904. DRAFT REPORT - The cat with the FLUTD - The beginning of the case

I will need time to review this case. Below is my earlier correspondence with the owners - after treatment of Tobi in April 2011.




Tobi's not peeing again ?!
2010emailsx


E-mails_Jun6,2009x


You Tubex


Owner
8/9/11

to me


Hi Dr Sing,

It's been a few months since i updated you about Tobi.
He was doing fine, up till 2 days ago.
Straining to pee and now vomitting after straining.
Some fur in his vomit too.
Very limited appetite too, as if he's scared to eat lest he throws it up.

I'll bring him to the clinic tomorrow morning.
Hope you can see him and advise what's troubling him.

Happy National Day !

J & S

-------------------------------------------------------------
Reply Forward


Owner S
8/10/11

to me


thanks. will try to be there by 1030. he managed to pee this morning!


On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>
> Ok. 10am best
>
>
> Sent from my iPhone

>
> On Aug 9, 2011, at 6:02 PM, ...@gmail.com> wrote:
>
> > Hi Dr Sing,
> >
> > It's been a few months since i updated you about Tobi.
> > He was doing fine, up till 2 days ago.
> > Straining to pee and now vomitting after straining.
> > Some fur in his vomit too.
> > Very limited appetite too, as if he's scared to eat lest he throws it up.
> >
> > I'll bring him to the clinic tomorrow morning.
> > Hope you can see him and advise what's troubling him.
> >
> > Happy National Day !
> >
> > J & S
> >
> >
--------------------------------------------------
Reply Forward


Owner S
8/12/11

to me


Hi Dr Sing,

Tobi's much more alert and not hazy-dazy anymore.
Pee's ok although i didn't get to see it.
Taken his meds too.
Up till now, he's been confined to a room.

Thanks so much for ur treatment and advice.
Will keep him indoors and deny entry to the garden and car porch.

:) suzy



On Fri, Aug 12, 2011 at 7:14 AM, Kong Yuen Sing <99pups@gmail.com> wrote:

I spoke to your husband and fax copies of blood and urine test results to him yesterday.

1. Significant finding of the blood test is the low platelet count and the high glucose level. The low platelet count is probably due to the cat ingesting some toxic chemicals via grooming his coat. There was some "fur vomited" too. Abdominal pain was present.

2. For the urine test, there are bacteria, epithelial cells, white cells and red blood cells and a trace of protein present. This indicated a urinary tract infection involving primarily the bladder. A trace of protein may not be serious at this stage.

3. There is no kidney disease based on the blood and urine tests. No urinary crystals are detected. As for the high glucose level, a 2nd test is needed in 2 months' time to assess whether he has diabetes.

4. A test 2 months later is advised.

5 Advice: Keep the cat indoors and away from eating grass and soil. He has lost weight and this may be due to the ingestion of toxic chemicals tainting his coat and paws when he plays in the garden outdoors. Toxic chemicals may include insecticide and fertilisers and mosquito fogging chemicals. Some cats love to nap under the car, staining themselves with engine oil etc. So, it is best to keep this cat indoors all the time.

------------------------------------------

On Wed, Aug 10, 2011 at 9:49 AM, Owner S...@gmail.com> wrote:
thanks. will try to be there by 1030. he managed to pee this morning!

On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>
> Ok. 10am best
>
>
> Sent from my iPhone
>----------------------------------------
> On Aug 9, 2011, at 6:02 PM, Owner S...@gmail.com> wrote:
>
> > Hi Dr Sing,
> >
> > It's been a few months since i updated you about Tobi.
> > He was doing fine, up till 2 days ago.
> > Straining to pee and now vomitting after straining.
> > Some fur in his vomit too.
> > Very limited appetite too, as if he's scared to eat lest he throws it up.
> >
> > I'll bring him to the clinic tomorrow morning.
> > Hope you can see him and advise what's troubling him.
> >
> > Happy National Day !
J & S
> >
>
-----------------------------------------------------------------
Owner S to me
8/13/11




yes, he does spend a good amt of time lying under the car.
he's more alert yesterday.
has started consuming more fluids and eating a little.
Pees fine too.
On 13 Aug 2011 07:35, "Kong Yuen Sing" <99pups@gmail.com> wrote:
> Did he go under the car to seek refuge in the past 2 months?

>
> On Fri, Aug 12, 2011 at 11:08 AM, Owner S...@gmail.com> wrote:
>
>> Hi Dr Sing,
>>
>> Tobi's much more alert and not hazy-dazy anymore.
>> Pee's ok although i didn't get to see it.
>> Taken his meds too.
>> Up till now, he's been confined to a room.
>>
>> Thanks so much for ur treatment and advice.
>> Will keep him indoors and deny entry to the garden and car porch.
>>
>> :) S
>>
>>
>>-------------------------------------------------
>> On Fri, Aug 12, 2011 at 7:14 AM, Kong Yuen Sing <99pups@gmail.com> wrote:
>>
>>> I spoke to your husband and fax copies of blood and urine test results to
>>> him yesterday.
>>>
>>> 1. Significant finding of the blood test is the low platelet count and the
>>> high glucose level. The low platelet count is probably due to the cat
>>> ingesting some toxic chemicals via grooming his coat. There was some "fur
>>> vomited" too. Abdominal pain was present.
>>>
>>> 2. For the urine test, there are bacteria, epithelial cells, white cells
>>> and red blood cells and a trace of protein present. This indicated a urinary
>>> tract infection involving primarily the bladder. A trace of protein may not
>>> be serious at this stage.
>>>
>>> 3. There is no kidney disease based on the blood and urine tests. No
>>> urinary crystals are detected. As for the high glucose level, a 2nd test is
>>> needed in 2 months' time to assess whether he has diabetes.
>>>
>>> 4. A test 2 months later is advised.
>>>
>>> 5 Advice: Keep the cat indoors and away from eating grass and soil. He
>>> has lost weight and this may be due to the ingestion of toxic chemicals
>>> tainting his coat and paws when he plays in the garden outdoors. Toxic
>>> chemicals may include insecticide and fertilisers and mosquito fogging
>>> chemicals. Some cats love to nap under the car, staining themselves with
>>> engine oil etc. So, it is best to keep this cat indoors all the time.
>>>
>>> On Wed, Aug 10, 2011 at 9:49 AM, suzy lau wrote:
>>>
>>>> thanks. will try to be there by 1030. he managed to pee this morning!
>>>>
>>>> On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>>>> >
>>>> > Ok. 10am best
>>>> >
>>>> >
>>>> > Sent from my iPhone
>>>> >
>>>> > On Aug 9, 2011, at 6:02 PM, suzy lau wrote:
>>>> >
>>>> > > Hi Dr Sing,
>>>> > >
>>>> > > It's been a few months since i updated you about Tobi.
>>>> > > He was doing fine, up till 2 days ago.
>>>> > > Straining to pee and now vomitting after straining.
>>>> > > Some fur in his vomit too.
>>>> > > Very limited appetite too, as if he's scared to eat lest he throws it
>>>> up.
>>>> > >
>>>> > > I'll bring him to the clinic tomorrow morning.
>>>> > > Hope you can see him and advise what's troubling him.
>>>> > >
>>>> > > Happy National Day !
>>>> > >
>>>> > > J & S
>>>> > >
>>>> > >
>>>>
>>>
>>>
>>

Reply Forward


Kong Yuen Sing
8/15/11

to S


What is he eating now?


On Sat, Aug 13, 2011 at 10:09 AM, Owner S...@gmail.com> wrote:
yes, he does spend a good amt of time lying under the car.he's more alert yesterday.
has started consuming more fluids and eating a little.
Pees fine too.On 13 Aug 2011 07:35, "Kong Yuen Sing" <99pups@gmail.com> wrote:
> Did he go under the car to seek refuge in the past 2 months?
>
> On Fri, Aug 12, 2011 at 11:08 AM, suzy lau wrote:
>
>> Hi Dr Sing,
>>
>> Tobi's much more alert and not hazy-dazy anymore.
>> Pee's ok although i didn't get to see it.
>> Taken his meds too.
>> Up till now, he's been confined to a room.
>>
>> Thanks so much for ur treatment and advice.
>> Will keep him indoors and deny entry to the garden and car porch.
>>
>> :) S>>
>>
>>
>> On Fri, Aug 12, 2011 at 7:14 AM, Kong Yuen Sing <99pups@gmail.com> wrote:
>>
>>> I spoke to your husband and fax copies of blood and urine test results to
>>> him yesterday.
>>>
>>> 1. Significant finding of the blood test is the low platelet count and the
>>> high glucose level. The low platelet count is probably due to the cat
>>> ingesting some toxic chemicals via grooming his coat. There was some "fur
>>> vomited" too. Abdominal pain was present.
>>>
>>> 2. For the urine test, there are bacteria, epithelial cells, white cells
>>> and red blood cells and a trace of protein present. This indicated a urinary
>>> tract infection involving primarily the bladder. A trace of protein may not
>>> be serious at this stage.
>>>
>>> 3. There is no kidney disease based on the blood and urine tests. No
>>> urinary crystals are detected. As for the high glucose level, a 2nd test is
>>> needed in 2 months' time to assess whether he has diabetes.
>>>
>>> 4. A test 2 months later is advised.
>>>
>>> 5 Advice: Keep the cat indoors and away from eating grass and soil. He
>>> has lost weight and this may be due to the ingestion of toxic chemicals
>>> tainting his coat and paws when he plays in the garden outdoors. Toxic
>>> chemicals may include insecticide and fertilisers and mosquito fogging
>>> chemicals. Some cats love to nap under the car, staining themselves with
>>> engine oil etc. So, it is best to keep this cat indoors all the time.
>>>
>>> On Wed, Aug 10, 2011 at 9:49 AM, Owner S...@gmail.com> wrote:
>>>
>>>> thanks. will try to be there by 1030. he managed to pee this morning!
>>>>
>>>> On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>>>> >
>>>> > Ok. 10am best
>>>> >
>>>> >
>>>> > Sent from my iPhone
>>>> >
>>>> > On Aug 9, 2011, at 6:02 PM, Owner S...@gmail.com> wrote:
>>>> >
>>>> > > Hi Dr Sing,
>>>> > >
>>>> > > It's been a few months since i updated you about Tobi.
>>>> > > He was doing fine, up till 2 days ago.
>>>> > > Straining to pee and now vomitting after straining.
>>>> > > Some fur in his vomit too.
>>>> > > Very limited appetite too, as if he's scared to eat lest he throws it
>>>> up.
>>>> > >
>>>> > > I'll bring him to the clinic tomorrow morning.
>>>> > > Hope you can see him and advise what's troubling him.
>>>> > >
>>>> > > Happy National Day !
>>>> > >
>>>> > > jeffrey & suzy
>>>> > >
>>>> > >
>>>>
>>>
>>>
>>


Reply Forward


suzy lau
8/15/11

to me


SD canned food.
becos he doesn't drink fresh water from bowl nor pet fountain, i add water to his food.
he laps up the soup but leaves the harder meat bits alone.
he can pee in a stream but only for a few seconds, then stops and come out of tray to lick his penis.
then he goes back again into the tray.
in out 4 or 5 times like that, then goes off elsewhere to lay down.
his antibiotic of half a tablet of baytril finishes today.
should i still continue his quarter tablet of prednisolone?
thank u so much for advice.

903. DRAFT - Searching for answers - The cat with the FLUTD - partial report

I am writing a draft of searching for answers in the case of the cat with the FLUTD that died after 5 days of hospitalisation at Vet 2. It is quite an emotional case for the young couple and for me too as the cat had been my patient too in April 2011 and I had written a case report to bring veterinary medicine alive for the poor vet students who are studying so hard to pass their examinations. Case studies will help them learn better than thick notes from their lecturers.

Tobi was one of those cats who hates vets and was outstanding for his hissing behaviour to warn vets and assistants not to touch him. See my report at:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

Suddenly I received an email from the owners that the cat had died and the email is as follows:

E-MAIL FROM OWNER DATED FEB 9, 2012

On Thu, Feb 9, 2012 at 4:12 PM, ...@yahoo.com.sg> wrote:
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 J & S



E-MAIL TO OWNER DATED FEB 10, 2012

Further to my email,
1. was there an X-ray of the kidney and bladder done?
2. I can review, free of charge, the treatment records and procedures done on Tobi for you and your wife to understand more of what had been done and to learn from the case. I do not do it for litigation or complaint to AVA purpose. If you want the review, you will need to get the vets to give you a detailed report and they should have no problems doing it.





Dear Dr Sing

Our profound appreciation and thanks for your condolences and offer to review the case.

In response to your first email,

1. Yes it was a urine test that showed the struvite crystals.
2. DNR - do not resuscitate
3. Two X-rays done on Sat (approximately an hour before he died)
4. Urine test - Sorry I'm not sure at which point in time you may be referring to. When he was warded or on the day of his passing?
Even though we are still coming to terms with Tobi's death, we are at peace. Our intention to learn what happened was never about assigning blame or instituting litigation. If there is an practice that could perhaps be improved or certain medications that may cause potential complications, we would like to highlight to the veterinarian concerned so that it may something they could look out for in the future that may help prevent another unfortunate outcome. Tobi's death, tragic as it is, may perhaps prove beneficial in providing valuable lessons so that a similiar result can be avoided in the future. We would like to think that a vet practice or any business for that matter would welcome feedback for the betterment of their business and ultimately better care and results for their patients.

We had already obtained most of the work that was done except for the X-rays shortly after Tobi's passing. We have also scheduled an appointment with the owner of the practice this coming Tuesday. Again, we are meeting him not to lay blame but to gain a better understanding of why certain things were done and to address certain issues which we feel could be improved on. We hope that by doing so, all of us can learn from this experience and hopefully make a difference in the quality and care for all animals.

I will discuss with my wife to arrange a time to meet you. We hope we are not putting you throught too much trouble in reviewing this case as I know you are very busy and what little spare time you have is limited.

Best Regards
J & S




E-MAIL FROM DR SING Friday, 10 February 2012, 7:32
Subject:Re: UPDATE ON TOBI


Further to my email,
1. was there an X-ray of the kidney and bladder done?
2. I can review, free of charge, the treatment records and procedures done on Tobi for you and your wife to understand more of what had been done and to learn from the case. I do not do it for litigation or complaint to AVA purpose. If you want the review, you will need to get the vets to give you a detailed report and they should have no problems doing it.




E-MAIL FROM DR SING DATED Feb 10 2012




All vets learn from experience including me. I am most interested in reviewing your case for my own learning and to make improvements in the processes of FLUTD.

Presently, I am writing SOPs (standard operating procedure) for some procedures like urinary stones in dogs to ensure a consistent practice amongst the younger Toa Payoh Vets' vets as I cannot live forever.

Urine tests and X-rays (2 views) on the day of consultation or next day will be most useful. Urine bacterial culture and antibiotic sensisitivity tests as well.

Best wishes.

DRAFT REPORT - NEEDS TIME TO REVIEW AND COME TO A CONCLUSION.
TODAY'S MARCH 13, 2012 FINDINGS BY ME ARE:

On 4.2.12, on emergency admission and around 45 minutes before the death of Tobi,

1. the blood test did show an abnormally low platelet count. This may be a cause internal bleeding or may lead to internal bleeding, gasping for air and death. Lymphocytes % was below normal (immuno-suppression?) but total WCC was normal. RBC was normal. FeLV and FIV tests were negative. So, was there a starting viral infection acquired? Hard to say.

2. The BUN and CRE values were still normal but trending towards the higher end of the range of values just before death.

3. The necropsy result stated that the cause of death was unknown. However, necropsy should be done by an outside party to avoid conflict of interest. There were interesting necropsy findings such as patches of atelectasis in lungs, haemorrhages in the bladder (indwelling catheter? intra-bladder injection of baytril and Vit C?).

4. Intra-bladder injections of baytril and Vitamin C on the first day of admission. As each vet has his or her own method of treatment, I would only say that I do not practise such procedures and cannot comment further.

5. Salivation in the cat on the 5th day of hospitalisation was recorded in the case report. As to its significance, it is hard to say.

6. Sedation was given several times via the IV during the first 4 days of hospitalisation to control the "fiesty kitty". This leads to a loss of control of the reflexes leading to asphyxiation?

A combination of the above factors could contribute to death.

902. Searching for answers for a FLUTD cat that died after 5 days at Vet 1

It had been more than a week since I met the couple who was searching for answers to their cat's death and had written a report at:
http://www.sinpets.com/F5/20120235FLUTD-cat-died-searching-answers-Singapore_ToaPayohVets.htm


It was an emotional meeting for all of us as I did know Tobi too.
After some time to let sadness go away, today, at 5.30 am, I spared some time to review the case to find some more answers.


The cat was hospitalised by Vet 1 for 5 days to treat what the owner had diagnosed was a FLUTD recurrence. The cat was sent home on day 5 and he died at home. I am reviewing the case to search for the answers as to why he died. Experiences are learnt from failures or a death in this case. Every vet will have deaths and many times, the answers are not present.







Toa Payoh Vets webpages in chronological order

1. http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

2. http://www.sinpets.com/F5/20120235FLUTD-cat-died-searching-answers-Singapore_ToaPayohVets.htm

A review may give some answers and to prevent other deaths. Unfortunately, vets are not Gods and deaths will occur for various reasons.

HISTORY:

1. April 2010. The owners referred the cat to me for treatment after being treated by Vet 1. The cat recovered from the FLUTD. I treated the cat a second time in Nov 2010 and did not see the cat anymore. The case is recorded at:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

2. Feb 2011. The owners brought the cat to Vet 1 who then referred the cat to the main surgery and there the cat was treated by various vets (collectively called "Vet 2"). The cat was "fiesty" according to the medical reports of Vet 1 and was given sedatives IV and an indwelling catheter over the 5 days of hospitalisation. The cat was discharged on Day 5. He went home, had breathing difficulty and was sent back to Vet 2 for an emergency treatment. The cat was X-rayed to find out whether the chest had any problems causing respiratory distress. The X-rays were done around 45 minutes before the cat passed away.

The husband e-mailed to me about the cat's death and since the couple was not going to litigate, I volunteered to help to search for answers as to why a cat with a simple medical condition called FLUTD (Feline Lower Urinary Tract Disease) could just die and to give advises as to how to prevent a similar occurrence should they get another cat. The wife must have loved the cat a lot and that was 7 years of companionship. The husband was sad too as he just could not understand why the cat would die. I spared some time to meet and talk to them. This was the least I could do for a nice couple who cared very well for this hissing cat.

SOME E-MAIL CORRESPONDENCES
Fw: tobi's 11 page report + 2 x-rays
E-MAIL TO DR SING FEB 27, 2012


Dear Dr Sing

Please find attached copies of Tobi's reports and X-Rays (X-Rays were taken apprx 45 mins before his death)

Additiional information and our observations that are not in the attached reports


27/1/2012 - Tobi was given Convenia & Dexaason injections & injectable sedative29/1/2012 - Tobi was given Dexaason & Diazepam injections & Anaesthesia (Gaseous)
31/1/2012 - Tobi was Anaesthesia (Gaseous) - in attached report

31/1/2012 - ate a little, never ate again after this, behavior still normal
31/1 to 1/2/2012 - behavior still normal
2/2/2012 - lethargic, unusually calm
3/2/2012 - lethargic, urine scalding, disinterested,lying down the whole time
4/2/2012 - before discharge - could barely move, nose & ears cold, dried drool (brown colour), breathing slightly shallow
4/2/2012 - at home after discharge - hind limb paralysis, laboured breathing, eyes could not track movement
4/2/2012 - few minutes before his death at the hospital- somehow struggled out of his bed, gave a slight meow, convulsed, threw up and shortly after passed away

Thank you once again for sparing the time from your busy schedule to review. Even now, we are still coming to terms with the suddeness of it. I will call you tomorrow and perhaps we can arrange a time to meet at your convenience.

Best Regards
Name of husband




E-MAIL FROM DR SING DATED FEB 28, 2012




Please accept my condolences again.
1. I cannot understand why the X-rays are taken
2. Why were X-rays not taken earlier during admission?
3. Any urine analysis report?
4. How about the preceding vet's treatment report?

Were X-rays taken of the bladder area or not? There seems to be a big abdominal swelling in one X-ray. I will talk to you when we meet. Pl bring printed out copies.


SUMMARY OF SIGNIFICANT FINDINGS ON MEDICAL RECORDS
Cat admitted: 31.1.12. Owner complaint: Keeps licking on his penis.
Cat discharged: 4.2.12
Cat re-admitted: 4.2.12 after hours emergency. Died.


Cat behaviour: Hissing, fiesty, growls when approached from 31.1.12 to 4.2.12.

Sedatives given, mainly via IV:
31.1.12 Ketamine 0.2 ml, Valium 0.2 ml, Atropine 0.1 ml IV. Isoflurane gas to induce, local anaesthesia for urinary catheterisation, PDS 3/0 stitching catheter
Torbugeic 10 mg 0.5 ml IV

1.2.12 Valium 0.2 ml IV twice a day

2.2.12 Valium 0.2 ml IV 6 am and 0.3 ml at 11 pm. connect tom catheter to urinary bag.

3.2.12 Removed cathether.
4.2.12 Not as fiesty as first day. Salivation seen. Able to urinate normally.
Blood test significant findings: BUN 27 (10-30), CRE 2.1 (0.3 - 2.1)

4.2.12 After hours emergency. 36.2C . Very lethargic. FIV/FeLv test negative. X-ray lungs. Blood test significant findings: Lymphocytes % 9.6 (20-55), Neutrophils 79% (35-80), Eosinophils 10.4% (0-10). Platelets 140 (300-800)

Necropsy as requested by the owner:
Cause of death: unknown
All NAD except bladder wall thickened, slightly haemorrhagic.
Lungs with patches of atalectasis - PM change or secondary to dyspnoea towards the end??

Drugs used:
31.1.12 Inject baytril 0.3 ml intrabladder,Vit C 3m intrabladder. torbugesic 10 mg 0.5 ml IV.

Vit C 1000mg + 0.5 ml cefaxone IV BID, Ornipural 1 ml, Vibion l ml IV BID for first 2 or 3 days of hospitalisation.

901. Hamster stitches may not dissolve if they are nylon

E-MAIL REPLY TO DR SING DATED MAR 11, 2011

On Sat, Mar 10, 2012 at 9:57 PM, ...gmail.com> wrote:

Hi,
A few weeks ago I brought in my hamster (Bob) to get a tumor removed but I'm a bit concerned how the stitches have not dissolved. I have been giving him the medicine he was subscribed, though unfortunately last week (or the week before?) one of them spilt by accident. How long does it usually take for them to dissolve, because on your website I saw it was supposed to be 4-7 days but it's already been much more then that.
I'm not sure if this is the correct email for these kind of inquires, but please feel free to correct me if I am mistaken.
Thank you and regards,
-Name of Owner

E-MAIL REPLY FROM DR SING DATED MAR 11, 2011



Pl bring hamster to the clinic for check up. Stitches should dissolve in 14-28 days if they are absorbable ones. Your hamster's stitches may be nylon and need to be removed by the vet as they don't dissolve by themselves.

900. The guinea pig passes "blood" in the urine. Review and follow up

FIRST CONSULTATION WITH DR SING ON FEB 19, 2012

The young lady had consulted Vet 1 about her young guinea pig passing blood in the urine. Vet 1 had done the ultrasound and other tests which the young lady had not kept any records. The blood in the urine came again after a few weeks and she consulted me.

"Was a urine test done by Vet 1?" I asked. According to her, it was not done. A urine test is important when the complaint is "blood in the urine". It can tell many things as guinea pigs and rabbits may pass "blood-coloured urine" due to dietary causes. However the owner sees the reddish urine and thinks her pet is passing blood in the urine.

How to take urine from a guinea pig? For expediency, the vet usually gives the antibiotics, suspecting Urinary Tract Infection (UTI) and that would be the end of it. However Vet 1 apparently did many tests including ultrasound and had cost the owner a bundle. When the guinea pig passed "blood" in the urine again, she came to me for a second opinion.

In private practice, the clinical outcome is important. Otherwise, the owner just go to another vet as in this case.

Passing "blood" in the urine. Real blood. I used evidence-based medicine to diagnose this case. I hospitalised the guinea pig. As he was peeing "blood" in large amounts, I was fortunate to capture his urine and sent it to the laboratory for a proper analysis. My method is described in the images below.

5072 - 5075. 2nd time, the young guinea pig passes blood in the urine. Owner wants an answer. Practise evidence-based medicine by doing urine analysis & X-rays



Collect urine for testing. I used a clean plastic tray cover under the grating and a sterile syringe to collect the freshly passed urine. In this case, the guinea pig passes lots of urine and immediately. So I was fortunate enough to collect a relatively clean sample. He also pooped and this showed he was in good health. Weigh the guinea pig always. His weight was 500 g.

The next day of hospitalisation, the urine was no more bloody. I collected the urine in a syringe to show it to the owner and for this report. I did not test this urine to save costs for the owner.



The 2 X-rays showed some radio-opaque material inside the large intestines. Two views of X-rays are best as one view (lateral view) may not give a mis-diagnosis of the material as being inside the bladder.
The laboratory test showed "blood ++++" in the urine but no bacteria or white cells indicative of an infection. So, in this case, I was able to provide evidence to show the owner that her guinea pig was actually passing blood in the urine.

Practise evidence-based medicine. That is the way to earn the owner's trust. I also did 2 x-rays of the guinea pig's abdomen. There was some radio-opaque crescent material in the intestines. Could this be the "metallic" rust or some radio-dense chewing of the guinea pig? This guinea pig loves gnawing at everything and Dr Daniel was of the opinion that he had chewed some toxic matter.

(Later, in one photo below sent to me on Feb 27, 2012, you can see that the guinea pig was standing in a cage that is actually rusting)

SECOND CONSULTATION WITH DR SING VIA E-MAIL ON FEB 27, 2012

Other than that, please be careful about over-use of disinfectants and chew blocks that may have chemicals inside the wood. Toxins to the kidneys due to chewing of blocks and fence may also damage the kidney and cause blood in the urine.


On Mon, Feb 27, 2012 at 12:59 PM, ...@gmail.com> wrote:

He loves standing this way and the plastic screen is placed before the fence. However, what I noticed is that he's just grabbing the top edge to stand now. (You can see in the photo that the fencing was really rusty and the plastic fencing was used by the owner to prevent him from gnawing it. Later, I guessed that the young lady went to buy a new replacement fencing as the other photo showed white fencing (see photo below).

THIRD CONSULTATION WITH DR SING ON SUNDAY, MAR 4, 2012

Haematuria. "The guinea pig passes blood in the urine again yesterday," the young lady messaged Dr Daniel and came to the surgery. Yet, the carrier's absorbent litter showed just yellowish brown urine but the owner confirmed that real red blood had been passed at home.

"There are many causes," Dr Daniel enumerated UTI, stones that were not visible on X-rays, tumours. What to do? Go for a 3rd opinion? "You were supposed to be the 2nd opinion," she said.

So what was the cause of bleeding in the urine? Bladder or kidney problem? Hard to say. We did not actually see the "bloody urine" as the guinea pig came without having passed blood in the urine in his carrier.

"An exploratory laparotomy would be highly risky," Dr Daniel advised. The guinea pig was now 650 g compared to the earlier visit some 10 days ago.

I gave the following advices:
1. Feed the guinea pig organic vegetables, fruits and hay for one month.
2. No treats and pellets.
3. Feed the medication as before.

"How about dried raisins?" the lady asked. "They are his favourite."
"No raisins too."

Could raisins be the cause since the guinea pig had recovered the next day when hospitalised at Toa Payoh Vets and fed only vegetables and apple? Not a drop of blood. He went home and the cage was screened to prevent him climbing and chewing the wires (pictures given by owner).


Photo (left) is the photo of his new enclosure. You can see that instead of wiring, its the blue plastic on all 3 sides within the enclosure.


In the Photo, you can see that the blue piece is before the wiring. Also, you can see the small rubber tubing (fish tank cleaning rubber tubing, sliced along an edge) that I have just added to cover the top-most horizontal wires. I noticed that he doesn't bite this material.
In the Photo, it shows the clear plastic sheet on his enclosure door. It is also placed before the wiring, from Bean's perspective when he is in the enclosure.

Noted the possible toxins from the cleaning items, chew toys and cage wirings.

Thank you!
Regards,
Name of owner


I will wait and see whether the guinea pig is OK. "Blood" in the urine may not be actual blood this 3rd time. The urine could be "discoloured" urine due to the raisins and diet. To save the owner vet expenses, I did not advise more urine testing and sent the guinea pig home on antibiotics and pred medication for the next 7 days. Three days later, I texted her and was told that the guinea pig did not pass blood in the urine. Then on March 9, 2012, I got the phone message below:

FOURTH CONSULTATION WITH DR SING VIA E-MAIL ON MAR 9, 2012

Hi,

I just gave B.B a tablespoon of pellets as his weight is 500gm now. He stopped eating the veggies that he usually likes. I tried apples, carrots, romaine lettuce, butterhead lettuce and cucumbers, all to no avail. He just ignores them or just take a few bites. His consumption of hay has also gone down.

He's not peeing blood and since the protein content in his pellets aren't high, I reintroduced it. He went straight to eat it and seems to be happier. For the past few days, he's been going to the pellet bowl and looking into it even though it was empty.

Sent from my iPhone

REPLY FROM DR SING, MAR 9, 2012

Monitor n record amount n type of food  daily.  Wait n see.

Comments: It seems that the guinea pig has not passed "blood-coloured" urine since March 4, after replacing the rusty fencing (as seen in an email picture from the owner) and not giving raisins. Only time will tell whether the guinea pig will be fully recovered. The interesting aspect of this case is that there is no way the vet can know that the guinea pig had gnawed on the rusty fencing till the picture was received. So, could the rusty fencing be the cause of "blood in the urine? Rust could damage the kidneys and cause bleeding. This is one possible cause.

It is really difficult for a vet to diagnose this case if the vet does not do urine analysis and speculate that it is always a urinary tract infection. The guinea pig is a valuable family member to the younger generation and it is imperative that a correct diagnosis be made and in this case, urinalysis is mandatory. There is no point doing ultrasound and other scanning when the urinalysis can provide clues and is much less expensive and more useful. But guinea pigs don't pee a lot and it is extremely difficult to collect the urine. Therefore, hospitalise the patient!




NOTES:
http://www.sinpets.com/F6/20120238guinea-pig-haematuria-singapore_ToaPayohVets.htm
gives the latest updates and pictures.

899. A dog care-giver's rage

On Tuesday, March 2, 2012, a dog care-giver was mouthing profanities for over an hour, repeating "can't ni lao boo chi bye". He was stout and had a broad face with bulging eyes that could frighten the weak-hearted.

He brought in a Spitz that had died. Caesarean and spay were done by Dr Jason on Saturday.

898. Sunday's interesting cases: The guinea pig passes blood in the urine for the 3rd time

Sunday Mar 4, 2012

Case 1. Haematuria. "The guinea pig passes blood in the urine again yesterday," the young lady messaged Dr Daniel and came to the surgery. Yet, the carrier's absorbent litter showed just yellowish brown urine but the owner confirmed that real red blood had been passed at home.

"There are many causes," Dr Daniel enumerated UTI, stones that were not visible on X-rays, tumours. What to do? Go for a 3rd opinion? "You were supposed to be the 2nd opinion," she said.

So what was the cause of bleeding in the urine? Bladder or kidney problem? Hard to say. An exploratory laparotomy would be highly risky. The guinea pig was now 650 g compared to the earlier visit some 10 days ago.

I gave the following advices:
1. Feed the guinea pig organic vegetables, fruits and hay for one month.
2. No treats and pellets.
3. Feed the medication as before.

"How about dried raisins?" the lady asked. "They are his favourite."
"No raisins too."

Could raisins be the cause since the guinea pig had recovered the next day when hospitalised at Toa Payoh Vets and fed only vegetables and apple? Not a drop of blood. He went home and the cage was screened to prevent him climbing and chewing the wires (pictures given by owner).

Will wait and see.



EARLIER CONSULTATION ON FEB 27, 2012

Other than that, please be careful about over-use of disinfectants and chew blocks that may have chemicals inside the wood. Toxins to the kidneys due to chewing of blocks and fence may also damage the kidney and cause blood in the urine.


On Mon, Feb 27, 2012 at 12:59 PM, ...@gmail.com> wrote:

He loves standing this way and the plastic screen is placed before the fence. However, what I noticed is that he's just grabbing the top edge to stand now.

EARLIER CONSULTATION ON FEB 28, 2012



Hi,


Photo 2 is the photo of his new enclosure. You can see that instead of wiring, its the blue plastic on all 3 sides within the enclosure.


In Photo, you can see that the blue piece is before the wiring. Also, you can see the small rubber tubing (fish tank cleaning rubber tubing, sliced along an edge) that I have just added to cover the top-most horizontal wires. I noticed that he doesn't bite this material.


In Photo 1, it shows the clear plastic sheet on his enclosure door. It is also placed before the wiring, from Bean's perspective when he is in the enclosure.


Noted the possible toxins from the cleaning items, chew toys and cage wirings.


Thank you!


Regards,
Name of owner

---------------------------------------------------------------------------
Case 2. Vaccination. Westie with lots of pus in both ears came for vaccination. I was surprised that he had recovered 90%. Some black specks in his spinal area whereas previously the whole area was tar black. "Ear canals are clean," I said as I taught Dr Daniel that I would smell the cotton tip after inserting into the ear canal. Most vets don't do it. Smell is a good indicator of ear canal health. I pressed the sides of the ears firmly. No pain. A bit more firmly on both ears. The dog gave a slight yelp. Overall, the ears were clean and had no more pus. I was surprised. The medication was working for this old dog obsessed with ear scratching for many months. The dog had ear irrigation twice and was OK now.

"Dental scaling is needed," the lady owner in her late 40s said. "When did your dog eat breakfast?" I asked. "Always at 6.30 am." Since I did not want the owner to come again, I advised dental scaling at 3 pm, using domitor and ketamine IV. No vomiting. All OK.

Case 3. Meeting with Mr Min, Dr Vanessa and Dr Daniel.
"There is a lot of administration that the lay staff like Mr Lim and Nicole had to do," I said to the 3 of them. "They loved to help out Dr Vanessa in consultation and surgery but they neglected to complete their project." They took a lot longer time to complete the project and they do take days off now and then. Therefore I had advised that they be advised to focus on their work.

"Technical aspect is just one aspect of veterinary medicine," I said to Dr Vanessa. "There is the administration side and the other aspects to support the vets. The vets must discourage idle gossip that lay staff love. They are paid to do a job but they prefer to see practice. That is not what I pay them to do."

I hope the vets have a better understanding that veterinary medicine is much more than just diagnosis and treatment. Lots of paperwork, taxation and other legal submission to the authorities, stock checking and control, payment and sterilisation, cleaning etc.

Case 4. Maltese with blood clot inside the eye, in front of the iris.
Mr Min suggested that the torch-light be shone from 6 o'clock upwards. Sure enough, the young couple could see pinkish blood clot inside the eye in front of the pupil. The dog had been rubbing its eye hard.

A durian seed undetected by X-ray and ultrasound

I shared with Daniel the owner's spending $3,000 for a durian seed inside her dog, at Vet 1. "A barium meal will have detected the durian seed," he said.

She had consulted me as her dog had vomited and would rather not have the blood tests, the X-rays and other tests as she had spent a lot of money at Vet 1. Conservative IV drip with medication for 24 hours warding at Toa Payoh Vets, resolved her problem. No durian seed this time as I palpated nothing inside the stomach. The lady wanted to show me a photo of the durian seed in her handphone, the seed removed by Vet 1 under exploratory laparotomy but could not find it.

895. An excellent article and surgery on megaesophagus & "vertical feeding"

The link is as follows:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC340085/

In practice, it will be most expensive for an owner to get all the tests done to determine the cause and the surgery. In my case, the owner was not keen on more tests.

"Vertical feeding," I asked Dr Gladys what it meant as stated in her University book. I was glad to see her now graduated and practising as last year, I met her in Perth and she was in her 5th year, studying very hard.

This was after we had taken the X-ray with barium meal to show the megaesophagus to the owner as he was not much convinced with the plain radiograph.

"Feed like a human being, being upright," she said.
"You mean, the dog should stand up and eat and drink?" I asked. Lucky for me she had the patience.
"Use a Bailey's chair," she replied.

Well, Bailey's chair are mentioned in the internet on megaesophagus nowadays and therefore is no secret.

It is actually a toddler's dining chair where you confine the toddler.
"It is not practical," the owner told me when I advised him to make one Bailey chair. "I don't expect my dog to sit in it for more than 5 minutes.

The theory is that gravity enables the dog that is fed soft food seated in a Bailey's chair to get the food into the stomach. The dog must sit in it for some time and this may not be to the dog's liking.

The dog had lymphoma and FNA (fine needle aspirate) done on the popliteal and cervical lymph nodes by Dr Gladys and Dr Daniel indicated abnormal cells. A lab test was recommended.

"The owner is more interested in the cure than in knowing that his dog had what type of lymphoma," I said to Dr Daniel. "Such test need money and the owner just wanted to cure the dog of regurgitation and the tongue ulcer. Will such test help? I will say not. So, in practice, economics play a big part unlike in the academic world of the Vet School."


UPDATE AND PICTURES WILL BE AT:
http://www.sinpets.com/dogs/20120237megaesophagus-vertical-feeding-dog-singapore_ToaPayohVets.htm

893. Sophisticated Singaporean pet owners

Yesterday, Friday, I had a meeting with Mr Min, Dr Vanessa and Dr Daniel, seated facing them in the small consultation room, at around 11.30 am when Dr V came to work. The topics covered were:

1. Trend of better educated younger clientele.

"Nowadays, Singapore clients are better informed, esp. on specific diseases as they research the internet," I said. "Therefore, the vet must be able to provide additional value and know the answers to resolve their problem. Clients already know some answers.

For example, megaesophagus in the dog. The diagnosis is easy. Give me 3 solutions or treatments," I asked Dr Vanessa. I continued as clients were waiting outside: "Vets can see the megaesophagus on the plain chest X-ray, but don't expect the owner to see it. That is why I had a barium meal done on the shih tzu so that the owner can really see the dilated esophagus. In fact, there was an esophageal diverticula in the front part of the esophagus.

Dr Gladys had warned that the dog could get aspiration pneumonia if he was given the barium meal," I looked at Dr Daniel who was present during the X-ray. "But this test had to be done and the risk taken. Now, the owner is satisfied with knowing what cause regurgitation in his dog for the past 3 months. As to the cure, that's another matter. Get the diagnosis accurately in a manner that the owner can relate to. Not just showing some area on the plain X-ray and expecting the owner to be convinced as that was not possible in this case earlier."

I read out a text message from a young girl whose rabbit had just given birth to 2 kits. "She's very knowledgeable," I said to Dr Daniel who had diagnosed pregnancy after palpation of a soft abdominal lump and predicted one rabbit.

I had said that "X-rays are necessary to confirm how many babu rabbits were there or whether it was a hairball as diagnosed by the young girl who had earlier texted me to say her 5-month-old rabbit was not eating and drinking.

I had asked: "When did you see the rabbit being mated by the 6-month-old male?". She said: "2 weeks ago."

She asked whether she ought to X-ray and I said it was not necessary. "Just separate from the male, keep her in a quiet place, feed her the fiberplex to move her bowel since the stool pellets are harder and syringe her with electrolytes. She came all the way from Tampenis and it was good that she had good news from her text message 3 days after consulting me.

2. Be meticulous in recording.
Proper and accurate recording ofsurgical procedures, hospitalisation records and anaesthetic records. "All vets will be responsible for their own records," I said. "When there is litigation, such records will be evidence of professionalism or lack of care," I said. "If you want to continue working as a vet, you have to be aware of the trend towards a litigious society and the many regulations of the veterinary authority. Such as the requirement to submit rabies and microchip records monthly. I cited examples of disciplinary enquiries of the liposuction death case where the anaesthetist record was said to be "doctored" and the acupuncturist who prescribed drugs but failed to keep proper and accurate records.

"There are more newspaper complaints and litigation in the medical profession nowadays," I said to the two young vets. "It is best to learn from the failings of others. Unless you want to be suspended or struck off for negligence or for not providing a reasonable standard of care. In the old days, there was not so much need to keep detailed records of anaesthesia and surgery. But times have changed and it is best to be up to date on trends and regulations."

"You two younger vets have at least 30 years of practice to look forward. It will be bad to be suspended or become infamous in litigation. Unfortunately, as a licensee, my name will be dragged in too in such circumstances."

Much more had been said by me than I can record. It is not easy to be a vet or doctor nowadays and so one must be careful. Very careful.