Friday, October 4, 2013

1177. Perineal hernia surgery - images













1176. Transparency of medical charges

The case of Dr Susan Lim v Singapore Medical Council (SMC)
The Court of Appeal delivered a verdict on Jun 28, 2013 ruled that Dr Susan Lim overcharged a member of the Brunei royal family supporting the SMC's charge of professional misconduct leading to her suspension.
The Court did not define "ethical limits" as regards overcharging.


1. His peers must decide that a fee is excessive
2. A fee that is absurd or unconscionable.

The listing of charges should provide transparency and let patients make informed decisions and uphold the honour, honesty and integrity of the profession. Charges must be accurate and detailed as possible and include the complexity of care, the doctor's experience and the cost of the service rendered. Some hospitals list the doctor's fees separately from the hospital charges.

Posting of prices online by public and private hospitals on procedures will be best.
   

1175. Self-publishing on CreateSpace at amazon.com


Here is an overview of our professional services we offer for book publishing if you'd like our team of publishing professionals, including our editors, book graphic design artists, and marketing experts, to take your book to the next level to publish a polished, paperback version.

You have the option to build out your own publishing package as I can help you select your services.

We offer your choice of professional editing services for any genre: https://www.createspace.com/pub/services.home.do?tab=EDITING

If you need help with designing a stand-out cover using a Custom Cover option or want to simply submit your Word document for book layout, below is a quick overview of our Cover and Interior options to publish a book with us as. You can elect to use our editing services and/or cover and layout services or do your own book cover and interior page layout.

Cover Options: https://www.createspace.com/Products/Book/#content2
Interior Options: https://www.createspace.com/Products/Book/#content3

Also, included in every signup package:
- An ISBN
- A bookselling page on www.Amazon.com and Amazon EU channels with a free Look Inside! feature
- Industry-leading discounts when you purchase copies of your book
- Flexible pricing that allows you to determine the royalty you receive and allows you to receive industry leading Amazon.com royalties:
https://www.createspace.com/Products/Book/#content6
==>CreateSpace authors pay only $3.25 for a 200 page BW paperback per unit! With a $15 list price on Amazon.com, earn $5.75 per retail order!

You'll be pleased to know we offer a Satisfaction Guarantee on our Professional Services: https://www.createspace.com/Special/Help/Rights/Guarantee.jsp

When you first sign-up for your account and title, you'll see your Member Dashboard and experience our Do It Yourself tools. To receive full support through our paid-services mentioned above, I'll need to set-up a service order and process payment to refresh your account so that your account is refreshed with the paid, service-specific instructions. You will then be assigned a Publishing Project Team who will provide you with online instruction and support throughout the process.

Let me know if you'd like to connect to pick out your custom package of services.


---------------------------
Email from amazon.com  Oct 4, 2013

Hi Kong Yuen Sing,
We do not charge per page for editing nor book design.
CreateSpace charges per WORD if you would like a line-editing service. See the Editing Levels and service fees here:
And, the fee for Interior Page Layout is $679 for Complex books with text and graphics as it includes custom page-by-page layout with up to 50 images (and extra images are $15 each) and charts or tables or diagrams can redesigned at $25 each if you cannot submit them as JPEG graphics for insertion in your page formatting.
And here are the different Cover Design fees: https://www.createspace.com/Products/Book/#content2
I hope this helps you better understand our fee structure.
Basically, you pay for what you may need as one-time fees for:
-Editing: Charged per word. So a Comprhensive Copyediting service is $0.021 per word. If you have 50,000 words, then the cost is $0.021 x 50,000 = $1,050.00
-Book Interior Layout: Complex Custom Interior $679
-Custom Cover Design Premier $599 (Or pick another cover design level based on your needs)
Total: $2,328.00


------------------

EMAIL REPLY DATED OCT 5, 2013

Yes, you can do all your own book interior page formatting using these guidelines and specifications:


Free Do-It-Yourself Option

Whether you have a print-ready pdf, or a Word® .doc, docx, or .rtf file, it's easy to upload your file and get it ready for publishing for free.

Interior Reviewer presents your file as an online virtual version of your book. You'll be able to see formatting issues highlighted visually to find and address formatting issues fast.




Print-ready PDF files created through desktop publishing software offer the most control over the appearance of your book.



(If you cannot create the PDF print-ready files, then you can provide us with your manuscript in Microsoft Word as we’ll do the custom book interior page formatting for you using our Complex Custom Interior service at $679 and recommend the best layout choices for book size, typography, text and graphic formatting- https://www.createspace.com/Services/ComplexCustomInterior.jsp)  

And, yes, you can purchase any of the Cover Options as seen here: https://www.createspace.com/Products/Book/#content2

What would you like to see on your cover?

------------------------
OCT 9, 2013 REPLY FROM AMAZON
I’m happy to call you and review our options further with you. Basically, you have the option to submit a PDF for printing/publishing of the interior pages if you are confident in the interior page layout and they meet these outlined specifications:

If you are providing us with a PDF, we review it to ensure it meets the outlined specifications for printing and use it as-is.
If you would like CreateSpace to do any professional line-editing or do the professional layout/design of the interior pages for you, then we require a Word document for editing and/or book interior page layout.
Choose to submit your own cover, use the FREE Cover Creator templates, or have us design a Custom Cover (fee-based): https://www.createspace.com/Products/Book/#content2
Choose to submit your own PDF print-ready files (per our submission guidelines) OR you will need us to do the interior page PDF layout for you using your Word document and images: https://www.createspace.com/Products/Book/#content3

If we do the book layout and design for you, we will need 5-6 weeks for book layout and design. Add 2-3 weeks additionally if you would like us to do any editing work for you.


Thursday, October 3, 2013

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. 








Wednesday, October 2, 2013

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.

 

Tuesday, October 1, 2013

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.