1149. The owner disbelieved that his 12-year-old Silkie had false pregnancy.

Today, Nov 5, 2013, Tuesday, the owner brought  back the Silkie Terrier with multiple breast tumours and a very large and painful armpit breast tumours.

"My dog could not sit on her chest," he said. "That is why I have to bring her to the vet."

The  I saw this dog 3 days ago and prescribed antibiotics. Definitely, this dog had widespread breast tumours and I asked the couple to seriously consider the high anaesthetic risk of surgery to remove so many tumours.

"The dog is old at 12 years and the tumours may have spread to the lungs and internally" I said. "The tumours are likely to recur after you spent so much money operating."

They could not decide. I had given the antibiotic injections and advised 3 days later to do the surgery.

"I went back to Vet 1 to ask whether she had seen the breast tumours during dental scaling 3 months ago," he had stated that the breast tumours were not present at that time and today was disbelieving that the diagnosis of false pregnancy was correct.. "Vet 1 said the large swelling on the left armpit was due to false pregnancy."

"It was possible false pregnancy and breast tumours," I said. "When was the dog on heat?"
"Very long ago."
"False pregnancy occurs 2-3 months after the heat and your dog could be on heat 3 months ago as I can see the vulva swelling now."

I advised spaying first to remove the female hormones and then breast tumour excision 2-4 weeks later.

1148. Management chat with vet assistant

I had another chat with my assistant about his work performance and attitude. The young people brought up in a stable affluent background with no worries of hunger behaves much differently from the older generation that has to strive for bread. So, the manager needs to talk one-on-one with them.

"When you were in University, would you do what your Professor wants or do what you like?" I asked Niang. "If you do what you want, you will just fail in your examinations and will not graduate. Now, you work. The employer asks you to do something urgent. You ignore and do your own task first. Is that being smart?"

"When an employee gets scolding to improve on mistakes, it is a good thing," I said to him. "If he is not scolded, this means the employer is waiting for a replacement."

"Have you met the Filipino workers?" I asked. He nodded. "They are usually very happy to provide service. They are happy to get a job and they are really happy to provide the service. Most vet clinics employ Filipino vet assistants as they are happier and can speak good English. I have employed 2 other Myanmar vet assistants and they have found better jobs after the contract. Other vets want them as they have the experience."

Management talks have to be given now and then as regards hospitalisation records and process to maintain a high standard of care. Sacking and hiring new staff is not my management style. There is no other way but to keep teaching the young ones till they understand one day, the realities of intense competition in business and that standards of care must be high and perceived and seen to be high.                  

1147. Three Singapore dogs have urinary stones

TOA PAYOH VETS toapayohvets.com Date:   04 November, 2013   Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits 1.  A young Shih Tzu cannot pee   2.  A Miniature Schnauzer pees blood 3.  An older Bichon Frise cannot pee 3 bladder stone case studies toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129. Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   04 November, 2013   A young Shih Tzu cannot pee   The owner had the Shih Tzu x-rayed at another practice. 3 X-rays were taken. One of them showed the spikes.  However, the images needed imagination and Photoshopping.It is not usual for vets to drain the bladder of urine via a catheter and pump in 20 ml of air to provide a good contrast. This is because the vet believes bacteria will be introduced into the bladder via the air. During surgery by Dr Daniel, the large beautiful stone looks so much like a lady's precious stone. FOLLOW UP ON NOV 3, 2013 9.50 AM SUNDAY Around 42 hours post-cystotomy,  on this bright sunshine Sunday, my assistant walked the dog at 9 am. I checked the wound.  The size 15 e-collar prevented direct licking of the surgical stitches but bruised the surrounding areas. There is no commercially available size 18. Size 20 will be too big. The dog is extremely active and is normal. He urine-marked the clinic floor. I noticed some discoloured urine. 3 rows of sutures were placed on the bladder according to Dr Daniel as the bladder was bleeding (a blood vessel was nearby and stitched). Usually, I place 2 rows of sutures and there will be bladder wall bleeding. Each vet has his or her own assessment on the spot and each case differs. Urine test 42 hrs post surgery. dipstick. Fed dry food from owner. Blood 4+  pH 5, SG 1.04, WBC +,  protein 2+. The dog should recover well and go home. Stone analysis is being done by the lab.   Stone analysis is being done.     Case 2.  A young Schnauzer pees blood"The urine test on Oct 2, 2013 shows the presence of occasional numbers of calcium oxalate and triple phosphate crystals," Dr Daniel said to me when I asked him about the urine test after he had completed the bladder stone removal surgery. He could see that the few numbers of crystals in the urine does not co-relate with the number of formed stones which exceeded 20 big and small ones in this case. "Absence of crystals in the urine" does not mean there is no bladder stone. X-rays will be best. Each vet has his own approach to this type of surgery.  He had injected saline into the bladder to check for leaks and there was none. "A fine needle was used," he said to me. I am aware of this way of checking for leakage. Usually I inject saline via the urinary catheter in the female dog. I did a video of the stones being taken out as there were numerous. I had done videos of bladder stone removal and so I do not video this type of surgery as it takes a lot of time to produce a video. AUDIT OF THIS CASE tp 42373 Miniature Schnauzer, White, Female, 3 years old. Born Nov 4, 2010. Significant time-lines Feb 24, 2012. I spayed the dog. Uterus was enlarged but not from pregnancy.  Blood test normal. Nov 30, 2012. Blood in the urine. I advised urine test and no dry food. Urinary tract infection. Jul 14, 2013.  During annual vaccination, I palpated the bladder and felt "crepitus" - feeling of gas and bladder stones rubbing against each other inside the bladder. I advised X-rays as I was quite sure these were bladder stones. Interestingly, I recorded the following 4 words "Dr Daniel said no." I had asked his opinion and he had palpated the bladder. Sometimes I would be present during his consultations as a mentor. Palpation of the bladder for crepitus is not as convincing to the owner as X-rays. Therefore, X-rays must be advised. Every vet has his or her own opinions and each vet, after palpation of the bladder may give different points of view as in this case and that does not reflect on the vet's competence. X-rays will be most helpful but the owner came for vaccination and not for urinary tract problems like blood in the urine in this case. So the owner does not want to incur "unnecessary" medical costs of X-rays. Oct 1, 2013. Dr Daniel was consulted for decreased in appetite of the dog and vomiting of digested food. He advised X-rays and urine tests. Urine tests showed pH 8.0, USG 1.020, bacteria 3+, blood 4+, calcium oxalate and triple phosphate occasional. X-rays showed numerous large stones. Dr Daniel opened up the bladder and removed the stones. FOLLOW UP WITH OWNER ON OCT 3, 2013. The owner said that he had given canned food since my advice to cut out the dry food in Nov 2012. He said that his relative's Shih Tzu called Mikki also had similar problems and eating the same brand of wet food called "Burp". I remember Mikki. He had difficulty in urination and urine tests showed triple phosphate. X-rays showed no stones and the dog is on S/D diet for the time being till the urine test is negative. It is important to follow up with the owner but this takes time and some vets may not want to do it. As to what to do now after the operation, the stone analysis will need to be known first. From appearance, I would say they are struvite stones. S/D canned diet for 1-3 months and urine test 3 monthly will be my advice but many owners have their own ideas. It is my opinion that the stones were formed much earlier and the changing to "Burp" canned food was too late and probably does not contribute to the struvite stone formation unless it alkalinises the urine. The bacterial infection of the bladder in an alkaline urine causes triple phosphates and struvites to form. It is inconclusive evidence that "Burp" cause the formation of stones. "Miniature Schnauzers are one breed famous for bladder stones," I said to the owner. Circumstantial evidence of "Burp" causing bladder stones in this Schnauzer is made because  Mikki had similar difficulty in urination problems too when fed on "Burp". But no stones were seen in Mikki's X-rays. I remember this Mikki very well since this Shih Tzu's owner had two episodes of urination difficulties in Mikki. In the 2nd episode, the couple had the X-rays done and no stones were seen. Now the dog is on S/D diet and so far, no more dysuria problems. Mikki is another story. Struvite stones confirmed by laboratory analysis FOLLOW UP ON OCT 7, 2013 BY PHONE AT 8.05 pm, 5 days post-removal of bladder stones by Dr Daniel. Owner is satisfied today as the dog is active, eats and drinks. Urine no blood. Stools are normal. As at November 4, 2013, no complaints from the owner.   3.  An older Bichon Frise cannot pee Medical dissolution of the stones is in progress. Final report to be written.       3827 - 3828. A Bichon Frise has difficulty in peeing (blog) Updates will be on this webpage: www.sinpets.com/F5/20131104 Singapore_dog_bladder_stones.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: November 04, 2013 Toa Payoh Vets

1146. Five tattooed Schnauzers on his body

I have known this client whose Schnauzers were once treated by me when they were young. He would send his dog to another vet, a senior vet for some reasons.

He visited me now and then for a chat. He is retired now. He kept saying that a senior vet had lost his mental prowess to diagnose at this old age. I was surprised as my meetings with this senior vet showed he was competent in mind and veterinary skills.

On this visit last week, he showed me 4 large tattoos covering his back and one on his front left chest. The dates of birth and death were also tattooed.  It would be very painful.

"Why did you tattoo the Schnauzers on your body?" I asked.
"I was very upset when they died and I got this idea surfing the internet. I feel much better now that they are with me."

One of them had a nasal discharge and the senior vet referred him to another vet who did surgery. "There is no hope but this vet advised surgery. In the end the dog had to be put to sleep."

"How much did you spend?" I asked.
"Over $3,000," he said. So, this was the episode which triggered his impression that the senior vet was out of touch with his practice of vet medicine and caused him to spend $3000 on an old Schnauzer with no hope of cure.

1145. Saturday Nov 2, 2013 - Deepavali - interesting cases

Nov 2, 2013  Deepavali

I believe many vet practices close today as Deepavali is a public holiday. Toa Payoh Vets opens during public holidays since some 30 years ago. Some new interesting cases are seen.

Case 1. The Golden Retriever with enamel hypoplasia.
"Did Dr Daniel receive my sms asking whether your clinic is opened during Deepavali?" he asked me. His message was present on the clinic's phone but no on Dr Daniel and so he did not receive any reply.

His sms at 8.45 pm & 9.24 pm said:
"Dear dr Daniel   
Is your clinic open tomorrow as my dog .... - golden retriever 19 months old, vomited a white liquid 2 days back and eats very little only - hardly 20% of his normal diet and just sleeps around the whole day."

I said to the gentleman in his late 40s: "It is best to phone rather than sms as sometimes I don't read sms in the clinic phone."

I put the dog on the table and examined him. I found nothing wrong with him generally. However, this dog was slightly hunched back. It was a slight hunch easily missed. I put my two fingers to press down on the spinal area from the neck to the tail. At the cervical/thoracic junction behind the ribs, the dog suddenly swung his head attempting to bite me. The owner saw this action. But he was not convinced when I said that the dog had a severe back ache and that would be why he was not moving much.
"Really?" he repeatedly said when I reproduced the behaviour, nearly getting bitten by the dog.

I put the dog on the floor and asked him to press on his spinal area.
"No pain, no pain!" he commented.
"You pressed on the wrong area or you did not press hard," I replied.
He pressed on the painful area. The dog turned his head, curled up his lips and bared his teeth. This time he was convinced.
"It is his active lifestyle," I said as the dog had sprained his left hip last month. "Did he fall down from the staircase or some heavy object fell on his back?"
"He is always dashing here and there inside the house," the owner could not confirm any fall or trauma.
However, now he knows why his dog was not active for the past 2 days and vomiting would be due to the extreme pain.

I got the blood test done and gave the dog the IV drip and painkillers. Confinement is necessary.

Case 2
An old Roboroskvi had two large globular tumours and was no longer as active as a young one. He did not attempt to escape when held.. "The only solution is surgery but the risks are very high since the hamster is old."
The lady had consulted another vet who said that these were fatty tumours and best left alone. However, the hamster's leg tumour obstructed his movement. Yet there needs to be surgery to enable him to live a good quality of life. Surgery would be done tomorrow. "One tumour at a time," I advised as the dwarf hamster will die of stress under prolonged surgery to remove 2 tumours.
This case illustrates that some clients do not go to the nearest vet practice owing to proximity. Sometimes it is the brand name.  She lives a short walk from Toa Payoh Vets. However the other vet did not want to operate on this hamster and now two large ones have developed!
The hamster will be operated on one tumour today.

Case 3
The old Silkie Terrier still would not eat and had loose bloody stools for the past 7 days, despite blood tests,  X-rays and ultrasound being done at another practice. "Nothing wrong with the dog," the owners said. However the clinic was closed and so no medical report was possible.
Owners go to another practice when their dog does not recover. This happens to all vet practices.
I palpated the throat and the dog winced.
"There is intense pain in the throat area," I said. "There may be a piece of chicken bone stuck there."
I could understand that the owners did not want to spend more money when I suggested X-ray of the throat area.
"The dog had X-rays," the owners said a family member who was not present had brought the dog to the first vet. They would seek medical records the next day as the clinic was closed for Deepavali.
This was an easy case to diagnose as the dog had eaten chicken bones before being sick. Chances are that this dog had injured his throat and intestines. "The pulse is weak," I said. The owners did not want another blood test and so evidence-based medicine could not be practised.

I hospitalised the dog to give IV drip and medication as this would be the cheapest method of treatment rather than X-rays.

Case 4
The Pom had bloody diarrhoea 1 day ago. His pulse is normal and strong. So this was a case likely to recover after an IV drip and medication and went home at 4 pm today. No need for hospitalisation.

Case 5.
The 12-year-old Silkie had a large painful lump below the right armpit. "It is a large breast tumour between MG 1 and MG2 on the right side," I said. Since the owner claimed that the large mass appeared rapidly, it would likely to be malignant. The dog had dental scaling done by another vet 3 months ago and there was no mention of the mammary gland tumours, now scattered on the right and left side.
"Is the dog spayed?" I asked.
"No," the couple said.
"Chances of getting breast tumours are very slim if the dog had been spayed young," I said. "As the dog is very old and the tumour is likely to recur soon after surgery, please think about surgery."
The dog had fever and would not be operated immediately. The owners decided on operation which will be done next week. Detailed explanation on the possibility of recurrence and spread to the lungs were given. The dog may die under anaesthesia. The owner had to decide and they wanted surgery. If only this dog had been spayed some 11 years ago, this situation would be unlikely to be presented. 

 
    

1144. Follow up on Bichon Frise - Nov 3, 2013

Sunday Nov 3, 2013

This morning, I noted that the Bichon had been housed overnight inside the kitchen. I told him to go to the backyard grass. He went there, raised his left hind leg, not the usual right hind and took around 10 seconds to pee. He was allowed into the kitchen by Dr Daniel.

It is important that this dog has access to the grass as this is the type of area he would pee. Unfortunately he had leaked urine or peed on the kitchen floor again yesterday afternoon when I came back from work at around 2 pm. Yesterday was Saturday and a public holiday, Deepavali (Festival of Lights) and I had worked from 9 am to 2 pm. Dr Daniel had brought the Bichon to the Dog's run in Bishan in the morning from around 10 am to noon. Then he was kept inside the kitchen instead of in the backyard area. So he peed on the kitchen floor.

Dogs with urinary stones do lose control of their bladder and this was the 2nd time this Bichon peed inside the kitchen since the trial for medical dissolution of the urinary stones. I confirmed this with the caregiver who was also feeling sorry for this Bichon who had to be housed in the backyard area with access to the grass. A barrier fencing blocks this Bichon from entering the kitchen but permits him to see inside and so he is not deprived of social sightings.

Medical dissolution of urinary stones needs a lot of patience. Peeing indoors means work for the caregiver. This is additional workload and the best way is to house the dog in the sheltered backyard area as he needs to pee quite frequently, given free water available and the irritation of urinary stones causing the need to pee.

Surgical removal of the stones is much less work.    

1143. A 2-year-old male Shih Tzu cannot pee at all - spiked urinary stone

The owner had the Shih Tzu x-rayed at another practice. 3 X-rays were taken. One of them showed the spikes.  However, the images needed imagination.

It is not usual for vets to drain the bladder of urine via a catheter and pump in 20 ml of air to provide a good contrast.

During surgery by Dr Daniel, the large beautiful stone looks so much like a lady's precious stone.

FOLLOW UP ON NOV 3, 2013 9.50 AM SUNDAY
Around 42 hours post-cystotomy,  my assistant walked the dog this morning. I checked the wound.  The xize-15 e-collar prevent direct licking of the surgical stitches but bruised the surrounding areas. The dog is extremely active and is normal. He urine-marked the clinic floor. I noticed some discoloured urine. 3 rows of sutures were placed on the bladder according to Dr Daniel as the bladder was bleeding (a blood vessel was nearby and stitched).

Usually, I place 2 rows of sutures and there will be bladder wall bleeding. Each vet has his or her own assessment on the spot and each case differs.

Urine test 42 hrs post surgery. dipstick. Fed dry food from owner.
Blood 4+  pH 5, SG 1.04, WBC +,  protein 2+