1047. Permission to use image of cat with rectal prolapse

On Sat, Jun 23, 2012 at 5:52 AM, Hannah Lieberman wrote:


Hi there,

I run a non-profit foundation mobile veterinary clinic that we take to low-income neighborhoods in Los Angeles, CA three days a week to perform veterinary surgeries on pets belonging to low-income residents. All services are completely free.


I am currently building a new website, and including photos of ailments that we're able to treat in our clinic. Since we treat rectal prolapses, I'd like to include a picture of one.

I really like the picture of the cat with the rectal prolapse you have your website, and would like to include it on ours. May we get permission to do that, please?

E-MAIL REPLY FROM DR SING DATED JUN 23, 2012
I am Dr Sing from Toa Payoh Vets. Which picture hyperlink is that? Please let me know.


You can use the picture of the cat with rectal prolapse if you use it without deleting "toapayohvets.com" acknowledgement. Good luck.

1046. Closed Pyometra - blood tests and x-rays

Golden Retriever, Female, 10 years

Not eating for 4 days. Lethargy. No fever.

History: Polydipsia & Polyuria

1.  Blood test:
Total WCC = 38 (6-17). N86%, L4%, M9%, E1%, B0%

2. X-rays: Uterine horns filled with pus
3. Ultrasound: Pus seen in both uterine horns. Cervix is closed.

Diagnosis: Closed pyometra

Surgery: 1 hour. Spayed.

Outcome: Good. Dog is back to normal.

High total white cell count and history indicated closed pyometra. X-rays and ultrasound are useful to confirm pus in the uterus.

1045. Example of a veterinary report

From Jun 23, 2012, all veterinary surgeries will be recorded in the following format:

http://www.bekindtopets.com/animals/20120613veterinary-report-format-adenocarcinomasingapore-ToaPayohVets.htm

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From Jun 23, 2012, all vets at Toa Payoh Vets will record the veterinary surgeries done in the following format and e-mail to Dr Sing. This e-mail will be stored in the "cloud". An example is given below:



Veterinary surgery report - excision of bladder adenocarcinoma on May 14, 2012 & follow up 38 days later on Jun 21, 2012



Date of Veterinary Surgery Report: Jun 22, 2012

Name of Veterinary Surgeon: Dr Sing Kong Yuen & Dr Daniel Sing



Case seen on May 14, 2012 by Dr Daniel Sing

1. History & Complaint: TP 43355, (Name of Dog), Beagle M, 13 years, attended by Dr Daniel Sing



2. Presenting Sign & Symptoms: Incontinent with bloody urine dripping all over the floor and passing blood clots for > 4 weeks. Haematuria + Anaemia



3. General Examination: Abdominal pain



4. Tests done & significant findings of tests:

4.1 Blood tests

May 10, 12. RBC low 5.1 (5.5-8.5), Total WCC 12.4 (6-17), N 75%, L12%, M7%, E5%,B1%

Jun 21, 12. RBC 5.6 (5.5-8.5), Total WCC 12.1 (6-17), N 77%, L16%, M7%, E0%,B1%



4.2 Urine tests

May 10, 12. pH 5, SG 1.005, Protein 3+, Ketones 1+, Blood 4+, WBC 90, RBC>2250, Bacteria 3+



Jun 21, 12 pH 7, SG 1.008, Protein 1+, Ketones -ve, Blood 3+, WBC 48, RBC 351, Bacteria 3+



4.3 Histopathology: Moderately differentiated adenocarcinoma



5. X-rays: Radio-dense "stones" seen in bladder area.



6. Anaesthesia: May 15, 12. Body weight: 16 kg. At 50%, Dom 0.32, Ket 0.4 ml IV. Isoflurane gas maintenance. Surgery time: 2 hours. Polysorb absorbable sutures 2/0 x 3 packets, 3/0 x 1 packet



7. Surgery: May 15, 12. Excision of hard gritty tumour, 1.8cm x 1.5cm x 0.5 cm, near the neck of the tumour. Sent for histopathology. Operating surgeon: Dr Sing K Y. Assisted by: Dr Daniel Sing



Follow-up dates: May 22, 12 7.35 pm, Dr Sing K Y phoned owner. No response.

Jun 22, 12, Dr Daniel Sing informed owner of the 2nd blood and urine test results



Signature of Veterinary Surgeon: Dr Sing K Y

Date of this report: Jun 22, 2012



Attached and owner has acknowledged receipt:

Blood tests given to owner: No

Urine tests given to owner: No

X-rays given to owner: No

Ultrasound report given to owner: Not Done.

Histopathology report given to owner: No

Sterilisation Certificate No. .... given to owner: NA

Others given to owner: NA



Anaesthetic & Surgical Record No. ........(Form is not printed yet).

Ear Scope: NA

Skin scraping: NA

Opthalmoscopy: NA

Urinary stone analysis report: NA

Others: NA



Comments by Dr Sing K Y

Another two attempts to phone the owners were not successful. On Jun 21, 12, the owners came with the complaint of painful left hip and re-stocking of anti-seizure medication which must be given daily to prevent seizures. Jun 21, 12 was 38 days after the surgery.



Outcome of surgery: Good. On Jun 21, 12, the couple is very happy that the dog is active and no longer drips dark brown blood and passes blood clots everywhere. They said the urine is clear and has no blood. The dog is able to control his bladder during the daytime but not at night. The dog weighed 15 kg compared to 16 kg during first visit but is putting on weight. Bladder palpation by Dr Sing elicited a painful whine from the Beagle. The bladder was around the size of the tennis ball. Catherisation by Dr Daniel Sing did not produce urine. The wife came later in the afternoon with a bottle of urine collected directly from the dog.



Results: This 2nd urine test indicated UTI and demonstrated the presence of blood. The lab reports will be given to the owner at the next visit.



2nd urine test: Jun 21, 12 pH 7, SG 1.008, Protein 1+, Ketones -ve, Blood 3+, WBC 48, RBC 351, Bacteria 3+



baldder adenocarcinoma seen during surgery. beagle, male, 13 yearsCase report at Toa Payoh Vets:

tpvets_logo.jpg (2726 bytes)5301.

Trust & Audit in a Case of an old Beagle with fits and bladder cancer



http://www.sinpets.com/dogs/20120440veterinary-audit-cystotomy-carcinoma-bladder-toapayohvets-singapore_ToaPayohVets.htm

1044. Veterinary surgery report will be recorded for every surgical case in the following format

A veterinary report will be recorded for every surgical case with the following format and filed on the discharge of the pet:

Date of Veterinary Surgery Report:
Name of Veterinary Surgeon

1. History & Complaint
2. Presenting Sign & Symptoms
3. General Examination
4. Tests done & significant findings of tests
5. Diagnosis - tentative and confirmed
6. Treatment
7. Anaesthetics, Surgical procedures, Sutures & No. of packets used (Record No. )
dates
8. Date admitted: Date discharged:
9. Clinical outcome 3 & 14 days or later - Follow-up dates:

Signature of Veterinary Surgeon
Date of this report

Attached and owner has acknowledged receipt:
Blood tests given to owner
Urine tests given to owner
X-rays given to owner
Ultrasound report given to owner
Histopathology report
Sterilisation Certificate No. given to owner
Others given to owner
Anaesthetic & Surgical Record No. ....................
Ear Scope
Skin scraping
Opthalmoscopy
Urinary stone analysis report
Others

Comments by Dr Sing K Y

1043. The cat bit his tongue - need for thorough exam of the mouth

Two cats fought on the ledge of the 7th storey HDB flat. Both fell at 10 pm yesterday. The stray cat died. The home cat came for treatment as she has blood stained chin.

Simple case. A horizontal lacerated wound. Stitched up 3/0 nylon for chin lacerated wound. 5/0 nylon for tongue vertically lacerated wound (lower and upper area) . I advised nylon instead of dissolvable as the area was infected due to trauma and cat fight.

After the surgery, I took some pictures and saw the lice running around the face. Also tartar in the teeth of this 3 year old cat. I phoned the owner to advise dental scaling and he said OK. During scaling, the vet noted a big laceration of the tongue. The owner was phoned to give permission to stitch up. I advised 5/0 nylon and 3 simple interrupted stitches on top and 2 below the tongue surface.

Always examine the whole mouth from end to end as vet medicine springs surprises.

1042. Failure to keep a proper record: $5,000 fine for senior cardiothoracic surgeon

Straits Times Jun 20, 2012
I showed the article to Dr Daniel and Dr Vanessa to illustrate the importance of meticulous recording to protect against litigation.

The cardiothoracic surgeon of the National Heart Centre was fined $5,000 by the Singapore Medical Council. He was censured and to give an undertaking that he would not repeat the clincial error and pay the cost of the legal proceedings.

What he did not do:

1. Failed to keep a proper record of his discussion with a patient's operation. Fined $5,000 for professional misconduct.
2. Failed to note the patient's consent to the operation (lobectomy).
3. Needed to maintain a higher standard as a senior doctor of 22 years so as to be a role model for junior doctors.

The Committee said that keeping proper medical records is part of patient treatment and these records avoid disputes between doctor and patient. The patient had given his informed consent but the surgeon had not recorded the informed consent given in this case. This is different from not obtaining informed consent.

FOR VETS
1. Patient to sign the informed consent form
2. Vet must record in writing that the patient has given informed consent (time, date).

The practice is usually to get the informed consent form signed by the pet owner.

      

1041. Follow up: Beagle with bladder cancer (adenocarcinoma)

Today, June 21, 2012 I was surprised to see the Beagle, Male, 14 years old so alert and able to control his urination (in the daytime). It was a great joy to see the happy couple as I did not expect this old dog to survive the 2-hour surgery to remove his bladder cancer. But here he was today at 10.30 am with the happiest client. They had made an appointment with Dr Daniel who is their vet surgeon. I come to Toa Payoh Vets for the past 10 days at 9 am and so am able to manage my "trust and audit" of the associate vets.

The complaint was that the dog cried when the wife wipe the left hind hip area after bathing. As for the bladder, there was no complaint now. No more leakage of urine with blood. I checked the op area. The dissolvable stitches had fallen off. The lower part of the body was stained yellow and the owner confirmed that he could not control his bladder when he sleeps.
HISTORY
Beagle, Male, 14 years. Haematuria and urinary incontinence. 
May 13, 12. Blood in the urine. Can't control the bladder at all. X-ray of bladder done but not so clear. I thought there were sharp stones. Blood and urine tests done.  Case report written.
May 14, 12. I removed most of the bladder tumour near the neck of the bladder in with Dr Daniel assisting. A 2-hour surgery. Histopathology of bladder tumour: a moderately differentiated adenocarcinoma.
May 16, 12. Went home.
May 17, 12. Paraparesis. He had bolted from his confined space at home and a luggage fell on his back!

CONSULTATION ON June 21, 12 for painful left hip area. Dr Daniel extended left hip. The dog wanted to move away and yelped. There could be arthritis of the left hip as he had difficulty getting up immediately. 

I was more interested in his bladder. "He looks younger," I said and had some pictures taken of him. A 14-year old looking like a younger Beagle. I palpated his bladder while he was standing on the consultation table. I could  feel a bladder the size of an orange. Yet when Dr Daniel and Min went to collect urine

"No more drinking lots of water like before," the husband said. "Now he drinks around l litre, not 1.5 litres or more."

1040. Executing my vision to be top 5 vet practice in Singapore

Yesterday, June 20, 2012, I stopped consultations and had another talk with Dr Vanessa and Dr Daniel seated opposite me to the left and right respectively, in the consultation room at around 12 noon. I know it is extremely difficult to get vets to buy into my vision to make Toa Payoh Vets a top 5 veterinary practice in Singapore.

It is always difficult in any business for the leader to execute a vision because each employee or associate vet has his or her own agendas.

1. "First Impression Counts," I said to Dr Daniel. "If a vet can be bothered to shave, it gives the impression that he can't be bothered to take good care of the customer's pets." I looked at Dr Vanessa's feet and said to Dr Daniel: "Wearing flip-flops and clogs to work is not permitted and a vet had done this in Toa Payoh Vets for some months."

2. My.hints and advices are ignored. "If vets don't accept hints to change their mindset to improve their standard of care, I will be frank. If vets bring down Toa Payoh Vets to the bottom 5 practice in Singapore, I will not hesitate to fire them. Simple as that. I will just close down the practice when I am unable to work. I don't believe in passing the practice to the next generation. I don't believe in leaving my legacy to the next generation. Dr Daniel will have to earn his stripes.

3. Practise evidence-based medicine and know what to do. For example, the rabbit came in with a jaw abscess and there was no advice from the vet to get an X-rays done to check the extent and location of the impacted and infected roots of the cheek teeth. This will not be tolerated by me. In this case, the owner was very knowledgeable about medical practices and was agreeable to the X-ray being done. But the associate vet did not even mention this. This should not be happening again nowadays when litigation and complaints are getting more common.
4. There are around 50 vet practices in Singapore. Why should the client come to Toa Payoh Vets if the practitioners are mediocre and cannot produce excellent clinical outcomes?

It is very hard to execute a vision to be top 5. Failure of associate vets to adopt best practices need to be monitored. Associate vets who don't meet my standards to implement my vision will have to go. It is no more open a practice and clients will come as in 20 years ago. A practice must be sustainable and not losing money over the years as operational costs keep escalating while fees are kept low due to competition. It is quite easy to lose money if the vets are not of a high standard to perform and so it will be better that they work elsewhere.

5. Working in a corporation. Employee and associate vets may feel they are independent contractors and don't take instructions from the licensee. In real life, the licensee is held accountable and if associate vets dress what they like and bring disrepute to the practice, it is best to fire them and just be a small surgery with good referrals and profitability rather than be a multi-doctor practice.  

 

1040. Follow up: Rabbit's hyphaema. Bleeding inside the eye.

Jun 20, 12

It is a rare case of bleeding in the rabbit's eye.

BEFORE TREATMENT




2 DAYS AFTER TREATMENT

FOLLOW UP ON JUNE 20, 2012
Thanks for the trouble to give me the feedback today to say that the rabbit's eye is now normal and that the bleeding has disappeared 3-4 days after going home. Much appreciated.

1039. Follow up: Hypoglycaemia & Atypical lymhphocytes

June 20, 2012
"The Jack Russell X is normal now," the wife came in for more antibiotics for the urinary tract infection and was most happy. "I consulted a lady who can communicate with my dog. She graduated from overseas. My dog told her he is going soon when I ask whether my dog should take chemotherapy."

"I am open-minded," I said. "Your dog is on prednisolone which is a form of chemotherapy without the toxic side effects and so he is feeling much better now.".