me and helped to open my car door so I could put the dog crate in. Service from the front-line staff was excellent in this clinic. As there was a "We reserve the right not to serve you" notice on the lower front of the receptionist table, I did not make any conversation with the staff. In case of misunderstanding? Actually they were too busy to make idle conversation too. Once I got into the car, the storm clouds burst.
On returning to Toa Payoh Vets, Intern Ms Toh came out to take the crate and the CD of the X-ray. "This CD is blank," Dr Daniel said to me. I was much amazed as this had not happened before. How did it happen? I don't know. Dr Daniel phoned the clinic to ask for the email copy. I answered the phone when the clinic called. The staff manning the phone said: "You will have to wait a while for us to email to Dr Daniel. The vets are busy."
Cock ups do happen in the service industry. It is one of those surprises in life. This must be a rare occurrence.
Monday, February 18, 2013
1295. Porto-systemic shunt in a young dog?
Feb 18, 2013
I note that many young vets who have grown up in an era of abundance don't have much spare time for more detailed research as they have their own hobbies and friends who want to go on vacations and spend late nights networking. The start up of their new clinics are paid for by benefactors and not from their sweat and tears.
However, research needs to be done if they want to excel in their profession and gain a solid reputation for being good at diagnosis and treatment. There is no short cut to veerinary excellence and the necessary sacrifices of hours must be spent in doing reading and reviewing challenging cases.
One example of a challenging cases I encountered was this very thin Maltese puppy who barked a lot, mostly at night and liked to lick objects and things. "He barks mostly at night because we don't permit him to enter our bedroom," the young lady side of a couple said to me. "My dad has to work overnight shifts and gets disturbed."
"Why don't you cage him at night and put him in the kitchen?" I said.
"He still barks."
So there was no solution.
"He has another problem. He will like all foreign objects and things and would vomit hairs! Can we muzzle him the whole day long?"
"Dogs need to breathe through panting and muzzling for a long time may kill them," I said. So there was no solution.
"He also urine marks all over the apartment," the lady said.
"Neuter him early," I said. "It will reduce his dominant personality. You will note that he is a dominant male and has no respect for female family members."
"You are quite correct," the young man confirmed. "He only listens to me if I am around."
"This dog is very thin, as if he has not been fed much," I said. "Or is there something wrong with his health? I advise a health screening blood test to check the liver and kidney functions as well as the blood system."
A blood test was agreed. The results show liver disorders in that ALT/SGPT = 294 (normal <59 0.02="" 262="" 6.8="" acid="" and="" ast="" at="" high="" nbsp="" normal="" slightly="" urea="" uric="" was="">and creatinine was low at 82 (normal 89-177).
Haemoglobin was high at 19.6 (normal = 12-18).
The main disorder was the high liver enzymes. Uric acid is normal. Serum urea is slightly high. Is there an early onset of a porto-systemic shunt or not? Congential liver disease? Liver damage due to licking of floors and objects getting poisoned?
I phoned the owner for a urine test to check for urate crystalluria. Due to economics, I did not ask earlier. Will need to follow up on this case.
I note that many young vets who have grown up in an era of abundance don't have much spare time for more detailed research as they have their own hobbies and friends who want to go on vacations and spend late nights networking. The start up of their new clinics are paid for by benefactors and not from their sweat and tears.
However, research needs to be done if they want to excel in their profession and gain a solid reputation for being good at diagnosis and treatment. There is no short cut to veerinary excellence and the necessary sacrifices of hours must be spent in doing reading and reviewing challenging cases.
One example of a challenging cases I encountered was this very thin Maltese puppy who barked a lot, mostly at night and liked to lick objects and things. "He barks mostly at night because we don't permit him to enter our bedroom," the young lady side of a couple said to me. "My dad has to work overnight shifts and gets disturbed."
"Why don't you cage him at night and put him in the kitchen?" I said.
"He still barks."
So there was no solution.
"He has another problem. He will like all foreign objects and things and would vomit hairs! Can we muzzle him the whole day long?"
"Dogs need to breathe through panting and muzzling for a long time may kill them," I said. So there was no solution.
"He also urine marks all over the apartment," the lady said.
"Neuter him early," I said. "It will reduce his dominant personality. You will note that he is a dominant male and has no respect for female family members."
"You are quite correct," the young man confirmed. "He only listens to me if I am around."
"This dog is very thin, as if he has not been fed much," I said. "Or is there something wrong with his health? I advise a health screening blood test to check the liver and kidney functions as well as the blood system."
A blood test was agreed. The results show liver disorders in that ALT/SGPT = 294 (normal <59 0.02="" 262="" 6.8="" acid="" and="" ast="" at="" high="" nbsp="" normal="" slightly="" urea="" uric="" was="">and creatinine was low at 82 (normal 89-177).
Haemoglobin was high at 19.6 (normal = 12-18).
The main disorder was the high liver enzymes. Uric acid is normal. Serum urea is slightly high. Is there an early onset of a porto-systemic shunt or not? Congential liver disease? Liver damage due to licking of floors and objects getting poisoned?
I phoned the owner for a urine test to check for urate crystalluria. Due to economics, I did not ask earlier. Will need to follow up on this case.
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