Friday, August 29, 2014

1480. The two RI interns - Interns must deliver

Friday Aug 30, 2014

The two RI interns presented me illustration of thanks for internship. I was surprised. "Interns must deliver results," I had said to both of them during their 2-week internship. "Just like any service providers, including vets.

For example, in the case of the 15-year-old dog with facial cysts, I had to ensure that the old dog die not die under anaesthesia and resolve the problem of his coughing by correct diagnosis." This real-life case could have been a good illustration of "delivering results".

The following tips I gave to them:

1. Eye contact. "You don't see lawyers typing and looking into his screen while consulting," I said to one intern who uncles are lawyers. "You see Dr Daniel doing it. Some doctors in hospitals do that too to key in case records. More time should be spent on eye contact."  This is because one intern kept keying in rapidly the discussions into his smartphone. Obviously he lost the meanings of what we discussed as he focused on typing. He could not see the body language.

2. "Amateurs use multiple colours in the video production and layout of reports." One intern loves different fonts and colours in his text. 3 colours would be best. Headings should be consistent in size and colour.

3. "Rule of third and cropping" in digital photography. No point showing the wide area of grass land when we want to show the butterfly's beauty as the background will be distracting..

4. Being meticulous. "Mis-spelling is not good."  One intern typed "pyometra" as "pyomettra" and I was so angry that he was not meticulous.  "Don't disgrace the name of RI," I said. "Many interns don't edit before submission of the work to me."




 

Thursday, August 28, 2014

1479. Eye examination and 3rd rabies vaccination

Aug 29, 2014
Had a routine eye examination at Tan Tock Seng Hospital.
A kind lady at the appointment counter last week recommended me an experienced "retina" specialist.

He really took the time to explain to me the causes of "lights" seen when I moved my head suddenly and sometimes at night. That was 2 years ago. Due to ageing, the vitreous has contracted and breaks off from the retina. So, there were phosphids lights seen. Now there is no more such detachment. I must read up more.

Went for 3rd rabies vaccination. Met a friend who was going to Sri Lanka on a "missionary" work.for her church. "Missionary means a long stay," I said to her as she would be visiting for 1 week.. "OK, it is mission work,"

She had also gone to Thailand on mission work. One dog bit her. She got one rabies vaccination in Thailand. "How did you get a dog to bite you?" I asked.

"I was staying in the University hostel. On the last day, I decide to jog outside the safe grounds of the University. I jogged past the roadside stalls. Suddenly 10 street dogs came towards me. They were guarding the stalls."
"What did you do?" I asked.
"I stopped and shouted at them. Staring at them. To run would encourage them to chase me. I stepped back slowly, step by step."
"So how could any dog bite you?

"One dog nipped me at my lower leg. He came from my side."
So she was defending the frontal assault and got flanked.
"I thought nothing of this dog bite. There was some bleeding above my knee when I went back to the hostel. I dismissed this bite but my church leader asked me to get a rabies vaccination. So I got one done and I went to Tan Tock Seng Travel Clinic for the next 4."

The clinic had no place for her. So she went to Raffles Medical which charged her $175 per vaccination as compared to $150 as Tan Tock Seng.

"The nurse told me I should get the antibodies injection. It would be very painful and costly. Around $3,000."

"Did you do it?" I asked.
"Dog bites in Thailand are classified not serious, serious and very serious (deep wound). Mine would be not serious. So I did not do it. Anyway, Raffles Medical did not have it. I got 5 vaccinations"

"Since you are still alive, you would not have rabies," I said.
"I prayed and prayed." she laughed.

Wednesday, August 27, 2014

1478. A 15-year-old dog has a large facial lump below the eye - carnaissal tooth abscess?

August 28, 2014  5 am report

The family vet said that the 15-year-old dog was too old for anaesthesia to remove the facial lump.. He prescribed medication. The soft swelling grew bigger and bigger.

"It did disappear once but it surfaced again below his right eye." the lady said to me on this fine sunny August 2014 day...  The location of the swelling and the thick tartar encrusting the teeth (dog was dental scaled 4 years ago by the reluctant family vet pressurised to do it as he deemed the dog too old at 11 years of age for anaethesia).

"It looked very much like a carnaissal tooth abscess also known as a malar abscess," I said to the worried young lady. "The soft swelling would be the pus from the root of th infected upper 4th premolar tooth breaking into sinus and then the skin, accumulating under the right eye."

Anaesthetic risk had increased greatly now that the dog is 15 years old. One dog's year is around 7 human years and so the dog would be equivalent to a person aged 105 years.

"Health screening can be done first," I auscultated the heart and got a blood test for complete cell count.

The dog had a left heart murmur. That is why he coughs when he lies on his side. Fluid had accumulated in his lungs. A coughing dog is at higher risk for anaesthesia.

I prescribed heart drug medication and antibiotics for the next 7 days prior to anaesthesia and dental work up. On Day 2 of medication, the dog coughed continuously overnight.

She SMS me, as all young people do, rather than phone:
"26.8.2014 Tue. 5.03 am. K has been coughing non stop. Almost 7-15 coughs every 1-2 mins at times. Longest interval is perhaps 5 mins. He could hardly sleep. I can't wait until Thurs to see u again. may I know what can be done? V distressing for us.. lany jabs to suppress the coughing? His yellowish green eye discharge keeps coming after I've wiped it off. Please advise me next course of action?Appreciate it lots..    

The lady and family members were much worried. I got the dog down for a check up. He was not coughing continuously at the Surgery.

The heart disease medication should be working to reduce coughing while lying on the side. But now the dog was coughing more, even when lying on the sternum. I phoned her to give furosemide tablet two times a day instead of once and stop all medication and to bring the dog down at 9 am on 26.8.2014.

As no chest X-rays were done to lower medical costs, ausculation and coughing history were the only means of diagnosing heart disease.

The owner gave informed consent for anaesthesia, dental work and exploratory surgery of the facial swelling. It was a cluster of cysts! No carnaissal tooth abscess. Another surprise. The teeth were all white and solidly strong. No loose teeth. As at Day 5 after the first consultation and antibiotic eyedrops, the dog is more active.

Her SMS to me on Aug 27, 2014:

"Hi Dr Sing. K is almost back to normal now. Eyes ok. Energy level getting back. Wound healing up and teeth so cleaned. I'm really very appreciative. Thank u so much (a frog symbol)".I have never seen a smiling "green frog symbol" at the end of an SMS. What does it mean?

I SMS to ask her the medication given, besides the antibiotic eye drops. She SMS:
Vetmedin at 8 am and 8 pm. Baytril (last dose) at 6.30am. Furosemide 8am and 8 pm. Trimaxazole at 8 am and 8 pm. Fortekor 20 at 8pm.

She did not mention whether the dog still coughs?  So on 28.8.2014, I SMS:
"Is he coughing lying down n on his sternum?" Another SMS from me: "How is his appetite? (a poodle symbol at the end of the SMS).

"Coughing is very much reduced. He could sleep on his side and sternum since yesterday already. Peeing and pooping normal. Appetite good too. she sms.

"Thanks."

2014 SMS FOLLOW UP
28,8.14  She sent me 3 images of K. "He has energy for longer walks" she sms.
                                                           "Need to let heart recover. Could have heart and lung bacterial infection in the past few days". K's eye discharges now no more.

"Once the medication is over, is there a need for review?" she sms

"High (blood) calcium. Need to check parathyroid hormones or do a blood test 4 weeks later. Heart disease medication may be needed to prevent coughing. Need to use warm water and cotton to scrub (facial) wound to remove blood. Your dog's cae really show that the vet has to physically cut open the (facial) lump. Not a carnaissal tooth abscess as it seems. Never judge a book by its cover but we do."

29.8.14

"All peaceful on the home front?" I sms. "Is K normal?"


"K is coughing less but still not totally gone. An d he is sneezing a bit today. I am still giving him the medication. (He is) sleeping well." she sms.

"Wait and see. Heart may need time to recover."

She sms K sleeping on his right side. "A peaceful sleeping dog."

"Dog looks peaceful but lost weight?"

"Don't think so," she sms.


This is one of the rare cases of a 15-year-old dog who came for a enlarging facial lump which was a facial cysts (evidence from video and images). I have never seen a facial cyst in my 30 years of practice. More than 10 cases of carnaissal tooth abscess.

Surprisngly, I have one old dog with a discharging carnaissal tooth abscess. The blood test of this dog showed a very high total white cell count and so the dog would be operated only one week later after antibiotics. The lady owner was most worried but surgery could not be rushed into as the infected old dog could die under anesthessia..This would also be a case of oro-nasal fistula.





 

Tuesday, August 26, 2014

1477. intern glenn. A young dog in Yangon bites people - has rabies - Images

A visit to Royal Asia Veterinary Surgery in Aug 14, 2014

This young dog bit the family members. So he was sent in for neuter on Aug 14, 2014.
I was visiting. The young vet had been practising for 2 years but had not done a neuter. So I asked Dr Aung for her to start her first neuter under my guidance.

Dog was neutered by closed pre-scrotal castration method. No bleeding. An hour later, I checked on this dog. Traumatic bruising on his scrotum due to his own biting. Swollen scrotal sacs. There would be bleeding.

"Bleeding?" he asked me. "I don't like closed pre-scrotal castration." 
Dr Aung operated and tied up the areas again.
We went to Yezin Univ to give lecturers to the final year student after this surgery.

The dog died the next day. Since he had bitten people, Dr Aung sent to the government for a check on rabies. Positive. results came in one week later.   I was back in Singapore and went to Tan Tock Seng Travel Clinic for treatment. I was exposed to the blood when supervising the young vet in her first neuter. No hand scratches. No bites from the dog. Still I consulted the doctor at the Travel Clinic.

"5 vaccinations" he recommended. "If you are exposed again, you will need two vaccinations again."

Yesterday, I went to the Travel Clinic for my 2nd vaccination IM, left arm as I write with my right hand.

"Can I just have 3 vaccinations?" I asked the nurse. I dislike injections.
"No," she said. "3 vaccinations are for those people not exposed to rabies. You need 5."
I could have been complacent and not go to be vaccinated. After all, I had no scratches on my hands or had been bitten. But would it be wise?

Once symptoms appear, it would be too late.
An older vet at RAVS apparently could not swallow and could not converse with me normally. Did she manifest signs of rabies infection? Or locked jaw from tetanus? Or just some other diseases? Update on Aug 30, 2014 by telephone: She is OK

Yangon has rabies. Biting street dogs are culled by the township. Usually poisoned bait. This is the responsibility of vets in the Yangon City Development Council.
AUDIO INTERVIEW WITH NAING

VIDEOS OF WET MARKET PLACE WITH STRAY DOGS.     

DIAGNOSIS
1. Serum neutralising antibodies
2. Brain Negri bodies

TREATMENT
Deep bite - Antibodies injections. Costly. $3000  


VACCINATION.
Non-exposed.  3 vaccinations
Exposed to rabies (e.g. bites, scratches) - 5 vaccinations
Exposed after vaccination - 2 vaccinations
$150/vaccination

Singapore is rabies-free











 

1476. INTERN A 33-year-old red-eared slider is sick

Do research.

1. How long does a red-eared slider live? Up to 50 years?
2. The 2-kg slider is plump, outgrowing her shell. Does the shell keep growing?
    At what age does the shell stop growing?
3. Gender of slider. How to sex it?
IMAGES AND ILLUSTRATIONS.

Goto:
https://www.google.com/cse/tools/create_onthefly
Check for images from toa payoh vets and elsewhere.


4. Holding the slider upside down. Will she die as she cannot breathe? Is this a myth?

5. HOUSING A 3-foot long tank for this 33-year-old slider.Too small?

6. Changing water every 2 days in this 3-foot tank. Is it too infrequent?
I suggested daily as the tank has no filtration

ILLUSTRATE AN IDEAL TANK ARRANGEMENT FOR BASKING, PUMP, UV LIGHT for this 33-year-old slider,

7. Left eyelid swollen and puffly. Video. Why?  Do thorough research


8. Not eating the commercial pellets now. Why?  2 other sliders had same problem when fed a new can of pellets from Taiwan.  Poor quality or toxic pellets? Advised changing to shrimps but owner afraid the slider will not eat pellets anymore (CONFLICT)


9. Used to eat shrimps and prawns from young. Suffered a serious disease, the owner said. Changed to commercial pellets. Recently, the slider does not eat.
So not stools.
Urine? Don't know.
Drinking? Don't know.


10. Mouth examination. How to open the mouth? Video.
A cyst at the back of the tongue and tongue ulcer. Can video show?

11. Cleanliness of the slider. Green skin scales need to be peeled off.


12. Hardened backside. Is this due to aging +/- lack of exercise?

13. Owner worried that
    13.1  bacteria from grass infect slider. Possible. A tiled area or much bigger tank.
    13.2  cats and birds kill it when exposed in the lawn.

14. Very rarely do I see a 33-year-old. Same age as the gentleman. Many Singaporeans dump the terrapins into the reservoirs.






     

1475. Spayed dogs die young - polydipsia and polyuria

Aug 26, 2014

The two ladies came with a female, not spayed, 13-year-old Miniature Schnauzer.
The dog had passed blood around 2 months ago, as part of her heat cycle.

"But she still has (vaginal) discharge on and off in the last 2 months," the older lady said. "Today, she is dry."

I examined the vulva. Swollen and congested mucosa. The belly was hyperpigmented and the nipples were all black. No milk was expressed from the nipples.

"This is a case of open pyometra," I said. "Is the dog drinking a lot of water? Many dog owners think this polydipsia is normal!"

"Yes, yes, we thought this was normal in the lst month after her heat. But she is still thirsty after the second month."

"Does she pee a lot of times?" I asked
"Yes, yes," the older lady said.

"Why didn't you get her spayed when she was younger?" I asked. "She would not have suffered from pyometra (an infection of the womb)."

"Dogs die young when they are spayed," the older woman said. "My friends' spayed female dogs are dead. One died at 5 years of age!"

Her dog is now 13 years old and much alive and plump.

"How many dogs of your friends have had died?" I asked.
"3 dogs, all spayed and much younger than our dog."

I did not argue that this sample of 3 spayed female dogs dying young was too small to come to a scientific conclusion that spayed female dogs die young.





"I don't believe that spayed dogs do die young," I said. "I have not read any scientific reports regarding this issue."

"I guess it could be genetics. Our dog has longevity genes," the older lady said."What should we do now?"



"A 13-year-old dog has a much higher risk of death from anaethesia," I said. "We will take a blood test to screen the health of the kidneys, liver and blood cells. She has a heart murmur and heart disease will increase the risk."

A blood test is taken. The dog goes home with antibiotics for 7 days. The owners will have to decide whether to risk spaying the companion or not.  Some old dogs do die on the operating table and so the owners must give informed consent for the spay surgery. The 13-year-old plump Miniature Schnauzer is considered aged, but she looks younger and is active. 

------------------------------------------------
IMAGES OF OPEN PYOMETRA X 10
IMAGES OF CLOSED PYOMETRA X 10


Definition of pyometra. - open and closed pyometra


Differential Diagnosis
Diagnosis
Treatment


Goto:
https://www.google.com/cse/tools/create_onthefly


Key in "www.toapayohvets.com"
Search "pyometra"

.

1474. About Dr Thein Tun Aung, Veterinary Surgeon

HOOK

On August 22, 2014, as I walked towards the Grand Hyatt, Singapore (Video) to celebrate the 60th birthday of a friend, I recalled happy memories of a house-call in this hotel.

A FEARLESS VET - Case of a cat that has a needle in his mouth.
It was in July 20, 2010. The cat of an expatriate manager living in the Grand Hyatt had swallowed a needle. The thread hung out from the mouth. The cat pawed the manager every time he tried to open the mouth. So he phoned Toa Payoh Vets.

I requested Dr Aung to help me and Dr Saw. I knew he was good at handling cats. Fearless. The cat hid between the WC and wall of the master bedroom bathroom. Dr Aung grabbed the cat by the scruff of the neck before I could say "hello". The cat clawed him and escaped to hide behind the curtains.

"Prepare the sedative injection first," I said to Dr Aung. Then he approached the cat behind the curtains and gripped his scruff. I injected the backside muscle.
.
Suddenly, another cart pounced onto Dr Aung in a suicide attack. This was unexpected. The expatriate removed this cat. We wrapped the patient in a towel and pulled out the needle (Images x 2). The cat was back to normal. A happy ending.
------------------------------------------------------------------------------------

A DEDICATED VET - Case of a chicken bone 3/4 in the gullet and 1/4 in the stomach of a Maltese.
Dr Aung would watch me performing this uncommon surgery on his day off from his employer.

In this case of the continuously vomiting dog, X-ray showed the chicken humerus bone stuck between the gullet and the stomach.  IMAGES X 1  X-RAY
"What will you do?" I asked him. This is part of my coaching method to elicit ideas from Dr Aung. "Should I cut it into two halves?"
He shook his head.
I had given an anti-spasmodic earlier. I pulled the bone out from the gullet and stomach easily. The dog recovered.

IMAGES X 3


PRESENTLY IN 2014
Now, it is 2014. Dr Aung has a busy practice in Yangon. Royal Asia Veterinary Surgery (video). He started his practice in 2010 and every day is a busy day. His medical and surgical skills acquired from his 20 years of working for vets in .....clinics in Singapore were a result of his sacrifices of being overseas.

Belief, Passion, Drive, Perseverance and Focus
20 years in Singapore working as an employee for vets in 5 vet clinics.
Acquired knowledge, skill and expertise.

SPENDING SPARE TIME TO ACQUIRE SURGICAL KNOWLEDGE
INSTEAD OF WATCHING MOVIES AND ONLINE GAMING
He was never my employee