878. Follow up on Chinese New Year 2nd day's cases

Feb 19, 2012. Time flies. I have written a follow-up on the interesting cases I saw on Chinese New Year 2nd day on Jan 24, 2012. The webpage and images are at:

http://www.sinpets.com/F5/20120231chinese-new-year-2nd-day-vet-cases-Singapore_ToaPayohVets.htm



839. Chinese New Year 2nd day - salivation - stinks the whole apartment
Tuesday Jan 24, 2012
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed

I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration.




5052 - 5055. A stray cat's serious fight wounds. I got a video produced by Nicole and this is at:
How to clean a badly wounded cat's paw wound, demonstrated by Dr Sing Kong Yuen
INTERESTING CASES

1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.

"Whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"

"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."

"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever. Dental work advised.
UPDATE: Feb 19, 2012. The owner did not return for review.
2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye. What is it?"









4990 - 4999. Abscess caused by two maxillary molar teeth. High fever. Anaesthesia to extract the two loose right maxillary molars was very risky. IV drips, antibiotics and anti-fever 24 hours first  
No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked.

"Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth.

Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.

UPDATE: Feb 19, 2012. The owner did not return for review of the right cheek wound. I presume it had closed by granulation as it would be too big to stitch up. I suspect this case is due to a flesh-eating bacterial infection as it is not typical of a malar abscess.

3. Persian cat of a son who is studying overseas. F, 13 years, not spayed. EMACIATED. Drooling. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.





5067 - 5071.
LPGS - lymphocytic plasmacytic gingivitis stomatitis in an old cat

UPDATE: Feb 19, 2012. To my surprise, the mother reported that the Persian cat was back to normal, eating and putting on weight. Her son, studying in Australia was happy as this was his cat. LPGS (lymphocytic plasmacytic gingivitis stomatitis) is diagnosed by biopsy of the ulcerated oral tissues, but this would cost the owner more money.

Therefore, I did not practise defensive medicine as I did not insist on getting this test done as the signs and symptoms were quite clear. The causes of LPGS are varied as there is no one cause known. It included stress, viral and bacterial infections (FIV, feline leukemia, feline calcivirus, Bartonella henselae bacteria, genetic predisposition, sensitivity of gums to bacterial plaque by provoking the aggressive inflammatory response sending large amounts of lymphocytes and plasma cells (two types of white blood cells) into the gums and oral tissues).

4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."
UPDATE: Feb 19, 2012. The guinea pig started eating but died "suddenly" around 3 weeks after my treatment. The owner requested an autopsy. The stomach was full. The lungs were infected and the chest had a lot of blood tinged fluid, causing great difficulty in breathing and death.

Guinea pig not eating for weeks


5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope to check the hamster's lungs. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.

"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."

"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.
UPDATE: Feb 19, 2012. The owner did not return for review.
In conclusion, on this Chinese New Year 2nd day, January 24, 2012, I had a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.



The updated webpage and images are at:

http://www.sinpets.com/F5/20120231chinese-new-year-2nd-day-vet-cases-Singapore_ToaPayohVets.htm

Guinea pig couldn't breathe. Autopsy.

The young girl who brought the guinea pig on 2nd day of Chinese New Year is a medical undergraduate for not eating for some weeks. She had consulted Vet 1 earlier and was given antibiotics but the pet still had no appetite. I anaesthesized it and clipped the overgrown lower premolar and molar teeth which had arched over the tongue.

She texted me today, February 14, 2011, at 7.30am for an urgent appointment as her GP was not breathing well. When I saw her at 9 am at the Surgery, the GP had just died.

"Why?" she said the GP had been eating on his own since she ordered the Critical Care from online petshop that delivered on the 7th day of CNY. The GP was hand fed and was eating well till yesterday, around 21 days after the teeth were clipped.

"An autopsy will give some answers," I said. She wanted one done and I asked Dr Daniel to do it with me. Significant autopsy findings were:

1. Stomach was full of Critical care mashed food and so the GP was really eating.
2. Gas in the large intestines could be normal and food seen in the caecum.
3. Some greenish mashed food inside the mouth. Could be after death.
4. Trachea was very clean, so no inhaled food from hand feeding.
5. Lungs severely congested.
6. Massive hydrothorax (reddish fluid splashed out) and this would cause respiratory distress and death.
7. Left lung had white fibrinous adhesions on the posterior lobes. The GP was not a healthy one and had pneumonia some months ago and had recovered, the owner said.
8. Heart had fibrinous pericarditis as the pericardium seemed to have small yellow nodules (abscesses?)

The young girl asked me what was the cause of sudden difficulty in breathing and death. "Hydrothorax is the cause and may be associated with cardio-respiratory infections in the past," I said. "The GP could have weakened immune system as he was not eating for many weeks."

"Is his sickness infectious to the other GP?" the girl asked me. The other GP was fat and ate well. She had just disinfected the crate. But I asked her to do again esp. water bottles and feed bowls.

CHEEK TEETH
I checked the cheek teeth as I had clipped the bottom premolars and molars under general anaesthesia around 21 days ago. I present the image for the benefit of GP owners and GP anatomy for vet students. The guinea pig has 20 teeth. The dental formula is I1,PM1,M3.

VETS TO NOTE
Many cases of the rabbit and guinea pig not eating are due to malocclusion. However, the teeth involved may be the inside premolars and molars, usually the bottom ones in the guinea pig. The overgrown teeth arch over the tongue and cause ulceration on the other side. Palpate the top of the premolars and molars with your finger to feel the sharp edges of malocclusion if possible or under anaesthesia. It is easier to do in the racehorse, but the principle of palpation is the same.

Wrap the guinea pig or rabbit in a towel and use a buccal separator to open the mouth for inspection. I used isoflurane gas anaesthesia for a few seconds to permit me to do the job of clipping the teeth. It is difficult to clip the teeth without anaesthesia as the tongue is in the way and may be accidentally cut.

Guinea pigs, hamsters and rabbits are not the favourite patients of many vets and there are some any internet postings from non-vet experts in the above-mentioned pets cursing the veterinarian for being incompetent and ignorant. Pass the case to other vets if you are not keen on treating such creatures rather than just give antibiotics for inappetance.

GUINEA PIG OWNERS
Check the mouth esp. the inner teeth weekly. Feel the cheek for painful reaction indicating an oral ulcer or abscess. Weigh your guinea pig weekly and if it is losing weight, consult your vet and ask for the teeth to be checked.





UPDATES will be at:

http://www.sinpets.com/F5/20120230guinea-pig-malocclusion-anorexia-inappetance-Singapore_ToaPayohVets.htm

876. Chihuahua had "died"

Yesterday, Tuesday Feb, I did an unuusual Chihuahua spay cum teaching session to Dr Daniel in the afternoon. In the evening, the mother phoned Dr Daniel and said the Chihuahua had died. I was shocked and very sad. However, the Chihuahua had given birth to 2 dead 52-day-old pups.

Today at 10 am, she phoned me to ask whether she should continue feeding egg yolk to the same Chihuahua. "Hold on," I said as I went to ask Dr Daniel as to what was happening. "She said the dog had died."

I asked the mother. "Oh, the dog was dying. She fainted but I could see her breathing. After 2 hours in this position, the dog woke up and is now OK."
This was incredible as I could not understand why the dog had died. Her death was on my mind this morning. She did have a cyantoic tongue on picture taking. She was taken home 2 hours after my surgery and Dr Daniel had checked she was OK.

BACKGROUND
Tuesday Feb 14, 2012
Home breeder Mr Lim phoned me to ask about Caesarean cost. I had charged $250-$300/Caesarean for breeders some 7 years ago and that was how he knew me as I was in the breeder Caesarean section business doing over 100 dystocias.

"The fees were too low," I had stopped servicing the breeders some 4 years ago. "It should be around $800 - $1,000."

VET 1 TREATMENT. Mr Lim was in Malaysia and so he sent his mum to Vet 1, a vet to get an IV drip first as his mum said the dam was dying since giving birth to two dead pups discovered on Monday morning. Now, it was Tuesday 1 pm and many hours had passed.

Vet 1 also did a blood test and ultrasounds. Possibly two dead fetus according to the ultrasound. I palpated the abdomen. There was a small firm lump of 8 cm x 8 cm which would be just the uterine body as a pup would be 2x larger. In any case, the mum said there were dead pups and so Caesarean was needed. But Mr Lim had instructed that I did it, and so the mum and daughter carried the Chihuahua and the IV drip bottle of 5% glucose saline, ultrasound and blood test from Vet 1 to my Surgery.

Home breeders want the least cost Caesarean sections and he just wanted Vet 1 to give the dog an IV drip first before sending to me. But he had the ultrasound and blood test. It was more costly now.

I spoke to Mr Lim by phone and advised spaying as the dog is 6 years old and had difficulty giving birth now. Mr Lim agreed and so I used this case as a demonstration of how I did a spay on a pregnant chihuahua to Dr Daniel. There was milk in the glands and so it was a surprise that Mr Lim said the pups born premature were 50-52 days. But he is a professional experienced home breeder and so I would accept his calculation.

The dog was severely dehydrated.

875. Sunday's interesting cases

Sunday, Feb 12, 2012

Bright sunny day. Two vets, excluding me are needed on Sunday to reduce waiting time to less than 15 minutes per client. Some cases like dental scaling takes around 30 minutes and if there is one vet, the clients who come later can complain of waiting over 2 hours. I had an early meeting with Dr Daniel, Mr Min and Mr Lim (intern) in the consultation room to discuss about work attitudes, behaviour, stock inventory, anaesthetic records, case records, surgical processes, efficiency and productivity, wastage of resources and time and consistency to enable my vision of Toa Payoh Vets to be the top 5 practices in Singapore. I asked Mr Lim to take minutes of this first meeting. Clients are younger and much more sophisticated as you can see from the cases described below.

Case 1
Golden Retriever's toe fracture as the wife had stepped on him. Review. Much less swollen. Still lame. I showed Dr Daniel how I would handle this case as I would have done in a racehorse. Outside the clinic, trotting and walking. He was limping but we knew which leg. Got X-rays. Cost the owners a bit of money.

"How's your daughter's guinea pig?" I enquired as I had clipped its overgrown cheek teeth and it was not eating for the next day. Vet 1 had treated it earlier with some injections but the GP was still not eating and had lost weight. I had the GP under anaesthesia to check the mouth and the cheek teeth were overgrown. So, this was the problem as the GP had become very thin by then.

"The GP is OK now. Eating," the wife said. "My daughter is a medical undergraduate. She ordered the emergency mixture via the internet and it cost a lot of money."

"I did advise her to go to a pet shop that specialises in GP and rabbits and will have it. In any case, how do you know it is expensive?"

Mum said: "I paid $50.00 for the goods delivered on the same day."

The internet is now what young adults do. I don't stock the mixture as there are not many cases of GP or rabbits. I had advised her to hand-fed the mashed up pellets and also the medication 6X/day in small amounts and also electrolytes. But she wanted prompt results of return to feeding and ordered the emergency mixture. It ended well for the GP. This case illustrates the importance of checking the cheek teeth and not just the front teeth. A similar case in a rabbit recently had been written in www.toapayohets.com

Case 2.
I did not expect any early birds as this was Sunday. Suddenly 2 young ladies came in at 10 am with an Italian Greyhound, 4 years, excellent bodily condition, and wanted dental scaling done. "Has the dog eaten?" I asked. "It may vomit out the food during anaesthesia or sedation."

"At 9am," one lady said. "Just a small amount. When I phoned for appointment yesterday, nobody told me not to feed the dog before surgery."
"I will do it at 4 pm, sufficient time to let the food pass through," I said.
"We live in Tampines," the lady said. This would take some time to go back and forth, at least 30 minutes.

To be practical, I got the dog done with Dr Daniel Sing, mentoring him by showing how I would do it. No problem using 50% of calculated dom and ket combination ination and isoflurane gas. Dog did not vomit. Went home to a happy lady after one hour.

Case 3
An elderly man came in specifically to see me to get his 8-year-old Jack Russell dental work. No dental done before. Dog was given same as the Italian Greyhound. But older. This is a higher risk. As before, I mentored Dr Daniel Sing. He had his own ideas from his professors and this is to be expected of young graduates. Full of theories and latest knowledge of vet medicine and that is good as you can see from one case of the sheltie with nasal discharge and the excellent X-rays taken.

However, the dog stopped breathing, according to Min. I was out a while but came back within 10 seconds, according to Dr Daniel in review of this case later. No time to test his theories. I know what the professors would have taught about injecting the emergency adrenalin etc. Time is of the essence.

I did cardiac massage, blew air into the lungs by cutting the tightly tied endotracheal tube to both jaws (I don't tie this way but the professors would have taught this is the correct way, in normal situations, correctly). "Give Antisedan inj IV" I said. Dog revived and was OK. Alert as a guard dog standing up. "Propofol to continue anaesthesia," Dr Daniel said as there was two teeth left to be scaled and the dog could bite.

"No more IV in this case as the dog's heart may stop," I said. "Just isoflurane gas by mask and it will take a longer time." The dog was treated.

P.S Propofol seems to be a favourite of recent Murdoch Univ trained vet graduates and is used much in the University. But I don't use propofol and there is no need for it as there are other alternatives available. New graduates must adapt to the workplace rather than replicating or using what they have seen being used by their professors.

A practice has to manage cost so as to provide the cheapest competitive veterinary services. It cannot stock similar drugs as they do expire and led to a high wastage of resources and money.

Follow up by vet - the persistent coughing shih tzu

Yesterday, Friday, Feb 10, 2012, the owner brought the Shih Tzu for review as I had phoned him to enquire about the dog's coughing of white mucus.

"Eats a lot, poop a lot. Pee a lot," the owner said to me. "Is his coughing infectious to other dogs or the children?"

"No," I said. "The blood test is normal and the dog is more active and has no fever."

No weight gain for the past 7 days. "The tongue ulcer on the tip is still there," the owner said as the dog prevented me from checking the tonsils for several trials of opening his mouth. "The dog eats dry food as he likes it," I said. "This may have caused the big tongue ulcer, 1.0 x 0.8 cm from healing, Give canned food for the next 4 weeks, if possible."

The submandibular and popliteal lymph nodes were reduced in size by around 20%. I asked the owner to feel the nodes. The axillary lymph nodes were not palpable. He would be checking the size of the nodes.

Urine test had indicated high serum urea and bacteria in the urine.

I palpated the throat. The dog retched and coughed white mucus onto the table and then the floor. The man took my tissue paper to wipe away the white mucus.

"My dog vomits when he drinks a bit of water, two teaspoonfuls per meal," the owner said and had complied with my advice to feed small amounts 5x/day. "Now, he throws up around 5X/day, but previously it was 10 times or more."

After my treatment last week, the dog threw up once per day. So, the problem has not been resolved.

A follow up is important. So, what's the problem? Pleural effusion of the lungs and enlarged heart. How about stomach gas. "We need to X-ray the stomach/gullet area if this problem persists," I said.

872. TOILET TRAINING - The 3rd dog shows he is the boss - urine marking

EMAIL TO DR SING DATED FEB 10, 2012
...singnet.com.sg

Dear Dr,



I really need your advice how I can train my schnauzer. I have a total of 3 dogs, this schnauzer give me the most problem and seem to be not learning. He was the last to come in to my house. At the moment he is already 3 years old and I really not sure can I still toilet train him. As I have try many way to ask him to go and pee but always love to give surprise.



Both my other 2 dog are well toilet train and do it at the right place. The schnauzer really give me a problem. When I ask all the dogs to pees they will go to the toilet and pee. Normally my other 2 dogs will go in to pee first. The schnauzer will only go to pee after both dog have pee and try to pee over my other 2 dog pee. This is not a problem with him.



He always love to any how pee near to the door and other part in the kitchen for no reason. He will just pee a little bit here and there. I am not sure is he trying to get my attentions. Even he know it is wrong to do it he still do it. He seem to love to just pee a little to cover the 2 dog pees and have his own pee outside the toilet. I try to catch him in the act but was not successful. Normally after feeding I will try to get him to the toilet. But he will not do it even I spent 30 mins trying to get him to do it in the toilet. The moment. I leave him go to my room 5-10 minutes time when I am out he will pee near to the door or at the wrong sport. Any solutions which I can house break his bad habits.



Please help me and give suggestion. I am totally lost.



Regards,



EMAIL REPLY FROM DR SING DATED FEB 11, 2012



Kong Yuen Sing



5:51 PM (16 hours ago)














to Edwin, bcc: me, bcc: daniel, bcc: jasonxll










I am Dr Sing from www.toapayohvets.com. Thank you for your email.
It will be difficult to house-train the Schnauzer as he is 3 years old, not a puppy. He is urine-marking (pee over the other 2 dog's pee and elsewhere) to make sure that the other 2 dogs know he is the boss.

Some suggestions:
1. Neuter him soon.
2. After neuter, start house-training by confinement to one area or room for 2-6 weeks, if you have any space. Or use crate-training and take him out every 3-4 hour to pee. Basically same training as for puppies as described in toapayohvets.com, puppy house toilet training webpages.
3. Firm commands in house-training with rewards on success.

With best wishes.

871. An e-mail to Dr Sing about a cat

Feb 10, 2012. Veterinary medicine is a diverse topic. Feedbacks are valuable but most are complaints. This is one feedback that was surprising to me.

EMAIL TO DR SING DATED FEB 9, 2012
Dear Dr Sing

A belated Happy Lunar New Year to you. I trust this email finds you in good health and standing. Its been quite some time since our male cat Tobi was treated at your wonderful practice. Unfortunately our beloved Tobi has passed away on Saturday, 4 February 2012.

Just a bit of history. Tobi was admitted to your care on 24 April 2011. His case is listed in your website under cat cases-UTI -1st FLUTD.The cat can't pee again dated 12 June 2011. Shortly after his discharge, we moved into our new home. Tobi recovered well as there were no territorial cats and stress was kept to a minimum. He was maintained strictly on Hill's C/D wet food.

However, sometime from October 2011, he seemed to be licking his private area again though not as frequently as when he had UTI , he was also peeing normally with good volume. His disposition and general health was very good. This continued until February 2012 when we noticed his urine volume seemed to have lessened somewhat and his penis appeared to be inflamed. We brought him to a vet(shall not mention the company name) who gave him an injection of antibiotics and anti-inflammation and discharged. Two days later, it did not seem to get better, we brought him back to the vet again, a blood test was performed with several struvite crystals detected. The vet advised us that a similar injection could be given or a catheter could be inserted. We chose the injections as we were trying to avoid Tobi being warded as it may be more stressful. In order to give the injections, Tobi had to be put under G.A. as he was putting up such a struggle. Anyway it was done and he went home.

Yet again two days he was still having difficulty peeing, this time we opted to bring him to another branch (this branch was 24 hrs with larger facilities). Tobi was sedated, warded with a catheter inserted and put on a drip via a Y-site. He was also given daily IV feeds with Cephalexin and calcium, diazepam amongst others. He seemed fairly alright the first two days, it was only on the 3rd day that we noticed he appeared rather "subdued", quiet, not he's normal fiesty self. By the 4th day ,he was lying down the whole time and didnt seemed to respond to us. We attributed this to possible lethargy and medication. The next day, his blood tests were normal and after a cursory examination he was declared fit for discharge despite the fact that by now he could not even stand up or move, we bascially had to carry him into his carrier to be brought home. We reached home in the mid afternoon and put him in the room, again we had to carry him out of the carrier. From the time we reached home right until 10 pm, Tobi condition just deteriorated, once in while he would sort of jerk himself to another area in the room, Im not sure how he did this as he was immobile from the front quarters, his eyes could not track movement, he was drooling brown liquid and had raspy breathing. We took him back to the 24 hr branch at around 10.30 and the vet on duty arrived about 15 mins later,another blood test was conducted plus a chest x-ray, all looked normal, tests for leukemia and FIV was also done, clear as well. At about 11.30am, Tobi convulsed, expelled fluid and stopped breathing, we had opted for DNR. An immediate autospy was done, organs again were all fine. Nobody seems to have an answer for his death.

Needless to say, we are extremely saddened as well as puzzled by his sudden demise, more so when he was brought in for what ought to be a routine treatment for am inflamed penis. Instead five days later, we are having to cremate him. We have since search everywhere for anything information that might explain his sudden death. From what we found, we suspect, of course this may speculative at best, but it appears to be anaphylactic shock ( the question is what was the cause). Again we suspect it could he may have been allergic to one or more of the medications prescibed via the IV drip. Admittedly there could be numerous other possible causes. However we feel it seems to fit the symptoms Tobi displayed - pale gums, immobility, drooling, low temperature, increased heart rate.

We are not ones to assign blame or find fault. Nonetheless, suffice to say we are disappointed with the level of monitoring at the vetirinarian branch Tobi was in. We are well aware that cats are notorious for masking pain and discomfort but honestly to discharge a cat that can't even stand on its feet! It would be like a doctor discharging a patient who can't walk and asking him to go home. While Tobi's blood tests looked fine, a more thorougly physical examination would have raised one or more red flags. From the time of his passing, not one person from the vet had called to offer their condolences or at least offer some theory as to Tobi's death. It's as if that there was no obvious cause, so nobody can be bothered about it.

My wife and I are still coping with his passing but we are doing well. I just thought that since you treated Tobi twice and did such a wonderful job each time, we would like to let you know what has happened since then.

Thank you for taking time to read this long email. Meanwhile, we wish you all the best in your practice and your great care towards all animals, big and small.

P.S. we would have like to gone back to you but the distance was a bit prohibitive. Anyway we thought it would be just a routine treatment but......

Best Wishes & Regards
Name of young couple


EMAIL REPLY FROM DR SING DATED FEB 10, 2012

Hi

I thank you for your compliments and good wishes.

1. You mentioned "a blood test was performed with several struvite crystals detected"? Is it a urine test?
2. What is DNR?
3. Was an X-ray done?
4. Was a urine test done?

Please accept my condolences for the passing away of Tobi. Pl phone me if you have any queries about Tobi as it is easier to discuss on phone than by writing emails.

With best wishes for both of you.