Tuesday, February 26, 2013

1396. Feb 26, 2013

Cat owner with bladder stones didn't phone me yesterday. Today Tue Feb 26, he phoned to report progress.

"My cat is drinking less, otherwise he is ok. No puking. I run out of K/D diet. Shall I feed him the S/D can (given by Vet 2?).
"As his bladder  stone is still being analysed, no point feeding the S/D unless he has struvite stones," I advised. He will buy more K/D for the time being. K/D is given because of renal impairment accordin to the Vet 2's blood test..

1395. Update: A cat has bladder stones and "renal failure".














Sunday, February 24, 2013

1394. Follow up. Sunday. Cat with bladder stone

Sunday Feb 24, 2013
6.23 pm Yishun public library to type this report
Communications post-op is most important. The cat owner phoned me twice and left his name and phone number. My receptionist reminded me to phone him after my consultations. I was kept busy with the owners of a cat from an American couple regarding removal of the claws, a rat with nasal swelling on the right and a large skin lump on its back and a rabbit from Woodlands for "spay" from a Malay family who had stated incorrectly the gender. Two big terrapins came yesterday for Dr Jason Teo - one would not eat and the other one had puffy eyes and I had them cleaned and given eye drops and bask in the bright morning sunshine. I had to supervise a new vet technician as Mr Min would be moving on to better future after having worked two years with me, increasing his value to the new employer as an experienced vet technician.

Back to the cat with the bladder stones was operated on Thursday, 3 days ago. The owner phoned me yesterday and today to provide me feedback and that was important.

"My cat did not vomit after eating food. He drank a lot, around 375 ml of water and peed a lot," he said. "He laid on his urine and so his surgical wound is very red."

"It is good news that he pees a lot," I said. "This shows that his bladder is normal." I tried not to joke that this showed that his bladder was not leaking after my surgery.

"What should I do to the red area of his wound?" the owner asked.

"It is very difficult for me to know what you are describing," I said. "Was the cat licking the wound since you did mention about taking off the e-collar?"

"No, he is still wearing the e-collar."

Since the owner was working, I suggested that he changed the plaster covering the wound and replace with a new square one. "It could be the blood clot from the skin after stitching," I said. Will wait and see.

It seems that the cat with the renal impairment based on blood tests taken by Vet 2 on Wednesday (4 days ago) is doing well.  He did not vomit his food. I asked the owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet yesterday. He has a good maid and with home care, this cat should thrive.

Before I forget, the Thursday surgery in brief is as follows:

ANAESTHESIA
5 kg bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one syringe. Isoflurane gas top up was necessary for a short while. Rectal temperature was 36.8 C after sedation as the cat was angry and we could not want to antagonise him more.

SURGERY to remove bladder stones seen on X-rays taken by Vet 2.
1. Catherise the bladder
2. Withdraw urine for urine analysis
3. Inflate bladder with 40 ml normal saline so that it is palpable.
4. Incise skin and linea alba.
5. Press out the distended bladder.
6. Incise at apex of 8 mm as I know the stone was around this diameter.
7. I insert an artery forceps to grab and take out the stone without making too big a bladder incision.
8. My assistant Min pumps in more normal saline as I closed the wound for a while.
9. 3 small pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and blood.
10. More irrigation of the bladder.
11. I stitched the mucosa 3/0 absorbable - inverting layer
12. I stitched the serosa similarly - another inverting laye.
13. To check leakage, I asked Min to pump in more saline via the catheter to inflate the bladder. No leakage.
14. I put the bladder back into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0 nylon).
14. I put the bladder back.
15. Post-op baytril and tolfedine
16. Cat goes home in the evening as the cat was quite ferocious and nursing at home would be better as the cat would be hand-fed food (K/D) and medication.

Friday - Day 1 after surgery. I phoned the cat owner.
"Vomiting one hour after food and medication," the owner reported as he had given medication on the evening of the surgery. I advised not giving the tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by hand.

Saturday - Day 2 after surgery.
Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due to the high BUN kidney disorders," I said. "That would account for vomiting. Feed less amounts"

Sunday - Day 3 after surgery.
Feedback in above paragraphs.  Will need to summarise all later,

Discovered and borrowed two thick books published in 2012 and 2013 from Yishun library.
1. Web Marketing All-in-one for Dummies. 8 books in one.
2. Social Media Marketing All-in-one for Dummies. 9 books in one.
Thick as a bible. No wonder most doctors and vets give them a miss.

1303. Bladder stone in a 7-year-old cat

Wednesday Feb 20, 2013
"Can you operate today?" the owner of this 7-year-old with a disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me by his vet friend working in Biopolis.  I had asked him how he came to know about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is about to open in Singapore.  

"I can operate today, but you may have a dead cat at the end of surgery," I showed him the high total white cell count and neutrophils of the cat's blood test taken earlier in the day. "These data showed that the cat has a generalised blood infection of bacteria and is not in a good health state to be under anaesthesia and surgery. He may die on the operating table."

"But Vet 2 told me that my cat is suffering from a serious kidney failure. She said I should operate soon and any delay will result in death." Vet 2's blood test result show BUN as "---", creatinine and phosphorus as exceedingly high. This indicated an acute renal failure.

"It is best to stabilise this cat first," I had read the medical reports and viewed the X-ray. "Was there any antibiotic injection given to the cat? Any fluid therapy? Any urine test? Any fever?"

"I don't think so," the gentleman is typical of the increasingly educated and well informed pet owners in Singapore putting vets on their toes as he would have done his internet research on his pet's urolithiasis with one click of the mouse. "Otherwise my bill will have this item charged. Vet 2 did say that the cat was slightly dehydrated"

The cat was now furious and the owner could not handle him. I did not want to provoke this frightened cat further as the cat would go crazy and very aggressive. I asked the owner to hold and talk to him while I gave the Baytril antibiotic injection SC. I assessed that this cat would not need the fluid therapy as he was drinking and peeing. Only that he was not eating for a few days and the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked him to return again if the cat had not recovered but Vet 1 closed on Wednesday and so he remembered Vet 2's colleague whom he had seen before. Vet 2 told him that she was not sufficiently experienced to operate and her colleague's surgical bookings were full house. So he had to find another vet and that was where his vet friend referred him to me. I don't know this vet friend and so it was a surprise.      

The operation would be done the next day. Weighing the cat, taking the rectal temperature and giving SC drip would be out of question as the cat was quite fed up with Vet 2's blood taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had managed well. I presumed she X-rayed first, otherwise it would be very difficult to restrain this little tiger.

Thursday Feb 21, 2013
The main worry was the possibility of death under anaesthesia as this cat was just not fit for surgery based on Vet 2's blood test of a severe kidney disorder. I would say it would be acute nephritis but this cat had no history of vomiting. Would this cat die on the operating table? This was one of those hot potatos vets prefer not to handle as death may result in bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to operate myself under such negative conditions of impending death of a cat. Ideally, the cat should wait 3 or more days before surgery. But the owner was much worried and the kidney disorder may worsen to severe vomiting and death owing to delays. The kidney enzymes were exceedingly high. To wait would be risky as a cat in deteriorating health would die anyway. 

So, I was holding the hot potato one way or another. To operate or to wait more than one day. 
What safe anaesthesia to give? This is hard to say.


 

    

Friday, February 22, 2013

1301. Update on recurring urate or oxalate urolithiasis

TOA PAYOH VETS
toapayohvets.com

Date:   22 February, 2013  
 

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
Prevention of recurring oxalate or urate stones  
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   22 February, 2013  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
Wed Feb 20, 2013 A review of the case operated by Dr Vanessa twice for oxalate bladder stones in May 2011 and September 2012. I audited the case and on Sep 26, 2012, I asked Dr Vanessa as to what follow up she had done to prevent a 3rd recurrence. She said she had advised U/D and had sms the calcium oxalate stone analysis results. Many owners will just ignore the advices till another recurrence and another operation or euthanasia of the poor old dog. I took the trouble to write to the owners to let them know the preventive measures as I don't want a recurrence too, although recurrence is in the interest of the practice. An extra effort had to be made to follow up and vets usually don't have the time to do the hard sell of prescription diets in the interest of the canine patient.
The father came to buy 12 cans of U/D again for the cocker spaniel, male, 11 years old today. "How's the dog?" I asked him as he had been feeding this U/D since Oct 5, 2012 when he bought 3 cans and came whenever he ran out of the stock. Seldom do I encounter such a disciplined owner as many Singaporean owners tend to forget about feeding the relevant diet to prevent bladder stone recurrence.
"His body condition is much better compared to previous times when he sheds hair all the time and has dry skin flakes," the father surprised me with this feedback. "I thought it was normal for dogs to shed hairs."
"How do you know this dog sheds hairs previously?" I asked. "Does he drink lots of water?"
"Hairs scatter all over the floor of the apartment and so this shows he has been losing hair. He drinks water too."
This was good news but it is too early to tell whether the dog will have recurrence of bladder stones. The 2nd episode occurred 16 months after the first cystotomy operation to remove the stones. It is only 5 months after the 2nd cystotomy.
From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd operation, he fed cheap canned food and meat and yet the stones recurred. Now, he is satisfied with the U/D.
PREVENTION MONITORING IS NOT DONE.
Many owners don't know that urine tests and X-rays are still necessary as part of the prevention of recurring urolithiasis as typical in this case. Feeding of prescription diet is just one aspect.

Monitoring includes urine tests and X-rays of the bladder. This should be 1-2 months for the first 6 months and thereafter, if negative results, 2-4 monthly. Very rarely do any Singaporean dog owner comply with this advice and there is not much the vet can do.

Monitoring and urine tests which show small stones can easily be treated with a process called urohydropropulsion in which the catheter is inserted into the bladder and the small stones are sucked out easily. These stones are analysed in case they are of different composition.
This case shows that the education of the dog owner with recurring urolithiasis is an uphill task and there are so many family members involved. Who in the family will have time to do the 1-2 monthly monitoring? The young ones are busy with their work and personalised life. The older members may not have the motivation to spare the time to get the dog tested.
Today, I reminded the father that he has to send the urine for analysis of crystals. He said: "Yes, you have given me the bottle to collect the urine." There is not much I can do. Urine test will monitor the urine pH, bacteria and other results as well as urine crystals and monthly urine tests will be more economical than another surgery. But Singaporeans seem to be time-pressed and so that is the culture. I don't expect any urine sample from this father as that is his personal matter.
P.S Monitoring of Urine to prevent or treat recurring urolithiasis: Absence of oxalate crystals in the urine does not mean no oxalate stones as can be seen in the 2 urine tests taken prior to bladder stone removal surgery as follows:
May 24, 2011 Urine pH 7.0, SG 1.028, Blood 4+, WBC 10, RBC >2250, Bacteria 3+, Crystals Calcium oxalate occasional
Aug 28, 2012 Urine pH 7.0, SG 1.029, Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals Nil
From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd operation, he fed cheap canned food and meat and yet the stones recurred.

Updates will be on this webpage:
http://www.asiahomes.com/new1/20130221urate_stones_recurring_toapayohvets.htm
 

Calcium oxalate urinary stones are radiodense. Take X-rays. Toa Payoh VetsA case of oxalate stones:
www.bekindtopets.com/animals/20090305Calcium_Oxalate_
Urinary_Stones_Chihuahua_ToaPayohVets.htm
 
More info at: Dogs or Cats
To make an appointment:
e-mail judy@toapayohvets.com
tel: +65 9668-6469, 6254-3326
tpvets_logo.jpg (2726 bytes)Toa Payoh Vets
Clinical Research
Copyright © Asiahomes
All rights reserved. Revised: February 22, 2013

Toa Payoh Vets

Wednesday, February 20, 2013

1300. Audit & Trust case follow up: Recurring urolithiasis - Cocker Spaniel

Wed Feb 20, 2013

A review of the case operated by Dr Vanessa twice for oxalate bladder stones in May 2011 and September 2012. I audited the case and on Sep 26, 2012, I asked Dr Vanessa as to what follow up she had done to prevent a 3rd recurrence. She said she had advised U/D and had sms the caclcium oxalate stone analysis results. Many owners will just ignore the advices till another recurrence and another operation or euthanasia of the poor old dog. I took the trouble to write to the owners to let them know the preventive measures as I don't want a recurrence too, although recurrence is in the interest of the practice. An extra effort had to be made to follow up and vets usually don't have the time to do the hard sell of prescription diets in the interest of the canine patient.

The father came to buy 12 cans of U/D again for the cocker spaniel, male, 11 years old today. "How's the dog?" I asked him as he had been feeding this U/D since Oct 5, 2012 when he bought 3 cans and came whenever he ran out of the stock. Seldom do I encounter such a disciplined owner as many Singaporean owners tend to forget about feeding the relevant diet to prevent bladder stone recurrence.

"His body condition is much better compared to previous times when he sheds hair all the time and has dry skin flakes," the father surprised me with this feedback. "I thought it was normal for dogs to shed hairs."

"How do you know this dog sheds hairs previously?" I asked. "Does he drink lots of water?"
"Hairs scatter all over the floor of the apartment and so this shows he has been losing hair. He drinks water too."
This was good news but it is too early to tell whether the dog will have recurrence of bladder stones. The 2nd episode occurred 16 months after the first cystotomy operation to remove the stones.  It is only 5 months after the 2nd cystotomy.

From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd oepration, he fed cheap canned food and meat and yet the stones recurred. Now, he is satisfied with the U/D.

PREVENTION MONITORING IS NOT DONE. 
Many owners don't know that urine tests and X-rays are still necessary as part of the prevention of recurring urolithiasis as typical in this case. Feeding of prescription diet is just one aspect. Monitoring should be 1-2 months for the first 6 months and thereafter, if negative results, 2-4 monthly. Very rarely do any Singaporean dog owner comply with this advice and there is not much the vet can do.

Monitoring and urine tests which show small stones can easily be treated with a process called urohydropropulsion in which the catheter is inserted into the bladder and the small stones are sucked out easily. These stones are anlaysed in case they are of different composition.

This case shows that the education of the dog owner with recurring urolithiasis is an uphill task and there are so many family members involved. Who in the family will have time to do the 1-2 monthly monitoring? The young ones are busy with their work and personalised life. The older members may not have the motivation to spare the time to get the dog tested.

Today, I reminded the father that he has to send the urine for analysis of crystals. He said: "Yes, you have given me the bottle to collect the urine."  There is not much I can do. Urine test will monitor the urine pH, bacteria and other results as well as urine crystals and monthly urine tests will be more economical than another surgery. But Singaporeans seem to be time-pressed and so that is the culture.  


P.S Urine tests. Absence of oxalate crystals in the urine doee not mean no oxalate stones as can be seen in the 2 urine tests taken prior to bladder stone removal surgery as follows:

May 24, 2011     Urine pH 7.0, SG 1.028, Blood 4+, WBC 10, RBC >2250, Bacteria 3+, Crystals Calcium oxalate occasional

Aug 28, 2012   Urine pH 7.0, SG 1.029, Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals Nil

From my case records, on Nov 1, 2012, the father told me that after the first operation, he had fed the dog dry food. After the 2nd oepration, he fed cheap canned food and meat and yet the stones recurred.





 

1299. Email advices on toilet training






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On Wed, Feb 13, 2013 at 1:20 PM, E@yahoo.com.sg> wrote:
Hi, I need your advice.
I have a toy poodle, she is spayed and can pee on tray 100%. But when she was 3 years old, I brought home a mini poodle puppy.
Since then she refuse to pee on the same tray. I put another tray in another room, she pee on the new tray some times. And rest of the times, she pee on the floor around the tray that the new dog pee.
I cant grab her to put her on the tray as she is very aggressive, and growl and bite.
I have tried to give her more attention, and also tried to beat her, but she just get worse
What should I do?
Thanks first


EMAIL REPLY FROM DR SING DATED FEB 16, 2013
 
From: Kong Yuen Sing <99pups@gmail.com>;
To: E@yahoo.com.sg>;
Subject: Re: Need help
Sent: Sat, Feb 16, 2013 11:55:32 PM

Hi
Thank you for your email. It is not easy to give advice in your situation of two poodles competing for your attention. Have you tried "positive reinforcement" method of treats and praises for performance? Or the clicker method?

1. Spend time with the old poodle.
2. When she pees on the tray, give her treats and/or praises or bring her for exerciseThis depends which motivates her.
3. Use the old tray which has her urine smell. What happened to it?
4. Neutralise the urine smell on the floor.
5. Confine to small area again as in puppy toilet training.
6. Spay her if relevant.
7. Many weeks and months of positive reinforcement training may be needed to change the behaviour as the dog is an adult and not a puppy with ease of training.
8. Ensure she has no urinary tract infection - check with your vet. Urine test.
9. There may be a need to separate both poodles for some time and to wash your hands when you handle the younger poodle before handling the older one.
10. Pee trays may NEED to be washed frequently if your old poodle is a cleanliness freak and this may be one reason she will not pee on the pee pan but outside the perimeter..
11. Use the commercial pee pads to absorb the urine as a different approach and trial?

The above are some of my suggestions and I don't know whether they will work. Best wishes.


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On Tue, Feb 19, 2013 at 8:29 PM, E..yahoo.com.sg> wrote:
Hi sorry, need to add. My old poodle is aggressive. Its tough to grab her to bring her to the tray like she was a puppy as she growl n bite. Would you recommend a behavorist to resolve tos aggression?

Sent from Yahoo! Mail on Android
 

 

EMAIL REPLY FROM DR SING DATED FEB 20, 2013
There must be a reason for her aggressive. See your vet for medical problems or a behaviorist.