Around 3 days ago, I read a Straits Times Report that SPCA Singapore will not be accepting any stray dogs as it had to clean and disinfect its kennels affecting parvoviral infections.
For some months, I have been telling my associate vets to check for parvoviral infections in older dogs that come in with blood in the watery stools. If the owner is against the test, record this in the medical case sheet. Adult dogs can also die from parvoviral infection as many are NOT vaccinated yearly. Most Singapore owners don't bother with annual vaccinations judging from my research in vaccination reminders.
Two years ago, I had an adult dog that had stayed in a boarding kennel. The owner wanted her spayed after boarding. I spayed her. She developed bloody diarrhoea 3 days after spay and was diagnosed with parvoviral infections. She died. From one of my do breeder sources, the owner had complained about me to him but the breeder tod the owner that it was not my fault. The dog was just not vaccinated and protected.
Subsequently, I had another similar request. The owner was fed up with me for asking her to wait 7-14 days before spay and so did not return to do the spay. It takes 7-14 days to know whether the dog has parvoviral infections from the boarding kennels. Many kennel operators do not bother with updated vaccinations too.
Monday, January 23, 2012
834. Perseverance v. passion to become a vet
Today, Chinese New Year, I phoned Kim to thank her for her SMS "Happy New Year Dr Sing! May your business prosper."
She had quit doing Sunday vet internship in 2012 saying that she had no money to study vet medicine anyway. I said: "Kim, Nobody can predict the future. There are ups and downs in life. Who knows? You may get an inheritance or good fortune. Or a vet scholarship with your track record of internship over the years. But do you really have the passion for vet medicine? If your father is rich, there is no need to have passion as the father pays all fees and open the clinic for you as well."
Kim said: "Maybe in 4 to 5 years' time, I will do the vet internship."
"Is it your husband who is against you doing Sunday internship? It is hard for a married woman to waste a Sunday afternoon instead of spending time with the husband!"
"No," she said. Well, I wish her good luck. This passion for veterinary medicine is difficult to define and harder to find in a Singaproean as it is hard work to excell and succeed to be a good vet.
She had quit doing Sunday vet internship in 2012 saying that she had no money to study vet medicine anyway. I said: "Kim, Nobody can predict the future. There are ups and downs in life. Who knows? You may get an inheritance or good fortune. Or a vet scholarship with your track record of internship over the years. But do you really have the passion for vet medicine? If your father is rich, there is no need to have passion as the father pays all fees and open the clinic for you as well."
Kim said: "Maybe in 4 to 5 years' time, I will do the vet internship."
"Is it your husband who is against you doing Sunday internship? It is hard for a married woman to waste a Sunday afternoon instead of spending time with the husband!"
"No," she said. Well, I wish her good luck. This passion for veterinary medicine is difficult to define and harder to find in a Singaproean as it is hard work to excell and succeed to be a good vet.
833. A dog with recurrent bladder stones - The Standard Operating Procedures (SOP)
First Written: Chinese New Year Jan 23, 2012 1.06 pm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
RECURRENT UROLITHIASIS - CALCIUM PHOSPHATE URINARY STONES
When a dog has urinary stones again, the following will be the Standard Operating Procedures (SOP) at Toa Payoh Vets to provide the highest standard of care. This SOP defends the vet during allegations of negligence litigation or complaint if the dog has another episode of recurrent urolithiasis.
1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your analysis of why the dog had recurrent urolithiasisa. In this case study of the Shih Tzu with 13 calcium phosphate urinary stones, the dog came to Toa Payoh Vets for recurrent urolithiasis and I took charge of this case which was operated by Vet 1.
Vet 1 had not done stone analysis, did not advise (in writing) on post-operation prevention and follow-through tests which would permit non-surgical treatment (e.g. voiding urohydropropulsion and urinary catheterisation when small stones are detected via X-rays 3-monthly). Could it also be some metabolic disorders of the parathyroid glands as calcium phosphate is quite rare in dogs?
2. GENERAL EXAMINATION. Demeanour. Weight, rectal temperature, pulse and respiratory rate. Abdominal pain, gas in the GIT and other observations.
3. DETAILED EXAMINATION. Urine test, blood test, radiography (calcium phosphate isradio-dense, check kidneys for calcium phosphate), ultrasonography (possible in calcium phosphate) and calculi analysis. There may be a case for veterinary negligence if the tests has not been advised or done. The advices must be recorded in the case sheets clearly.
4. TREATMENT. According to symptoms. IV, SC or oral fluid therapy depending on dehydration situation. Antibiotics to treat UTI. Urinary catheterisation to relieve urethral obstruction.
The vet in charge of the case is responsible for details of time, amount and other information will be recorded in the hospitalisation sheet.
5. COMMUNICATIONS WITH THE OWNER IN WRITING. A veterinary report explaining the significance of the tests and case must be given to the owner on discharge/death of the puppy. It is best to keep the owner informed daily of the health of the dog. Such phone calls must be recorded in the medical case files.
6. RECORD AMA (Against Medical Advice) the owner's rejection of advices of the test in your medical record. Failure to do so implies that the vet has not advised at all in cases of litigation/complaint. As Singapore is becoming a litigious society, I advise that the highest standard of care to be given at all times. An example of a case done by me is down shown in the images.
TOA PAYOH VETS CASE STUDY BY DR SING
Chinese New Year Eve 4.56pm
Jan 22, 2012
PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.
It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.
The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.
DIAGNOSIS: Calcium phosphate urolithiasis
CASE MANAGEMENT AT TOA PAYOH VETS
14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.
8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.
13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.
Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.
X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.
TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.
2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.
4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.
HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).
REFERENCE: The 5-min veterinary consult - Tiley Smith
1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.
2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder
OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.
PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.
INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D
FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.
TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet
A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm
B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.
Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)
BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)
Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.
TOA PAYOH VETS webpage will be written later:
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
RECURRENT UROLITHIASIS - CALCIUM PHOSPHATE URINARY STONES
When a dog has urinary stones again, the following will be the Standard Operating Procedures (SOP) at Toa Payoh Vets to provide the highest standard of care. This SOP defends the vet during allegations of negligence litigation or complaint if the dog has another episode of recurrent urolithiasis.
1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your analysis of why the dog had recurrent urolithiasisa. In this case study of the Shih Tzu with 13 calcium phosphate urinary stones, the dog came to Toa Payoh Vets for recurrent urolithiasis and I took charge of this case which was operated by Vet 1.
Vet 1 had not done stone analysis, did not advise (in writing) on post-operation prevention and follow-through tests which would permit non-surgical treatment (e.g. voiding urohydropropulsion and urinary catheterisation when small stones are detected via X-rays 3-monthly). Could it also be some metabolic disorders of the parathyroid glands as calcium phosphate is quite rare in dogs?
2. GENERAL EXAMINATION. Demeanour. Weight, rectal temperature, pulse and respiratory rate. Abdominal pain, gas in the GIT and other observations.
3. DETAILED EXAMINATION. Urine test, blood test, radiography (calcium phosphate isradio-dense, check kidneys for calcium phosphate), ultrasonography (possible in calcium phosphate) and calculi analysis. There may be a case for veterinary negligence if the tests has not been advised or done. The advices must be recorded in the case sheets clearly.
4. TREATMENT. According to symptoms. IV, SC or oral fluid therapy depending on dehydration situation. Antibiotics to treat UTI. Urinary catheterisation to relieve urethral obstruction.
The vet in charge of the case is responsible for details of time, amount and other information will be recorded in the hospitalisation sheet.
5. COMMUNICATIONS WITH THE OWNER IN WRITING. A veterinary report explaining the significance of the tests and case must be given to the owner on discharge/death of the puppy. It is best to keep the owner informed daily of the health of the dog. Such phone calls must be recorded in the medical case files.
6. RECORD AMA (Against Medical Advice) the owner's rejection of advices of the test in your medical record. Failure to do so implies that the vet has not advised at all in cases of litigation/complaint. As Singapore is becoming a litigious society, I advise that the highest standard of care to be given at all times. An example of a case done by me is down shown in the images.
TOA PAYOH VETS CASE STUDY BY DR SING
Chinese New Year Eve 4.56pm
Jan 22, 2012
PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.
It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.
The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.
DIAGNOSIS: Calcium phosphate urolithiasis
CASE MANAGEMENT AT TOA PAYOH VETS
14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.
8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.
13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.
Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.
X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.
TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.
2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.
4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.
HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).
REFERENCE: The 5-min veterinary consult - Tiley Smith
1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.
2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder
OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.
PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.
INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D
FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.
TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet
A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm
B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.
Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)
BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)
Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.
TOA PAYOH VETS webpage will be written later:
833. Chinese New Year's Eve Reunion Dinner stories
Jan 22, 2012 Sunday was Chinese New Year's Eve Reunion Dinner. Time to catch up. My advice to the young adults would be to ask questions to sustain a conversation rather than keep looking at their smartphones and texting. Ask what your cousins or uncles and aunties have been doing and you can learn much.
There were two Chinese idioms which I can't translate into English.
1. Teochew expression of 6 words. The Teochew mother expresses herself in Teochew and has dropped hints to the late 20s son who does not contribute one cent to the household by giving a bit of his salary to the mother. The daughter gives money monthly but the son forgets about it. In Chinese custom, children should give some part of their pay to the mother as they still live with the parents. So she said the six words. Nobody could translate into English. "It means scrounger," Julia said. Well, that is a public hint to the son to part with a bit of his salary to the mum. It will be like talking to the wall as he said that he is on hard times, having to save up for his wedding and his new HDB apartment renovation. In any case, the parents don't need his money. It is just a custom of some Chinese mothers to expect children to give some token to them when they start work and still live in the parents' house. As for the father, he said to me when I asked his opinion: "If my children don't ask money from me, I am OK!"
2. Teochew expression regarding a "golden chair". This refers to a young man who should marry an older woman. After all, an older woman is secure financially (hence the golden chair) while a younger woman wants money and security from the man. So, the niece with the fairest famed complexion of the Teochew ladies advised Jason not to marry wives younger than himself. "2 years older," she gave an example of a man dating a woman 8 years older but failing in the relationship. "Why not build your own golden chair?" her brother suggested.
Conversations can be sustained if you asked about the other party's welfare. Dogs are one favourite part in conversation. "How do you know it is dangling?" I asked the brother of the fair lady who had asked Daniel some advice about the cost of removal of a lump which keeps growing bigger in a 13-year-old Cross bred of her boyfriend. This boyfriend loves animals and she related an incredible story. One day, his favourite Jack Russell escaped and was hit by a car. The dog waited for him to return home from work. Once he reached home, the dog passed away. "He was holding on to life till he had seen his owner," she said.
To return to the dangling lump, the brother of the fair lady said he had not seen the dog. Daniel presumed it to be a growth from the groin area. I asked in more detail from the fair lady: "Where is the lump? Is it in the breast area?" She said: "No, it is dangling from between the legs and keeps growing bigger fast every day."
Since this is a male old dog, I said: "It is likely to be a testicular cancer. I can arrange a transport man to bring it down for surgery. The earlier it is done, the better for the dog." I doubt that there will be any follow through action by this young lady as it is not her dog.
Sadly, many dog owners feed their dogs and do not bother when there are growths or bad breath. However, recently, it seems that there are more cases of dental work being requested on dogs.
As can be seen in a last-minute request by a mother and her two pre-teen daughters bringing a 13-year-old small breed dog today at 4pm as the dog was not eating. As the dog had eaten at 6 am, I proposed dental work after a general examination. "This dog will not bite," I said to Dr Vanessa as she tried to muzzle him and examine his mouth via the muzzle. This small breed does look ferocious and open-eyed, being a mini-pinscher cross and so I did not blame her for being careful. I lifted the side of the dog's mouth to expose the back teeth full of tartar. "Give an IV drip plus antibiotic IV before dental work," I advised. There was a need for blood test and an anaesthetic consent form. However, the blood test would add up the cost and so this was not done. A general examination would do. Domitor 0.1 ml and isoflurane gas. 3 teeth extracted by Dr Vanessa.
The dog went home to a happy mother with two daughters on Chinese New Year's eve. Many of such cases need dental work but can get frightened by warnings about deaths from anaesthesia from the vet. Obviously the vet has to cover himself by getting the consent form signed as this is an old dog and could die. Hospital doctors do the same too. In this case, no consent form was asked to be signed. Careful anaesthesia resulted in a happy outcome for this dog. Old dogs seldom die from dental work if there is careful anaesthesia and no chatting between the vet and the assistant. Focus on the patient and in my 30 years of experience, I can be confident that the old dog will not die on the operating table as the anaesthesia duration is very short if the vet prepares and knows what to do efficiently and productively.
There were two Chinese idioms which I can't translate into English.
1. Teochew expression of 6 words. The Teochew mother expresses herself in Teochew and has dropped hints to the late 20s son who does not contribute one cent to the household by giving a bit of his salary to the mother. The daughter gives money monthly but the son forgets about it. In Chinese custom, children should give some part of their pay to the mother as they still live with the parents. So she said the six words. Nobody could translate into English. "It means scrounger," Julia said. Well, that is a public hint to the son to part with a bit of his salary to the mum. It will be like talking to the wall as he said that he is on hard times, having to save up for his wedding and his new HDB apartment renovation. In any case, the parents don't need his money. It is just a custom of some Chinese mothers to expect children to give some token to them when they start work and still live in the parents' house. As for the father, he said to me when I asked his opinion: "If my children don't ask money from me, I am OK!"
2. Teochew expression regarding a "golden chair". This refers to a young man who should marry an older woman. After all, an older woman is secure financially (hence the golden chair) while a younger woman wants money and security from the man. So, the niece with the fairest famed complexion of the Teochew ladies advised Jason not to marry wives younger than himself. "2 years older," she gave an example of a man dating a woman 8 years older but failing in the relationship. "Why not build your own golden chair?" her brother suggested.
Conversations can be sustained if you asked about the other party's welfare. Dogs are one favourite part in conversation. "How do you know it is dangling?" I asked the brother of the fair lady who had asked Daniel some advice about the cost of removal of a lump which keeps growing bigger in a 13-year-old Cross bred of her boyfriend. This boyfriend loves animals and she related an incredible story. One day, his favourite Jack Russell escaped and was hit by a car. The dog waited for him to return home from work. Once he reached home, the dog passed away. "He was holding on to life till he had seen his owner," she said.
To return to the dangling lump, the brother of the fair lady said he had not seen the dog. Daniel presumed it to be a growth from the groin area. I asked in more detail from the fair lady: "Where is the lump? Is it in the breast area?" She said: "No, it is dangling from between the legs and keeps growing bigger fast every day."
Since this is a male old dog, I said: "It is likely to be a testicular cancer. I can arrange a transport man to bring it down for surgery. The earlier it is done, the better for the dog." I doubt that there will be any follow through action by this young lady as it is not her dog.
Sadly, many dog owners feed their dogs and do not bother when there are growths or bad breath. However, recently, it seems that there are more cases of dental work being requested on dogs.
As can be seen in a last-minute request by a mother and her two pre-teen daughters bringing a 13-year-old small breed dog today at 4pm as the dog was not eating. As the dog had eaten at 6 am, I proposed dental work after a general examination. "This dog will not bite," I said to Dr Vanessa as she tried to muzzle him and examine his mouth via the muzzle. This small breed does look ferocious and open-eyed, being a mini-pinscher cross and so I did not blame her for being careful. I lifted the side of the dog's mouth to expose the back teeth full of tartar. "Give an IV drip plus antibiotic IV before dental work," I advised. There was a need for blood test and an anaesthetic consent form. However, the blood test would add up the cost and so this was not done. A general examination would do. Domitor 0.1 ml and isoflurane gas. 3 teeth extracted by Dr Vanessa.
The dog went home to a happy mother with two daughters on Chinese New Year's eve. Many of such cases need dental work but can get frightened by warnings about deaths from anaesthesia from the vet. Obviously the vet has to cover himself by getting the consent form signed as this is an old dog and could die. Hospital doctors do the same too. In this case, no consent form was asked to be signed. Careful anaesthesia resulted in a happy outcome for this dog. Old dogs seldom die from dental work if there is careful anaesthesia and no chatting between the vet and the assistant. Focus on the patient and in my 30 years of experience, I can be confident that the old dog will not die on the operating table as the anaesthesia duration is very short if the vet prepares and knows what to do efficiently and productively.
832. Tonsillitis in an old dog
E-MAIL TO DR SING DATED JAN 21, 2012
Dear Dr. Sing,
Patient Ref. No. ... (... (Silkie, 8.5 yrs old))
We were at your clinic last Sunday (15 Jan).
I'd like to have a better understanding regarding B's lump at his throat:
On 11 Dec 2011 after his dental scaling (during which you checked on his throat), we were told that the tip of his epiglottis was red. Antibiotics prescribed, to be reviewed.
15 Jan 2012 review: we were told there is a lump at his left tonsil (right tonsil could not be seen as Bowie was struggling too much). I forgot to ask, what about the redness at tip of epiglottis?
Your advice was to put him on antibiotics first and to review again in 1-2 months' time. As B is such a nervous dog, he'll be sedated for a proper diagnosis for his next review. You said that if it is indeed a lump, the tonsil/s will be removed. Is tonsil/s removal the only treatment option, even though the lump may be benign? Without tonsil/s, wouldn't he be more susceptible to virus infection in the future? What if the lump is a cyst or an abscess?
Your reply via e-mail will be greatly appreciated, Dr. Sing. Thank you!
PHONE REPLY FROM DR SING
It is best to speak by phone as email replies can be misinterpreted. Questions can be answered immediately and clarification can be made immediately too.
In this case, tonsil removal is advised in case the tonsil is a growing malignant tonsillar carcinoma as the dog is old. The red lump of the is around 0.5 cm x 0.5 cm and visible. An aspiration biopsy can also be done in this case to check whether the tonsil is an abscess, cyst or cancerous. Sedation will be needed and anaesthetic risks are always there.
It is worrisome for the owner. The vet's duty is to inform the owner of the presence of the tonsillar growth. Excision or biopsy depends on the economics and malignancy or otherwise of the growth.
I have an image of an 8-year-old Chihuahua with tonsillitis and will post it later. 13 teeth were extracted.
Dear Dr. Sing,
Patient Ref. No. ... (... (Silkie, 8.5 yrs old))
We were at your clinic last Sunday (15 Jan).
I'd like to have a better understanding regarding B's lump at his throat:
On 11 Dec 2011 after his dental scaling (during which you checked on his throat), we were told that the tip of his epiglottis was red. Antibiotics prescribed, to be reviewed.
15 Jan 2012 review: we were told there is a lump at his left tonsil (right tonsil could not be seen as Bowie was struggling too much). I forgot to ask, what about the redness at tip of epiglottis?
Your advice was to put him on antibiotics first and to review again in 1-2 months' time. As B is such a nervous dog, he'll be sedated for a proper diagnosis for his next review. You said that if it is indeed a lump, the tonsil/s will be removed. Is tonsil/s removal the only treatment option, even though the lump may be benign? Without tonsil/s, wouldn't he be more susceptible to virus infection in the future? What if the lump is a cyst or an abscess?
Your reply via e-mail will be greatly appreciated, Dr. Sing. Thank you!
PHONE REPLY FROM DR SING
It is best to speak by phone as email replies can be misinterpreted. Questions can be answered immediately and clarification can be made immediately too.
In this case, tonsil removal is advised in case the tonsil is a growing malignant tonsillar carcinoma as the dog is old. The red lump of the is around 0.5 cm x 0.5 cm and visible. An aspiration biopsy can also be done in this case to check whether the tonsil is an abscess, cyst or cancerous. Sedation will be needed and anaesthetic risks are always there.
It is worrisome for the owner. The vet's duty is to inform the owner of the presence of the tonsillar growth. Excision or biopsy depends on the economics and malignancy or otherwise of the growth.
I have an image of an 8-year-old Chihuahua with tonsillitis and will post it later. 13 teeth were extracted.
Sunday, January 22, 2012
831. The Shih Tzu has reccurent urolithiasis. 13 calcium phosphate stones
Chinese New Year Eve 4.56pm
Jan 22, 2012
PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.
It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.
The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.
DIAGNOSIS: Calcium phosphate urolithiasis
CASE MANAGEMENT AT TOA PAYOH VETS
14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.
8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.
13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.
Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.
X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.
TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.
2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.
4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.
HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).
REFERENCE: The 5-min veterinary consult - Tiley Smith
1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.
2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder
OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.
PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.
INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D
FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.
TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet
A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm
B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.
Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)
BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)
Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.
Jan 22, 2012
PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.
It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.
The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.
DIAGNOSIS: Calcium phosphate urolithiasis
CASE MANAGEMENT AT TOA PAYOH VETS
14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.
8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.
13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.
Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.
X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.
TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.
2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.
4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.
HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).
REFERENCE: The 5-min veterinary consult - Tiley Smith
1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.
2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder
OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.
PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.
INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D
FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.
TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet
A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm
B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.
Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)
BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)
Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.
830. Sunday's Jan 22, 2012 interesting case (Chinese New Year's Eve)
Sunday, bright. sunny. Most vet practices close in the afternoon as there would be no clients. Toa Payoh Vets open till 5 pm. In the afternoon, no clients as at 3 pm when I am writing this report on a new client whose poodle, male, neutered, vomited blood yesterday and vomtied without blood today.
General exam was normal.
ABDOMINAL PALPATION
The dog arched his back when his ant aabdomen was palpated. "Hunched" said the lady owner. Mild pain in the liver, kidney, gastric area. The lady owner said: "Hunch back."
HISTORY
Since young, the dog had been vomiting every 1-2 months. Usually threw up without food. Vet 1 said nothing was wrong. I proposed X-ray or ultrasound after the Chinese New Year. For the time being, put on antibioitcs for 10 days.
TREATMENT
1. Dextrose saine 500 ml IV drip + anti-spasmogesic + antibiotic. Goes home later.
ADVICES
My hypothesis. Most likely the dog had been eating outside objects on the grass when walked by the domestic worker during the evening. Domestic workers meet their friends when they walk the dog and so it was possible that the dog gets fed some food or had gone onto the grass to eat anything . It is hard to say.
Blood test, X-ray and ultrasound can be done a few days later if vomiting continues. Cost is nto a problem with this owner. I said: "It is also possible that this dog has a small gastric foreign body that can't be vomited out nor passed through the intestines and so the dog vomits 1-2 monthly due to gastric inflammation and irritation by the movement of this foreign body and bacterial infection of the stomach (gastric mucosa)."
RIGHT EYE TEARING AND ITCHY
Swollen eyelids of the right eye due to rubbing. "Fluorescein eye stain is useful to check whether the eye cornea has ulcers or not," I put the fluroescein strip under the upper eyelid of both eyes. "Can you see the green stain on the cornea?" I shone the white light tangentially at the the right eye. "Yes," the lady owner said; "Green patches in the central cornea and at 12 o'clock and 2 o'clock. What is an ulcer?" she asked me as she could not understand. "It is a wound like the skin that has been cut, you will get a skin ulcer. A broken surface." She understood and translated it into Mandarin. I don't know how to translate ulcers in Mandarin. I must learn Mandarin as there are more Chinese Nationals nowadays and many Singaporeans speak Mandarin!
3 EMERGENCY CASES
1. One year old, female, Corgi, itchy back, wet areas. Their Vet is off, but the dog is still v. itchy. "Very good appetite after Shincort inj by Vet 1," the owner said. Wife and young son came. I advised clipping all bald just as Dr V wanted to clip just the back half. "There may be other areas and it is best to get hairs grow together." Owner said he saw "flea dirt," although Vet 1 saw a tick. A flea bite allergy not controlled by Vet 1's Shin cort injection?
2. Westie now not eating again. Wanted to see Dr Vanessa.
3. A dog with loose teeth or bad teeth. Made an appointment. Saw Dr Jason Teo yesterday.
General exam was normal.
ABDOMINAL PALPATION
The dog arched his back when his ant aabdomen was palpated. "Hunched" said the lady owner. Mild pain in the liver, kidney, gastric area. The lady owner said: "Hunch back."
HISTORY
Since young, the dog had been vomiting every 1-2 months. Usually threw up without food. Vet 1 said nothing was wrong. I proposed X-ray or ultrasound after the Chinese New Year. For the time being, put on antibioitcs for 10 days.
TREATMENT
1. Dextrose saine 500 ml IV drip + anti-spasmogesic + antibiotic. Goes home later.
ADVICES
My hypothesis. Most likely the dog had been eating outside objects on the grass when walked by the domestic worker during the evening. Domestic workers meet their friends when they walk the dog and so it was possible that the dog gets fed some food or had gone onto the grass to eat anything . It is hard to say.
Blood test, X-ray and ultrasound can be done a few days later if vomiting continues. Cost is nto a problem with this owner. I said: "It is also possible that this dog has a small gastric foreign body that can't be vomited out nor passed through the intestines and so the dog vomits 1-2 monthly due to gastric inflammation and irritation by the movement of this foreign body and bacterial infection of the stomach (gastric mucosa)."
RIGHT EYE TEARING AND ITCHY
Swollen eyelids of the right eye due to rubbing. "Fluorescein eye stain is useful to check whether the eye cornea has ulcers or not," I put the fluroescein strip under the upper eyelid of both eyes. "Can you see the green stain on the cornea?" I shone the white light tangentially at the the right eye. "Yes," the lady owner said; "Green patches in the central cornea and at 12 o'clock and 2 o'clock. What is an ulcer?" she asked me as she could not understand. "It is a wound like the skin that has been cut, you will get a skin ulcer. A broken surface." She understood and translated it into Mandarin. I don't know how to translate ulcers in Mandarin. I must learn Mandarin as there are more Chinese Nationals nowadays and many Singaporeans speak Mandarin!
3 EMERGENCY CASES
1. One year old, female, Corgi, itchy back, wet areas. Their Vet is off, but the dog is still v. itchy. "Very good appetite after Shincort inj by Vet 1," the owner said. Wife and young son came. I advised clipping all bald just as Dr V wanted to clip just the back half. "There may be other areas and it is best to get hairs grow together." Owner said he saw "flea dirt," although Vet 1 saw a tick. A flea bite allergy not controlled by Vet 1's Shin cort injection?
2. Westie now not eating again. Wanted to see Dr Vanessa.
3. A dog with loose teeth or bad teeth. Made an appointment. Saw Dr Jason Teo yesterday.
Subscribe to:
Posts (Atom)