1. I was surprised to see the young couple from Tampines as they had brought in their rabbit for treatment of scabies after purchase and I did not expect to see them again since many Singapore pet owners go for proximity and Tampines is a 20-minute drive to Toa Payoh.
"How long did it take the rabbit to recover from the scabies and ear mites after the injection?" I could see that the rabbit is fully cured. They had bought the rabbit with scabies in the ears, nose and paws and had consulted me some weeks ago. The rabbit seemed to have changed coat colour as I remembered he was grey and not brown. I wondered if it is a replacement rabbit. I have a video of it as it was used as a case study of the Lemon Law by Intern Terrence. The video is "Lemon Law for diseased/defective pets in Singapore" and is at:
http://www.youtube.com/watch?v=uHXcYlGmvOI&feature=youtu.be
"We complained to the Seller. He sent the rabbit back to the breeder who kept him for 3 weeks before returning to us!" the slim young lady said.
"Did you use a pee grate and tray for this rabbit's toilet?" I noted that the rabbit has urine-stained fur in the lower part of the four feet.
"No," the slim young man said. "We used one but it was so small in area that the rabbit stepped on it and peed outside the tray! So we put the brown cat litter pellets at one corner of the playpen and he would go above the cat litter to pee and poop."
"That explains why he has four paws urine stained. There should be a larger grate like the plastic one in your rabbit carrier you are carrying your rabbit to the vet. In this way, the urine can flow through onto the cat litter which would be enclosed by the tray. Go to the pet shop to buy one pee tray + grate for puppy toilet training. "
"The reason for the urine stain could be that we have not placed sufficient litter and so he stepped on the urine. We find it very difficult to wash off the urine stains."
"I will get the yellow urine-stained hairs cut off. Also the matted hair near the scrotum. It is important that your rabbit be free of urine and matted hairs, otherwise he may become sick."
The couple purchased a puppy grate + pen when they come to collect the rabbit at 4 pm. I asked Dr Daniel to hold the rabbit for them to check the absorbable stitches after neutering by Dr Daniel to make sure there is no bleeding. They were quite happy.
"Place urine-stained litter inside the tray and smear some smell at the corner of the grate," I advised. "Usually the owner will spread all litter covering 100% of the tray. You may find that the rabbit pees out of the tray as he has no clearance of the non-urine-stained area." The couple wanted to cover the whole tray with cat litter but this may not work as the rabbit may pee outside the tray owing to his positioning.
It was great to see this rabbit again and I did take some images. Certainly he looks like the same rabbit that had gone to live with the breeder for 3 weeks to get cured but it is hard to tell since there is no micro-chipping in rabbits! The couple was inexperienced in rabbits and so a replacement rabbit will be the same as the other one.
Sunday, September 29, 2013
Saturday, September 28, 2013
1164. Update on old Maltese. Abdomino-centesis shows bleeding inside the abdomen - old Maltese
Maltese, M, 14 years
Large abdominal mass 50% size of orange
Breathing difficulty around last 4 days
Abdominocentesis drew out 20 ml of blood which clotted soon, indicating fresh blood from abdominal mass.
Probably a splenic tumour starting to bleed. The kidney and liver enzymes were normal. IV drip
with amino acids and vitamins given. Dog went home and was active pacing the next day. Surgery is too risky. Owner does not want surgery anyway. Prognosis poor if bleeding continues.
Dog does eat but is emaciated.
Sep 28, 2013 Saturday 10.15 am
Spoke to husband
Dog has much less breathing difficulty. Active. Gums pinker.
"Any abdominal swelling?" I asked.
"No," he said. That means the bleeding of the tumour has stopped.
Will not want to eat the egg yolk or chicken liver. Husband asked whether he can get repeat medication in 7 days' time.
Advised hand-feeding of egg yolk and liver to build up red blood cells. Feeding 6x/day in small amounts and electrolytes. Heart medication given as well.
Large abdominal mass 50% size of orange
Breathing difficulty around last 4 days
Abdominocentesis drew out 20 ml of blood which clotted soon, indicating fresh blood from abdominal mass.
Probably a splenic tumour starting to bleed. The kidney and liver enzymes were normal. IV drip
with amino acids and vitamins given. Dog went home and was active pacing the next day. Surgery is too risky. Owner does not want surgery anyway. Prognosis poor if bleeding continues.
Sep 28, 2013 Saturday 10.15 am
Spoke to husband
Dog has much less breathing difficulty. Active. Gums pinker.
"Any abdominal swelling?" I asked.
"No," he said. That means the bleeding of the tumour has stopped.
Will not want to eat the egg yolk or chicken liver. Husband asked whether he can get repeat medication in 7 days' time.
Advised hand-feeding of egg yolk and liver to build up red blood cells. Feeding 6x/day in small amounts and electrolytes. Heart medication given as well.
Friday, September 27, 2013
1163. Update on cerebellar ataxia dog
On Sep 25, 2013
"What's the cause and what more medication is needed?" the lady owner asked me again when she came in late for some repeat medication and consultation after 8 pm. "It is hard to say," I told her. She showed me a short handphone clip of her 6-year-old female poodle taken the day before. The head and body tremors were not so pronounced as when I first saw it. The dog could amble for a short distance.
"In some nervous disease cases, more money has to be spent on tests like CT Scan, MRI, CSF fluid and more blood tests and other X-rays. But I know there is a financial limit and so the one blood test done was not sufficient. There is a possibility of a liver disorder and the causes can be infectious, toxic or other unknown causes
"Furthermore, each vet has his or her own way of treatment of this disease which is a rare disease," I said. "The first vet gave glucosamine.The 2nd vet referred you for a CT scan and prescribed no tests but the scans costs from $1500 - 2,000 and so your husband contacted me as the 3rd vet."
So far, with my medication, the dog can eat and that is what the owner wants.
"However, the cure is not available for cerebellar ataxia," I said. "Unless the cause is known or can be treated."
"What's the cause and what more medication is needed?" the lady owner asked me again when she came in late for some repeat medication and consultation after 8 pm. "It is hard to say," I told her. She showed me a short handphone clip of her 6-year-old female poodle taken the day before. The head and body tremors were not so pronounced as when I first saw it. The dog could amble for a short distance.
"In some nervous disease cases, more money has to be spent on tests like CT Scan, MRI, CSF fluid and more blood tests and other X-rays. But I know there is a financial limit and so the one blood test done was not sufficient. There is a possibility of a liver disorder and the causes can be infectious, toxic or other unknown causes
"Furthermore, each vet has his or her own way of treatment of this disease which is a rare disease," I said. "The first vet gave glucosamine.The 2nd vet referred you for a CT scan and prescribed no tests but the scans costs from $1500 - 2,000 and so your husband contacted me as the 3rd vet."
So far, with my medication, the dog can eat and that is what the owner wants.
"However, the cure is not available for cerebellar ataxia," I said. "Unless the cause is known or can be treated."
1162. Being organised and systematic
Today I asked my assistant Niang to sit down and have a chat with him as regards adding value to his employer. Management requires many re-education of the employees.
"A man must be able to control his temper," I said. "Especially with his employer. Later, when you want to find another better job, you don't expect your old employer to support you if you don't care about his business by not being organised,"
I gave him two examples of vets not being organised.
"Yesterday, you heard the owner of 2 dogs complaining that she had asked this vet who has set up her own practice that she wanted dental scaling in addition to neuter of 2 dogs. The vet did not do any dental scaling. I have a system where any job to be done on the pet to be written down, but many younger vets or their assistants don't do it. So, the practice loses income as the dental scaling of 2 dogs would have been additional income. Also, now the owner thinks badly of this vet who had been referred to her by her brother."
In another example today, the lady owner of the pug brought in the dog for me to examine the lameness in the left fore paw. I reviewed the medical records and there was a blood test done on this pug previously.
As I studied the blood test result report with this pug's name on it, she said of the vet who was not meticulous. "The name is incorrect. It is the name of my other pug."
She has 2 pugs and the young vet incorrectly labelled the blood tubes as belonging to the other pug.
"It is hard to teach young ones to be meticulous and organised and systematic if they don't want to be," I said to my assistant. "You just ruin your reputation if you are not meticulous as the owners will not want you to treat their dogs!"
Earlier in the morning, I was speaking to Julia, a manager of more than 20 staff and at one time more than 200 staff, about the younger generation. "The young ones have their ways of doing work and may not want to do it your way as your way is 'Old School'"
I replied: "Whether it is Old or New School, certain tasks must be done in an organised and systematic way. To be efficient and productive. If a surgery can be completed in 10 minutes, why take 30 minutes to do so? That has nothing to do with Old School of thoughts. It is the personality and character of the younger generation. "
"Unfortunately, the younger generation of Singaporeans behave "lassia faire" and in my organisation, we have to put up a "step by step" process of doing tasks too. You only manage so few younger staff."
I guess this problem of the younger generation born to an affluent period is common in all organisations.
"A man must be able to control his temper," I said. "Especially with his employer. Later, when you want to find another better job, you don't expect your old employer to support you if you don't care about his business by not being organised,"
I gave him two examples of vets not being organised.
"Yesterday, you heard the owner of 2 dogs complaining that she had asked this vet who has set up her own practice that she wanted dental scaling in addition to neuter of 2 dogs. The vet did not do any dental scaling. I have a system where any job to be done on the pet to be written down, but many younger vets or their assistants don't do it. So, the practice loses income as the dental scaling of 2 dogs would have been additional income. Also, now the owner thinks badly of this vet who had been referred to her by her brother."
In another example today, the lady owner of the pug brought in the dog for me to examine the lameness in the left fore paw. I reviewed the medical records and there was a blood test done on this pug previously.
As I studied the blood test result report with this pug's name on it, she said of the vet who was not meticulous. "The name is incorrect. It is the name of my other pug."
She has 2 pugs and the young vet incorrectly labelled the blood tubes as belonging to the other pug.
"It is hard to teach young ones to be meticulous and organised and systematic if they don't want to be," I said to my assistant. "You just ruin your reputation if you are not meticulous as the owners will not want you to treat their dogs!"
Earlier in the morning, I was speaking to Julia, a manager of more than 20 staff and at one time more than 200 staff, about the younger generation. "The young ones have their ways of doing work and may not want to do it your way as your way is 'Old School'"
I replied: "Whether it is Old or New School, certain tasks must be done in an organised and systematic way. To be efficient and productive. If a surgery can be completed in 10 minutes, why take 30 minutes to do so? That has nothing to do with Old School of thoughts. It is the personality and character of the younger generation. "
"Unfortunately, the younger generation of Singaporeans behave "lassia faire" and in my organisation, we have to put up a "step by step" process of doing tasks too. You only manage so few younger staff."
I guess this problem of the younger generation born to an affluent period is common in all organisations.
1161. Practising evidence-based medicine for an anorexic cat
On Sep 29, 2013, a cat owner said that his one-eyed cat has not been eating for the past 5 days. This is said to be a British Shorthair and Dr Daniel had remoed an ingrown toe-nail Right Digit 3 on Sep 11, 2013.
"My cat has not been eating after the ingrown toe nail surgery," he said to me.
"How long has the cat not been eating?" I palpated a bigger than golf-ball size firm lump in the mid-abdomen, similar in location to the 14-year-old Maltese case I wrote about recently.
"Past 5 days."
"There is a big spherical lump inside the abdomen," I had palpated a painless mass the size of a bigger golf ball. "It could be an enlarged kidney, bladder or hair ball in this young cat. X-rays and blood tests are needed."
It is extremely difficult to diagnose without lab evidence like X-ray and blood test.
Blood test results showed kidney disorder likely to be an infection as the neutrophils was over 90%. The cat was given an IV drip and medication to remove lots of gas inside the intestines as seen in the X-rays and ate nearly one can of K/D diet and drank water overnight at the surgery. Will be going home today.
Heartlander clientele wants the least medical cost but what to know the cause of the disease. So, in this case, the owner had to give permission for the test and get a diagnosis.
"My cat has not been eating after the ingrown toe nail surgery," he said to me.
"How long has the cat not been eating?" I palpated a bigger than golf-ball size firm lump in the mid-abdomen, similar in location to the 14-year-old Maltese case I wrote about recently.
"Past 5 days."
"There is a big spherical lump inside the abdomen," I had palpated a painless mass the size of a bigger golf ball. "It could be an enlarged kidney, bladder or hair ball in this young cat. X-rays and blood tests are needed."
It is extremely difficult to diagnose without lab evidence like X-ray and blood test.
Blood test results showed kidney disorder likely to be an infection as the neutrophils was over 90%. The cat was given an IV drip and medication to remove lots of gas inside the intestines as seen in the X-rays and ate nearly one can of K/D diet and drank water overnight at the surgery. Will be going home today.
Heartlander clientele wants the least medical cost but what to know the cause of the disease. So, in this case, the owner had to give permission for the test and get a diagnosis.
Update: Sebaceous adenoma in the old Husky's right eye
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UPDATE AS AT SEP 25, 2013
Thursday, September 26, 2013
1160. Seven days for the Maltese to live
On Wed, Sep 25, 2013 I received a phone call from a young lady for a 2nd opinion. Her 14-year-old male Maltese had breathing difficulties and was not eating. Vet 1 diagnosed anaemia and a big abdominal mass. She advised surgery but the owner did not want it. So the lady searched the internet forums and there were some recommendations for her to phone for Dr Jason Teo at Toa Payoh Vets.
"Dr Teo works at Toa Payoh Vets on Saturdays only," I said.
"Another vet at Toa Payoh Vets will be OK," she replied.
"What's the name of Vet 1 whom you first consulted?"
"I do not wish to disclose her name."
"Did she have X-rays and blood test results for your dog?" I asked as she was telling me the findings without the documentary evidence.
"Yes," she said.
"You can ask Vet 1 to fax or email to me at Toa Payoh Vets," I said.
"I don't think it is possible," she replied.
"Why not? Are the documents illegal?" I asked. "Vets do pass clinical records to each other when the owner seeks a 2nd opinion. I have done it before and other vets have done it. You just have to phone them and ask for the medical records."
She phoned later to say that Vet 1 would want her to go to the practice to take over the records and so would be late for the appointment. This was OK with me. Around 3 pm she came and saw Dr Daniel first. He had recorded "4 days of changed behaviour, increased breathing, decreased appetite and cannot walk. No vomiting, diarrhoea and no change in diet. Cheese treat for one week and polyuria and polydipsia.
Blood test from Vet 1. No abnormalities in the liver and kidneys or total white cell count. But RBC 3.37 (5.5 - 5.8), HGB 8.4 (12-18) and HCT 23.9 (37-55) were very low. I told the owner that the gums were purplish and the tongue was pale. This was not good.
The mid-abdominal lump was solid, painless and half the size of an orange. What is it?
Vet 1 was consulted for a "breathing problem". She had taken a lateral X-ray showing much fluid inside the swollen abdomen. Opaque areas obscured the views of intestines. Vet 1 said heart was enlarged. An abdominal mass pushed guts up and above. She recorded that the owner was not keen on surgery. Dog was anaemic and lung sounds were dry. She proposed pain relief since surgery was not acceptable.
Overall, Vet 1 was spot on in her diagnosis but the owner was not satisfied.
"Is it because you went when the practice was going to close?" I asked.
"Yes," she said.
Sometimes it is difficult to satisfy the owner on the first consultation in a medical condition with no cure except surgery. Yet this dog was 14 years old, very thin and I would say emaciated. Surgery would kill him. So I don't even want to propose surgery as this dog will never survive the long time needed to remove this large abdominal lump. In any case, the couple was never in favour of it.
But what is this large abdominal lump and what should the couple do?
"Euthanase the dog," one young vet suggested when I spoke to her after X-raying two views of the dog's chest and abdomen at her practice. "This dog is suffering and should not prolong her suffering"
"There was one government vet before your time," I said to this young lady. "He recommends euthanasia so many times that he has a reputation to be avoided. This is because the owners say that he will advise euthanasia in very sick cases. His intention was to save money for the owners but he gained the reputation of being an "euthanasia" vet to be avoided.
"In this case, the couple is against euthanasia. They want to know what is the nature of the abdominal tumour." Dr Daniel had proposed ultrasound scanning. From my reading of the couple, they want an acceptable solution such that the dog would live the last few days of his life without pain."
What more can be done other than ultrasound?
Dr Daniel elaborated on the causes of the swollen abdomen - bleeding, chyle, fluid from heart failure since the liver and kidneys were OK based on blood test from Vet 1, peritonitis. He also advised surgery to remove the abdominal mass as the only option. He advised abdomino-centesis to draw out the fluid to send to the lab for examination but sedation would be required and this would be risky as it may kill the dog. So the couple did not accept his suggestion and wanted to take the dog home.
I let Dr Daniel handle the case to the conclusion but I did give my take on this medical condition.
What should be done for this dog if surgery was not an option? "There is no need for sedation," I said to the couple. "We need to draw out the abdominal fluid so that your dog can breathe easier at least for the next 2 days and start eating." Each vet has his or her own opinion and my opinion was that abdomino-centesis could be done without much pain on this ill dog and so without any risk of death.
The only risk is in putting the needle into the abdominal mass. This was what I was concerned and so was the thinking behind the young lady vet who looked at the X-ray with me earlier. The needle might puncture this big lump.
"Not if you slide the needle under the umbilical skin," I did that with a 19G needle and fresh blood came out.
"Dr Teo works at Toa Payoh Vets on Saturdays only," I said.
"Another vet at Toa Payoh Vets will be OK," she replied.
"What's the name of Vet 1 whom you first consulted?"
"I do not wish to disclose her name."
"Did she have X-rays and blood test results for your dog?" I asked as she was telling me the findings without the documentary evidence.
"Yes," she said.
"You can ask Vet 1 to fax or email to me at Toa Payoh Vets," I said.
"I don't think it is possible," she replied.
"Why not? Are the documents illegal?" I asked. "Vets do pass clinical records to each other when the owner seeks a 2nd opinion. I have done it before and other vets have done it. You just have to phone them and ask for the medical records."
She phoned later to say that Vet 1 would want her to go to the practice to take over the records and so would be late for the appointment. This was OK with me. Around 3 pm she came and saw Dr Daniel first. He had recorded "4 days of changed behaviour, increased breathing, decreased appetite and cannot walk. No vomiting, diarrhoea and no change in diet. Cheese treat for one week and polyuria and polydipsia.
Blood test from Vet 1. No abnormalities in the liver and kidneys or total white cell count. But RBC 3.37 (5.5 - 5.8), HGB 8.4 (12-18) and HCT 23.9 (37-55) were very low. I told the owner that the gums were purplish and the tongue was pale. This was not good.
The mid-abdominal lump was solid, painless and half the size of an orange. What is it?
Vet 1 was consulted for a "breathing problem". She had taken a lateral X-ray showing much fluid inside the swollen abdomen. Opaque areas obscured the views of intestines. Vet 1 said heart was enlarged. An abdominal mass pushed guts up and above. She recorded that the owner was not keen on surgery. Dog was anaemic and lung sounds were dry. She proposed pain relief since surgery was not acceptable.
Overall, Vet 1 was spot on in her diagnosis but the owner was not satisfied.
"Is it because you went when the practice was going to close?" I asked.
"Yes," she said.
Sometimes it is difficult to satisfy the owner on the first consultation in a medical condition with no cure except surgery. Yet this dog was 14 years old, very thin and I would say emaciated. Surgery would kill him. So I don't even want to propose surgery as this dog will never survive the long time needed to remove this large abdominal lump. In any case, the couple was never in favour of it.
But what is this large abdominal lump and what should the couple do?
"Euthanase the dog," one young vet suggested when I spoke to her after X-raying two views of the dog's chest and abdomen at her practice. "This dog is suffering and should not prolong her suffering"
"There was one government vet before your time," I said to this young lady. "He recommends euthanasia so many times that he has a reputation to be avoided. This is because the owners say that he will advise euthanasia in very sick cases. His intention was to save money for the owners but he gained the reputation of being an "euthanasia" vet to be avoided.
"In this case, the couple is against euthanasia. They want to know what is the nature of the abdominal tumour." Dr Daniel had proposed ultrasound scanning. From my reading of the couple, they want an acceptable solution such that the dog would live the last few days of his life without pain."
What more can be done other than ultrasound?
Dr Daniel elaborated on the causes of the swollen abdomen - bleeding, chyle, fluid from heart failure since the liver and kidneys were OK based on blood test from Vet 1, peritonitis. He also advised surgery to remove the abdominal mass as the only option. He advised abdomino-centesis to draw out the fluid to send to the lab for examination but sedation would be required and this would be risky as it may kill the dog. So the couple did not accept his suggestion and wanted to take the dog home.
I let Dr Daniel handle the case to the conclusion but I did give my take on this medical condition.
What should be done for this dog if surgery was not an option? "There is no need for sedation," I said to the couple. "We need to draw out the abdominal fluid so that your dog can breathe easier at least for the next 2 days and start eating." Each vet has his or her own opinion and my opinion was that abdomino-centesis could be done without much pain on this ill dog and so without any risk of death.
The only risk is in putting the needle into the abdominal mass. This was what I was concerned and so was the thinking behind the young lady vet who looked at the X-ray with me earlier. The needle might puncture this big lump.
"Not if you slide the needle under the umbilical skin," I did that with a 19G needle and fresh blood came out.
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