Thursday, March 31, 2016

6. Two Chihuahuas tilted the heads abnormally. Why?

Jun 15, 2015
TP ..xx6270
Chihuahua, F, S, Black/White, 3 years

Onset: Mid June 2015.
25.6.15  Boarded 15 days. Inappetant, cough and night panting.
Night panting. Coughing and sits on backside with front legs straight, head tilting upwards
Vet 1.  Diet changes from eating boarding operator's food. Elevated liver enzymes and low White Cell count.  (viral infection during boarding affecting heart muscles?)

14.7.15. Still has nocturnal cough. Vet 2. X-ray heart. Heart disease. Invoril tab 5 mg.

15.7.15. Vet 3. Abdominal ultrasound. Heart murmur stage 1. Arranged French heart specialist to do ECG.  ECG normal.

17.7.15  Vet 4. Toa Payoh Vets. Cyanotic tongue. Painful throat. Nocturnal panting. Usual fursoemide, vetmedin and fortekor drugs for one month. Follow up. Less coughing.

17.8.15  Vet 4. Toa Payoh Vets. Unproductive Coughing 4-5X/day for one week. Owner and dog has ringworm. Treatment for ringworm.  Dog does not want to eat H/D and so none was given.

1.4.16   Follow up since no news.  Dog coughs around 5X/month. On Vetmedin 1/2 tab per day. Overweight. Fed commercial fish-based diet.

CONCLUSION. The lady owner loved the dog very much by seeking so many opinions. She found it hard to believe that such a young Chihuahua could have heart disease. It is very rare. Most likely the dog could have suffered an attack of viral myocarditis at the boarding kennel and the heart muscles had been damaged. Circumstantial evidence was based on the low white cell count in the first visit to Vet 1 in mid Jun 2015. The dog has not fully recovered. My follow up today Apr 1, 2016 shows that the heart disease was not well controlled as evident by some occasions of coughing.


TP ..xx5720
Chihuahua, F, S, Sable/White, 11 years
An interesting case of posture believed to be due to heart disease. So I review the records today as there is close follow up by the couple who treated this pet as a family member wanting her to live the longest life possible.

Vet 1 - loyal to a family vet until the vet vaccinated the dog SC right hand side and cartophen for stiffness on the neck skin area on Dec 2, 2014. The dog screamed. Vet 1 x-rayed spines and did blood test for liver and kidney function on Dec 5 and 14 but nothing abnormal was discovered.

The dog was lethargic on Dec 19, 2014, 7 days after vaccination.  She lay on the right hand side but had good appetite. So the owner switched vet to Toa Payoh Vets in Dec 19 2014.  Palpation showed to the owner a very painful right paralumbar area, probably a cellulitis due to vaccination injection reaction.

Abnormally high urea, haemoglobin and platelets. Low creatinine but no high total white cell count and so no sytemic bacterial infection.

pH 7 (5-8).   SG 1.016 (1.005-1.030). Trace of protein, blood and 1+ bacteria.

Chest heart and lungs normal. Abdomen right hind back area - possible cellulitis. The dog was had a painful right back area after vaccination. 

20.7.15   The dog ate, stopped eating and ate. The couple in their 50s diagnosed tooth ache. Came to Toa Payoh Vets, probably by surfing the internet or by reason of close proximity as in many Singaporean pet owners.  Extracted 7 teeth. 

Abnormally high red blood cells, haemoglobin, platelets and urea. Low creatinine. I advised review of blood one month later. Cut down on supplements including glucosamine and check quality.

Follow up on 24.7.15, the dog was more active, eating well. No painful mouth.


The dog always sleeps curled up on her right side. Why?
Some pain in the back of the rib page around the liver and spleen area.
Supplements given were flaxseed oil and glucosamine.

Abnormally high platelets. Low urea and creatinine.


Abdomen. Liver slightly enlarged. Spleen is normal.

Given hepatavite 30 days and painkillers 4 days. Follow up tel on 18.8.16, dog is normal, not curled up on right hand side but now "sleeps on chest" as in normal sternal recumbency.


Unusual head flexed downwards position and pants.. Pulse pressure higher than normal. Few nocturnal coughs.
Left heart systolic murmurs
Heart medication (vetmedin, fortekor and furosemide) and change to H/D diet.
The dog had no problem eating the H/D diet unlike the chihuahua in Case 1.
Follow up on 31.3.16.  Dog is energetic and full of life. No more coughing or head downwards.

Tuesday, March 29, 2016

5. An old Pom is diagnosed PLN (Protein Losing Nephropathy)

March 30, 2016

March 29, 2016
Patient: Pom, FS, 11 years
Vet 1 - low albumin
Vet 2 - PLN. Advised kidney biopsy.

The following are the tests done by the vets:

9.5.13    ALKP, ALT, CREA, LIPA  normal

6.9.14    ALKP, ALT, CREA, GLU, K  normal.  Na/K  38
              CPL (pancreatic lipase) 0  normal
SUMMARY:  CBC, Electrolytes, Kidney/Liver, Pancreatic lipase tests normal
 Maropitant citrate 16 mg tab  1/4 sid as necessary

18.3.16   CBC normal. GHP & Electrolyte tests NA.
               Urinalysis  - pH 7 (5.5-8.5)    SG 1.011 (1.015 - 1.045)   Protein 3+   2+cocci

28.3.16  ALB  2 g/dL  (2.2-3.9).  Lipemic plasma.
              UPRO  309  mg/dL (0)
              UCRE   30  mg/dL (0)
              UPC 10.3  (abnormal)*

28.3.16  Urinalysis  - pH 6.5 (5.5-8.5)    SG 1.009 (1.015 - 1.045)   Protein 3+   1+cocci
Blood pressure check done.  Fortekor 5 mg (benazepril) 1/2 tab once daily.


Significant findings:
Urinary protein was 3+ on 18.3.16 and 28.3.16
UPC was 10.3 on 28.3.16
However, there is no kidney failure at this time.

1. Owner was apprehensive about damage in a kidney biopsy advised by Vet 2.
2. Dog was given Bravecto in Nov 2015 (anti-tick lasting 3 months) and said to be very effective against tick infestation.
3. Urine test on 30.3.16 to another lab. 
    Urinalysis  - pH 6.0 (5.5-8.0)    SG 1.019 (1.005 - 1.030)   Protein 4+   2+bacteria,  WBC 30/uL, Epithelial cells 5/uL.  No RBC. No Casts or Crystals.  

4.  To monitor water intake and urine protein (dipstick) daily for 2 weeks
5.  To consult Cornell Univ Nutrition to look into how to formulate a home diet for PLN.
      Owner - surfed internet. US commercial companies for dietary management of PLN. One company formulates special diet but will not add vitmains and minerals. Another will advise home diet in working with her local vet.

After the blood and urine tests, the next stage will be ultrasound to look for
for blood clots, stones, injury or other abnormalities. If any stone, clots or damage is found, an x-ray or CT scan may be needed.

There is no cure for PLN. Treatment depends on the causes.   Causes of PLN include:  autoimmune diseases, diabetes, blood clots, stones or damage to the kidneys, parasitic infections, food allergy or intolerance and genetics.

Vet 2 has prescribed benazepril which is an angiotensin converting enzyme (or ACE) which decreases the amount of protein lost in urine.  A low dose aspirin to avoid blood clotting. Buffered aspirin helps minimize the inflammation or irritation while still allowing proper absorption. A beta-blocker or a calcium channel inhibitor that is used to treat high blood pressure that can occur in dogs with protein-losing-nephropathy e.g. Amlodipine Besylate is a calcium channel inhibitor or Atenolol is a beta blocker. A diet low in salt and protein is advised. 

Owner will wait 2 weeks and am consulting Cornell Univ Nutrition for home-formulated diet for PLN.

4. A Shih Tzu puppy prefers to sleep on the pee tray nowadays

Email to Dr Sing of Toa Payoh Vets,  dated Mar 30, 2016

Good day!

I read your article on potty training and I am adhering to your advice. I have recently took home a shih tzu puppy. She is now around 7 weeks plus of age. I practice play pan confinement when I am not around. When j am around, i opened the area but she stays within her bed and confinement area even though I opened up the play pan area. I have practice bringing her to her designated spot to pee and poop everytime I noticed she is about to make a mistake. When she does make a mistake I clean it with white vinegar+detol+water.

She is extremely smart and has on several occasions successfully peed at the right spot (in the pee tray). She doesn't pee on her bed or toys. However, recently I have noticed that she will lay on her pee tray. Is there a reason to this?

I have tried to collect the smell of her urine in the pee tray by inserting a napkin in between the tray. Hence, after she eliminate, i simply just remove the stools and wipe the top of the tray leaving the bottom to be absorbed by the smell of her urine. Could this be a reason why she is sleeping on the pee tray? Could it be possible she likes the smell of her pee? I have tried to think of possible reasons why and I am simply lost and unsure of how to tackle this situation.

She do sleep on her bed, however sometimes she lays on the pee tray or near the pee tray.

Hope you can advice me on how to stop her from laying on her pee tray and use it only to pee and to poop.


I am Dr Sing Kong Yuen from Toa Payoh Vets.  Thank you for your email regarding toilet training of your Shih Tzu.

The following may be the reasons:

1.  It is possible that you have cleaned the pee tray free of urine and stools very well. So, it is a clean area.
2.  It is possible that the surrounding "clean" area has become a dirty area (too much cleaning liquid etc). It could have been soiled by the puppy's feet (stools and urine smells which only the puppy knows). So she lays on the cleaner pee tray.
3. The surrounding "clean" area is not comfortable e.g. no towel or cushion to lay on.
4. The puppy might have preferred sleeping on the clean pee tray from a young age.  The seller had got her used to her sleeping on the pee tray and she likes it.
5. You or a family member/friend could have praised and rewarded her with a treat when she lie down on the pee tray.
6. Other causes due to management I am not aware of.

Possible solution that may or may not work: 
1. Reduce the size of the crate to hold only the pee tray.
2. Let the puppy stay outside the crate by enlarging the total confinement area. Feed and water bowls are outside the crate. A cushion or towel for the puppy to lie down.
3. Place the pee tray inside the crate only for pee and poo by re-training the puppy again. The puppy will be trained to think that the toilet area is inside the crate and the outside area is the den.
Please let me know if the suggested solution works. Best wishes.

Warmest regards, E.....

Sent from my iPhone

Monday, March 28, 2016

3. A 3-year-old rabbit went to the vet for tooth trimming for the past 3 years but now needed extraction of overgrown teeth

March 28, 2016

VIDEO. A rabbit has overgrown curved lower front teeth.

"Every 2 months, for the past 3 years, I will bring him to the vet to have his overgrown lower front teeth clipped by the vet," the lady in her late 30s said to me. "Sometimes, the teeth fracture and so there is no need to go. 

Now I want the teeth extracted and I had phoned some vets. But they said they only clip the teeth and not do extraction. I remember your receptionist saying that Toa Payoh Vets do extract rabbit teeth and so I am here."

"The rabbit has 6 front teeth," I opened the rabbit's mouth. "4 upper front teeth and the two lower ones you see."  She was surprised to see two upper front teeth curled inwards and downwards onto the floor of the mouth. However, the other two upper front teeth behind the front upper front teeth are small and short and did not curl.

Anatomy - Dentistry of normal front teeth location - Illustration and images

"Nobody told me that my rabbit had curled upper front teeth," the lady was astonished. "The vet assistant would would bring the rabbit to the treatment room for clipping and return the rabbit to me all these years! Poor rabbit. She must have suffered from the pain of the upper front teeth growing into the floor of her mouth!"

Dr Daniel of Queen's Veterinary Surgery
Sedation and gas anaesthesia.
Rabbit dental equipment
The owner must be warned that the upper right tooth could not be fully extracted and there might be a re-appearance of the tooth.

In dental extraction, the vet takes out as much as possible of the deep root. However, no vet can guarantee that there will never be re-appearance of the teeth after   

This male 3-year-old white rabbit does not eat hay and is fussy about what he eats. Could it be the overgrown lower and upper front teeth make it difficult for him to enjoy his hay and certain types of food?  Will he enjoy his hay now?  A follow up will provide the answers.   

Sunday, March 27, 2016

2. A cat fell 6 storeys and broke her leg.

Mar 28, 2016

TP 46233
Cat, female, not spayed, 7 months, fell from 3 storeys yesterday.
X ray by Vet 1. Vet 1 refers to Vet 2 quoting $3,000 surgery fees as screws are needed.
Came to Toa Payoh Vets for 2nd opinion. 

Fracture repair surgery costs from $1,000. In this case, the fracture is more complicated as it is near to the femoral head and will require screws and wires to join the broken pieces. If it is mid-femoral fracture, an intramedullary pin and cast will do and this will be much cheaper.

As cat is growing, osteoarthritis may result after the surgery.  So, the owner has to decide on what to do.   

1. Case No: 44399. A male cat has difficulty peeing again. What to do? - VIDEO production

March 31, 2016


Video of Singapore's apartments  eg. outside Queen's Vets including houses, condos and HDB.
Narrate:   Singapore is a city state with over 80% of the population living in apartments. Cats are becoming more popular with their numbers increasing over the last 5 years. They are usually fed dry food and live in multi-cat households.  (VIDEO OF KITTENS OR CATS VACCINATION AT QUEEN'S VETS - SEE WEBSITE). Most of the time, Singapore cats do not have medical problems.

However, there are many cases of the male cat suffering from difficulty in passing urine. This is known as DYSURIA.  Sometimes blood is seen in the urine and this is known as HAEMATURIA. The cat usually pee outside the litter box and dribbles urine in various places inside the apartment. This is known as POLLAKIURIA. The bladder becomes distended to as large as a tennis ball and the cat becomes very ill, vomiting and not eating. 

There are 3 ways to treat this case to relieve the bladder obstruction.
1.  The vet passes a urinary catheter into the bladder and the urine flows out.
2.  The vet has to open up the bladder to take out the bladder stones. This surgery is called CYSTOTOMY.
3.  tHE   


Perineal Urethrostomy to resolve painful urination in male cats with recurrence. A very good solution rather than repeat urinary catherisation and euthanasia.

Likely cause of reccurence. Anatomy of male cat (illustration). The bend of the urethra had suffered serious traumatic injury  due to urethral stone embedded in July 2015. Scarring of urethral opening at this bend causes difficulty in peeing.

A final video for the July case had been produced and is at:




1  male and 2 female. l litter box
Male cat suffers from bladder and urethral stones


1. July 2015.  Cystotomy
2. Sep 2015. Recurrence of dysuria. Urethrostomy
3. Mar 28, 2016.  Telephone follow up. Cat is OK. 

In Toa Payoh Vets, Singapore, difficulty in passing urine (dysuria) is more common in male cats than in female cats. The medical condition is called "Urethral Obstruction".  The causes can be bladder stones or bladder crystals obstructing the flow of urine.
The treatment respectively will be surgery to remove the bladder stones or a catheter to "unblock" the urethra if there are no stones.   

Case No. 44399
Date: Jul 2, 2015
Patient:  ANGEL, Domestic Shorthaired cat, Male, Neutered, 3 years. Shared 1 litter box with 2 other female cats in apartment. Had been fed dry food for the past 3 years.

Signs and symptoms: Vomiting 2x, Anorexia, dysuria (difficulty in urination), haematuria (blood in the urine), pollakuria (pee outside the litter box) 

Palpation: The bladder is swollen to the size of an apple (illustration). Kidneys not enlarged.

Laboratory tests

Blood test
urea  19.8 mmol/L (7.2-10.8)
creatinine 285 umol/L  (71-160)
      Acute renal failure

Total white cell count  2.14 x 10(9)/L  (5.5 - 19.5)
Neutrophils 95%  (37-75%)   Absolute   (2.5-12.5)    
Platelets  131 x 10(9)/L  (300-800)

Urine test
pH 6  (5-8)    SG 1.038 (1.005-1.030)
protein 2+ (negative) blood4+ (negative)
crystals nil



Cystotomy (stones in bladder and at bend of urethra)

Urinary catheterisation and irrigate bladder. 
Kidney failure   - I/V infusion 5% dextrose saline  (image) dialysis

Warded 3 days. Goes home
Change to feline C/D for 3 months.
10.12.15  Purchased feline CD  2 kg but did not feed CD for 3 months as advised. The owner added other food.



Sep 22, 2015
Dysuria 2 weeks. Vomiting 1X
What to do?

Blood test - normal  except low platelets 278  (300-800). No renal failure or leucocytosis.

pH 6.5   SG  1.040    Protein 4+, Blood 4+. No crystals

(Use a table to show test results for Jul and Sep 2016)

Sep 25, 2016  
Dr Daniel   URETHOSTOMY   (illustration).

FOLLOW UP  MAR 28, 2016

Cat is OK. Fed dry food and fish.


Friday, July 17, 2015

2498. INTERN Bladder and urethral stone cat and kidney failure. Angel the cat who meows hello to me.


Time lines

Thursday, July 2, 2015

A cat sits on the litter box

Jul 2, 2015

Cat, MN, 3 years
Vomiting 1 day. Dysuria, pollakiuria, haematuria, urethral obstruction (urethral stones).

"Have you encountered such cases?" the lady with a baby asked me about her cat having great difficulty in peeing, sitting on the litter box all day long. He vomited twice yesterday, July 1, 2015.

"It is quite a common problem in male neutered cats," I replied. This cat eats only dry food and lives with two other female cats.

I palpated no enlarged kidneys but a big swollen bladder as big as an orange. The cat dribbled blood-tinged urine on the consultation table.

Under gas anaesthesia, the urinary cathether was not easily passed into the bladder, despite syringing normal saline. Some urine did flow out and the bladder was emptied 50%. I got the x-rays done and there were stones inside the bend of the urethra.

At home, 2 other female cats had no problem. One litter box and water bowl. Dry food only.

The owner gave permission for surgery. Dr Daniel did it in the afternoon. Body weight  4.8kg, temp = 38.3C.   Sedation xylazine + ketamine 0.1 + 04 ml IM. Maintenance with isoflurane and oxygen gas.
Cystotomy. Syringed saline into the urethra to get the 2 urethral stones into the bladder.

Warded. E-collar and urinary cathether. Antibiotics and pain-killers


Tuesday, July 14, 2015

2495. Angel the cat is admitted for dysuria

1. Monday, Jul 13, 2015. The cat was admitted as the owner said he had difficulty in peeing. Bladder and urethral stones were removed some 7 days ago. The cat was given IV drips on Jul 10 and 11 and I discharged him on Saturday Jul 11, 2015 since he was eating. I took out his stitched urinary catheter as it is not good for the cat to have it for more than 3 days, in my opinion, as it irritates the bladder.  However, he ate little at home, the owner said and was worried.

Dr Daniel and I discussed his treatment. Perineal urethrostomy will be the last resort.

"There is bound to be inflammation in his urethra as he had urethral stones stuck at the bend of the urethra," I said. "The bladder is not much swollen as before, not as big as an orange. Pain killers and antibiotics will be needed."
The cat was given gas anaesthesia. Dr Daniel lavaged the bladder by sucking out the bloody urine (video). An injection of painkiller and antibiotic was given.

2. Tues July 14, 2015. The cat meowed when he saw me. His bladder was not swollen. He preferred to sit inside the litter box where there is sand, than outside the box. He ate when my assistant hand- fed feline C/D with water. The owner came to visit around 6 pm and was happy to see him.

This is a case of the intense inflammation inside the bladder and urethra as the owner had delayed seeking treatment, base on blood test result showing kidney failure and the much swollen and red bladder (image).


Ju1 2, 2015    Cannot pee, blood in urine. Surgery. urethral stones and bladder stones removed.
Jul  5             Dr Daniel sent home 2 days after surgery.

Jul 8              Vomiting and dysuria. Had kidney failure based on blood test of high creatinine and urea. Given 2 days IV drips

Jul 11            I sent home as he was eating.

Jul 13          Warded. Bladder lavage. urine analysis. Catheter not stitched. 

Jul 15          Bladder swollen 1/3 size of orange. Cat eats when hand fed dry feline C/D + water. Bladder lavage. urine analysis. Catheter not stitched.  Alert.

Jul 16          Bladder small like ping pong ball, painful. --------------------------------
July 18, 2015  10am

Another bright sunny morning

Jul 18, 2015. Angel meowed to greet me as I checked on him. I lifted him out of the sand litter box which he plonked himself on instead of being out. I palpated his bladder which was small and not painful now. He had eaten all his dry and moist feline C/D overnight and had pooped. So, he should be fully recovered.

Angel, Cat, MN, 3 years

Jun 2, 2015  Stranguria (painful frequent urination in small amounts by straining. Muscle spasms of the urethra and bladder) for 2 days. Vomiting.  I palpated a big swollen bladder the size of an orange. Urinary catheter could not be passed into the bladder.

I advised X-rays which showed urethral stones and bladder stones (video).
Sharp brown stones

Jul 2, 2015
Urea  19.8  (7.2-10.8)
Creatinine 285  (71-160)
Total white cell count  21.4  (5.5-19.5)
N  95%  (35-75%).  Absolute  20.3  (2.5 -12.5)
Platelets  131 (300-800)

Blood test show kidney failure and bacterial infections of the blood. So, this is not a simple cystitis or FIC (Feline Interstitial Cystitis) case.

Jul 2, 2015
red, turbid. pH 7 (5-8)  SG 1.015 (1.005-1.030)  Protein 3+ (negative), Glucose + (negative), blood 4+ (negative). Bacteria (Occasional), Crystals Nil

Surgery by Dr Daniel. Cystotomy. bladder and urethral  stone removal. Urethral stones flushed into the bladder and removed.

Jul 14, 2015
yellow, turbid. pH 6, SG 1.038. Protein 2+, Blood 4+, No bacteria or crystals.  Health improves.

Owner did not want stone analysis.  Small sharp brown stones, biggest 4 mm across. Probably calcium oxalate?

Jun 5.  Cat goes home.

Jun 8. Cat admitted. Vomiting and dysuria. Bladder is swollen. I diagnose kidney failure.
Bladder catheterised and lavaged with normal saline. 2 days of IV drip of Hartmann and dextrose saline to flush out toxins. Meloxicam oral for 4 days

Jul 11. I sent the cat home as he was eating and drinking. He was vocal, meowing to greet me.
Urinary catheter was taken out.
Owner to continue with hand feeding A/D and dry feline C/D. Leave C/D overnight.


Jul 19,  Ate food by himself. Sat outside the litterbox. That means he has recovered. Sent home.


I sms the owner as she did not answer the phone call:
10.36 am   "Is Angel back to normal urination? Dr Sing, Toa Payoh Vets?"

Her reply
10.58 am   "Hi Dr Sing, thank you for following up on Angel. He is coping well. Have a good day!"

11.24  I sms "Is he eating 100% the dry feline C/D and no other food or treats?"

11.37 am   "He is eating the CD mainly but I do feed him canned food once in a while."

11.46 am  My reply
"Try not to include other food as this affects the urine acidity and cause recurrence of urinary stones or cystitis."

Outcome good.
Case closed.