2297. A 13-year-old male cat and dog came from North Singapore

Wed Sep 16, 2015


Unusual twos.  Two cases from the owners of a 13-year-old cat and a 13-year-old dog from the same neighbourhood in North Singapore in successive days. As Singaporeans prefer proximity, I rarely have one case from North Singapore during the past years. The location is a 30-minute drive away and it has nearer clinics than Toa Payoh Vets. 

Vet 1 from the same clinic in North Singapore treated both cases from owners unrelated and unknown to one another. So I was much surprised at the coincidences of two sick 13-year-olds. 


CASE 1 ON SEP 15, 2015
13-YEAR-OLD CAT
The first case was a cat not eating and lethargic. I got a blood test done as Vet 1 had done X-rays and ultrasound but was not given the permission to do X-rays. The cat did not recover and so the owner consulted me for a second opinion. She consented to X-rays which showed a low platelet count indicating toxicity causing the left kidney to be painful. I palpated the left kidney and the cat meowed in protest, telling me that it is painful. For normal kidneys, the cat will not react to palpation.

TREATMENT - Dental scaling (gingivitis on back teeth and tartar). Left ear irrigation. IV drip x 1 bottle Hartmans with antibiotic and painkiller. Overnight inpatient. The next day, the cat ate and was meowing happily. Went home.

In retrospect, the owner recalled a possible ingestion of commercial ear drops purchased from the pet shop as the owner noted that the old cat pawed at the ear drops after she had put inside the left ear. The cat could have been poisoned resulting in ear pain. This was not obvious without the blood test. Cats are very sensitive to chemicals and pain.  


Lethargic and anorexic for 7 days. The owner had purchased ear drops  to treat the left ear discharge since April 2015. Treated by Vet 1. Ok. Problem came back in June and so she decided to buy the pet shop's ear drops which irritated the cat around 7 days before the sickness. The likely cause could be the chemical toxicity affecting the left kidney which has a radio-dense stone of 3 mm in diameter.

No hairball snacks and treats
Only First Choice For Senior Cats
I warned that the left kidney had a stone which could cause kidney pain and swelling later. As at Sep 30, 2015, the cat was eating and drinking and was active. There was no ear discharge.


CASE 2
The old dog's veterinary bills amounted to a large sum and so the brother who works in the same building as Toa Payoh Vets referred the sister to me.
"As the dog had heart, kidney and prostatic diseases, the bills will add up," I said to the brother today. "Chronic diseases tend to cost much to treat."  Many Singaporean owners only look at the absolute amount and would pronounce to the world: "This vet is expensive and cut-throat."

URETHROSTOMY DONE yesterday.
"Very high risk of death on the op table," I said to the brother and sister as the chihuahua had this loud heart murmurs of Grade 4 confirmed by Vet 1.
"50%?" the brother said.
"Hard to say it is 50:50," I would not be precise as the dog's bladder swelled up to a mango size.
Vet 1 had taken out 15 ml of the urine from the bladder by cystocentesis and given a Tardak injection to reduce the massive prostatic swelling which could cause urination problems. Two weeks ago, he had given one and the dog had no problem urinating.

On going home, the dog just could not pee and some urine dribbled out despite treatment by Vet 1. This appeared to have shaken the confidence of the owner and so the brother asked her to consult me. 

The bladder ballooned.
"It is death if you don't operate. It may be death if you opeerate," the brother told the sister. There was no time to waste. 


URETHROSTOMY
Weight 3.5 kg. T=37.8C. Cyanotic mucous membrane.

1. I gave 1/2 tablet Fortekor 5 orally and inject frusemide 1 ml SC and waited for 1.5 hours. The bladder had swollen to a ballon.

2. IV drip. IV baytril and tolfedine.
3. Atropine 0.6 ml SC
4. No sedatives
5. Isoflurane gas only.
6. Catheter blocked from behind the os penis where the stone was lodged. Marker pen to draw the length of catether at the obstruction. This confirms that the enlarged prostate was not the cause of this anuria as the prostate could be having tumours. In any case, Vet 1 had given Tardak injection the day before.
7. I electro-incise behind the os penis and pre-scrotal for around 3cm length. A large 4mm x 4mm brown stone was seen. 3 smaller ones of 2 mm across were seen.
8. I located the urether which was around 1.3 mm in diameter as my assistant compressed the bladder, squirting out the urine.
9. I inserted the cat catheter into the narrow urethra and stitched up the 4 holes.
10. I stitch skin and muscles to either side so as not to close up the wound in front of the catheter.

The whole process of start of anaethesia by mask to completion of stitching took around 40 minutes. The dog was alive and woke up as soon as the gas was taken off. This was a big relief to me.

COMMENTS
1.  A vet book mentioned minimal sedation and local anaesthetic for dogs with kidney or serious health problems. In this case, the heart disease was bad. So, I did not give sedation by injection.

2. In normal urethrostomy, the catether can be seen as the urethra is incised 2-4 cm since it is placed inside from the penile tip. In this case, I had to open behind the obstruction and so was not able to view the very narrow 1.3 mm cathether of this chihuahua. I used the squirting urine to locate it and anchor the cat's cathether.

3. Today, 16 hours post-op, the dog is active and alert.

4. I advise neutering in case the prostate swelled up more to obstruct urine flow, instead of Tardak injections regularly. The anaesthetic risks of dying are there.

5. Urine test and stone analysis need to be done as a minimum. I did not ask for blood test as the owner was not in favour of additional medical cost.
. 
6. As to the need for regular weekly SC dialysis by Vet 1, I told the brother that he ought to have blood test to check on the kidneys and whether there is still renal failure. In the meantime the dog is given Hartmann's 250 ml SC once a week.    


SEP 18, 2015
I sent the Chihuahua back on Day 2 but he licked his wound causing bleeding. There was another dog in the apartment wanting to play with him.

The dog came back and I saw a large pink purplish bruise on the right side of the scrotal area due to licking. As an in-patient, he had no distractions and was recuperating well. The owner wished to have him in-patient for the next 3 days. The catheter was still in place and the urine coming out looked clear. The dog is an in-patient now and will be given dialysis SC today.    

The prostatic enlargement will cause urination problem later and Tardak injections may need to be given regularly. A neuter would be best but the owners have their worries about anaesthetic risks and so did not accept my advice. The neuter surgery is much shorter than this urethrostomy but the risks are still there. If the dog had been neutered at a young age, there will be no prostatic hypertrophy which could cause obstruction to the flow of urine.

During surgery, I noticed that the urine from the distended bladder did not flow freely after I removed the 4-mm x 4mm urethral stone. My assistant had to compress the bladder manually to release the urine. So, it is possible that the enlarged prostate or prostatic tumour will cause dysuria.

Neuter will be the best advice but the owners think of anaesthetic risks and death and so, nothing will be done till another dysuria episode comes.
     
FOLLW UP.
Sep 30, 2015
1.  The dog is at home. He had been neutered under a 2nd general anaesthesia. Dr Daniel did the neuter on Sep 27, 2015.  As this dog had swollen testicles, he did a scrotal ablation which involved removal of the scrotal sac as well and the testicles which may be having abnormal growth. Neuter removes the testosterone hormones which cause prostate enlargement (see X-ray) and require weekly Tardak injections. If the dog had been neutered at a young age, there would be no prostate enlargement but many young Singaporean dog owners believe it is "cruel" to neuter a dog.

There was the risk that this dog could die under the 2nd anaesthesia, being very old and in poor health. But he survived, much to the happiness of the young lady owner and family.  

2. The stone analysis of the urethral stone was calcium oxalate. The two big stones are inside the bladder.

3. The blood test showed high urea and creatinine levels and low red blood cell count and haemoglobin. This confirms that the dog has chronic kidney disease and would need the twice a week dialysis. The owner now understands that the dog needs to be given the K/D diet. The dog ate a whole can but 6 hours later vomited some food. I advised that the dog, being thirsty due to kidney failure, not be given large amounts of water to drink at one time.

4. This case illustrates the need to patiently communicate with the family members regarding the costs and treatment of the heart, kidney and prostate diseases in this old Chihuahua. Medical costs are high in chronic disesease due to the various tests and procedures required. A perseverance to train the dog owner how to give  the Prescription K/D diet to avoid more damage to the kidneys and to live longer finally pays off now. All the while, the owner feeds the dog hamburgers from McDonalds as he would not eat the K/D/

   

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URETHRAL OBSTRUCTION AND FIC IN CATS

May 10, 2015. The talk at M Hotel, on Sunday, a Mother's Day was limited to 50 pax and was full house. Dr Susan Little is co-owner of 2 cat clinics and an author of cat books, amongst other veterinary achievements

Here are some of her opinions.

1.  URETHRAL OBSTRUCTION

1.1 Stablise the cat by decompressing the bladder in some cases, before catherisation. Do cystocentesis. Insert 25-G needle at 45 degrees towards the neck of the bladder. Not at 90 degrees or into the apex of bladder as bladder shrinks away freom the needle when urine is collected.

1.2. Use 3-way stop valve to draw urine and collect it for urine analysis

1.3 Massage penile tip for some time  -around 10 minutes to express out the urethral plug and so avoid the need to catetherise. This does happen in some hh of her cases.

1.4. She uses warmed saline with sterile lubricant to flush the bladder. Apparently the lubricant is effective in cleaering the mucosa?

1.5 A commercial firm sells the appropriate cat cathether. An orange one which is softer for indwelling. The one with the stylet (costs more) but can be used for both purposes - flushing and indwelling. Has a butterfly for suturing to penile skin.

1.6. Pain relief is important. Suggested opiod and NSAID.

Medocab for cats (Boelinger?) is great as it is tasteless and given in the cat's food. She uses it.  Her opinion is that tolfedine is old school and not as good as meloxicam.  

1.7  ACP 2.5 mg/cat oral as anti-spasomodic and anti-anxiety is said to be effective.

1.8. Duration of indwelling catheter depends on lab analysis of urine and blood electrolytes.

1.9. Recurring cases. She did not mention perineal urethrostomy in her lecture.

1.10. Damage to pelvic urethra from catherisation rupture case - dye seen pooling in pelvic area on X-ray shown.

1.11. Blood test. Monitor for K+

2. FIC

2.1  Only 5% are due to bacterial infections. 60-70% idiopathic. Therefore she does not prescribe antibiotics.

2.2 Most cases are self-limiting according to her, whether treatment is given or not.

2.3 Litter boxes insufficient. Should be 4 boxes for 3 cats instead of lesser.

2.4  Pain relief is important. Opiod. Her favourite is given.

NASAL TUBE FEEDING OF CATS

She said it is easy in her practice with the nurse holding the cat. But given sedation if necessary.

Can email to her if you have queries.

2296. Eye injury in a pug and prosthetic eye - email diagnosis is unreliable

Hi, 

As spoken to you earlier regarding my dog eye.  I have attached an image of how bad his eye is, currently his eye is cover by blood clot as yesterday was in minor 

bleeding compare to his first time bleeding. please do let me know whether you  guys provide fake eye ball implant. By the way this coming Thursday morning he will

be going to remove his eye from a vet from jurong. If you do have solution to cure his eye, please don't hesitate, contact me asap. Thank you so much for your 

concern & time.  

Best regards, 

V

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

EMAIL REPLY FROM DR SING K Y

Sep 15, 2015

 

I need a better front view (with good lighting) and a side view to be able to assess via email. Ideally, I should be able to see the dog but since you have had seen 3 vets, it will be difficult for you. Advices by email reference eye conditions can be unreliable sometimes.

2295. An 80-year-old book binder still works

Sep 15, 2015

He is 80 years old but still works. His 3 children of over 30 years, 2 single and 1 married, wanted him to stop. They bought him a small car. 
"One goes to NUS, one goes to NTI and the other one studies ACCA," he said to me today. "I did not even pass my primary school and so had to work very hard to educate them!"

He had to tolerate the bad tempers of his boss who was demanding. The boss lived up to 90 years of age and was a tough task master. He learnt the trade from him, from finding the best glue for the binding at least cost. In 1952, he imported his paper machine from Italy, a Priano which had two small bulbs and is still working. He had wired a short longer fluroescent lighting tube now.

Last year, an agent offered him $500 to get someone to assign the lease for $60,000. The deal fell through as the HDB disallowed any assignment for the new tenant. "At least I have till 2019," he told me. Many commercial shops have till 2016 to find an assignee if they want to quit. This is a policy to prevent rental hikes due to assignment fees increasing over the years. The HDB will police the trade and make sure that the tenant is really at work and not subletting.  So there is no incentive to take over and the old book-binder now works half a day.

"I can't tender for the business," he emphasized. "I don't even know my ABC!". He is the subcontractor.
"Did you print and bind the condolence book for Mr Lee Kuan Yew?" I asked.
"Yes," he showed me a page. He also showed me a cover for the Anaesthetic Record book of a local hospital.
"How do you manage all by yourself?" I asked as his wife of over 70 years of age had not turned up. She is ill.
"I don't accept more than I can handle," he said. "I will ask for part-time help if I need it."

A much loved father and a loving husband. Mentally sharp at 80 years of age. Cluttered shop full of left over papers and 3X5" cards.

"No use for such cards," I said. "Now, the records are computerised."
"The government forces the people to computerise," he said."Or they will lose their operating licence.. Even for btothels as I print their visitors' book."
"For brohels in Geylang?" I was surprised.
"Yes, yes. However, the old workers do not want to touch the computer. And it is hard to find young Singaporeans to work in brothels to use computers to keep visitors' records. The government wants it so that they can come in and grab the whole computer in cases of investigation! The owner had to learn how to computerise but the workers are aged and do not want to do it!"

2294. 2nd visit: A lovable dwarf hamster keeps losing weight - sand bath allergy?

Sep 15, 2015

This dwarf hamster, around one year old, is very active but he scratches his sides and bites his bely. His chest hairs have dropped by 50% and he has actually lost weight.

In Aug 30, 2015, the daughter owner consulted me saying he keeps losing weight. He keeps scratching his left ear when I saw him. He weighed 46 g, a ball of action. A big abscess in his scent gland was drained and his longer lower incisor teeth were trimmed.

In Sep 7, the owner took him to another vet as the hamster had not put on weight. A skin test on the chest showed no skin mites. Anti-fungal, appetite stimulant, baytril antibiotics and anti-histamine oral were prescribed. Yet the hamster did not put on weight. So the mother consulted me as the hamster was not putting on weight.

Findings: A large nose pimple (digging into pelleted bedding and sand?).
Hair loss on both sides of the cheek pouch (sharp seeds stored inside the pouches?)
Hair loss on chest and top half of lower body (sand bath of different fragrances used daily, according to the mother).

What is the solution to the continuous body scratching and biting?
An allergy is suspected but the cause is unknown. It could be the fragrant sand.

"A change of lifestyle is needed," I advised not giving the daily fragrant sand bath and switch to paper litter. I would get the hairs clipped bald. The lower front teeth were OK and the hamster is hyperactive and much loved. But he just did not put on weight as all his litter food intake had been burnt out by his continuous scratching. (VIDEO).

Will need to follow up.    

2293. 2 days after the General Election

Sep 13, 2015

It seems that the bookies had forecasted more opposition wins as all 89 seats were contested. The large crowds at rallies held by the opposition supported the forecast. The PAP would lose more seats as it had lost to the opposition in by-election due to a PAP MP resignation from an affair around 2011. There was a pattern of favouring the opposition to check the powers of a dominant party. Some high-handed civil servants caused much unhappiness and these have had impact on the ruling party. 

But the PAP won with a bigger share of the votes. The PAP had more concern with the problems of the ordinary people, like job competition from foreigners, subway train breakdowns  and high cost of housing. These were bread and butter issues brought up by the opposition in 2011. These issues were tackled well and shown to be caring.

So, there was a general increase in PAP's votes across the 83 seats and now it has the majority, it has the support of over 70% of the population. The bookies may have lost money. As for me, I have always voted for the PAP as it has a record of good governance as evident by the progress seen in infrastructure and economy.

For example, in Potong Pasir. It looks much brighter under the PAP which won the seat only in 2011 when Mr Chiam See Tong left to campaign in Bishan-Toa Payoh, leaving his wife to rally the residents to vote for her in the 2011. She lost by around 118 votes. This time, she around 30% as the residents are happy with the hard working and persevering PAP MP whom I have not met. The election success speaks for his efforts. I predicted he would win in a video 7 days before the election as he had the advantage of being an incumbent and had worked hard. I am not in his constituency but I could see the improvements.

Where other countries have high employment, here in Singapore, the unemployment is probably 5%.  Therefore Singaporean employees are like kings as they are in great demand and many do not want weekend work. A work-life balance for them. So, who does the weekend and evening jobs in the private sector? Some employers need to close their operations. In 4 years' time, there may be a higher unemployment rate and the government gets the blame. Will the civil servants become more high-handed since they can't be corrupted with money? 

Many Singaporeans including myself have had suffered from some of these high-handed unsympathetic civil servants in the regulatory authorities. I gave two examples:


1. A friend who used to vote for the PAP told me he voted for the opposition to check the powers of the PAP. He had seen many financial hardship cases. In one case, the woman asked for financial help to treat her husband's cancer. The bureaucrat said she did not qualify as her son was working. By the time the government gave her the check, she told the officer to present it to the coffin where her husband was in. This friend said that the government has lots of money and in this case, could have helped out. So he stopped voting for the PAP.  

2. Some years ago, I did not meet the deadline for 100% completion of re-building of my veterinary premises.

The only fittings I did not have were no wooden cabinets and a receptionist table. There were the airconditioners, the water, electricity, the drugs, the anaesthetic machines, the lighting, the crates. The AVA officer, Dr Lau E K came to inspect and pointed to the absence of these items. He said I could sue the contractor for the delays. In any case, he would not license me to practise till I had these two items. He had the power and he exercise his power absolutely. Mine would be the first veterinary clinic that would not be licensed for lacking in wooden cabinets and a receptionist counter. Never mind that I had mobile cabinets and a table and chairs for the receptionist and clients. There was no mercy. Bad luck to me. He said no to my appeal to him to re-consider and walked out to go home after the inspection. 

I just can't believe his lack of concern whereas the HDB officers tried their best to expedite my construction at all times and these HDB officers were also regulatory government officers. I appealed to the Director of Primary Production, Dr Ngiam and he could see that my clinic was operational. He permitted my licence renewal.

It is a hard to believe story but it is a true life experience I share with readers as regards the high-handedness of some regulatory officers.

  




   

     

2292. The commercial palm tree sucked out all water

Sunday Sep 13, 2015

After more than 10 years in my small plot of back garden, the palm tree had grown in girth to over 3 feet in diameter. Centipedes nested inside the trunk and crawl into the kitchen. All the cow grass had withered and the soil is exposed.

I got a contractor to uproot and take it away before it cracks the retaining wall of my back garden. I just can't believe this palm tree could be so water thirsty and large as Singapore does not have palm plantations. The other type of palm tree you see in Singapore grows slim and tall. 

2991. Titan the cat has difficulty peeing

Sunday Sep 13, 2015

I have known Titan the neutered male cat for many years. He had difficulty peeing many years ago. The problem was the high litter tray lined with newspapers. Every time he gets into the litter tray, he bruised his lower belly and penile area leading to pain. I discovered this by querying the owner as I did not see the litter tray. No more problems.

Then today, he came in with difficulty in peeing. He had also been rubbing his backside on the floor, Mr Thiru, the father had said.   
"Has he been to the groomer?" I asked.
"Yes, last week." the Primary School teacher daughter said. Her father had sprained his left ankle and would wait outside the consultation room while I examined the fat Titan.
"Was he OK after grooming?" I noted that this lady groomer referred by me had done a great job (video).
"Yes," the daughter said. "He looked forward to grooming, but he is quiet when he sees the vet."
Titan was like a statute and did not claw or growl at me. Visiting a vet was not pleasant for him as he remembers me for giving him injections.
"He has stained anal areas as he had been licking it,": I expressed brown oil from the left anal sac. "He probably has an itchy backside, licking it to relieve his anal sac impaction. He needs to reduce weight as it is difficult to express his anal sacs with so much perianal fat tissues.

"His inflamed prepuce is swollen now and it is not possible to protrude his penis as in normal slim cats," I said. "That could be one reason he had difficulty in peeing. The reason I asked about a recent grooming visit is that the groomer may have had accidentally clipped his preputial area. This is unlikely as Clara is very experienced and the cat was OK for the past week after grooming."

"Titan loves the dry feline W/D food," the father said. "He would ask for more and my parents would pity him and give him."
"Give him a certain amount to achieve his weight of 6 kg," I referred the owners to a table of amount to be fed on the W/D bag to attain 6 kg.
"He will claw when he asks and no food is given," the father said.  "I will let my parents know."
Titan is 12 years old but he is as fit as a young cat, dashing after birds and lizards. However, the daughter could not film him in action.

I prescribed antibiotics and painkillers for the next 5 days. No urine was available. The bladder was not swollen but painful on palpation. So, I could not do urine test. No X-ray for the time being. 

I have a video of him for readers to appreciate his vitality and health.

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