1157. STORY. The meowing cat. Kidney disease FLUTD cat passes blood in the urine - follow up

A challenging medical case. On March 17, 2015, the cat came to me for a 2nd opinion. He had bladder obstruction and had been treated by the other vet for around 4 days before discharge. But the cat was not eating and had blood in the urine. I got X-rays done after palpating much enlarged painful kidneys of 3-6X normal and seeing the inflamed red prepuce of this 1-year-old male, not neutered cat much loved by the family for his vocalisation.

He would meow to greet people unlike the dumb sterilised cats in the apartment.  He meowed as if saying "good morning" when he recovered after 2 days of in-patient. So I could understand how much he was loved. He looked good and I sent him home.

However, the owner could not feed him or syringe him. He came back with ulcers in his tongue, right lip commissure and right upper gum. I suspected he was forced fed and suffered traumatic ulcerations. So he would rather die than be forced fed by the owner. Severe dehydration and recumbent. Low body temperature or hypothermia. Poor pulse volume.

I thought he would die soon on this date of admission - Mar 24, 2015. I gave him 250 ml of SC fluids with all the multivitamins and amino acids and antibiotics per day for 2 days and did not expect him to revive.

But he bounced back to life after 2 days of in-patient treatment when he meowed again on the 3rd day. The owner did not want him home and wanted another 2 days for him in Toa Payoh Vets. He recuperated and meowed whenever he saw the staff. Such a lovely behaviour. Much as if he appreciated being visited. So he went home on Mar 26, 2015.




No bad news till Mar 29, 2015 when the owner said he had passed blood in the urine.  


Mar 30, 2015

"My cat is eating and drinking a lot, but he passes blood in the urine!"   the owner phoned today.

Advised:
1. Stop medication
2. Urine test
3. Switch to dry Renal within 3 days.

The cat has not fully recovered from kidney disease. He went home 2 days ago, meowing and eating a bit of his canned food. Alert. But the owner phoned to say he is passing blood in the urine. A urine test was done on
---------------------------------------------------------------------------
Mar 30, 2015
pH 6.5, SG 1.025, Protein 2+, Blood 4+, White blood cells >2250, Red blood cells >2250. Bacteria Nil. Casts and crystals Nil.


Compare to the previous 2 urine tests.

Mar 24, 2015
pH 6.5, SG 1.019, Protein 3+, Blood 4+, White blood cells >2250, Red blood cells >2250. Bacteria 2+. Casts and crystals Nil.

Mar 17, 2015 (first consult at Toa Payoh Vets)
pH 6.5, SG 1.025, Protein 3+, Blood 4+, White blood cells 1791, Red blood cells >2250. Bacteria 2+, Casts and crystals Nil. Spermatozoa +, Ketones Trace.

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

Mar 17, 2015 URINE CULTURE
Amoxycillin+Clavulanic Acid, Cefuroxime, Nitrofurantoin, Ampicillin+Sulbactam, Ampicilin --- Resistant

Cipofloxacin, Gentamicin, Cotrimoxazole, Fosfomycin  --- Susceptible. 
The first vet had prescribed amoxycillin + clavulanic which is commonly given to cats in Singapore.

CONCLUSION
The cat is eating and drinking, but the kidneys have not recovered fully. There is no bacteria in the urine in the 3rd test on Mar 30, 2015.  He was not "passing blood in the urine" from March 19 to Mar 29 after a change of antibiotics and 2 days of inpatient treatment.

But on Mar 29, the owner phoned me to say he was passing blood in the urine. Will the cat get kidney failure again?

This FLUTD plus kidney infection is a complex case to resolve.

Bulying in guinea pigs

Mar 30, 2015

FEEDBACK FROM GUINEA PIG OWNER

Dear Dr Sing

Just to let you know that Mochi is doing well so far after the UTI & diarrhea last month. In fact, she still had blood in her urine after the second visit for diarrhea. I suspected it may be bladder stones so I continued to monitor for a while. Then one day, I discovered some transparent jelly like substance in the litter box...bladder stones? Subsequently no more blood in the urine which brought much relief to me. 

After that couple of weeks of isolation from Mocha, Mochi was so afraid of her when I tried to put them back in the same cage. They were so tensed & nervous that I had to assemble another cage for Mochi. Now they seem happy having their own space.

Mochi used to bully Mocha so Mocha is now more relaxed being alone. Previously, Mochi competed with Mocha for food, water & litter box. She's happy to have everything to herself at present.

Last visit, I promised to send you info on how I assembled the cage for my guinea pigs. Please refer to attachment.

Best regards


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

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

Guinea pigs do compete for dominance and space like people. Bullying is quite common but the owner is not aware of it. 

 

1155. Sunday Mar 29, 2015 Remembering Lee Kuan Yew

I closed Toa Payoh Vets in the rainy afternoon so that the staff can watch the State Funeral possession of Mr Lee Kuan Yew and listen to the 10 eulogies. I feel great sadness as he had done alot for the ordinary Singaporean esp. with undergraduate scholarships given on merit, rather than on favouritism.  In this way, the poor can better themselves if they excel academically.   

1154. A stray cat trapper in Singapore

Mar 27, 2015

I met a cat activist, a lady in her late 40s,  bringing in stray cats for sterilisation at James Tan Vet Centre. She was washing the metallic cat traps outside. Her black car was a SUV. The seat was packed with carriers, dry cat food and  cat traps.  

"I would have liked to buy a bigger commercial vehicle," she said. "But I don't have a company to register this van."
"You don't need a private limited company to do it," I said. "You can register a sole proprietorship."
"The ROC (Register of Companies) will close it down as I don't make profits."


"I don't think the government will close a private company that is not making profits annually," I said.

"It can be quite costly for the feeders if there is more than one stray cat," she said. She was a volunteer who would trap stray cats if the feeders agree to pay for the petrol costs, sterilisation and hospitalisation fees at the Vet Centre. The Cat Welfare Society had approved her project.

"Over the years, there have been many stray cats trapped and sterilised," I said. "How come there are still stray cats still breeding? " I don't see more than one stray cats in the Toa Payoh housing estates, the hawker centres and the public parks. Some town councils even employ pest controllers to cull them and at one time, the government AVA was active in doing it."

"There are people who dump their pregnant cats," she said.
"How do you know these cats are not really stray cat?"
"They are not feral cats as they behave, being friendly to people," she replied.
"Where do you she find such cats?" I asked.
"In the Kim Chuan industrial parks. I place food inside the cat traps. They are hungry and so enter the traps."

"I notice you have only one type of dry cat food and one colour," I said. "Instead of the multi-coloured pellets."

"Those multi-coloured pellets are too high in salt," she said. "These light brown ones are better." 
"What brand is it?" I asked.
"SAVA brand. You can buy them from any pet shop "
"Where are they made?" I enquired.
"From Thailand. They are good enough for the strays."

She had her career but spent rime trapping stray cats for sterilisation and release if the cat feeders are willing to pay for the costs. .
  . 

A guinea pig has sudden onset bloat - clostridial infections?

This 4-year-old male guinea pig was OK the day before but overnight, became lethargic and would not eat. The owner consulted me. I noted a large abdominal distension, esp. the left side. There was gas inside the bloated stomach. The guinea pig was hypothermic at 36C and the gums were pale and cyanotic. I got the X-rays done and released the gas using a 23G needle and 10ml syringe to suck out. The guinea pig felt better. 

The stomach deflated. SC drips plus baytril antibiotics did not help. Around 2 hours later, he passed away.  Toxins from Clostridial bacteria could have killed him. Gastric volvulus or distension was present. The prognosis was poor.  No more hay for the other guinea pig which was still OK and eating the same hay.

Bubbles in the abdomen indicate that the intestines had lost blood supply and leak gas into the abdomen. The guinea pig died from septicaemic shock as Clostridial bacteria is highly pathogenic. No post-mortem or bacterial culture was done. 

Empathy in medicine

Educating For Empathy - Journal of General Internal Medicine 2006.

Empathy in doctors significantly influences patient satisfaction, adherence to medical recommendations, clinical outcomes and professional satisfaction. Frequency of medical errors among doctors decrease as the empathy levels increase

1151. Video on annual health screening for a 10-year-old Shih Tzu

This trim fair lady loves her female, spayed 10-year-old dog very much as she will present her dog yearly for the vaccination. She had made an appointment today after receiving my vaccination reminder card.

This time she requested a blood test. I was surprised that she was well informed.
As for the dental scaling, she said: "I am worried about anaesthesia. Maybe another time."
The back teeth were full of tartar but the teeth were still strong and solid. When I opened the dog's mouth wider, she gasped although the shy Shih Tzu with clear corneas did not flinch a bit.

 "It is necessary to check for mouth ulcers and tumours," I explained to her.


Normally, some of my vets just give the vaccination and general examination or just the vaccination owing to the owner's financial cost constraints.  So no blood and urine tests were done or advised by my vets.

I did a health check video for the benefit of the younger dog owners. The dog was a good patient. The overall experience was eventful as more and more dark brown anal sac oil kept discharging as I expressed the anal sacs. Yet the dog did not bite her backside. The tell-tale sign was just some hair loss and skin irritation at the end of the tail. The ear canals were dirty and need cleaning.

This was a happy interaction for the vet, the dog and the lady dog owner on this Friday morning.

A 7-year-old Pom coughs non-stop - x-rays

Chihuahua, F, 6 years.
No respiratory distress. X-rays of normal heart and lungs for comparison with the Pom case below.



Pom, F, 7 years
Acute respiratory distress
Non-stop coughing
The first vet had taken a 2nd X-ray 7 days ago when the dog started coughing again and prescribed medication. He did not think it was a heart problem.

Yet the dog's coughing got worst and became continuous during the past week. The owner consulted me.  No X-rays were taken by me.


No heart murmurs. Irregular heart beats.
What is the problem? Any cure?

X RAYS FROM THE FIRST VET

ANALYSIS - COMPARISON WITH X RAYS OF 2 OTHER DOGS
VENTRAL-DORSAL VIEWS OF X-RAYS

7-year-old Pom with continuous coughing. Pulmonary edema (cloudy lungs).
The right and left ventricles are enlarged when you compare to the normal heart of the Chihuahua. No heart murmurs. Irregular heart beats.  
As a Mar 27, 2015, the dog no longer coughs, being given heart medication

Compare that to the 6-year-old Chihuahua with no heart problem. Clear lungs (black)

Compare to a 1-year-old Pom with right-sided heart enlargement, coughed blood and panting

No cardiogram or another X-ray were done during consultation at Toa Payoh Vets,owing to cost constraints.



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

ANALYSIS - COMPARISON WITH X RAYS OF 2 OTHER DOGS
LATERAL VIEWS OF X-RAYS

7-year-old Pom with continuous coughing. The heart looks normal.  This X-ray by the first vet was taken around 7 days before the non-stop coughing presented itself.  I did not have any X-rays taken to lower medical costs for the owner. 



A 6-year-old Chihuahua with a normal heart and lungs


A 1-year-old Pom with right-sided heart enlargement








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


ANOTHER CASE OF COUGHING AND PANTING in a Pom seen by me in 2009.
POM, F, 1 year old.

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



A CHIHUAHUA WITH NO PANTING OR HEART PROBLEMS FOR REFERENCE

1149. Singapore: A safe and prosperous haven

"I am not a free lance tour guide," the girl with the deep set sad eyes said. "I am a part-time tour guide."  She was on duty at the travel agency office, just like a car salesman but this was the first time I saw her, despite over 10 visits to this office.   

"What is your target sales?" I asked.

"150," she has no problem getting 150 people to go on tours since she is an "old bird". She said she would be on duty this coming Sunday March 29, 2015 at Marina Bay Sands as she was required to be present. But with the passing of Mr Lee Kuan Yew on March 23, the travel fair was cancelled.

It is Mr Lee's transformation of Singapore from a swamp land to a First World Country with almost full employment, making Singapore a safe and prosperous haven in churning waters that this lady can work part-time. 

The older generation would worry about losing a full-time job and getting another. Here, she could work part-time for this agency and also for other agencies whenever she likes. There is a labour crunch due to the full employment, unlike countries like Greece with 25% unemployment.

1148. Skin diseases: White skin spots or patches in a dog or cat

Skin cells called melanocytes produce pigment giving the skin its colour. If melanocytes disappear or is not produced or produced less, the skin loses its colour. "White spots appear".

In people, the causes are:
1. Pityriasis versicolor (white spot disases), body and limbs, mild itchiness. The acids secreted by yeasts - Malassezia, inhibit melanocytes from making melanin. Selenium sulphide solution and clotrimazole cream are common treatments.  Oral anti-fungal medication for severe cases. Recovery of normal skin pigmentation may take many months.

2.   Vitiligo is a skin disordr. Melanocytes are destroyed. The skin is usually completely white and clearly demarcated from the surrounding normal skin.

3. Idiopathic guttate hypomelanosis are 2-4 mm flat pale spots on the face, arms and legs. Extnesive and chronic sun exposure causing skin damage.

4. Post-inflammatory hypopigmentation - previous skin injury. Pigment temporary disappear.  After vaccination or injection in the dog or cat.

5. Chronic arsenic poisoning. Rare cases where contaminated well water or traditional Chinese medicines containing arsenic is consumed for a long time.

6. Hypopigmented mycosis fungoides is a form of skin cancer. White patches on the body. Uncommon.  Slow progress

Skin colour may take several months to recover after successful treatment.

In Toa Payoh Vets, the number one skin disease in dogs is ringworm which is curable.