Toa Payoh Vets
Clinical Research Making veterinary surgery alive to
veterinary students using real case studies
and pictures
Standard Operating Procedure - Writing a Veterinary
Surgery Report to share knowledge and to maintain a
consistent standard of care Dr Sing Kong
Yuen, BVMS (Glasgow), MRCVS 23 June, 2012
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+
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.