Monday, October 8, 2012
1132. Struvite urolithiasis in cats
.
Cat, Male, Not Neutered, Ginger, 10 months old.
"I was renting an HDB flat and living in Toa Payoh," the slim Malay woman said. "You gave me a car ride home as I was pregnant. Now her big son came with me to consult me regarding her orange male cat born on Dec 23, 2011 as her cat could not pee again after treatment by Vet 1. She had bought her apartment in North Singapore and went to the vet near her home.
"I went to Vet 1 because the clinic is just downstairs," she said. "I can't afford the treatment again as I had already paid $240.00 on Sep 29. Vet 1 wanted around $800 but I can't afford the fees. Yesterday (Oct 1), my cat can't pee again."
"It is not cheap to treat this blocked bladder disease," I said. The owner wants an excellent outcome for one treatment. Is it possible? Yes, in some cases if the owner complies with vet instructions.
VET 1'S TREATMENT ON SEP 29, 2012
Urolithiasis with urethral obstruction
Cat has not urinated for 2 days.
Rock hard fist-sized bladder
IV catheter. valium 0.5 ml slow IV. Methone 0.08ml IM. Alfaxan 0.7 ml slow IV. Iso/O2 maintenance. Urethral obstruction unblocked. Copious saline flushed and emptied bladder.
UA.
pH 6.5 SG 1.05 Blood 3+, Protein 3+. WBC 3+, Urobilingoen 2+
Microscopy: Struvites 4+, Bact +, RBC+, WCC+, yaline casts +
Advised hospitalisation and urinary catheter in the bladder for 2 days but owner was not in favour owing to budget constraints.
.
Owner was warned that bladder would be blocked in the next few days and the consequences of
cat dying. Home on clavomox for 5 days. RC urinary S/O diet for at least 6-8 weeks and re-check urine.
TOA PAYOH VET'S TREATMENT ON OCT 2, 2012
Owner agreed to the cat being hospitalised.
Case handled by Dr Daniel and his written surgical plans were as follows:
Cat 4.9 kg, 39.2C
1. Sedation xylazine 0.2 ml + ketamine 0.8 ml IM
2. Catherisation + lavage + indwelling
3. Baytril + tolfedine inj
4. e-collar
5. vibravet 50mg 1 tab sid x 10
6. multivit x 1 bot
Urethral obstruction
Cat has not urinated yesterday. .
UA.
pH 7.0 SG 1.015 Blood 4+, Protein 2+. , Urobilinogen Normal
Microscopy: Crystals Nil, Bact Occasional, RBC >2250, WCC 198, hyaline casts Nil, spermatozoa +
Advised hospitalisation and urinary catheter in the bladder for 2 days but owner was not in favour owing to budget constraints.
.
Owner was warned that bladder would be blocked in the next few days and the consequences of
cat dying. Home on clavomox for 5 days. RC urinary S/O diet for at least 6-8 weeks and re-check urine.
CONCLUSION
There have been a few cases of urethral obstruction in male cats seen by me recently. It is a common condition in cats. As to the cause, it is difficult to say.
In this case, struvite urolithiasis has the same conditions of alkaline pH, bacterial infection and struvite crystals. It can be prevented by the use of anti-struvite reduction diet like C/D but most owners are not educated sufficiently to get the cat to switch over to C/D for at least one month and then to maintenance C/D. For economy reasons, I advise C/D for at least one month and then canned food. No dry food at all times. This cat was fed dry food (Snappy Tom) since kittenhood as his dam is also eating the same. No urolithiasis problem for the female.
Follow up education for struvite urolithiasis is essential to ensure that the owner complies with the feeding of C/D. In this case, the cat rejected the C/D when given 100%. I had to educate the owner to give 5% of C/D + 95% of the commercial canned food and slowly increase to 100% over a period of two weeks. She was willing to listen as recurrence will involve costly vet treatment. She was able to medicate the cat with antibiotics given via the food. Many cats will not take antibiotics and many owners simply give up easily.
In strurvite cases, bacterial infection of the bladder needs to be eliminated and an acidic pH of the urine is maintained by feeding of C/D diet. It is extremely difficult to educate most Singapore cat owners and vets don't have much time to do so. Urine checks should be done monthly and 3-monthly but none will be done in most cat cases. The theory is sound but in reality, the Singapore cat owners generally are not interested in follow up urine analysis in 2012.
I noted that owners may buy one can of C/D for a trial and then no more news from them. Unfortunately, most vets just don't have the time to educate their clients. The younger generation will be more sophisticated and educated by the internet and be more demanding for results and excellent outcome. Struvites are easier to dissolve by dietary management rather than surgery but it is up to the owners to accept vet advices for preventive check ups.
1130. Urban stress & barking dogs
On Saturday, Oct 6, 2012, I was having a business meeting with a 62-year-old slim man who was introduced to me by an old acquaintance realtor. This businessman had this offer of a S$150,000 rental commission per year from an oil rig company sending expatriates to Singapore. As he is not a licensed Singapore realtor, he could not handle this "lucrative" account. S$150,000 is a large source of revenue for a small-time realty.
My acquaintance said I needed only to pay 15% of the commissions to this man and to house the expats in serviced apartments. I agreed to meet him.
During the meeting, he said the 15% would go to the American who would give him the exclusive deal. "I will get 40% of the commissions from you," he said. "This is a $150,000 yearly income. Both sides will sign an agreement to pay a penalty of 10% if they don't fulfill their obligations. However, you and I have to pay this American $6,000 upfront, otherwise, he will not give us the deal. You foot $3,000. This $3,000 is deductable from the 15% of the commissions you get. I give you 2 days to consider before I contact my other agents."
So, I was to pay $3,000 to somebody I don't know. I have to pay this American 15% and then 40% of the commissions to this broker. The expat arrivals would live in long term housing which means I have to co-broke with other agents at 50:50.
Assuming $150,000 commissions per year and 2/3 of it is due to co-broking as the other agent represents the Landlord. The gross income from co-broking will be 50:50 and this equals to 2/3x$150,000/2 = $100,000. 50% is given to the co-broker. So, the balance will be $50,000 for me. 15% goes to the American. The balance for me is $42,500. 40% goes to this man. I get $25,500.
Assume 1/3 of $150,000 is full commission to me. Following the above formula, I get $25,500. The estimated income per year is $50,000. This assumes that there is $150,000 worth of business. I would have to provide 24-hour services to pick up the expat on arrival in Singapore at any hour of the day and give advices on education and provide after-sales services.
The man gets $50,000 for introducing this expat to me. He wants the $3,000 upfront and 2 days to decide.
Suddenly a thin balding man with a worried look passed by. I knew him as an industrial park tenant and as a Landlord of a cluster bungalow in Punggol for many years. He had come to my Surgery 3 weeks ago to complain that the dogs were barking and depriving him of sleep. Now he brought up the same topic that I was not feeding the dogs and that was why they barked all day long.
"Please have a seat," I said to him. He did not want to sit.
"Why are you confrontational?" I asked him. "You came suddenly to complain about the dogs barking as they did not get fed some 3 weeks ago. I invited you into my Surgery to see the dogs. You saw the feed bowls were filled with dog food. Water bowls were full. "
"Your dogs are still barking today. They are not fed."
I was patient with him as I understood he had some loss in his business in this extremely competitive world where China is the world's factory, leaving little for the small-time businessman or manufacturer.
My acquaintance said I needed only to pay 15% of the commissions to this man and to house the expats in serviced apartments. I agreed to meet him.
During the meeting, he said the 15% would go to the American who would give him the exclusive deal. "I will get 40% of the commissions from you," he said. "This is a $150,000 yearly income. Both sides will sign an agreement to pay a penalty of 10% if they don't fulfill their obligations. However, you and I have to pay this American $6,000 upfront, otherwise, he will not give us the deal. You foot $3,000. This $3,000 is deductable from the 15% of the commissions you get. I give you 2 days to consider before I contact my other agents."
So, I was to pay $3,000 to somebody I don't know. I have to pay this American 15% and then 40% of the commissions to this broker. The expat arrivals would live in long term housing which means I have to co-broke with other agents at 50:50.
Assuming $150,000 commissions per year and 2/3 of it is due to co-broking as the other agent represents the Landlord. The gross income from co-broking will be 50:50 and this equals to 2/3x$150,000/2 = $100,000. 50% is given to the co-broker. So, the balance will be $50,000 for me. 15% goes to the American. The balance for me is $42,500. 40% goes to this man. I get $25,500.
Assume 1/3 of $150,000 is full commission to me. Following the above formula, I get $25,500. The estimated income per year is $50,000. This assumes that there is $150,000 worth of business. I would have to provide 24-hour services to pick up the expat on arrival in Singapore at any hour of the day and give advices on education and provide after-sales services.
The man gets $50,000 for introducing this expat to me. He wants the $3,000 upfront and 2 days to decide.
Suddenly a thin balding man with a worried look passed by. I knew him as an industrial park tenant and as a Landlord of a cluster bungalow in Punggol for many years. He had come to my Surgery 3 weeks ago to complain that the dogs were barking and depriving him of sleep. Now he brought up the same topic that I was not feeding the dogs and that was why they barked all day long.
"Please have a seat," I said to him. He did not want to sit.
"Why are you confrontational?" I asked him. "You came suddenly to complain about the dogs barking as they did not get fed some 3 weeks ago. I invited you into my Surgery to see the dogs. You saw the feed bowls were filled with dog food. Water bowls were full. "
"Your dogs are still barking today. They are not fed."
I was patient with him as I understood he had some loss in his business in this extremely competitive world where China is the world's factory, leaving little for the small-time businessman or manufacturer.
Wednesday, October 3, 2012
1129. A schwanoma in a dwarf hamster?
"Why didn't you see such a large tumour on the hamster's hand?" I asked the mother who brought it in for surgery and hoped that it would not die under anaesthesia as the one.
"Usually he hides inside the litter and eat and so we didn't see it."
Big tumours in the hand or leg may be inoperable. The whole paw will then need to be amputated. Front paws are like our hands and are very important for the hamster.
"What is your surgical approach to this case?" I asked Dr Daniel.
"Amputate the paw," he replied.
"That's what I thought at first," I asked him to hold the gentle 18-month-old dwarf hamster for me to take digital images of various positions of the hand tumour. The hamster was put in a bowl and we observed him climbing out of the bowl.
The tumour was gigantic. Imagine your hand having the biggest durian growing out of it.
"It is possible to excise the tumour without amputation," I said to Dr Daniel. "But the vet needs to produce a live hamster at the end of the surgery. To succeed, the surgery must be short and the anaesthesia must be sufficient to prevent pain. Severe pain may kill the hamster as in the bird."
No point doing an excellent surgery and showing a dead hamster on the operating table. "Isoflurane gas anaesthesia is too short and too risky if prolonged," I said to Dr Daniel. "I will use Zoletil 50 IM."
In a cat and dog, IM injections are common and routine. In a dwarf hamster, the needle must be just into the thin backside muscle. Not much of the muscles. Dr Daniel held the hamster while I injected 0.02 ml Zoletil 50 diluted with 0.03 ml saline and injected IM.
"The hamster will become groggy if the IM injection is given correctly," I said. In 60 seconds, the hamster stumbled. Dr Daniel operated. "Give isoflurane gas top up when the hamster moves," I said. "Otherwise he may die from fright and severe pain." The whole procedure took less than one minute.
"Should more tumour tissues be cut off," Dr Daniel asked. "No," I said. "The area is down to the bone and tendons. Any further incision will damage the superficial flexor tendons and the hamster will not be able to hold his seeds and grains with the right hand."
The hamster appeared groggly during the first hour after anaesthesia and this is a common observation. The mother was very happy to see him alive as her son was the one most concerned. Produce good anaesthetic outcome and you get more referrals. It is extremely risky to anaesthesia hamsters for long surgeries as they don't survive. Be observant and be careful.
The owner did not want histopathology as it would cost money. It was a firm white tumour. Could it be a schwannoma? A nerve sheath tumour? Examine your hamster daily and get small tumours excised by your vet early. Tumours don't disappear with antibiotics and so, find a vet who operates on hamsters.
I saw another case of a lady who brought in a hamster saying there was a small lump on the belly area. This hamster had been licking bald the lower part of the belly, below the navel. I held the hamster and felt the nodule which was around 2 mm in diameter. The hamster squealed. However, the owner's preferred vet could not feel any nodule and so sent the hamster home with oral medication and asked to review it in 2 weeks' time. Owners know their hamsters best and if they find a nodule, it is usually there.
More pic at
http://www.sinpets.com/hamsters/20121005dwarf_hamster_hand_tumour_toapayohvets.htm
"Usually he hides inside the litter and eat and so we didn't see it."
Big tumours in the hand or leg may be inoperable. The whole paw will then need to be amputated. Front paws are like our hands and are very important for the hamster.
"What is your surgical approach to this case?" I asked Dr Daniel.
"Amputate the paw," he replied.
"That's what I thought at first," I asked him to hold the gentle 18-month-old dwarf hamster for me to take digital images of various positions of the hand tumour. The hamster was put in a bowl and we observed him climbing out of the bowl.
The tumour was gigantic. Imagine your hand having the biggest durian growing out of it.
"It is possible to excise the tumour without amputation," I said to Dr Daniel. "But the vet needs to produce a live hamster at the end of the surgery. To succeed, the surgery must be short and the anaesthesia must be sufficient to prevent pain. Severe pain may kill the hamster as in the bird."
No point doing an excellent surgery and showing a dead hamster on the operating table. "Isoflurane gas anaesthesia is too short and too risky if prolonged," I said to Dr Daniel. "I will use Zoletil 50 IM."
In a cat and dog, IM injections are common and routine. In a dwarf hamster, the needle must be just into the thin backside muscle. Not much of the muscles. Dr Daniel held the hamster while I injected 0.02 ml Zoletil 50 diluted with 0.03 ml saline and injected IM.
"The hamster will become groggy if the IM injection is given correctly," I said. In 60 seconds, the hamster stumbled. Dr Daniel operated. "Give isoflurane gas top up when the hamster moves," I said. "Otherwise he may die from fright and severe pain." The whole procedure took less than one minute.
"Should more tumour tissues be cut off," Dr Daniel asked. "No," I said. "The area is down to the bone and tendons. Any further incision will damage the superficial flexor tendons and the hamster will not be able to hold his seeds and grains with the right hand."
The hamster appeared groggly during the first hour after anaesthesia and this is a common observation. The mother was very happy to see him alive as her son was the one most concerned. Produce good anaesthetic outcome and you get more referrals. It is extremely risky to anaesthesia hamsters for long surgeries as they don't survive. Be observant and be careful.
The owner did not want histopathology as it would cost money. It was a firm white tumour. Could it be a schwannoma? A nerve sheath tumour? Examine your hamster daily and get small tumours excised by your vet early. Tumours don't disappear with antibiotics and so, find a vet who operates on hamsters.
I saw another case of a lady who brought in a hamster saying there was a small lump on the belly area. This hamster had been licking bald the lower part of the belly, below the navel. I held the hamster and felt the nodule which was around 2 mm in diameter. The hamster squealed. However, the owner's preferred vet could not feel any nodule and so sent the hamster home with oral medication and asked to review it in 2 weeks' time. Owners know their hamsters best and if they find a nodule, it is usually there.
More pic at
http://www.sinpets.com/hamsters/20121005dwarf_hamster_hand_tumour_toapayohvets.htm
1128. A guinea pig drools for weeks and loses weight
The young couple's guinea pig kept losing weight and kept drooling despite treatments and 5 X-rays in a veterinary practice. "What is the cause?" the wife asked. "I hand feed the critical care but she loses weight to 370 g. She had given birth to two litters and her offspring is 800 g. She would be interested in food but wouldn't eat it."
This is a very complex and emotional situation for the wife. What more could be done? They consulted me for a 2nd opinion. I said: "Anaesthesia is necessary to examine the mouth properly." But the guinea pig is so weak and so thin. So the wife deferred any such examination and went home 2 days ago. I asked her to get all the medical records from the other vet who was most helpful. Today, she came with her husband at 2pm sharp. I reviewed the records. "Very good records," I said. "Dr X is a very good vet," the husband replied. "But she just can't put her finger on what causes this drooling."
There were 5 x-rays. Only one showed the head. "There seemed to be a curved "tooth" coming from the hard palate to the floor of the mouth," I said to the other vet. She looked at her X-ray copy simultaneously and said it could be the maxilla. In any case, I advised another X-ray of the side and bottom top view of the skull and also the chest and abdomen. I told her I do not have X-ray facilities and she was happy to help out.
The couple went there and then phoned me to say they would not want any anaesthesia to open the mouth for examination today. They would go home to feed the guinea pig. I said it was OK with me.
This guinea pig had drooling, slobbering (wet chin), runny nose, loss of weight, not able to eat. These are signs of dental problems in the guinea pig. So, what is the cause of the dental problem? Malocclusion? Another "entrapment of the tongue" by the arching cheek teeth? Protrusions of the cheek teeth not obvious?
This is a complete mystery till I see the X-rays tomorrow. As the X-ray did not require anaesthesia, the couple was happy. Still, the mouth cannot be examined properly just by opening it. It needs anaesthesia. But the risk is so high. So, we are back to square one.
NOTES
1. Dental disease. Runny eyes, runny nose, drooling, teeth grinding, selective eating, not eating, weight loss, slobbering.
2. Guinea pig may not have the palpable protrusions at the ventral aspects of the mandible or at the lateral aspects of the maxilla as in the rabbit or chinchilla. Therefore, it may be hard to detect malocclusion.
3. GP + chinchilla
2(I1/1, C0/0, PM 1/1, M3/3) = 20 teeth.
Rabbit has I2/1 in case you don't know. It has 4 obvious front teeth and 2 more shorter and smaller upper front teeth behind the front teeth!
This is a very complex and emotional situation for the wife. What more could be done? They consulted me for a 2nd opinion. I said: "Anaesthesia is necessary to examine the mouth properly." But the guinea pig is so weak and so thin. So the wife deferred any such examination and went home 2 days ago. I asked her to get all the medical records from the other vet who was most helpful. Today, she came with her husband at 2pm sharp. I reviewed the records. "Very good records," I said. "Dr X is a very good vet," the husband replied. "But she just can't put her finger on what causes this drooling."
There were 5 x-rays. Only one showed the head. "There seemed to be a curved "tooth" coming from the hard palate to the floor of the mouth," I said to the other vet. She looked at her X-ray copy simultaneously and said it could be the maxilla. In any case, I advised another X-ray of the side and bottom top view of the skull and also the chest and abdomen. I told her I do not have X-ray facilities and she was happy to help out.
The couple went there and then phoned me to say they would not want any anaesthesia to open the mouth for examination today. They would go home to feed the guinea pig. I said it was OK with me.
This guinea pig had drooling, slobbering (wet chin), runny nose, loss of weight, not able to eat. These are signs of dental problems in the guinea pig. So, what is the cause of the dental problem? Malocclusion? Another "entrapment of the tongue" by the arching cheek teeth? Protrusions of the cheek teeth not obvious?
This is a complete mystery till I see the X-rays tomorrow. As the X-ray did not require anaesthesia, the couple was happy. Still, the mouth cannot be examined properly just by opening it. It needs anaesthesia. But the risk is so high. So, we are back to square one.
NOTES
1. Dental disease. Runny eyes, runny nose, drooling, teeth grinding, selective eating, not eating, weight loss, slobbering.
2. Guinea pig may not have the palpable protrusions at the ventral aspects of the mandible or at the lateral aspects of the maxilla as in the rabbit or chinchilla. Therefore, it may be hard to detect malocclusion.
3. GP + chinchilla
2(I1/1, C0/0, PM 1/1, M3/3) = 20 teeth.
Rabbit has I2/1 in case you don't know. It has 4 obvious front teeth and 2 more shorter and smaller upper front teeth behind the front teeth!
1127. Follow up: 3rd sister and 13-year-old X with 3 bladder stones
Oct 2, 2012, a Tuesday. I took time off and went to Khin Khin Employment Agency at Peninsula Plaza to teach her manager more about the management of the business. The Government had increased increased the foreign worker quota and clamped down on phantom workers.
Now, a company must employ 5 Singaporeans before it can employ 1 foreign worker instead of 4 to 1. In addition, many companies have been fined for using "phantom workers" who are mainly retirees and others not gainfully employed by the company to make up the 4 Singaporeans to get approval for 1 foreign worker.
After the elections in which foreign workers were said to depress wages of Singaporeans, the foreign worker quota is raised and the foreign worker levy on employer is increased. "Many of the retirees are now out of CPF contributions since they were phantom workers," I observed.
The euro crisis and economic recession reduced the demand for foreign workers. Some have to be sent home due to the increased quota and loss of phantom workers. So Khin Khin and other employment agencies find that they have little demand for their services from the small businesses looking for waitresses and drivers. No quota at all. Close shop or do other services.
As Khin Khin is in Yangon, I dropped in to check on her manager Ni Ni. He had been working 6 months on the S Pass and is supporting his wife and son in Yangon.
Suddenly a young lady in her late 20s and wearing greyish dental braces appeared at the door. Khin Khin's office door does not shut unlike other offices. She came closer and said to me: "Have I seen you somewhere before?" I was astonished. I could not recall. I did see her somewhere. "Are you Dr Sing?" she asked. "Yes," I said.
"Do you remember my dog Brandy?"
"Yes," I said. "The 13-year-old cross bred with three bladder stones.
What a coincidence. I phoned her earlier to tell enquire about her dog's urination situation. The dog was OK but not eating the S/D.
I did advise neutering to reduce the enlarged and inflammed prostate to be done on Monday. But it is Wednesday today. The dog was no longer painful in the prostate when I discharged it 3 days ago but it was very painful when I took over the case. An enlarged painful prostate with bacteria in the bladder can cause painful and difficult urination, other than the 3 bladder stones. But it is hard to explain to the 3 sisters. After all, the dog is peeing normally. Owner compliance is much more difficult.
I did not remove the bladder stones because this dog was so skinny and might die under anaesthesia. Neutering is a short surgery and so I advised it to prevent prostate enlargement and inflammation. But it is extremely difficult to convince the owner to do it and this is a common situation in all medical practices.
Now, a company must employ 5 Singaporeans before it can employ 1 foreign worker instead of 4 to 1. In addition, many companies have been fined for using "phantom workers" who are mainly retirees and others not gainfully employed by the company to make up the 4 Singaporeans to get approval for 1 foreign worker.
After the elections in which foreign workers were said to depress wages of Singaporeans, the foreign worker quota is raised and the foreign worker levy on employer is increased. "Many of the retirees are now out of CPF contributions since they were phantom workers," I observed.
The euro crisis and economic recession reduced the demand for foreign workers. Some have to be sent home due to the increased quota and loss of phantom workers. So Khin Khin and other employment agencies find that they have little demand for their services from the small businesses looking for waitresses and drivers. No quota at all. Close shop or do other services.
As Khin Khin is in Yangon, I dropped in to check on her manager Ni Ni. He had been working 6 months on the S Pass and is supporting his wife and son in Yangon.
Suddenly a young lady in her late 20s and wearing greyish dental braces appeared at the door. Khin Khin's office door does not shut unlike other offices. She came closer and said to me: "Have I seen you somewhere before?" I was astonished. I could not recall. I did see her somewhere. "Are you Dr Sing?" she asked. "Yes," I said.
"Do you remember my dog Brandy?"
"Yes," I said. "The 13-year-old cross bred with three bladder stones.
What a coincidence. I phoned her earlier to tell enquire about her dog's urination situation. The dog was OK but not eating the S/D.
I did advise neutering to reduce the enlarged and inflammed prostate to be done on Monday. But it is Wednesday today. The dog was no longer painful in the prostate when I discharged it 3 days ago but it was very painful when I took over the case. An enlarged painful prostate with bacteria in the bladder can cause painful and difficult urination, other than the 3 bladder stones. But it is hard to explain to the 3 sisters. After all, the dog is peeing normally. Owner compliance is much more difficult.
I did not remove the bladder stones because this dog was so skinny and might die under anaesthesia. Neutering is a short surgery and so I advised it to prevent prostate enlargement and inflammation. But it is extremely difficult to convince the owner to do it and this is a common situation in all medical practices.
Monday, October 1, 2012
1126. Audit - intestinal surgery - removal of foreign body
Every vet at Toa Payoh Vets is required to maintain a proper record of anaesthesia and surgery in a book dedicated to each vet. I audit some cases now and then. This case is interesting as it has been performed in a short time, using only domitor and ketamine, without isoflurane gas.
AUDIT OF ANAESTHESIA & SURGERY BY ASSOCIATE VET
Bichon, Male, 3 months
Vomiting over 5 days
Ate prayer food
Hard lump 3x2x2 cm in large intestine. Painful
ANAESTHESIA
Sep 30, 2012 (Sunday) 1.8 kg 3 months
Dom/Ket 0.07/0.09
50% given 0.04/0.05 IV
A: Injection D+K IV 3.47 pm
D: First skin incision 3.56 pm
E: Completion of skin stitching 4.11 pm
No isoflurane gas used for enterotomy
E-A = 24 min
E-D = 5 min
SURGERY
Around 3 cm incision. Big greenish hairy hard lump taken out.
"Apricot seed," my vet said.
3/0 monosyn appositional stitches.
I saw the intestinal wall as over 4 mm in width. Blackish edge over red inflamed patch where hard Foreign Body was lodged. Gangrene had set in. That was why dog was vomiting.
Vet has 3 years of experience. A good surgery done.
No blood test and no x-ray due to financial reasons. The owner decided on surgery on Friday evening but I advised the associate vet to wait 2 more days to strengthen the health (vomiting for past 5 days due to financial reasons, not seeking vet treatment). On Sunday afternoon, this dog was operated and today, he looks as good as gold.
Day 2 Oct 1, 2012 11.32 am, I checked the dog and took some pictures. Active. Disliked e-collar.
AUDIT OF ANAESTHESIA & SURGERY BY ASSOCIATE VET
Bichon, Male, 3 months
Vomiting over 5 days
Ate prayer food
Hard lump 3x2x2 cm in large intestine. Painful
ANAESTHESIA
Sep 30, 2012 (Sunday) 1.8 kg 3 months
Dom/Ket 0.07/0.09
50% given 0.04/0.05 IV
A: Injection D+K IV 3.47 pm
D: First skin incision 3.56 pm
E: Completion of skin stitching 4.11 pm
No isoflurane gas used for enterotomy
E-A = 24 min
E-D = 5 min
SURGERY
Around 3 cm incision. Big greenish hairy hard lump taken out.
"Apricot seed," my vet said.
3/0 monosyn appositional stitches.
I saw the intestinal wall as over 4 mm in width. Blackish edge over red inflamed patch where hard Foreign Body was lodged. Gangrene had set in. That was why dog was vomiting.
Vet has 3 years of experience. A good surgery done.
No blood test and no x-ray due to financial reasons. The owner decided on surgery on Friday evening but I advised the associate vet to wait 2 more days to strengthen the health (vomiting for past 5 days due to financial reasons, not seeking vet treatment). On Sunday afternoon, this dog was operated and today, he looks as good as gold.
Day 2 Oct 1, 2012 11.32 am, I checked the dog and took some pictures. Active. Disliked e-collar.
Sunday, September 30, 2012
1125. Sunday's interesting cases - Sep 30, 2012
Sep 30, 2012
Bright sunny day
Case 1. Red-eared slider with "smaller and sunken" left eye. The husband and wife came for a review. "How many turtles have you treated?" she asked me.
"Around seven cases last year," I said. "Singaporeans seldom keep turtles to an older age like yours and there are not many." Maybe Toa Payoh Vets get less turtle cases. Who knows?
"They release the turtles to the reservoirs," the slim wife with dark rimmed glasses said. "What type of cases you see?"
"Mostly eye problems like closed eyes. Rectal prolapse, cracked shells and not eating."
2 days ago, the husband brought the turtle for consultation as he observed the left eye sunken and smaller than the right eye. He is an observant man as his wife did not know any eye change.
I could see the haziness in the upper part of the cornea of the smaller left eye and took some images to document corneal ulceration (green flurosecein stain). Dr Daniel gave an IM injection in the back thigh muscle of an anti-inflam and antibiotics.
I advised cleaning up the turtle as it smelled fishy, giving eyedrops 3x/day and not letting the eye get wet unless eating time. After eating, wash the eye with boiled water. "Or tap water left overnight as there is chlorine in the water and that will evaporate overnight," I said.
However the husband said: "The tap water has only fluoride, not chlorine." I can't substantiate this and so said nothing.
Today, the husband was to bring the turtle for review and he did so. The turtle's left eye looked so much clearer. It is still sunken but lesser. How to prove it? It was difficult as the turtle did not permit me to take image head-on of both eyes on the reception counter. He was restless and moving. "Do it inside the consultation room after switching off the lights, as before," the husband advised. "Use ISO 3200."
"The images are not so good compared to natural light in the waiting room," I said. "I used ISO 6400 the last time." As I did not want to upset the owner, I took images inside the darkened consultation room. The turtle was calmer. The cornea looked much more transparent esp. in the 11 to 2 o'clock area where there was cloudiness 2 days ago.
Case 2.
Shih Tzu, 1 year old, with red ear lumps in both ears but the lady in her 40s said that there was no scratching. The right ear was more painful when I palpated the vertical canal and the dog cried.
She had seen my associate vet for the past 3 times with the same problems. Antibiotics, injection and ear flushing again.
"I had spent much money in the eye ulceration treatment last time," she said to me when I advised lateral ear resection surgery. Now she trimmed the hairs around the eyes and put eye drops daily. No more eye ulcerations but this ear inflammation and pus could not be resolved since Jan 2012.
"It is usually the money matters," I said. "Ear surgery is the solution to open up the vertical canal to enable the horizontal canal to be ventilated and drained as the shih tzu's floppy ears covered up the canals 24 hours/day. But most owners will not accept the surgery due to its costs."
"How much?" she asked.
"I estimate $500 for one ear, including nursing care for around 7 days post surgery. It is just an estimate."
Now she had seen my associate vet 4 times and tried to clean the ears and give medication. The total costs and her time would be $600.
"It is just the luck of the owner," I said. "Some families have children with health problems and incur lots of medical expenses. I just have a case of a Shih Tzu dog owner who spent over $8,000 just for 5 bladder stones removal in the dog. Other Shih Tzu owners have no need to spend a cent."
Case 3.
An apricot seed inside the large intestine of the Maltese. I came back to the surgery at 3.30 pm to check whether my associate vet had operated on this Maltese. The owner had delayed operation but the dog kept vomiting and she decided on the operation on Friday. I advised against immediate operation for expediency as Saturday was the day off for my associate vet. The dog needed the IV drip and antibiotics to recover. Today, Sunday, the dog was in much better health but still vomited. My associate vet took out the apricot seed, put in interrupted appositional stitches to close up the wound. The large intestines were inflamed to 6 mm in depth of mucosa and serosa. The dog was alert and well after surgery. That was good.
Case 4
The old Minature Schnauzer with the bloated stomach of closed pyometra came back for stitch removal as required by Dr Vanessaa. I asked Dr Daniel to remove the stitches. The pyometra surgery was done on 31 August. None of the nylon stitches were present now as it is past one month since surgery. This dog had pus in the hairy ears and dry skin problems in the forearm and body. At least she did survive the surgery as I thought the pyometra would burst if you see the images in my case studies.
"Today, there is a white spot in the left eye," the wife said.
Bright sunny day
Case 1. Red-eared slider with "smaller and sunken" left eye. The husband and wife came for a review. "How many turtles have you treated?" she asked me.
"Around seven cases last year," I said. "Singaporeans seldom keep turtles to an older age like yours and there are not many." Maybe Toa Payoh Vets get less turtle cases. Who knows?
"They release the turtles to the reservoirs," the slim wife with dark rimmed glasses said. "What type of cases you see?"
"Mostly eye problems like closed eyes. Rectal prolapse, cracked shells and not eating."
2 days ago, the husband brought the turtle for consultation as he observed the left eye sunken and smaller than the right eye. He is an observant man as his wife did not know any eye change.
I could see the haziness in the upper part of the cornea of the smaller left eye and took some images to document corneal ulceration (green flurosecein stain). Dr Daniel gave an IM injection in the back thigh muscle of an anti-inflam and antibiotics.
I advised cleaning up the turtle as it smelled fishy, giving eyedrops 3x/day and not letting the eye get wet unless eating time. After eating, wash the eye with boiled water. "Or tap water left overnight as there is chlorine in the water and that will evaporate overnight," I said.
However the husband said: "The tap water has only fluoride, not chlorine." I can't substantiate this and so said nothing.
Today, the husband was to bring the turtle for review and he did so. The turtle's left eye looked so much clearer. It is still sunken but lesser. How to prove it? It was difficult as the turtle did not permit me to take image head-on of both eyes on the reception counter. He was restless and moving. "Do it inside the consultation room after switching off the lights, as before," the husband advised. "Use ISO 3200."
"The images are not so good compared to natural light in the waiting room," I said. "I used ISO 6400 the last time." As I did not want to upset the owner, I took images inside the darkened consultation room. The turtle was calmer. The cornea looked much more transparent esp. in the 11 to 2 o'clock area where there was cloudiness 2 days ago.
Case 2.
Shih Tzu, 1 year old, with red ear lumps in both ears but the lady in her 40s said that there was no scratching. The right ear was more painful when I palpated the vertical canal and the dog cried.
She had seen my associate vet for the past 3 times with the same problems. Antibiotics, injection and ear flushing again.
"I had spent much money in the eye ulceration treatment last time," she said to me when I advised lateral ear resection surgery. Now she trimmed the hairs around the eyes and put eye drops daily. No more eye ulcerations but this ear inflammation and pus could not be resolved since Jan 2012.
"It is usually the money matters," I said. "Ear surgery is the solution to open up the vertical canal to enable the horizontal canal to be ventilated and drained as the shih tzu's floppy ears covered up the canals 24 hours/day. But most owners will not accept the surgery due to its costs."
"How much?" she asked.
"I estimate $500 for one ear, including nursing care for around 7 days post surgery. It is just an estimate."
Now she had seen my associate vet 4 times and tried to clean the ears and give medication. The total costs and her time would be $600.
"It is just the luck of the owner," I said. "Some families have children with health problems and incur lots of medical expenses. I just have a case of a Shih Tzu dog owner who spent over $8,000 just for 5 bladder stones removal in the dog. Other Shih Tzu owners have no need to spend a cent."
Case 3.
An apricot seed inside the large intestine of the Maltese. I came back to the surgery at 3.30 pm to check whether my associate vet had operated on this Maltese. The owner had delayed operation but the dog kept vomiting and she decided on the operation on Friday. I advised against immediate operation for expediency as Saturday was the day off for my associate vet. The dog needed the IV drip and antibiotics to recover. Today, Sunday, the dog was in much better health but still vomited. My associate vet took out the apricot seed, put in interrupted appositional stitches to close up the wound. The large intestines were inflamed to 6 mm in depth of mucosa and serosa. The dog was alert and well after surgery. That was good.
Case 4
The old Minature Schnauzer with the bloated stomach of closed pyometra came back for stitch removal as required by Dr Vanessaa. I asked Dr Daniel to remove the stitches. The pyometra surgery was done on 31 August. None of the nylon stitches were present now as it is past one month since surgery. This dog had pus in the hairy ears and dry skin problems in the forearm and body. At least she did survive the surgery as I thought the pyometra would burst if you see the images in my case studies.
"Today, there is a white spot in the left eye," the wife said.
1124. Cost, Duration & Complications of spaying a 3-year-old jack russell query
On Sun, Sep 30, 2012 at 2:39 PM, ...1989@hotmail.com> wrote:
Hi,
I have a female jack russell coming 36 months but has yet to be spay.. Can i knw if there're any complications doing this procedure at this age? And roughly the duration and cost of it? Kindly advise, thank you.Cheers,J Y
EMAIL REPLY FROM DR SING DATED SEP 30, 2012
Thank you for your email. I am Dr Sing K Y from Toa Payoh Vets.
Generally, all healthy female dogs at around 36 months of age will have no complications during or after spay.
Generally, all healthy female dogs at around 36 months of age will have no complications during or after spay.
Complications refer to anaesthetic deaths, post-op deaths, bleeding and infections. The duration of spay should be less than 30 minutes and the estimated total cost is around $250-350 at Toa Payoh Vets ( including anaesthesia, surgery, post-op injections and medication and e-collar). Pl make an appointment at 6254 3326 one day in advance.
The best time to spay is 2-3 months after the last heat (bleeding)
The best time to spay is 2-3 months after the last heat (bleeding)
1123. VETERINARY TIPS. Take digital images of complicated post-operation cases to make you a better vet
Taking images of cases with your camerar or phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon.
There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review and plan your surgery in your office.
For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. This is shown below:
This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catheterised with a smaller sized urinary catheter
Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid.
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area.
For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. This is shown below:
This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catheterised with a smaller sized urinary catheter
According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage.
This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones).
How to resolve this problem with the least cost to the owner?
How to resolve this problem with the least cost to the owner?
That is the tough part. Will a 2nd urethrostomy and closure of the first urethral stoma and scrotal ablation resolve the problem for once and for all?
Vet 4 at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg and Vet 4 stitched up the urethral stoma (first urethrostomy done by Vet 1).
Would this resolve the problem? Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid.
(I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days after Vet 4's surgery.
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area.
"It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means more money expenditure for the owner."
As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem.
As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem.
This involved talking to Vet 3 as to what had been done. Vet 3 said that an ultrasound revealed fluid inside the scrotum and this was not recorded in the case report as the owner was not charged.
Ultrasound can reveal fluid in an organ but will not be able to tell whether it was urine or blood or both.
This is where the perineal swelling in this image substantiates a possible urine leakage. It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.
So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.
My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.
In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.
This is where the perineal swelling in this image substantiates a possible urine leakage. It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.
So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.
My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.
In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.
Not all bladder surgery is free from complications. In this case, the perineal urethra could have been damaged. Hence the urine leaked into the perineum (causing large swellings). The urine also flowed into the scrotal sace, hence another large swelling.
Friday, September 28, 2012
1122. The vet transports the dog for an X-ray
"Surely it is not (befitting) your status to personally drive and transport the dog to get an X-ray done!" Dr Jason Teo's transport man met me at a Clinic where he had taken a cat for x-ray of the pyometra.
"My transport man had sold his van and the others were not available," I explained.
Steven pointed to an old Mercedes outside the clinic. Its engine old and smoke from the exhaust puffing out and said: "Surely, the petrol of the Mercedes would cost more than your transport cost. Why don't you just phone me?"
"I thought you just groom dogs for Jason," I did not tell him that the black Mercedes was not mine and I don't idle the engine when I park the car. It takes some time at this clinic to get the dog X-rays. In any case, I dislike polluting the environment by idling the engine unnecessarily.
"I do dog transport when I need the money," he laughed. He is an old guard in this pet business.
I find that much can be learnt just by transporting the dog for X-ray to any clinic. In one clinic, I was made most welcome by the vets. In another clinic, I would not be permitted to see any vet nor proceed past the waiting room as it has an awesome gate-keeper. So I learnt a lot by being on the ground.
"My transport man had sold his van and the others were not available," I explained.
Steven pointed to an old Mercedes outside the clinic. Its engine old and smoke from the exhaust puffing out and said: "Surely, the petrol of the Mercedes would cost more than your transport cost. Why don't you just phone me?"
"I thought you just groom dogs for Jason," I did not tell him that the black Mercedes was not mine and I don't idle the engine when I park the car. It takes some time at this clinic to get the dog X-rays. In any case, I dislike polluting the environment by idling the engine unnecessarily.
"I do dog transport when I need the money," he laughed. He is an old guard in this pet business.
I find that much can be learnt just by transporting the dog for X-ray to any clinic. In one clinic, I was made most welcome by the vets. In another clinic, I would not be permitted to see any vet nor proceed past the waiting room as it has an awesome gate-keeper. So I learnt a lot by being on the ground.
Subscribe to:
Posts (Atom)