Oct 2, 2012, a Tuesday. I took time off and went to Khin Khin Employment Agency at Peninsula Plaza to teach her manager more about the management of the business. The Government had increased increased the foreign worker quota and clamped down on phantom workers.
Now, a company must employ 5 Singaporeans before it can employ 1 foreign worker instead of 4 to 1. In addition, many companies have been fined for using "phantom workers" who are mainly retirees and others not gainfully employed by the company to make up the 4 Singaporeans to get approval for 1 foreign worker.
After the elections in which foreign workers were said to depress wages of Singaporeans, the foreign worker quota is raised and the foreign worker levy on employer is increased. "Many of the retirees are now out of CPF contributions since they were phantom workers," I observed.
The euro crisis and economic recession reduced the demand for foreign workers. Some have to be sent home due to the increased quota and loss of phantom workers. So Khin Khin and other employment agencies find that they have little demand for their services from the small businesses looking for waitresses and drivers. No quota at all. Close shop or do other services.
As Khin Khin is in Yangon, I dropped in to check on her manager Ni Ni. He had been working 6 months on the S Pass and is supporting his wife and son in Yangon.
Suddenly a young lady in her late 20s and wearing greyish dental braces appeared at the door. Khin Khin's office door does not shut unlike other offices. She came closer and said to me: "Have I seen you somewhere before?" I was astonished. I could not recall. I did see her somewhere. "Are you Dr Sing?" she asked. "Yes," I said.
"Do you remember my dog Brandy?"
"Yes," I said. "The 13-year-old cross bred with three bladder stones.
What a coincidence. I phoned her earlier to tell enquire about her dog's urination situation. The dog was OK but not eating the S/D.
I did advise neutering to reduce the enlarged and inflammed prostate to be done on Monday. But it is Wednesday today. The dog was no longer painful in the prostate when I discharged it 3 days ago but it was very painful when I took over the case. An enlarged painful prostate with bacteria in the bladder can cause painful and difficult urination, other than the 3 bladder stones. But it is hard to explain to the 3 sisters. After all, the dog is peeing normally. Owner compliance is much more difficult.
I did not remove the bladder stones because this dog was so skinny and might die under anaesthesia. Neutering is a short surgery and so I advised it to prevent prostate enlargement and inflammation. But it is extremely difficult to convince the owner to do it and this is a common situation in all medical practices.
Wednesday, October 3, 2012
Monday, October 1, 2012
1126. Audit - intestinal surgery - removal of foreign body
Every vet at Toa Payoh Vets is required to maintain a proper record of anaesthesia and surgery in a book dedicated to each vet. I audit some cases now and then. This case is interesting as it has been performed in a short time, using only domitor and ketamine, without isoflurane gas.
AUDIT OF ANAESTHESIA & SURGERY BY ASSOCIATE VET
Bichon, Male, 3 months
Vomiting over 5 days
Ate prayer food
Hard lump 3x2x2 cm in large intestine. Painful
ANAESTHESIA
Sep 30, 2012 (Sunday) 1.8 kg 3 months
Dom/Ket 0.07/0.09
50% given 0.04/0.05 IV
A: Injection D+K IV 3.47 pm
D: First skin incision 3.56 pm
E: Completion of skin stitching 4.11 pm
No isoflurane gas used for enterotomy
E-A = 24 min
E-D = 5 min
SURGERY
Around 3 cm incision. Big greenish hairy hard lump taken out.
"Apricot seed," my vet said.
3/0 monosyn appositional stitches.
I saw the intestinal wall as over 4 mm in width. Blackish edge over red inflamed patch where hard Foreign Body was lodged. Gangrene had set in. That was why dog was vomiting.
Vet has 3 years of experience. A good surgery done.
No blood test and no x-ray due to financial reasons. The owner decided on surgery on Friday evening but I advised the associate vet to wait 2 more days to strengthen the health (vomiting for past 5 days due to financial reasons, not seeking vet treatment). On Sunday afternoon, this dog was operated and today, he looks as good as gold.
Day 2 Oct 1, 2012 11.32 am, I checked the dog and took some pictures. Active. Disliked e-collar.
AUDIT OF ANAESTHESIA & SURGERY BY ASSOCIATE VET
Bichon, Male, 3 months
Vomiting over 5 days
Ate prayer food
Hard lump 3x2x2 cm in large intestine. Painful
ANAESTHESIA
Sep 30, 2012 (Sunday) 1.8 kg 3 months
Dom/Ket 0.07/0.09
50% given 0.04/0.05 IV
A: Injection D+K IV 3.47 pm
D: First skin incision 3.56 pm
E: Completion of skin stitching 4.11 pm
No isoflurane gas used for enterotomy
E-A = 24 min
E-D = 5 min
SURGERY
Around 3 cm incision. Big greenish hairy hard lump taken out.
"Apricot seed," my vet said.
3/0 monosyn appositional stitches.
I saw the intestinal wall as over 4 mm in width. Blackish edge over red inflamed patch where hard Foreign Body was lodged. Gangrene had set in. That was why dog was vomiting.
Vet has 3 years of experience. A good surgery done.
No blood test and no x-ray due to financial reasons. The owner decided on surgery on Friday evening but I advised the associate vet to wait 2 more days to strengthen the health (vomiting for past 5 days due to financial reasons, not seeking vet treatment). On Sunday afternoon, this dog was operated and today, he looks as good as gold.
Day 2 Oct 1, 2012 11.32 am, I checked the dog and took some pictures. Active. Disliked e-collar.
Sunday, September 30, 2012
1125. Sunday's interesting cases - Sep 30, 2012
Sep 30, 2012
Bright sunny day
Case 1. Red-eared slider with "smaller and sunken" left eye. The husband and wife came for a review. "How many turtles have you treated?" she asked me.
"Around seven cases last year," I said. "Singaporeans seldom keep turtles to an older age like yours and there are not many." Maybe Toa Payoh Vets get less turtle cases. Who knows?
"They release the turtles to the reservoirs," the slim wife with dark rimmed glasses said. "What type of cases you see?"
"Mostly eye problems like closed eyes. Rectal prolapse, cracked shells and not eating."
2 days ago, the husband brought the turtle for consultation as he observed the left eye sunken and smaller than the right eye. He is an observant man as his wife did not know any eye change.
I could see the haziness in the upper part of the cornea of the smaller left eye and took some images to document corneal ulceration (green flurosecein stain). Dr Daniel gave an IM injection in the back thigh muscle of an anti-inflam and antibiotics.
I advised cleaning up the turtle as it smelled fishy, giving eyedrops 3x/day and not letting the eye get wet unless eating time. After eating, wash the eye with boiled water. "Or tap water left overnight as there is chlorine in the water and that will evaporate overnight," I said.
However the husband said: "The tap water has only fluoride, not chlorine." I can't substantiate this and so said nothing.
Today, the husband was to bring the turtle for review and he did so. The turtle's left eye looked so much clearer. It is still sunken but lesser. How to prove it? It was difficult as the turtle did not permit me to take image head-on of both eyes on the reception counter. He was restless and moving. "Do it inside the consultation room after switching off the lights, as before," the husband advised. "Use ISO 3200."
"The images are not so good compared to natural light in the waiting room," I said. "I used ISO 6400 the last time." As I did not want to upset the owner, I took images inside the darkened consultation room. The turtle was calmer. The cornea looked much more transparent esp. in the 11 to 2 o'clock area where there was cloudiness 2 days ago.
Case 2.
Shih Tzu, 1 year old, with red ear lumps in both ears but the lady in her 40s said that there was no scratching. The right ear was more painful when I palpated the vertical canal and the dog cried.
She had seen my associate vet for the past 3 times with the same problems. Antibiotics, injection and ear flushing again.
"I had spent much money in the eye ulceration treatment last time," she said to me when I advised lateral ear resection surgery. Now she trimmed the hairs around the eyes and put eye drops daily. No more eye ulcerations but this ear inflammation and pus could not be resolved since Jan 2012.
"It is usually the money matters," I said. "Ear surgery is the solution to open up the vertical canal to enable the horizontal canal to be ventilated and drained as the shih tzu's floppy ears covered up the canals 24 hours/day. But most owners will not accept the surgery due to its costs."
"How much?" she asked.
"I estimate $500 for one ear, including nursing care for around 7 days post surgery. It is just an estimate."
Now she had seen my associate vet 4 times and tried to clean the ears and give medication. The total costs and her time would be $600.
"It is just the luck of the owner," I said. "Some families have children with health problems and incur lots of medical expenses. I just have a case of a Shih Tzu dog owner who spent over $8,000 just for 5 bladder stones removal in the dog. Other Shih Tzu owners have no need to spend a cent."
Case 3.
An apricot seed inside the large intestine of the Maltese. I came back to the surgery at 3.30 pm to check whether my associate vet had operated on this Maltese. The owner had delayed operation but the dog kept vomiting and she decided on the operation on Friday. I advised against immediate operation for expediency as Saturday was the day off for my associate vet. The dog needed the IV drip and antibiotics to recover. Today, Sunday, the dog was in much better health but still vomited. My associate vet took out the apricot seed, put in interrupted appositional stitches to close up the wound. The large intestines were inflamed to 6 mm in depth of mucosa and serosa. The dog was alert and well after surgery. That was good.
Case 4
The old Minature Schnauzer with the bloated stomach of closed pyometra came back for stitch removal as required by Dr Vanessaa. I asked Dr Daniel to remove the stitches. The pyometra surgery was done on 31 August. None of the nylon stitches were present now as it is past one month since surgery. This dog had pus in the hairy ears and dry skin problems in the forearm and body. At least she did survive the surgery as I thought the pyometra would burst if you see the images in my case studies.
"Today, there is a white spot in the left eye," the wife said.
Bright sunny day
Case 1. Red-eared slider with "smaller and sunken" left eye. The husband and wife came for a review. "How many turtles have you treated?" she asked me.
"Around seven cases last year," I said. "Singaporeans seldom keep turtles to an older age like yours and there are not many." Maybe Toa Payoh Vets get less turtle cases. Who knows?
"They release the turtles to the reservoirs," the slim wife with dark rimmed glasses said. "What type of cases you see?"
"Mostly eye problems like closed eyes. Rectal prolapse, cracked shells and not eating."
2 days ago, the husband brought the turtle for consultation as he observed the left eye sunken and smaller than the right eye. He is an observant man as his wife did not know any eye change.
I could see the haziness in the upper part of the cornea of the smaller left eye and took some images to document corneal ulceration (green flurosecein stain). Dr Daniel gave an IM injection in the back thigh muscle of an anti-inflam and antibiotics.
I advised cleaning up the turtle as it smelled fishy, giving eyedrops 3x/day and not letting the eye get wet unless eating time. After eating, wash the eye with boiled water. "Or tap water left overnight as there is chlorine in the water and that will evaporate overnight," I said.
However the husband said: "The tap water has only fluoride, not chlorine." I can't substantiate this and so said nothing.
Today, the husband was to bring the turtle for review and he did so. The turtle's left eye looked so much clearer. It is still sunken but lesser. How to prove it? It was difficult as the turtle did not permit me to take image head-on of both eyes on the reception counter. He was restless and moving. "Do it inside the consultation room after switching off the lights, as before," the husband advised. "Use ISO 3200."
"The images are not so good compared to natural light in the waiting room," I said. "I used ISO 6400 the last time." As I did not want to upset the owner, I took images inside the darkened consultation room. The turtle was calmer. The cornea looked much more transparent esp. in the 11 to 2 o'clock area where there was cloudiness 2 days ago.
Case 2.
Shih Tzu, 1 year old, with red ear lumps in both ears but the lady in her 40s said that there was no scratching. The right ear was more painful when I palpated the vertical canal and the dog cried.
She had seen my associate vet for the past 3 times with the same problems. Antibiotics, injection and ear flushing again.
"I had spent much money in the eye ulceration treatment last time," she said to me when I advised lateral ear resection surgery. Now she trimmed the hairs around the eyes and put eye drops daily. No more eye ulcerations but this ear inflammation and pus could not be resolved since Jan 2012.
"It is usually the money matters," I said. "Ear surgery is the solution to open up the vertical canal to enable the horizontal canal to be ventilated and drained as the shih tzu's floppy ears covered up the canals 24 hours/day. But most owners will not accept the surgery due to its costs."
"How much?" she asked.
"I estimate $500 for one ear, including nursing care for around 7 days post surgery. It is just an estimate."
Now she had seen my associate vet 4 times and tried to clean the ears and give medication. The total costs and her time would be $600.
"It is just the luck of the owner," I said. "Some families have children with health problems and incur lots of medical expenses. I just have a case of a Shih Tzu dog owner who spent over $8,000 just for 5 bladder stones removal in the dog. Other Shih Tzu owners have no need to spend a cent."
Case 3.
An apricot seed inside the large intestine of the Maltese. I came back to the surgery at 3.30 pm to check whether my associate vet had operated on this Maltese. The owner had delayed operation but the dog kept vomiting and she decided on the operation on Friday. I advised against immediate operation for expediency as Saturday was the day off for my associate vet. The dog needed the IV drip and antibiotics to recover. Today, Sunday, the dog was in much better health but still vomited. My associate vet took out the apricot seed, put in interrupted appositional stitches to close up the wound. The large intestines were inflamed to 6 mm in depth of mucosa and serosa. The dog was alert and well after surgery. That was good.
Case 4
The old Minature Schnauzer with the bloated stomach of closed pyometra came back for stitch removal as required by Dr Vanessaa. I asked Dr Daniel to remove the stitches. The pyometra surgery was done on 31 August. None of the nylon stitches were present now as it is past one month since surgery. This dog had pus in the hairy ears and dry skin problems in the forearm and body. At least she did survive the surgery as I thought the pyometra would burst if you see the images in my case studies.
"Today, there is a white spot in the left eye," the wife said.
1124. Cost, Duration & Complications of spaying a 3-year-old jack russell query
On Sun, Sep 30, 2012 at 2:39 PM, ...1989@hotmail.com> wrote:
Hi,
I have a female jack russell coming 36 months but has yet to be spay.. Can i knw if there're any complications doing this procedure at this age? And roughly the duration and cost of it? Kindly advise, thank you.Cheers,J Y
EMAIL REPLY FROM DR SING DATED SEP 30, 2012
Thank you for your email. I am Dr Sing K Y from Toa Payoh Vets.
Generally, all healthy female dogs at around 36 months of age will have no complications during or after spay.
Generally, all healthy female dogs at around 36 months of age will have no complications during or after spay.
Complications refer to anaesthetic deaths, post-op deaths, bleeding and infections. The duration of spay should be less than 30 minutes and the estimated total cost is around $250-350 at Toa Payoh Vets ( including anaesthesia, surgery, post-op injections and medication and e-collar). Pl make an appointment at 6254 3326 one day in advance.
The best time to spay is 2-3 months after the last heat (bleeding)
The best time to spay is 2-3 months after the last heat (bleeding)
1123. VETERINARY TIPS. Take digital images of complicated post-operation cases to make you a better vet
Taking images of cases with your camerar or phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon.
There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review and plan your surgery in your office.
For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. This is shown below:
This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catheterised with a smaller sized urinary catheter
Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid.
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area.
For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. This is shown below:
This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catheterised with a smaller sized urinary catheter
According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage.
This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones).
How to resolve this problem with the least cost to the owner?
How to resolve this problem with the least cost to the owner?
That is the tough part. Will a 2nd urethrostomy and closure of the first urethral stoma and scrotal ablation resolve the problem for once and for all?
Vet 4 at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg and Vet 4 stitched up the urethral stoma (first urethrostomy done by Vet 1).
Would this resolve the problem? Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid.
(I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days after Vet 4's surgery.
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area.
"It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means more money expenditure for the owner."
As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem.
As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem.
This involved talking to Vet 3 as to what had been done. Vet 3 said that an ultrasound revealed fluid inside the scrotum and this was not recorded in the case report as the owner was not charged.
Ultrasound can reveal fluid in an organ but will not be able to tell whether it was urine or blood or both.
This is where the perineal swelling in this image substantiates a possible urine leakage. It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.
So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.
My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.
In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.
This is where the perineal swelling in this image substantiates a possible urine leakage. It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.
So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.
My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.
In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.
Not all bladder surgery is free from complications. In this case, the perineal urethra could have been damaged. Hence the urine leaked into the perineum (causing large swellings). The urine also flowed into the scrotal sace, hence another large swelling.
Friday, September 28, 2012
1122. The vet transports the dog for an X-ray
"Surely it is not (befitting) your status to personally drive and transport the dog to get an X-ray done!" Dr Jason Teo's transport man met me at a Clinic where he had taken a cat for x-ray of the pyometra.
"My transport man had sold his van and the others were not available," I explained.
Steven pointed to an old Mercedes outside the clinic. Its engine old and smoke from the exhaust puffing out and said: "Surely, the petrol of the Mercedes would cost more than your transport cost. Why don't you just phone me?"
"I thought you just groom dogs for Jason," I did not tell him that the black Mercedes was not mine and I don't idle the engine when I park the car. It takes some time at this clinic to get the dog X-rays. In any case, I dislike polluting the environment by idling the engine unnecessarily.
"I do dog transport when I need the money," he laughed. He is an old guard in this pet business.
I find that much can be learnt just by transporting the dog for X-ray to any clinic. In one clinic, I was made most welcome by the vets. In another clinic, I would not be permitted to see any vet nor proceed past the waiting room as it has an awesome gate-keeper. So I learnt a lot by being on the ground.
"My transport man had sold his van and the others were not available," I explained.
Steven pointed to an old Mercedes outside the clinic. Its engine old and smoke from the exhaust puffing out and said: "Surely, the petrol of the Mercedes would cost more than your transport cost. Why don't you just phone me?"
"I thought you just groom dogs for Jason," I did not tell him that the black Mercedes was not mine and I don't idle the engine when I park the car. It takes some time at this clinic to get the dog X-rays. In any case, I dislike polluting the environment by idling the engine unnecessarily.
"I do dog transport when I need the money," he laughed. He is an old guard in this pet business.
I find that much can be learnt just by transporting the dog for X-ray to any clinic. In one clinic, I was made most welcome by the vets. In another clinic, I would not be permitted to see any vet nor proceed past the waiting room as it has an awesome gate-keeper. So I learnt a lot by being on the ground.
Follow up: The 3rd sister loves and cares for the old dog
1121. Bladder stone dog goes home - 3 sisters
"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.
"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.
I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.
"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."
"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."
"Why must he be neutered?" 2nd sister asked.
"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."
The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.
"I have advised no bladder stone removal operation as the dog is very thin and will wait till he has difficulty in urination the next time," I said. "Although there is no crystals or struvite crystals present in his urine analysis, it does not mean he has no struvite stones. The pH is 6.0 for the past two urine analysis but bacteria is present in the urine. The bacteria in his bladder may have gone to the prostate, causing pain and inflammation of the prostate.
As the 2nd sister is an adult, she understood what a prostate is and so I need not explain further.
EXPLANATION
1. The male dog does not urine mark for the past two days. He just pees a few times in the morning when taken out for the walk. Why? This is because he was given an anti-male-hormone injection called Tardak by Vet 1 around 1 week ago and he is "feminised."
2. The urinary pH is 6.0. In struvite stone formation, the pH is usually alkaline and urease bacteria must be present. That is the norm. However, Vet 1 had recommended K/D diet and the dog was eating it. So, the urinary pH may have been affected. It is hard to say. It is too technical to explain to the sisters about alkaline urinary pH and struvite stone formation as there is information overload.
3. I advised S/D diet for the next 3 weeks as an alternative to surgery due to the high anaesthetic risks involved at present (prostate enlargement and infection, bladder infection with bacteria). This old dog much loved by this 3rd sister and it is better to build up the dog's weight and health if the bladder stone surgery is needed in the future. Neutering is advised next week as neuter is a very short 5-10-minute surgery compared to around one hour for bladder stone removal. Struvites are more common in dogs seen by me and if this S/D trial works and X-rays of the bladder are taken in a month's time, the stones would have dissolved or reduced in size, permitting urohydropropulsion. That will get rid of all the smaller stones.
4. Owners seldom comply with veterinary instructions and so much depends on educating the owner and the 3rd sister. Somebody who loves the old dog and usually it is a lady family member who cares very much for this old companion to get things done by the vet.
"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.
"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.
I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.
"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."
"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."
"Why must he be neutered?" 2nd sister asked.
"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."
The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.
"I have advised no bladder stone removal operation as the dog is very thin and will wait till he has difficulty in urination the next time," I said. "Although there is no crystals or struvite crystals present in his urine analysis, it does not mean he has no struvite stones. The pH is 6.0 for the past two urine analysis but bacteria is present in the urine. The bacteria in his bladder may have gone to the prostate, causing pain and inflammation of the prostate.
As the 2nd sister is an adult, she understood what a prostate is and so I need not explain further.
EXPLANATION
1. The male dog does not urine mark for the past two days. He just pees a few times in the morning when taken out for the walk. Why? This is because he was given an anti-male-hormone injection called Tardak by Vet 1 around 1 week ago and he is "feminised."
2. The urinary pH is 6.0. In struvite stone formation, the pH is usually alkaline and urease bacteria must be present. That is the norm. However, Vet 1 had recommended K/D diet and the dog was eating it. So, the urinary pH may have been affected. It is hard to say. It is too technical to explain to the sisters about alkaline urinary pH and struvite stone formation as there is information overload.
3. I advised S/D diet for the next 3 weeks as an alternative to surgery due to the high anaesthetic risks involved at present (prostate enlargement and infection, bladder infection with bacteria). This old dog much loved by this 3rd sister and it is better to build up the dog's weight and health if the bladder stone surgery is needed in the future. Neutering is advised next week as neuter is a very short 5-10-minute surgery compared to around one hour for bladder stone removal. Struvites are more common in dogs seen by me and if this S/D trial works and X-rays of the bladder are taken in a month's time, the stones would have dissolved or reduced in size, permitting urohydropropulsion. That will get rid of all the smaller stones.
4. Owners seldom comply with veterinary instructions and so much depends on educating the owner and the 3rd sister. Somebody who loves the old dog and usually it is a lady family member who cares very much for this old companion to get things done by the vet.
Thursday, September 27, 2012
1121. Bladder stone dog goes home - 3 sisters
"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.
"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.
I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.
"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."
"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."
"Why must he be neutered?" 2nd sister asked.
"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."
The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.
"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.
I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.
"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."
"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."
"Why must he be neutered?" 2nd sister asked.
"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."
The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.
1121. Fits in a 12-year-old Silkie Terrier - what is the cause?
A Silkie Terrier had fits at around 6 am yesterday and today Sep 27, 2012. First episode. What is the cause?
"There are many causes," I said to the owner who told me that the old dog had a dental scaling 1.5 months ago at Vet 1's place and the right submandibular lymph node would be due to bacterial infection from the bad teeth.
"The lump is nodular and quite large and painful," I said. "The dog reacted to the palpation and coughed a bit. One possible cause of this early morning fit could be the sharp pain in this lump," I said. "If only dogs can talk."
I advised an X-ray. "It is best not to operate now as the lump appeared to have spread inwards," I said. "This is an inoperable tumour, likely cancerous."
"Please forgive me for asking. How do you know it is cancerous?"
"I do not know for sure, unless it has grown aggressively since 1.5 months ago. If Vet 1 had recorded the size of the lump and it is now 2 or 4X bigger, then it is likely to be cancerous." He would try to get the report from Vet 1.
"If it is just an inflamed right submandibular lymph node, then medication will reduce it considerably," I said. "We have to review in 2 weeks time. Blood test did reveal liver disorder as the enzymes are increased. However, some vets will say that the liver enzymes must be considerablv higher than today to cause fits in your dog. I mean, you ask 10 vets and you get 10 different opinions."
I will be working with this owner to monitor the fits after taking medication, but no fits medication for the time being. X-rays are as follows:
.
"There are many causes," I said to the owner who told me that the old dog had a dental scaling 1.5 months ago at Vet 1's place and the right submandibular lymph node would be due to bacterial infection from the bad teeth.
"The lump is nodular and quite large and painful," I said. "The dog reacted to the palpation and coughed a bit. One possible cause of this early morning fit could be the sharp pain in this lump," I said. "If only dogs can talk."
I advised an X-ray. "It is best not to operate now as the lump appeared to have spread inwards," I said. "This is an inoperable tumour, likely cancerous."
"Please forgive me for asking. How do you know it is cancerous?"
"I do not know for sure, unless it has grown aggressively since 1.5 months ago. If Vet 1 had recorded the size of the lump and it is now 2 or 4X bigger, then it is likely to be cancerous." He would try to get the report from Vet 1.
"If it is just an inflamed right submandibular lymph node, then medication will reduce it considerably," I said. "We have to review in 2 weeks time. Blood test did reveal liver disorder as the enzymes are increased. However, some vets will say that the liver enzymes must be considerablv higher than today to cause fits in your dog. I mean, you ask 10 vets and you get 10 different opinions."
.
Wednesday, September 26, 2012
A kind Buddhist teacher
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PAYOH VETS toapayohvets.com Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074 Tel: 6254-3326, 9668-6469, 9668-6468. judy@toapayohvets.com 22 May, 2015 Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits |
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Mammary adenomas in an American Cocker Spaniel Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First written: 21 September, 2012 Update: 22 May, 2015 "Why did you delay seeking surgery till the breast lump is gigantic in size, like two tennis balls combined?" I asked the Buddhist temple teacher who taught Buddhism and morals to over 800 children of devotees. "The breast lumps grow very fast in the last 2 weeks," she replied. "Nobody in the family wants to bring the dog for surgery. My brother said to let her die." The solution was surgical removal but the family did not want to pay the medical costs. She was kind to enough to bring in this old dog for surgery at Toa Payoh Vets.
I tacked in "walk-in sutures" through the muscle layer and then the skin, using 2/0 sutures to ensure that the large long wound would not break down.. The dog came back 4 days later. There was a swelling at one end of the tumour. " "There's seepage at the left Mammary Gland 5 area," I said to Dr Daniel who is in charge of the case. "Just cut off two stitches," I said to him. "In this way, the serum can drain out. No need to re-stitch." After that, we had no more visit from the Buddhist teacher. I was glad that this dog was not abandoned when she had the tumours. Such incidents do occur in Singapore. It is best to spay the female dog when she is young as breast tumours are less likely to develop in spayed dogs.
More case studies, go to: Cats or Dogs Make an appointment with your vet. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements. |
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