1174. $7,000 for the surgery of perineal hernias in a Yorkshire Terrier

"Are you sure you have heard correctly?" I asked the owner of this 8-year-old Yorkshire Terrier with two backside swellings called bilateral perineal hernias. Her dog was constipated and Vet 1 quoted $7,000 to repair the perineal hernias.

"Yes, I am sure," she said. "My husband is not happy."
"Perhaps it is $700 for one perineal hernia?"
"No, no," she was adamant.
"$7,000! Vet 1 had stuck her finger into my dog's rectum to remove the constipated stools . "

1173. Audit: A young Miniature Schnauzer has a bladder full of big stones

"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 cathether 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.

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.

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 bladdder 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.

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 normal. 

1172. Quadraparesis: A young Pom cannot stand or walk

Oct 1, 2013
The care-giver brought in a 7-month-old Pom, not able to stand at all. The couple had volunteered to care for this dog as her lady owner's apartment was being renovated and this would take some time.

Vet 1 had seen her twice and had given meloxicam, tramadol pain-killers. No medical records were presented at the first consultation with me. As the dog had pain-killers, it was difficult to find the source of pain. Spinal palpation elicited some pain in the T/L area and the dog cried when het left hind was extended for the X-rays.

Oct 2, 2013
This morning, the dog was not able to become upright when laid sideways to the left and to the right. However she could sit on her sternum. The pedal reflexes of 4 limbs were poor, esp. left fore and right hind. Shining a light constricted both pupils.  I palpated from the neck to the tail spinal area. The dog screamed at the spinal area between the neck and the shoulder blade. I had this scene videoed.

What was the problem? Would the dog recover? The caregiver was worried and so was the owner. This was a young dog and she could not walk or stand. When laid sideways to the left and to the right, she could not upright herself.  I videoed this behaviour. This was worrisome as there seemed to be a very serious injury of the brain or upper spinal cord.  I phoned Vet 1 for the medical records. Only pain-killers were given orally and one was injected. No blood test or X-rays were done. As the dog salivated, the care-givers brought the dog to consult me since I had treated their dog with difficulty in breathing successfully curing it within 2 days. It is not every dog that I treat recover within 2 days and this case was probably a mild upper respiratory infection.  Unfortunately, pet owners judge the vet's expertise by the speed of recovery and this is not right.    

After videoing, I gave this dog a subcutaneous injection of saline, glucose and amino acids and anti-inflammatory and antibiotics, expecting no response.

BLOOD TEST & VISIT BY THE OWNER ON OCTOBER 2, 2013
"It is best to take a blood test to check whether there is any infection causing this ataxia," I advised the owner who came in the morning. She agreed to the blood test and was most happy that the Pom was walking on four legs.

Yesterday, Dr Daniel thought that a blood test would add to the cost as I had 4 X-rays taken. "It should be done since the owner wanted to know why the dog had been ill for two weeks." I explained.

SIGNIFICANT BLOOD TEST RESULTS
Total white cell count was 19.1 (6-17). Neutrophils was 88%, Absolute 17.00 indicating a bacterial infection. The dog was put on antibiotics.
Platelets were higher at 720 (200-500).

VET 1'S MEDICAL RECORDS. 
Vet 1 had diagnosed traumatic injury to the back and advised strict rest. But no supporting evidence was deemed necessary in the two visits. Each vet has his or her own point of view and so the diagnosis of trauma was correct and pain-killers of NSAID of 3 types were given. Meloxicam on first visit. Then tramadol and injection of bup under the neck skin.

"But there were 3 adult dogs inside the caregiver's apartment and they jump onto this young Pom during play time and feeding," the owner complained to me when she visited on Oct 2, 2013.  She was quite upset as Vet 1 had already given instructions to let this Pom rest.

"It will be much difficult for me to advise your sister-in-law to restrain their 3 dogs. When your Pom is crated, she will bark furiously, causing noise nuisance to neighbours.
Is there any possibility of you taking back the dog to your apartment and crate her? Then there will be no pouncing upon her by the big "heavy" dogs of your sister-in-law.  The in-laws did phone me a few times asking when the dog will recover as they had got some backlash. "I don't know when she will recover," I said frankly.    

Surprisingly, in the afternoon of Oct 2, 2013, the Pom could walk and pace inside the crate. She would eat some of the A/D canned food.  When the owner came with the brown rice, she was elated as the dog was shrieking to go home. "The dog has not recovered yet," I said. "It is the drugs."




OCT 3, 2013
A bright sunny morning. I videoed the dog. She was reluctant to move. At around 10 am, the owner came and she was prancing and shrieking. In the afternoon, the caregivers came. Too much walking. At 7.22 pm, I checked on her. She was reluctant to stand, with her hind legs underneath her body and between the front legs. However, she could walk on 4 legs but there was incoordination in the back legs.

Expected to go home tomorrow. If confined properly, she should recover.

CONCLUSION
An unusual case of quadraparesis starting with back limb ataxia for 2 weeks earlier. Most likely there is traumatic injury of the neck and back area. There was intense pain in the neck area on Oct 2, 2013 when I palpated the neck to shoulder area of the backbone. This would lead to the quadraparesis (unable to stand on 4 legs tempoarily).

As to the cause of the bacterial infection of the blood, it is hard to locate the source.

 

1171. Estimated cost of ear wound and skin disease treatment for a Miniature Schnauzer

Hi Ms. Judy,

Hope this email finds you well.

Currently my dog (Miniature Schnauzer) has a serious case of ear infection and common skin problem.

His ear infection is an open wound and i do not know how did it happen. It does not heal up at all.

Can you provide me with an estimated cost for the treatment? Would really like to get my dog back in shape but at the same time equally worried about the cost of visiting a vet.

Hope to hear from you soon.

Oct 1, 2013. REPLY FROM DR SING KY

Thank you for your email. Most likely your dog needs a sedation to clean and irrigate the ears. The skin infections may need clipping and diagnosis. Treatment is needed. The estimated costs are around $200 - $300 depending on the seriousness of the conditions. 

1170. Update on 2nd cat not eating. Blood test

2nd cat, boarded for 2 weeks with a friend, was eating and went home yesterday sunday.


Blood test results:

High urea and creatinine, low platelet count.
Neutrophils high % but total white cell count normal.
A kidney infection.

1169. Incredible Singapore stories - "Ah Pek"

Monday Sep 30, 2013

This is the 2nd incredible story I hear from one of my clients. The first was regarding drops of blood appeared out of thin air onto the glass table top, fore-head and clothing when one of my clients, a successful businesswoman asked me to help her in the placement of design for her new company logo. 

Today, my client in his 40s, of medium height and solid build works in a logistic firm. He came to buy medication for his old dog having serious coughing. The dog would not cough if he was given this medication.  This Indian man was an excellent story teller spinning an incredible tale of "Ah Pek" which I saw on the dashboard of his 5-year-old shiny Subaru sportscar, immaculate polished shiny with wheel rims very clean, just like a new car.  

"How come you have the figures of two "Ah Peks" glued onto your dashboard?" I noted one Ah Pek wore white and one wore black robes. Both had long black beards and wore hats. The colours had faded to silvery and blue respectively. I must confess ignorance of this Chinese belief of "Ah Peks". According to him, "Ah Peks" ranked 2nd and below were 5 dieties including the monkey god. Above them was another level and the 4th tier was the Judge.  


BIKE ACCIDENT
The client said: "On a rainy day, a lady dashed across the road. I braked my bike and my whole face hit the road as I swerved to avoid this lady. I was in intensive care with tubes into my mouth. I had head and facial fractures. I vomited blood daily as I had internal injuries. The doctor said that he needed to open my skull to operate and remove my injured left eye.

"Those are serious injuries," I said. "Yet you look normal today."
"I was lying in the hospital bed and I asked my friend to ask 'Ah Pek' to help me before the operation.

He gave me a piece of paper blessed by the Ah Pek to put under my pillow.
 I did not interrupt his narrative but I had no reason to doubt his integrity of the events happening to him personally. He was seriously ill and the doctor had given him a poor prognosis for recovery.

He continued: "At night, 'Ah Pek' came to the hospital."
"You really saw him?"
"No, at night,  I heard the dragging of chains of somebody walking into my room. The next day, when I came out from the operating table, there was no skull operation. Two titanium plates are now fixed on either side of my nose but you don't see it. My left eye was OK as I have normal vision."

Certainly this was a tall tale.

"I offered my thanks to Ah Peks via my friend at a medium's house."

"Where's the house? Is it an HDB apartment as I had seen some of such places of worship."
"In Woodlands," he mentioned a place which believers would know.
"Did you have to pay money to the medium?"
"No, just two bottles of beer and fruits," he replied. "The lady who dashed across the road had only a small wound on her right arm. She was quite plump and I guessed she had been cushioned."

DRIVING TEST
He had another tall tale. After the bike accident which nearly snuffed out his life, he decided to drive a car.  He failed his driving test for 6 times. So he sought the help of "Ah Peks" via his Chinese friend who translated the "Hokkien" speech from the medium. "The Hokkien is too cheem (of a high standard) for me."

"I was given a green piece of paper which I had to drink part of it and to smear on my face." 
"Just a green piece of paper? What type of paper is it?" I asked.
"The green paper had signature and chop on it" he said. "One has to believe and I did accordingly. The driving test was in Circuit One at Ubi."

To me, I do not know why Circut One is so fearsome as I took my driving test in the UK. "What's so fearsome about Circuit One?" I wondered but did not interrupt his story telling.
"I hit the kerb during the test," he told me. "The tester would usually fail the driver. Hitting the kerb is like hitting a person's leg. So, I should fail. But the tester did not inform me immediately. He was having a discussion with somebody. I was waiting nervously. Just tell me I had failed so that I can book for another test. The waiting was terrible."

"Why did you hit the kerb?" I asked.
"Circuit One has a road full of bends and if the driver hits the kerb, he or she fails. No mercy from the tester."I was thinking that "Ah Peks" had failed him this time. According to him, the Ah Pek in white extends life and the one in black takes away a person's life.

"After some time, the tester told me I had passed!"
It is hard for me to believe that this is because of "Ah Pek's" blessings.

SPEED TRAPS
Another story he told me as that he had been advised to "Ah Pek" to drive fast as he tended to be collided often when he drove slowly. 
"Once I sped along the straight stretch of Mandai Road. At one end, I saw a motorist being booked before me. Then I sped back to the other end. Another motorist was booked before me."
This sounded too hard to believe. Twice not being caught as if he had a protective order. He had a mat blessed by Ah Pek inside his car to protect him when he drove in Malaysia.
"Speeding can kill people," I said to him.
"I don't do it often."

PEEING ON BROKEN GODS
This was the most incredible of his stories. "During my brash younger days, I purposely peed onto the broken idols discarded near a tree," he told me. "The next day, my right arm burst out with big swellings as big as a 5-cent coin. All over the arm. No itchiness. No pain. The doctors could not diagnose what's wrong and hence they could not prescribe a cure."

I thought it was urticarial weals but it happened only on his right arm and no other parts of his body.
"Well, I asked my friend for help. He consulted the medium. I went to the idols to ask for forgiveness and offer them some fruits and food. The next day, all my skin swellings disappear. My experience illustrates than we must respect the religions of others."

"What type of Gods were they?" I had to ask as I had read of a similar incident in a book called "32 true stories of Ghosts and Spirits & Gods Plus Questions & Answers on the paranormal" by Andrew Tan Chee Khoon, born in 1939.

"Guan Yin (The Goddess of Mercy), the Judge and others, like those you see under a tree in some places."

"Yes, I have seen them and  I don't disturb them."


FACE IS ALL BLACK
He narrated an incident which I cannot recall when the cleaner told him that his face is all black.
"What do you mean 'black'?" I asked him. He has dark complexion because he is Indian, more towards dark brown.
"Very black, the colour of black"
"Like Kiwi black shoe polish?" I asked.
"Yes. Yes."
After he made some apologies to the dieties, the cleaner said his face was back to normal colour.

A clientj with a Yorkshire Terrier had come to the clinic and so I could not talk further.

1168. Update on large abdominal mass in an old Malese

TOA PAYOH VETS toapayohvets.com Date:   30 September, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits The old Maltese with breathing difficulty has 7 days to live     Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   30 September, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Thursday, September 26, 2013 1160. Seven days for the Maltese to live On Wed, Sep 25, 2013 I received a phone call from a young lady for a 2nd opinion. Her 14-year-old male Maltese had breathing difficulties and was not eating. Vet 1 diagnosed anaemia and a big abdominal mass. She advised surgery but the owner did not want it. So the lady searched the internet forums and there were some recommendations for her to phone for Dr Jason Teo at Toa Payoh Vets.  "Dr Teo works at Toa Payoh Vets on Saturdays only," I said. "Another vet at Toa Payoh Vets will be OK," she replied.  "What's the name of Vet 1 whom you first consulted?" "I do not wish to disclose her name." "Did she have X-rays and blood test results for your dog?" I asked as she was telling me the findings without the documentary evidence. "Yes," she said. "You can ask Vet 1 to fax or email to me at Toa Payoh Vets," I said. "I don't think it is possible," she replied. "Why not? Are the documents illegal?" I asked. "Vets do pass clinical records to each other when the owner seeks a 2nd opinion. I have done it before and other vets have done it. You just have to phone them and ask for the medical records." She phoned later to say that Vet 1 would want her to go to the practice to take over the records and so would be late for the appointment. This was OK with me.  Around 3 pm she came and saw Dr Daniel first. He had recorded "4 days of changed behaviour, increased breathing, decreased appetite and cannot walk. No vomiting, diarrhoea and no change in diet. Cheese treat for one week and polyuria and polydipsia. Blood test from Vet 1. No abnormalities in the liver and kidneys or total white cell count. But RBC 3.37 (5.5 - 5.8), HGB 8.4 (12-18) and HCT 23.9 (37-55) were very low. I told the owner that the gums were purplish and the tongue was pale. This was not good. The mid-abdominal lump was solid, painless and half the size of an orange. What is it? Vet 1 was consulted for a "breathing problem". She had taken a lateral X-ray showing much fluid inside the swollen abdomen. A large opaque areas obscured the views of intestines. Vet 1 recorded that the heart was enlarged.  An abdominal mass pushed guts up and above. She recorded that the owner was not keen on surgery. Dog was anaemic and lung sounds were dry. She proposed pain relief since surgery was not acceptable. Overall, Vet 1 was spot on in her diagnosis but the owner was not satisfied. "Is it because you went when the practice was going to close?" I asked. "Yes," she said. Sometimes it is difficult to satisfy the owner on the first consultation in a medical condition with no cure except surgery. Yet this dog was 14 years old, very thin and I would say emaciated. Surgery would kill him. So I don't even want to propose surgery as this dog will never survive the long time needed to remove this large abdominal lump. In any case, the young couple was never in favour of it as they must have done their internet research and know the high risks involved.. But what is this large abdominal lump and what should the couple do? "Euthanase the dog," one young lady et suggested when I spoke to her after X-raying two views of the dog's chest and abdomen at her practice. "This dog is suffering and the owner should not prolong her suffering." "The owner does not want euthanasia," I replied. "Why? Is it for religious reasons?" "It is for personal reasons," I know of owners who rather not put the old companion to sleep by lethal injection at the onset of signs and symptoms of difficulty in breathing. In this case, there might be medication to alleviate such a condition. "There was one government vet before your time," I said to this young lady vet who had worked for over a year in another practice. "He is now retired. He recommended euthanasia so many times that he has a reputation to be avoided. This is because the owners would forecast that he would advise euthanasia in many sick cases. "His intention was to save money for the owners but he gained the reputation of being an "euthanasia" vet to be avoided at all costs by pet lovers with sick pets. "In this case, the couple is against euthanasia. They want to know what is the nature of the abdominal tumour."  Dr Daniel had proposed ultrasound scanning. From my reading of the couple, they want an acceptable solution such that the dog would live the last few days of his life without pain." What more can be done other than ultrasound? Dr Daniel elaborated on the causes of the swollen abdomen - bleeding, chyle, fluid from heart failure since the liver and kidneys were OK based on blood test from Vet 1, peritonitis. He also advised surgery to remove the abdominal mass as the only option. He advised abdomino-centesis to draw out the fluid to send to the lab for examination but sedation would be required and this would be risky as it may kill the dog. So the couple did not accept his suggestion and wanted to take the dog home. I let Dr Daniel handle the case to the conclusion but I did give my take on this medical condition. What should be done for this dog if surgery was not an option? "There is no need for sedation," I said to the couple. "We need to draw out the abdominal fluid so that your dog can breathe easier at least for the next 2 days and start eating."  Each vet has his or her own opinion and my opinion was that abdomino-centesis could be done without much pain on this ill dog and so without any risk of death. The only risk is in putting the needle into the abdominal mass. This was what I was concerned and so was the thinking behind the young lady vet who looked at the X-ray with me earlier after X-ray. "The needle might puncture this big lump," she said.. "Not if you slide the needle under the umbilical skin area," I did that with a 19G needle and fresh blood came out. Dr Daniel inserted a finer butterfly clip needle and withdrew another small amount of blood. Total amount was around 20 ml. The blood clotted soon indicating that bleeding was very recent. This blood collection in a bottle was shown to the couple as they wanted to know the cause of anaemia and the nature of the abdominal tumour. No exploratory surgery but just to know what the abdominal mass is.     3806 - 3809. Large abdominal mass palpated and seen in the X-ray. Blood tests showed liver and kidneys were normal. The heart is enlarged and lung sounds were "dry" on auscultation. l Friday, September 27, 2013 1164. Update on old Maltese. Abdomino-centesis shows bleeding inside the abdomen - old Maltese Maltese, M, 14 years Large abdominal mass 50% size of orange Breathing difficulty around last 4 days Abdomino-centesis drew out 20 ml of blood which clotted soon, indicating fresh blood from abdominal mass. Probably a splenic tumour starting to bleed. The kidney and liver enzymes were normal. IV drip with amino acids and vitamins given. Dog went home and was active pacing the next day. Surgery is too risky. Owner does not want surgery anyway. Prognosis poor if bleeding continues. Dog does eat but is emaciated. Sep 28, 2013  Saturday 10.15 am Spoke to the husband Dog has much less breathing difficulty. Active. Gums pinker. "Any abdominal swelling?" I asked. "No," he said. That means the bleeding of the tumour has stopped but in any case, the abdominal swelling was not that large since the dog was sent for treatment early.. Will not want to eat the egg yolk or chicken liver. Husband asked whether he can get repeat medication in 7 days' time. I had advised hand-feeding of egg yolk to build up red blood cells. The lady owner asked whether liver was OK. "Chicken liver would be good," I said.   Feeding 6x/day in small amounts and electrolytes. Heart medication given as well. For this dog, a blood transfusion would be normally advised. In this case, after the amino-acid, glucose and electrolyte drip IV, the dog was much alert and with home feeding and medication, the dog lived a comfortable life as at Sep 30, 2013. I hope the dog lives longer than 7 days.   Updates will be on this webpage: www.sinpets.com/F5/ 20130930abdominal_tumour.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: September 30, 2013 Toa Payoh Vets