June 19, 2012
Yesterday, X-rays were done. A 70-ml normal saline enema via the whole dog's cathether was gently squirted into the colon. When blocked, squirted saline and push catheter in. So, the whole length of the catheter was passed in. An enema and oil laxative was given. Today, the owner phoned Dr Daniel to say one very hard stool had been passed by the cat this morning.
"Should feed canned food," I advised. The cat would eat only dry food. The cat ate a bit and vomited the oil. Wait and see.
Tuesday, June 19, 2012
1032. Follow up: Monday Jun 18, 2012 JRX leukaemia
Trembling, recumbent on Thursday June 14, 12
Not eating for 5 days. Intensive IV fluid including amino acids, Vit K1
Went back on Saturday with poor prognosis of acute leukaemia. The shivering was attribute to a very low blood glucose from the blood test.
I phoned up on Monday Jun 18, 12
"The dog is good," the caregiver maid said. "He eats and drinks. No shivering. He does not want me to carry him downstairs to pee. He will walk to the lift and then walk on the ground floor." This dog will never pees inside the apartment. I was surprised at his rapid recovery considering that he was shaking all over his body 4 days ago.
Not eating for 5 days. Intensive IV fluid including amino acids, Vit K1
Went back on Saturday with poor prognosis of acute leukaemia. The shivering was attribute to a very low blood glucose from the blood test.
I phoned up on Monday Jun 18, 12
"The dog is good," the caregiver maid said. "He eats and drinks. No shivering. He does not want me to carry him downstairs to pee. He will walk to the lift and then walk on the ground floor." This dog will never pees inside the apartment. I was surprised at his rapid recovery considering that he was shaking all over his body 4 days ago.
Sunday, June 17, 2012
1031. Sunday Jun 17, 12 interesting cases
Sunday Jun 17, 12
1. A Shih Tzu with the "decomposed corpse" smell
Yesterday was a Saturday. I came to the Surgery by bus and subway and reached at 9 am to help Mr Min and get feedback. Dr Vanessa was on duty to my surprise. A phone call came in and the owner said: "Are you Dr Sing?"
I said yes. "I want to send my Shih Tzu to the SPCA as I can't stand his decomposing smell anymore. 2 or 3 days after bathing, the odour of rotten flesh comes from his lower body. The top half of his body has no smell. I had consulted other vets and your vet (name given) 4 times but there is the same foul smell in the whole apartment. I prefer not to send him to the SPCA if you can resolve his body odour."
"Have I treated this dog before?" I asked.
"No," he said. I asked the owner to leave the dog overnight as I would be off duty. Then, on Sunday today, I had a good check up of this dog.
SIGNIFICANT FINDINGS
Shih Tzu, Male, Neutered, 8 years old, 8.2 kg.
1. Ventral part of the body has been shaved. It is inflamed and has some flakes. I smelled the ventral areea. A faint vinegar smell but no stinking rotten flesh smell. When I told the owner about this, he said: "I had bathed the dog recently. But the whole bedroom will be full of rotten flesh smell after a few days."
2. Right anal sac was full of dark grey oily graunules. Left anal sac had some too. When I put the tissue paper with this oil, onto a table, outside the surgery for photography, at least two flies and one insect buzzed in excitely. No foul smell.
HISTORY AT TOA PAYOH VETS
Dec 09 skin problem
May 10 buy medicine for skin problem
Aug 10 buy medicine for skin problem
Oct 10 skin esp. ventral region.
Apr 11 skin, anal sac rupture
Jul 11 buy medicine for skin problem
Jun 17, 12 Phoned Dr Sing. I told him to bring reports of another vet he saw "2 months ago" and to write what has happend to the dog during the past years.
HISTORY AT OTHER VET PRACTICE
Feb & Mar 12 Consulted another practice, according to reports presented by the owner.
Vomited and had bloody diarrhoea when he took 3 types of medication and so the owner stopped them.
LETTER FROM OWNER
The main point of the detailed letter is that the dog uses his hind legs to scratch the lower part of his body and makes some noise as if in pain. The foul smell comes after the first day of shower.
SIGNIFICANT FINDING TODAY
Ventral dermatitis with redness and scales. Ringworm +ve. Check for yeast.
Anal sac full of dark brown anal oil.
1. A Shih Tzu with the "decomposed corpse" smell
Yesterday was a Saturday. I came to the Surgery by bus and subway and reached at 9 am to help Mr Min and get feedback. Dr Vanessa was on duty to my surprise. A phone call came in and the owner said: "Are you Dr Sing?"
I said yes. "I want to send my Shih Tzu to the SPCA as I can't stand his decomposing smell anymore. 2 or 3 days after bathing, the odour of rotten flesh comes from his lower body. The top half of his body has no smell. I had consulted other vets and your vet (name given) 4 times but there is the same foul smell in the whole apartment. I prefer not to send him to the SPCA if you can resolve his body odour."
"Have I treated this dog before?" I asked.
"No," he said. I asked the owner to leave the dog overnight as I would be off duty. Then, on Sunday today, I had a good check up of this dog.
SIGNIFICANT FINDINGS
Shih Tzu, Male, Neutered, 8 years old, 8.2 kg.
1. Ventral part of the body has been shaved. It is inflamed and has some flakes. I smelled the ventral areea. A faint vinegar smell but no stinking rotten flesh smell. When I told the owner about this, he said: "I had bathed the dog recently. But the whole bedroom will be full of rotten flesh smell after a few days."
2. Right anal sac was full of dark grey oily graunules. Left anal sac had some too. When I put the tissue paper with this oil, onto a table, outside the surgery for photography, at least two flies and one insect buzzed in excitely. No foul smell.
HISTORY AT TOA PAYOH VETS
Dec 09 skin problem
May 10 buy medicine for skin problem
Aug 10 buy medicine for skin problem
Oct 10 skin esp. ventral region.
Apr 11 skin, anal sac rupture
Jul 11 buy medicine for skin problem
Jun 17, 12 Phoned Dr Sing. I told him to bring reports of another vet he saw "2 months ago" and to write what has happend to the dog during the past years.
HISTORY AT OTHER VET PRACTICE
Feb & Mar 12 Consulted another practice, according to reports presented by the owner.
Vomited and had bloody diarrhoea when he took 3 types of medication and so the owner stopped them.
LETTER FROM OWNER
The main point of the detailed letter is that the dog uses his hind legs to scratch the lower part of his body and makes some noise as if in pain. The foul smell comes after the first day of shower.
SIGNIFICANT FINDING TODAY
Ventral dermatitis with redness and scales. Ringworm +ve. Check for yeast.
Anal sac full of dark brown anal oil.
Saturday, June 16, 2012
1030. Consistent professional advice for struvite UTI
http://www.bekindtopets.com/dogs/20120614veterinary-database-UTI_singapore-ToaPayohVets.htm
From Jun 23, 2012, all vets at Toa Payoh Vets will practise evidence-based medicine. In cases of urinary tract infection, urethral obstruction and urinary stone removal, urine test is the minimal test to be done.
Blood test, X-rays, ultrasound, urinary stone analysis (in urinary stone removal) should be advised and recorded that advices have been given. These tests (esp. urinary stone analysis) should be done, whenever relevant and possible unless the owner has economic reasons for not wanting tests done. An example is given below:
Friday, June 15, 2012
1030. Consistent professional advice for struvite UTI
I have spoken to Dr V and Dr D regarding the need to give a consistent advice on the management of struvite UTI in dogs. Many Singaporean owners check the internet and are more sophisticated than in the old days.
A case is illustrated:
Case of the female Shetland, one year old. Dr Daniel's case
Jun 10, 2012. Complaint of blood in the urine for 2-3 months.
X-ray of bladder advised but not accepted
Urine test
pH 9.0 (5-8)
SG 1.026 (1.005-1.030)
Protein +
Blood trace
WBC 30
RBC 10
Bacteria 2+
Triple phosphate occasional
Tentative diagnosis should be UTI with struvites. Dietary management, acidification of the urine and antibiotics should be the treatment, not just antibiotics.
Follow-up urine test in 4 weeks is the minimum. X-rays of the bladder will be preferred. Most owners don't bother with follow-up. It is important.
Note: Triple phosphates are "struvites".
Toa Payoh Vets' Dog Spay's Key Performance Indicators
129. Follow up: The female Schnauzer peed out 5 urinary stones
HISTORY
The female Miniature Schnauzer peed blood in the urine. Urine test showed struvite crystals. X-ray showed several bladder stones. The owners wanted spay and urinary stone removal at the same time. I did not agree to this as the anaesthetic and surgical risk would be higher. So nothing was done. When I was in Hong Kong on May 25, 2012, I received a phone call from the husband. The dog had difficulty peeing and was lethargic. I referred him to another vet who took an X-ray and was willing to do spay and urinary stone removal at the same time. Since it was Saturday, the fees would be higher. On Sunday, the owners took the dog back. No news from them. Around June 11, 2012, the owner asked me to spay the dog first. The following is a follow-up on the spay.
E-MAIL TO DR SING DATED Jun 13, 2012
Hi Dr. Sing,
Attached is a picture of the bladder stones passed out together with the urine by XXX.
The stones started to show up 2 days after putting her on the *S/D diet prescribed by you.
The largest of the five stones came out on 24 May 2012 (Thursday). That was the day before she had difficulty to urinate and we sent her to your referred vet.
Thanks.
*2 cans of S/D diet were purchased by the owner although a 30-days' supply was advised. They felt that the dog might not eat the diet.
E-MAIL FROM DR SING DATED JUN 14, 2012
Hi
Thank you for your email and pictures.
How is XXX recovering from the spay? When she starts eating normally?
E-MAIL TO DR SING DATED Jun 16, 2012
Hi Dr. Sing
Thank you for your concern. XXX is recovering well as if nothing had happened and she is eating well, except that I noticed a red patch (about 2cm in dia) forming on her skin close to the incision point.
I am quite curious to see mytwo male dogs are getting very excited and trying persistently to climb on her these few days but she doesn't seem to be on heat. Any idea why they are behaving this way ?
E-MAIL FROM DR SING DATED JUN 16, 2012
Thank you for your email.The red patch may be due to the dog licking. Did your dog wear an e-collar? As for the male dogs being interested in her, she appeared to be on heat based on my observation of enlarged ovaries during the spay. You said her last heat was 4 months ago butit could be 5-6 months ago and so the dog came onto heat. So the male dogs would still be interested as spaying does not immediately stop the female dog from being attractive to male dogs.
You got 6 cans of S/D diet for her. Please note that the recommendation is to give S/D diet daily for 1-3 months if you wish to dissolve the struvite stones. The remaining 3 bigger stones may not dissolve even on S/D diet is given as recommended and surgical removal may be the option if there is persistent blood in the urine.
Best wishes.
The female Miniature Schnauzer peed blood in the urine. Urine test showed struvite crystals. X-ray showed several bladder stones. The owners wanted spay and urinary stone removal at the same time. I did not agree to this as the anaesthetic and surgical risk would be higher. So nothing was done. When I was in Hong Kong on May 25, 2012, I received a phone call from the husband. The dog had difficulty peeing and was lethargic. I referred him to another vet who took an X-ray and was willing to do spay and urinary stone removal at the same time. Since it was Saturday, the fees would be higher. On Sunday, the owners took the dog back. No news from them. Around June 11, 2012, the owner asked me to spay the dog first. The following is a follow-up on the spay.
E-MAIL TO DR SING DATED Jun 13, 2012
Hi Dr. Sing,
Attached is a picture of the bladder stones passed out together with the urine by XXX.
The stones started to show up 2 days after putting her on the *S/D diet prescribed by you.
The largest of the five stones came out on 24 May 2012 (Thursday). That was the day before she had difficulty to urinate and we sent her to your referred vet.
Thanks.
*2 cans of S/D diet were purchased by the owner although a 30-days' supply was advised. They felt that the dog might not eat the diet.
E-MAIL FROM DR SING DATED JUN 14, 2012
Hi
Thank you for your email and pictures.
How is XXX recovering from the spay? When she starts eating normally?
E-MAIL TO DR SING DATED Jun 16, 2012
Hi Dr. Sing
Thank you for your concern. XXX is recovering well as if nothing had happened and she is eating well, except that I noticed a red patch (about 2cm in dia) forming on her skin close to the incision point.
I am quite curious to see mytwo male dogs are getting very excited and trying persistently to climb on her these few days but she doesn't seem to be on heat. Any idea why they are behaving this way ?
E-MAIL FROM DR SING DATED JUN 16, 2012
Thank you for your email.The red patch may be due to the dog licking. Did your dog wear an e-collar? As for the male dogs being interested in her, she appeared to be on heat based on my observation of enlarged ovaries during the spay. You said her last heat was 4 months ago butit could be 5-6 months ago and so the dog came onto heat. So the male dogs would still be interested as spaying does not immediately stop the female dog from being attractive to male dogs.
You got 6 cans of S/D diet for her. Please note that the recommendation is to give S/D diet daily for 1-3 months if you wish to dissolve the struvite stones. The remaining 3 bigger stones may not dissolve even on S/D diet is given as recommended and surgical removal may be the option if there is persistent blood in the urine.
Best wishes.
Friday, June 15, 2012
1028. The rabbit keeps rubbing his right eye for 2 weeks
Today Jun 15, 2012 Friday, I was at the Surgery the whole day from 9am onwards. This is the 3rd day I took the feeder bus and subway train and feeder bus to Toa Payoh Vets as I used to drive over the past years. It is a form of exercise and an experience to appreciate life, the morning sun and the heartlanders going to work. It is humid and sweaty but that is living.
I did my trust and audit cases of the associate vets. One of these cases involved eye problems in the rabbit. Many rabbits seem to have eye problems and some vets may not be keen on treating them. I assessed how my vets treat such cases in the "trust and audit" checks. I got the dwarf rabbit into the consultation room and did the examination together with Dr Vanessa.
"You don't need to be a licensed vet if you just prescribe eye drops for "eye cases," I said to Dr Vanessa. "Any owner can buy eye drops and treat themselves if the vet just prescribe eye drops!"
The young couple came with a male 2-month-old Netherland dwarf rabbit with a red itchy right eye and a red nose. "We went to Vet 1," the fair trim lady said. "But my rabbit is still scratching his right eye."
"What did Vet 1 do?" I asked.
"He gave eye drops. We have used up the eye drops now. But the rabbit is still scratching!"
"Your rabbit may have an eye ulcer," I said.
EYE EXAMINATION
1. White light shone onto the cornea. Nothing. The cornea was as clear and transparent.
2. "Use the fluorescein eye stain," I said to Dr Vanessa. "It will stain the ulcer. This should be standard operating procedure but many vets don't do it. Just prescribe eye drops and send the rabbit home."
3. As the rabbit was frisky, I advised a gas anaesthetic by mask. Surprisingly, a green stain from 11 to 1 o'clock showed up the corneal ulcer. I asked the couple to go into the op room to see the ulcer.
CAUSE OF THE ULCERATION
The owner did not know. "Do you have hanging balls with sharp hay inside?" I asked. "The hay may have injured the eye."
"We have the ball with hay stuck inside, on the cage floor" the couple said.
TREATMENT
2 WAYS
1. Conservative. Irrigation of the 3rd eyelid. Subcon injection and e-collar. Cage rest in a dark place for around 30 days.
2. Stitching up the upper and lower eyelid. This would be my choice as the healing of the ulcer is much faster. But there is a lot of nursing.
As the young couple will be unable to do the nursing, I did the conservative way. I asked my assistant Min to give them an old carrier as they have been taking the rabbit in an open basket. The rabbit may suddenly jump up and fall and fracture his leg or back.
CONCLUSION
Solving the owner's problem should be the best practice. Otherwise the owner just go to another practice.
I did my trust and audit cases of the associate vets. One of these cases involved eye problems in the rabbit. Many rabbits seem to have eye problems and some vets may not be keen on treating them. I assessed how my vets treat such cases in the "trust and audit" checks. I got the dwarf rabbit into the consultation room and did the examination together with Dr Vanessa.
"You don't need to be a licensed vet if you just prescribe eye drops for "eye cases," I said to Dr Vanessa. "Any owner can buy eye drops and treat themselves if the vet just prescribe eye drops!"
The young couple came with a male 2-month-old Netherland dwarf rabbit with a red itchy right eye and a red nose. "We went to Vet 1," the fair trim lady said. "But my rabbit is still scratching his right eye."
"What did Vet 1 do?" I asked.
"He gave eye drops. We have used up the eye drops now. But the rabbit is still scratching!"
"Your rabbit may have an eye ulcer," I said.
EYE EXAMINATION
1. White light shone onto the cornea. Nothing. The cornea was as clear and transparent.
2. "Use the fluorescein eye stain," I said to Dr Vanessa. "It will stain the ulcer. This should be standard operating procedure but many vets don't do it. Just prescribe eye drops and send the rabbit home."
3. As the rabbit was frisky, I advised a gas anaesthetic by mask. Surprisingly, a green stain from 11 to 1 o'clock showed up the corneal ulcer. I asked the couple to go into the op room to see the ulcer.
CAUSE OF THE ULCERATION
The owner did not know. "Do you have hanging balls with sharp hay inside?" I asked. "The hay may have injured the eye."
"We have the ball with hay stuck inside, on the cage floor" the couple said.
TREATMENT
2 WAYS
1. Conservative. Irrigation of the 3rd eyelid. Subcon injection and e-collar. Cage rest in a dark place for around 30 days.
2. Stitching up the upper and lower eyelid. This would be my choice as the healing of the ulcer is much faster. But there is a lot of nursing.
As the young couple will be unable to do the nursing, I did the conservative way. I asked my assistant Min to give them an old carrier as they have been taking the rabbit in an open basket. The rabbit may suddenly jump up and fall and fracture his leg or back.
CONCLUSION
Solving the owner's problem should be the best practice. Otherwise the owner just go to another practice.
1027. Follow up: Acute lymphoblastic leukaemia. Whole body shivering 12-year-old Jack Russell X
Acute lymphoblastic leukaemia - low RBC, low WBC, low platelets
Prognosis is poor. Vincristine and prednisolone advised. Remission does occur.
COMPARED TO 3 MONTHS AGO. Blood in the urine. Recovered 2 days after antibiotics.
BLOOD TEST
Date 27 Mar 2012
Glucose 4.1 (3.9 - 6)
Liver ALT 6.2 (<59)
AST 56 (<81)
Urea 8.0 (4.2 - 6.3)
Creatinine 85 (89-177)
Hb 16.3 (12-18)
Red Cell Count 6.5 (5.5-8.5)
Total WCC 10.7 (6-17)
N=75%, L=10%, M=12%, E=0%, B=2.3%, Atypical Lymphocytes - None
PCV 0.45 (0.37 - 0.55)
Platelets 487 (200-500)
Platelet clumping noted. Large platelets present. Occasional nucleated RBC seen.
URINE TEST. I had discussed this in another article earlier.
TREATMENT - CHEMOTHERAPY
A bone marrow biopsy is needed. Every treatment is around $1,000 and 6 treatments
Prognosis is poor. Vincristine and prednisolone advised. Remission does occur.
COMPARED TO 3 MONTHS AGO. Blood in the urine. Recovered 2 days after antibiotics.
BLOOD TEST
Date 27 Mar 2012
Glucose 4.1 (3.9 - 6)
Liver ALT 6.2 (<59)
AST 56 (<81)
Urea 8.0 (4.2 - 6.3)
Creatinine 85 (89-177)
Hb 16.3 (12-18)
Red Cell Count 6.5 (5.5-8.5)
Total WCC 10.7 (6-17)
N=75%, L=10%, M=12%, E=0%, B=2.3%, Atypical Lymphocytes - None
PCV 0.45 (0.37 - 0.55)
Platelets 487 (200-500)
Platelet clumping noted. Large platelets present. Occasional nucleated RBC seen.
URINE TEST. I had discussed this in another article earlier.
TREATMENT - CHEMOTHERAPY
A bone marrow biopsy is needed. Every treatment is around $1,000 and 6 treatments
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