1380. Update: The cat with the bladder stones over 50 days after surgery

TOA PAYOH VETS toapayohvets.com Date: 21 April, 2013 Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits Case 1: A cat has bladder stones Case 2: A cat could not pee Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate: 21 April, 2013 toapayohvets.com Be Kind To Pets Veterinary Education Project 2010-0129 Case 1: A CAT HAS BLADDER STONES 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. "---" denotes that the value is too high to be read. 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 furiously hissing 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 whom he had consulted before. Vet 2 told him that she was not sufficiently experienced to operate and her senior vet's surgical bookings were full house. So he had to find another vet. He phoned his vet friend who works at the Biopolis. She referred him to me. I don't know this vet friend and so it was a great 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. 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 potatoes 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 so that the feline patient is delivered alive to the owner? A surgeon must deliver. A cat alive at the end of surgery. No excuses. 1394. Follow up. Sunday. Cat with bladder stone 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 layer. 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. Blood Test showed high total white cell count. X-ray showed >1bladder stones 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 Feb 24, 2013 - Day 3 after surgery. 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 operated 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. Day 7 after surgery. Feb 27, 2013 - I phoned the busy gentleman owner of the cat with the bladder stones as I was reviewing the past few days' cases. All cases done by associate vets and be me are reviewed by me as much can be learned from cases done. But this takes a lot of time and time is not much when there are many other things to do. "My cat is back to as good as normal," he said that the cat was jumping and his stools and urine were normal. He had told me the day before that the cat drank less. I explained that the cat was fed canned K/D diet and canned food has a lot of water. "Does he eat on his own?" I asked this important question. "He eats a bit and does not mind spoon-feeding by my maid." This was a moment of great joy to know that a surgical patient who was having kidney disease based on blood test by Vet 2 had recovered almost fully. The stitched bladder with a 8-mm cut by me to extract the 8-mm diameter stone must have healed well, otherwise this cat would be dead. Follow ups are much appreciated and great learning lessons for any vet but we seldom have much time to do it. It creates an excellent customer service experience. This owner loves his grandmother as he did bring her to take the cat home the day after surgery. Grandmothers are most loved as they usually spend most time with the grand children while the parents are out working and surviving in the corporate jungle. His grandmother was over 80 years old and her mind was sharp and alert. "Remember the S/D can of food given by Vet 2?" I asked the owner. "It may not be useful as the cat's urinary pH is acidic at pH=5.0. That means that the bladder stones are unlikely to be struvites as S/D is for prevention and dissolution of struvites stones. Most likely, they are calcium oxalate stones but we have to wait for the results of the stone analysis." This info was obtained when I collected urine before opening up the bladder for stone removal. It is important that the vet performs this procedure as it may not be possible to collect urine from an angry non-sedated cat earlier. That could be one reason Vet 2 did not do a urine analysis and just prescribed S/D of one can. It is best to practise evidence-based medicine by doing urine analysis. In this case, there were no crystals in the urine. A 4th year vet student from the top Portugal Vet University was with me and I asked Catarina Mateu : "No crystals in the urine test means no bladder stones. Many vets will come to this conclusion. What about you?" "Yes," she replied. "I also think this way." UPDATE ON MARCH 1, 2013. Day 9 after surgery I phoned the owner to inform him that stone analysis revealed calcium, oxalate and magnesium in the bladder stone. I advised canned C/D food for at life. But it is relatively expensive compared to the usual canned foods. He said: "My cat is ok now. Only that he is inactive when he wears the e-collar. When do I come for stitch removal?" "Your cat has never worn e-collars before. Once the skin stitches are removed on this Sunday, your cat will be free of the burden of this collar." UPDATE ON MARCH 5, 2013, Day 13 after surgery The cat's nylon skin stitches were removed by me. The owner said that the cat was withdrawn and quiet when he was wearing the e-collar but would be more active when he was not wearing it. "No need to wear the collar now since I had removed the stitches." UPDATE ON MARCH 10, 2013. Day 18 after surgery The cat with the bladder stone surgery came for stitch removal on Sunday, March 3, 2013. No need to wear e-collar. The owner got 48 cans of C/D for his cat and will buy from the vet near his apartment later. No further news from the owner. As for the cat with urethral obstruction, no recurrence and no news from the owner. UPDATE ON MARCH 22, 2013, Day 22 after surgery7.22 am from home, as I review this case to be produced as an educational video. No news or complaint from the owner. No news is good news in the case of the cat with the bladder stones removed. It is good to know that the cat is back to normal. The owner will be buying his feline C/D from Vet 2 as the surgery is across his home. UPDATE ON APRIL 21, 2013. Day 52 after surgeryNo news is good news or phone call from the owner. The owner complies with the medical instruction to feed the cat only C/D and nothing else. Case 2: A CAT CANNOT PEE March 1, 2013 The above-mentioned case of the cat with the bladder stones had a different history from Case 2. In Case 1, the owner had complained that the cat was not eating for 5 days, not blood or difficulty in urination. The cat could pee. Case 2 reviewed another cat of around the same age came soon. Emergency catherisation and treatment removed the obstruction of the urethra. On March 1, 2013 I discharged this 8-year-old male neutered cat with a catheter one day of hospitalisation. He was a good-natured cat. The owner had told me that the cat could not pass urine for 2 days. I found her history unreliable when I checked the blood test results. Based on the blood test results, the history of difficulty in urination for 2 days was dubious. "The high urea and creatinine values, more than 6X the higher range of normal and the vomiting indicated that the cat was having urination problems more than 2 days," I said to her. "There is kidney damage and the cat may get kidney failure now." "He had peed blood for over a month. A 10-cent coin of red urine appeared on the floor many times. I was too busy to bring him to the vet. When he could not pee at all for 2 days, I knew I had no choice but to send him to you for treatment." Under sedation, Dr Daniel had a urinary catheter passed into the bladder with great difficulty as the urinary sand blocked the passage at the bend of the urethra. So the bladder started filling to half the size of the mango and the cat could not pee at all. He had to pump in normal saline via the catheter to dislodge the sand back into the bladder. Then he irrigated the bladder with more saline and sucked out the blood and sand. The urinary catheter was stitched on the prepuce and kept for 3 days. As no X-rays were done to lower the veterinary costs and as no stones were palpable in the bladder, I told the owner that there might be bladder stones if the condition recurred. X-rays would have to be done. The heartlanders have a limit as to veterinary expenditure in these times of rising costs and economic recession. "No more dry cat food or cat treats," I said to the working lady in her 50s. "Just this can of K/D and then C/D." "What if he eats the food from the other cats?" she asked. "Then you may get a recurrence of the bladder blockage problem." "I know what I will do," she had a solution. "I will feed him in another room. When he is full, he will not eat the other cat's food." P.S I spoke to Hills' supplier. He told me that feline S/D was no longer produced since 9 months ago. The feline C/D is found to be effective to prevent S/D as well and so it is the only product for kidney health for cats. He was surprised that Vet 2 still had cans of feline S/D. Saturday, April 20, 2013 RECURRENCE 50 DAYS LATER IN APRIL 20, 2013 1378. The FLUTD cat returned with a blocked bladder again. With heartlanders, the least cost veterinary medicine is practised. For one and a half months after the cat fainted from a blocked bladder, the white grey cat now had difficulty peeing for the last 5 days. Dr Daniel handled the case and he decided to catherise the urethra to unblock the bladder. There was great difficulty in catherisation. The cat had no complaints but she would stop feeding the 10 cans of C/D diet and feed other canned food since the C/D was expensive. "Clear" urine leaked onto the table. "He was licking his penis," the owner said. I turned the cat upside down and noted that his penile tip was bright red. Clear urine dribbled onto the examination table. I taught my new veterinary assistant Nai how to use the urine dipstick to check the urine for pH, SG, blood, protein, white cells and others. Nai is a young veterinarian graduated from Myanmar. He is new to this job and has lots to learn. It takes great patience to train a rookie from the internet generation. He would mumble in Myanmarese whenever I told him off for not doing a good job after I had taught him how it should be done. Many young people has a different mindset nowadays. They would do a task their own way and so needed to be supervised closely as a recording system and process must be adhered to if the practice wants consistently a high standard of care. One day I told him that he should quit as there are others who can speak good English. They have the advantage of being able to handle phone queries and client discharge. If he wanted to stay, he should not grumble as nobody wants to employ or train him if he has this attitude. "This is not your father's office," I said to him. Other practices would have sacked him. Recently he understood that he had to change his mindset. Working in an established Singapore small animal practice like mine gave him the opportunity to see various cases and challenging surgeries as compared to working in a Yangon practice where it is difficult to handle complex cases due to financial constraints of the average pet owner. A cat spayed in Yangon costs S$20 which is at least 5 times cheaper than in Singapore. In 2 years, he would have gained much veterinary knowledge and would open his own clinic in Yangon. Presently there are around 100 small animal veterinary practices in Yangon from one of my sources. Singapore has more than 50. Back to this cat. There was a need to cut medical costs as the owner was worried about cost based on the fact that she had waited for many weeks till her cat "fainted" and could not pee at all, before seeking vet treatment in the first consultation one and a half months ago. This second consultation, she came after the cat had dysuria (difficulty in peeing) after 5 days. In theory, this cat should be sedated and catherised as in the earlier incident. To save costs, I gave injections to reduce pain and infection followed by oral antibiotics and 10 cans of C/D. The owner had complained that the C/D was costly as compared to the commercial canned foods. It is like comparing apples to oranges. The C/D is specially formulated to prevent FLUTD (Feline Lower Urinary Tract Disease). . The owner swore she had not fed the cat any dry food. But only canned food. But her other two cats were eating dry food. "Can you guarantee that this cat has not eaten any dry food?" I asked. She was not sure. Failure to comply with medical instructions lead to a recurrence of FLUTD. This cat could have bladder stones but no X-rays were done to save money. If there is a 3rd recurrence, X-rays would have to be done. Contrast this case to the other cat with bladder stone removed by me in an earlier report of these 2 cats. No news from the other cat at all. No problem. No news is good news. Updates will be on this webpage; http://www.bekindtopets.com/stories/ 20130301cat_bladder_stones_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: April 21, 2013 Toa Payoh Vets

1379. Health screening costs for the older dog

On Sun, Apr 21, 2013 at 12:17 AM, Elaine @gmail.com> wrote:

Hi Judy,

I would like to send my Jack Russell Terrier for a health checkup/screening, as he is already about 7 years old, and we have not sent for him any check up yet. Just recently we noticed a 'growth-like lump' on his left hind leg, we're not sure what it exactly is but we want to make sure that he's perfectly fine and healthy :)

Do you provide health screening or checkup? What does it include and about how much would that cost? Thanks.


Regards,
Elaine



----------------------------

 April 21, 2013

Hi
Thank you for your email.

I am Dr Sing Kong Yuen from Toa Payoh Vets. A health check up/screening of the normal adult dog includes the following:

1. General examination of the dog including checking for visible tumours   $65 - $100
2. Eye and ear scope examination  $150 - $200
3. Blood test $150 - $250
4. Urine test $50
5. Stool test for parasites and blood  $50
6. X-rays/ultrasound of chest and abdomen. $150 - $300
7. Histology of tumours $150 - $250


In the older dog, I will advise excision of any skin lump on the leg or body early when it is small in size as some may be cancerous sarcomas. The anaesthetic and surgical costs are much lower when the tumour is smaller, estimated to be from $300 - $500. 

1378. The FLUTD cat returned with a blocked bladder again.

With heartlanders, the least cost veterinary medicine is practised. For one and a half months after the cat fainted from a blocked bladder, the white grey cat now had difficulty peeing for the last 5 days. Dr Daniel handled the case and he decided to catherise the urethra to unblock the bladder. There was great difficulty in catherisation. The cat had no complaints but she would stop feeding the 10 cans of C/D diet and feed other canned food since the C/D was expensive.

"Clear" urine  leaked onto the table. "He was licking his penis," the owner said. I turned the cat upside down and noted that his penile tip was bright red. Clear urine dribbled onto the examination table.

I taught my new veterinary assistant Nai how to use the urine dipstick to check the urine for pH, SG, blood, protein, white cells and others. Nai is a young veterinarian graduated from Myanmar. He is new to this job and has lots to learn. It takes great patience to train a rookie from the internet generation. He would mumble in Myanmarese whenever I told him off for not doing a good job after I had taught him how it should be done. Many young people has a different mindset nowadays. They would do a task their own way and so needed to be supervised closely as a recordingsystem and process must be adhered to if the practice wants consistently a high standard of care.  

One day I told him that he should quit as there are others who can speak good English. They have the advantage of being able to handle phone queries and client discharge. If he wanted to stay, he should not grumble as nobody wants to employ or  train him if he has this attitude. "This is not your father's office," I said to him. Other practices would have sacked him.

Recently he understood that he had to change his mindset. Working in an established Singapore small animal practice like mine gave him the opportunity to see various cases and challenging surgeries as compared to working in a Yangon practice where it is difficult to handle complex cases due to financial constraints of the average pet owner. A cat spayed in Yangon costs S$20 which is at least 5 times cheaper than in Singapore.  In 2 years, he would have gained much veterinary knowledge and would open his own clinic in Yangon. Presently there are around 100 small animal veterinary practices in Yangon from one of my sources. Singapore has more than 50.

Back to this cat. There was a need to cut medical costs as the owner was worried. In theory, this cat should be sedated and catherised as in the earlier incident.

To save costs, I gave injections to reduce pain and infection followed by oral antibiotics and 10 cans of C/D.  The owner had complained that the C/D was costly as compared to the commercial canned foods.

It is like comparing apples to oranges. The C/D is specially formulated to prevent FLUTD (Feline Lower Urinary Tract Disease). .

The owner swore she had not fed the cat any dry food. But only canned food. But her other two cats were eating dry food. "Can you guarantee that this cat has not eaten any dry food?" I asked. She was not sure. Failure to comply with medical instructions lead to a recurrence of FLUTD.

This cat could have bladder stones but no X-rays were done to save money. If there is a 3rd recurrence, X-rays would have to be done.

Contrast this case to the other cat with bladder stone removed by me in an earlier report of these 2 cats. No news from the other cat at all. No problem. No news is good news.          
See case at:
http://www.bekindtopets.com/stories/20130301cat_bladder_stones_toapayohvets.htm

1377. Saturday's interesting cases. Let the cat see better. Horner's Syndrome in a young cat?

April 20, 2013  4.26pm NEX public library

Today is a bright sunny Saturday. At 9 am, I reviewed the two surgical cases done by Dr Daniel as he is off on Saturdays.  Both will go home today. \

Case 1. Right Perineal hernia in an old male Pom. No more vomiting. The hernia repair tissues were weepy and the stitches were not holding well as the skin was gangrenous. The owner had waited 2 months. The dog had kidney disorder and vomited. The bladder was trapped inside the hernia and the dog could not poop. \

"Ensure the dog drinks at least 200 ml of water twice a day,"  I reminded the owner and offered to give her a 20-ml syringe.  I escorted her to her car parked to the side of the surgery although she said no need to do so. Dr Daniel was not present and normally he would not have done it. Carrying a bigger-sized Pom and opening the car door would be difficult. She had a driver whom I mistook for her husband.

"Hand feed sufficient amount of food. Use clean water to flush away the blood and stools near the wound."  


Case 2. This young cat of around one year old had a protruding 3rd eyelid since young. He came in to be neutered.  The owner had sent it to another vet earlier. Then the kitten was treated by Dr Daniel for swollen conjunctivitis at the age of one month. The owner asked me what's wrong with the left eye?  3/4 of the eyeball was covered by a brown 3rd eyelid permanently. I could not see 60% of the eyeball and so I could not see the whole pupil. 

I had not seen such an eye condition in my over 40 years of practice. "It could be a persistent 3rd eyelid," I said as it reminded me of the condition of "persistent pupillary membrane" in dogs. "During neuter and anaesthesia," a piece could be snipped off.

I discussed the case with Dr Daniel. He said: "This could be Horner's syndrome in the cat. The 3rd eyelid protrudes as the eyeball shrinks or is pulled inwards."

Horner's syndrome is due to brain injury. The upper eyelid droops (the upper eyelid is wet at the margin compared to the right eye). The eyeball does not look shrunken but then this is not so obvious. There should be miosis (constriction of the pupil) but I could not see the whole pupil as it is the eyeball is around 60% covered and only a slit of the pupil could be seen.

Somehow I don't think this is Horner's Syndrome although it has some of the elements. To me, it looks like a developmental defect with the dorsal upper end of the 3rd eyelid stretched out and fixed to the lateral canthus (see images). "The purpose of excising the 3rd eyelid is to let the cat see better," I said to Dr Daniel. He voiced his opinion that it would not work as the cat has a shrunkened eyeball and so the 3rd eyelid would still cover the eyeball due to muscular pull.

"We could test for intra-ocular eye pressure," I decided. "In any case, snip off the triangular piece between the upper and lower corners of the 3rd eyelid so that the cat can see as this area obstructs the vision of his pupil. Dr Daniel neutered the cat and did accordingly yesterday.

This morning, I looked forward to seeing whether this cat can see better. What do you think? I will let the images tell the story.



.

   

1376. Being a vet video production - Love your veterinary profession

1375. Talk to prospective undergraduate vets at Raffles Institution

 

 

 EMAIL TO DR SING DATED APR 15, 2013

Suzanne Ou	Apr 15 (5 days ago)
to Singdaniel, me

Dear Dr Daniel Sing and Dr Sing Kong Yuen,

I am Suzanne Ou, Chairperson of the Raffles Society of Biological Sciences in Raffles Institution (Junior College). As the largest Science Club CCA in RI, we aim to offer members a broad view of all fields of Biology, as such, we hope to invite you down to for a talk on veterinary sciences on 25th April 2013, Thursday, 5.30 - 6.30 pm.

As the seniors are preparing for A levels and choosing a career path, we hope that you will be able to share about what is it like being a vet as well as studying for it in university. One of our alumni, Gina Ng, mentioned that her internship with your clinic was very interesting, and we hope to know more about the surgeries you conduct and about the cases you encounter.

We sincerely hope that both of you will be able to come and we look forward to your favourable reply.

Thank you!

Regards,

Suzanne Ou

Chairperson of Raffles Society of Biological Sciences

------------------------------------------------------------------------------------------------

					Kong Yuen Sing	April 16, 2013 Thank you for your invitation. I am Dr Sing Kong Yuen, from To...	Apr 16 (4 days ago)

Suzanne Ou	2:57 PM (15 hours ago)
to me

Dear Dr Sing,

Thank you for your reply and information! We will be faxing the official invitation to your clinic for confirmation along with the information of time and venue.

Would it be possible if he were to share photos and videos of surgeries? We hope to be able to hear your stories as well as for our members to get a better understanding of the profession.

Thank you and we look forward to having Dr Daniel Sing to speak!

Regards,

Suzanne Ou

 

-----------------------------------

 

EMAIL FROM DR SING DATED APR 20, 2013 6.02 AM

to Suzanne, bcc: daniel

Thank you for email.
Pl confirm whether your people has facilities to show the following veterinary surgery and medicine educational videos (Emergency Caesarean section) videos directly from youtube to the audience?

The videos are:
http://www.youtube.com/watch?v=8f0LHTFRVSc

http://www.youtube.com/watch?v=z9sRvi_9fPQ

http://www.youtube.com/watch?v=hGafvWdIPTE&feature=youtu.be

Pl phone me at 9668 6468 rather than email as time is short.
Thank you.

1374. How to medicate your gasping turtle?

 EMAIL TO DR SING DATED APR 18, 2013

K	Apr 18 (2 days ago)
to judy

Dear Dr Sing,

I brought my pet turtle Toe to you for treatment of pneumonia last Monday (TP Ref. No. 44319; Invoice No. 21954) and I've followed your instructions of quarantining it from swimming, basking for 30 min every day, and feeding it with medicine by dripping near its food while it eats.

I noticed that its appetite has improved significantly, but it still seems to gasp occasionally.

It still shows the swelling action in its throat area. It has not been easy feeding Toe with the antibiotics as it gets suspicious of its food and will avoid the water and food once it tastes the medicine. Hence I am not sure if it has been taking the medicine effectively.

I have yet to place it in a tank of water to see if it would be listing while swimming. Can you advise me on an effective way of feeding with with the medicine please? May I also know if it is necessary to get a basking lamp for the turtle in addition to the daily routine of basking in sunlight for 30 minutes every day? Thank you for your kind attention to this email.

Yours sincerely,

K

 ---------------------------------
EMAIL REPLY FROM DR SING DATED APR 20, 2013  5.45 AM

April 20, 2013.

I just got your email today Apr 20, 2013. Pl phone if you have queries instead of email or sms as I have numerous spam emails and have had missed out yours.

In reply, your turtle has a respiratory tract infection and is gasping for oxygen (gasping and throat swelling of dyspnoea). This infection is hard to treat because turtles dislike medication via the feed or water but yours seem to have taken some antibiotics.

Many young and old turtles die of respiratory infections owing to the owner's difficulty in compliance with medication at home. Yours appear to be a success story.

1, Injections are an alternative if they are bigger in size. In some cases,
2. I advised covering the nostrils with your finger and when the turtle opens its mouth to breathe, squirt the antibiotics into the front of the mouth, via an eye dropper or syringe. This method works sometimes.
3. A basking lamp will be good.
4. No swimming till the turtle has recovered fully. This may take a few weeks. 
5. Ensure that the turtle is fed and given water daily. 

Pl phone the Surgery if you have more queries rather than email.  Best wishes.

1373. Right perineal hernia in an old Pom

"It is your decision and judgment," I said to Dr Daniel. The male Pom had a hard swollen right perineal hernia and had not pooped for the last 2 days. Difficulty in urination. The swelling was bigger than an orange and the skin was cyanotic and shiny.

Dr Daniel felt that the bladder was obstructed while prolapsed inside this hernia and if the operation was not done, the dog would die.

"The rectal temp is below normal," I had advised IV drips, antibiotics and painkillers. It was an emergency surgery done after the IV drip and medication. The owner said the lump was like a marble two months ago, but ignored it till now.

POST OP
24 hours after surgery- I noted that the dog was not able to stand.  He had pooped. Urine catherisation. relieved the bladder. His cyanotic skin near the anal area turned black as there was no more blood supply. Much of the other cyanotic and shiny skin were cut away as they were necrotic.   

1372. Two new lumps above the old rabbit's left eyelid - sarcoma?

Adeline Teo	Apr 9 (8 days ago)
to me

Hi Dr Sing,

my rabbit Xiaoban, has who had recently been to your clinic for removal of her sarcoma near her left eye.

Today we again felt a small spherical lump around 0.3-0.5cm in diameter big in an area just a little higher up the previous area, this time its sitting quite near the eye (just a little above the eyelid). Do you think we should just bring her over this sun for you to take a look and discuss what is best for her?

Otherwise she is eating well and elated to be just reunited with her companion. Her stitches are still there, has not dissolved yet, but since the boy has no lower teeth, he can't do anything to it.

Regards,

A...

 

EMAIL REPLY FROM DR SING

Kong Yuen Sing <99pups gmail.com="">	Apr 10 (7 days ago)

Best to get it removed when it is very small and operable. However, please note that the sarcoma is spreading via the skin and there will be more recurrences.

DISCUSSION WITH THE OWNER

APRIL 15, 2013
Female rabbit was spayed by me 8 years ago. "The next day, the rabbit jumped and was very active," the medical technician lady told me as I sent her friend and her home to Toa Payoh Lor 1. She came to take the rabbit home and since I was closing at 8 pm, I gave her a lift.

"How are the younger doctors in the General Hospital?" I asked. "Do they arrive late for work? Do they spend lots of time texting and viewing movies on their mobile phone or laptop? This is my observation of the staff who worked at Toa Payoh Vets. 

"Yes, they do that. Sometimes text us too!" she said. "The senior doctors come to work early!"

"What makes a good doctor?" I asked when the two ladies was saying that there was one doctor who was a good doctor.

"He cares for his patient and waive off his fees for those in need," the medical technician said. "Sometimes we feel that we spent so much time on the patient and he just waived the charges!"

This female rabbit had no problem since spay, till recently. The two ladies had sent me an e-card of thanks some 8 years ago. I still have it somewhere.

Sarcoma diagnosed in upper eyelid (more cranial) was excised by Dr Daniel last month. Now the present 2 lumps under the skin above the upper eyelid have been excised and sent for histology.

The ladies brought up the fact that this rabbit had false pregnancy last year when I asked why a small area of the skin near the vulval area was bald. "Last year, her whole hind legs were as bald as a chicken! She chewed the hairs off as she had false pregnancy."

"No rabbit can have false pregnancy when she is spayed," I said.
"Well, the internet sites said it is possible. Even the House Rabbit website says so."
This is news to me. The younger generation of owners possess niche knowledge. I must check this out. 

There is another rabbit which had jaw abscess. "How is he now?" I asked. "It is hard to tell one rabbit from another," I said. "I guess it is the same with people e.g. all Asians look the same to Caucasians?"

"We can tell," the ladies said. "He has no more jaw abscess after two treatments by your clinic. Maybe the rotten tooth root had dropped off! Every 8 weeks I clip his upper teeth as they overgrow. He has only one lower front teeth, deviated."  These two rabbits in old age seem to require more info.

The ladies were waiting for me to finish my consultation on a guinea pig which had rapid breathing on that evening. They had palpated a lump on the left mandible, around 8 mm x 8 mm. "Could this be another sarcoma?" they asked. "It could be a developing jaw abscess," I palpated this lump which was absent in the right mandible.. The two rabbits were well loved.  

1371. Tips for newly graduated vets and pet owners - closed pyometra

TOA PAYOH VETS toapayohvets.com Date:   17 April, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits Against Medical Advices: Closed Pyometra   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   17 April, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 SCRIPT FOR VIDEO  HOOK INTRODUCTION Pyometra is an infection of the womb. There is the open pyometra where the owner can see brownish sticky vaginal discharge and the closed pyometra where the presenting sign may be a swollen abdomen. TWO CASE STUDIES Two closed pyometra cases from my case files, in two breeds of dogs of similar ages are presented. Both dogs had large swollen abdomens as the presenting sign.  The Miniature Schnauzer survived the anaesthesia and surgery but the Siberian Husky did not. The Siberian Husky was very thin when she was operated as an emergency case by me. She had been treated by Vet 1 with antibiotics but had not responded and there was a delay in seeking veterinary attention. .  Miniature Schnauzer       X-ray showed swollen uterine bodies X-ray showed swollen uterine bodies Uterine bodies swollen with pus Dog is OK after surgery 5618 - 5621.  Closed pyometra anaesthesia and surgery is highly risky compared to a spay and costs much more as it is a long surgery. The dog survived the surgery performed by Dr Vanessa. The owner was most happy as the dog survived the anaesthesia. Siberian Husky         Weight loss and distended abdomen X-ray showed swollen uterine bodies Uterine bodies swollen with pus   2094 - 2906.  Spay your female dog when she is young as the younger Singaporean generation usually has to work long hours and has little time  for her when she is older.  In this case, pus had accumulated in the womb which weighed 4 kg. The Siberian Husky had lost weight considerably and was only 18 kg when presented for surgery. Her net weight was 14 kg as the pyometra womb weighed 4 kg. She was extremely high risk for anaesthesia and passed away on the operating table when an emergency spay was done by me.  For reasons unknown to me, Vet 1 had prescribed antibiotics for the swollen abdomen. There could be financial distress on the part of the owner as regards further testing for the swollen abdomen. The owner might just want some antibiotics. In such situations, the vet should record in writing his advices for evidence of close pyometra in his case file.  In this Siberian Husky, there was a delay in seeking surgical treatment. The dog was too ill to survive the anaesthesia and there was much sadness, unhappiness and resentment by the family members towards Vet 1.   TIPS & ADVICES for the Dog Owner: 1.  SEEK PROMPT VETERINARY ATTENTION when your dog does not eat around 4-8 weeks after her heat period. That is when pyometra develops. Many younger Singaporean dog owners feel that it is cruel to sterilise their dogs. As they become busy in their careers, they neglect their older dog's health. The dog is well provided for in food and there are the parents and the domestic worker to look after the dog. They don't have time to bring their dogs for walks and when their dogs are not well, they delay seeking veterinary treatment or second opinions.   2. SPAY your female dog when she is young and healthy. Pyometra surgeries to remove the womb are high-risk anaesthestic cases since the dog is already very sick. Some do die during anaesthesia. TIPS & ADVICES for the newly graduated Veterinary Surgeon: 1.  DIFFERENTIAL DIAGNOSIS Pyometra should top the list of differential diagnosis in female dogs presented with distended abdomen with or without vomiting. The onset of estrus should be asked and recorded in the medical case sheets. However, some owners give incorrect dates of estrus and this could lead to a mis-diagnosis of closed pyometra as gas in the stomach and intestines. In some cases, the owner's mother knows the onset but she is not present during consultation.    2.  HIGH MEDICAL COSTS Compared to a spay, pyometra surgery costs a lot more. If the owner desires the least medical costs, he will not want to pay for the blood tests and X-rays. I usually advise a spay to be done soon once the dog is fit for surgery. Evidence-based medicine should be practised but compassion will be needed for financial distressed owners.             3.  AGAINST MEDICAL ADVICES The vet should record "Against Medical Advices" on the medical records, if the owner declines blood tests and X-rays of the swollen abdomen. This written advice will be a defence in cases of complaints and litigation. A good vet will be meticulous in writing his case records and advices given to the owner. Write your advices as you talk rather than wait till the end of consultation as you will have omitted certain information.   CREDITS FOR MORE INFORMATION   Update will be on this webpage: http://www.sinpets.com/F5/201304017closed _pyometra_dogs_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

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