Thursday, July 30, 2015

2957. INTERN. Cystic Endometrial Hyperplasia

I have a rare case of CEH as evident by the image below.

What is CEH?

Who
Where
When

How





The female Maltese, 8 years, came in for removal of the breast nodules (Left MG3 nodules). I had advised spay earlier but the owner did not do it. This time he agreed to the spay.

The dog has a fully distended thin uterine horn filled with clear fluid. She was spayed as well as removal of the mastectomy.
She recovered fully and went home.

Monday, July 27, 2015

2956. Under-feeding a terrapin for 7 years

Monday, July 27, 2015.
"The 7-year-old terrapin does not have swollen eyes," I said. "However, he is underweight and has the shell length of a 1-year-old".

The owner wanted to prevent obesity. So he feed 5 pellets every 2 days and allow the terrapin, measuring 7 cm in shell length. The shell was bleached light brown. The terrapin loved to be submerged in water most of the time and would snap at the pellets eagerly. A calcium tablet in the shape of a terrapin was put in the water every 2 months, so the water is filled with this calcium.

Today, the terrapin's neck area has loose flabby skin, as if, swollen. "This swelling occurs in the past week," the gentleman said.

It is hard to know what causes this neck swelling. It could be calcium deposits near the thoracic inlet, nutritional imbalance with too much calcium or a tumour.



The back leg muscles and skin were normal and not flabby.

Removal of the calcium, allow more time to bask by not giving water all the time, a variety of food and sunshine, including medication dripped into the pellets for the next 14 days. We will need to follow up.  



Saturday, July 25, 2015

2955, INTERN. Good Performance Counts - emergency Caesearean section

Sat July 25, 2015

I was surprised to see the poodle coming in for Caesearean section again as I have not seen the dog after the milk fever in the first emergency C-section around 2 years ago.

The lady showed me her mobile phone image of x-rays taken by another clinic, showing 2 puppies. She had decided not to go to this vet as I had a good outcome for her first surgery.  (Video clip of first C-section).


Jun 25, 2015.
C-section  - 2 large pups in one uterine horn.

1. Brown pup was nearer the cervix and had lungs clogged with mucus. Swinging saved her life as mucus in nose and mouth showed lungs were filled with mucus.

2. White pup took at least 5 minutes to cry. No need swinging.
   

Sunday. Jun 26, 2015 - good outcome as dam and puppies are OK. The parents are most happy.
Puppies came in for tail docking (SEPARATE VIDEO ON VET SURGERY OF TAIL DOCKING).





    ---------------------------------

How to extract videos from youtube

Dear Dr Sing,
to extract videos from youtube,

1.  all we need to do is visit the website: http://www.clipconverter.cc/
2. Under " media url to download" insert the url of the youtube video you want to extract
3. and press continue and convert.


The website is very user-friendly and actually shows the steps you need to take, it should be easy for the interns to use. Hope this helps.

Yours sincerely, 
Gin 


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

go to toapayohvets.com for latest relevant videos as well.
puppies tail docked today. Make a separate video from above. TAIL DOCKING POODLES 

Thursday, July 23, 2015

2504. INTERN The guinea pig with the left head tilt has left nostril discharge and pneumonia again

Jul 23, 2015

The guinea pig with the left head tilt has pneumonia again. Came in yesterday evening.
Owner was not able to treat previously the guinea pig at home. 
"Some vets don't like to give subcutaneous injection," I said to the man. "Sometimes the owner blames the vet for the painful reaction or death from the injection in seriously ill guinea pigs." I said. "The owner would say that the sick guinea pig was still alive but after the injection, he dies. So, it is due to the injection."


"I understand my guinea pig is seriously ill," he said. "I will not blame you if you give the injections."

Informed consent is important nowadays. I gave the guinea pig SC baytril and 2 ml of dextrose saline and Vit B + C at 6.30 p.m.  This morning, he is better and no longer pants so fast. I had given the same treatment last time and the guinea pig had felt better, according to the owner. He had seen my associate who prescribed him oral medication and I was around and so he asked me about the injection. I warded the guinea pig as he could not manage the medication administration.

So far so good.    

Wednesday, July 22, 2015

2503. INTERN Cat owner's education - religious retreat - giving medication to a clever roaming cat.

July 22, 2015

"I have to cancel my retreat as my cat needs two people to give him antibiotic and pain medication," the slim woman in her 50s had brought in her cat for cat bite wound stitching. "The retreat in this temple is for one week and is held only once a year." I had told her that the cat needed to be given medication for the next 7 days.

"I should have my cat treated when she had a small bite wound from the other cat," she said. "Now it is a very big wound, due to the cat continuous licking. He needs stitching."

After anaesthesia, cleaning and debridement of the wound and stitching, the cat was ready to go home. But the owner had to go for the retreat. "Living in the temple clears my mind," she had looked forward to this residential retreat which requires waking up at 4 am to chant. "I will go next year."

"A year is too long and many things can happen to our lives," I said.
"This cat is much loved as even my neighbour who hates cat, loves him," she told me. "He is like a human being. When my neighbour asks him to jump onto the chair, he does it. When she tells him to jump onto the table, he does it. He will meow in appreciation when given food unlike other cats who will be silent."

This was indeed a clever cat. He would not take medication unless the owner and his son do it together to coax him into taking the medicine via a syringe with water and medicine.

"Go for your Buddhist retreat tomorrow," I said. "This cat is not suffering from a life-and-death disease. The worst case is that his stitch breaks down, but he has an e-collar round his neck to prevent licking."

"Prepare the medication by crushing the tablet and mixing with milk.  Fill two 1-ml syringe with milk and one syringe with milk and medication.     Wrap the cat in a towel covering his four legs and put him on a table.  Make him hungry for dinner. Your son will give him the first two syringes with milk alone. He will like the milk syringed into his mouth. Then, the 3rd syringe with medication.

"Tonight, you and your son practise"  I said. "So you can go to your temple retreat tomorrow."


This 7-year-old cat came in for difficulty in peeing. Now he is OK.  However, he has tearing eyes and runny nose now. This is due to his lack of vaccination and his encounter with a stray cat that had bitten him, passing to him the cat virus. He should recover.

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

Mimi  Cat MN  8 years   yellow brown. Allowed to roam outdoors daily. Used to return by climbing up 16 floors of steps to apartment. But would now wait at 3rd floor for the owners to come and pick him up.

Jul 14, 2015.
1. pollakiuria, haematuria, dysuria 1 week
2. Change sand litter to paper litter about 1-2 weeks ago.  Sand particles mess up the house.
3. Painful kidneys. Bladder not swollen. Cat growled when I palpated the kidney area and became unfriendly.
4. Fed dry food only past 8 years
5. One cat in household
6. One water bowl.

IV drip. medication.


Jul 14, 2015
BLOOD TEST
All normal except low platelets 69  (300-800) and high glucose 14.9  (3.9-6.0). Urine test was positive for glucose.  This high glucose level may be due to urinary tract disease rather than diabetes.

Below are normal values
Total WCC  13.3  (5.5 - 19.5)
N 76%   Absolute 10.11
serum  6.4  (7.2-10.8)
Creatinine 100 (71-160)


URINE TEST
Bladder has insufficient urine expressed into a bottle. But analysis shows no crystals.
Dipstick  blood 4+, glucose+, Protein 2+, WBC, pH 8. SG 1.005

X RAYS  Cat needed sedation Xyla 0.4 ml IM. Reversin 0.03 ml IM.
No radio dense stones.
Kidneys enlarged.  






FOLLOW UP

JUL 15.  Not eating much of feline C/D. Drinks a bit. Stay indoors. Little motion. Urinate more. No dysuria.

CONCLUSION
A change of litter type may stress this cat. FLUTD is caused by stress and other factors like not drinking water and dry food. Antibiotics. Painkillers.  Feline CD
Jul 24, 2015. No problem.

Outcome Good
Case closed.



   

Sunday, July 19, 2015

2502. INTERN The dwarf hamster has right eyelid abscess and impaced left chhek pouch


July 19, 2015
Butter. Dwarf hamster. F, 2 yrs?

Scratching right eye and lame RH - looked like dragging his right hind foot. Some time.
1. R lower eyelid much swollen  - diagnosed subconjunctival abscess. To lance and drain. Owner to do it at home with opening the incision wound, cotton bud to express the pus, daily.












2. L cheek pouch hairless area nearer to the face - diagnosed impacted cheek pouch. irritation. rubs till hairless (see video).  To excise.
TREATMENT
1. V. thin. 30 g.  Informed consent. anaesthetic death likely.  Zoletil 100 IM. (video).
2. Surgery  (video). Hamster took >1 hour to recover and walk. Sent home.  Owner to express pus from eyelid daily without fail. Wound will close. Must keep it open to express the pus. Medication for 7 days.



FOLLOW UP
July 24, 2015  phone
Tone of voice of owner seems happier.
Hamster more active.
Eyelid abscess - still has pus coming out. Expressed pus.

Left cheek pouch. No more swelling.
RH leg still dragging. Been like that for some time.
Owner gave smaller pieces of seeds, vegetables. hamster is very thin now.
"Stool pellets more now?" I asked.  Can't say.

Advised exercise wheel and stop  medication at 7th day (this Sunday)

Asked her to email me a video clip of hamster. Will do.   

PREVIOUS VIDEO.
Right cheek pouch impaction 3 times. Excised.
seems to be an obsessive hoarder of food inside cheek pouch. Much loved by the lady owner.


Outcome Good.
Case closed.



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

EVERTED CHEEK POUCH

Like a grocery bag (image), the hamster can hoard his food inside this expandable thin bag inside his cheek. This is called cheek pouch. Similarly to a money pouch (image) for travellers. 

The cheek pouch can be a liability if it everts and hangs loose as in this dwarf hamster.
It is painful and irritating to the hamster. The hamster tries to pull the dangling pouch away but it cannot do it.

CONCLUSION

See toapayohvets.com for more cases of everted cheek pouch pre and post-op and get their images to present 




The treatment is surgery. A hamster vet will anaesthesize your hamster and cut it away. See video.


Get videos from youtube of toapayohvets.com

Saturday, July 18, 2015

2501. Unbelievable tale: The owner of the cat who climbed 16 storeys home

July 15, 2015

"He is still angry with me for bringing him to the vet," the lady owner visited me today to say that the cat no longer has difficulty in urination. This cat would never get into the car as he associated this with visit to the vet.

"That's good news," I explained the blood test results of her cat to her. She had to go for her Buddhist retreat and so she was worried about this cat.

"A famous Aljunied fortune-teller had told my father that one of his 8 children would become a Buddhist," she said. "I would have become a Buddhist nun if I was not married as I am into the Buddhist faith. At first I thought it would my younger son as he was interested in the Buddhist practices and would go to the temple often."

"What happened to him?"
"I took him out of the temple as there was a lot of swearing," she said. "In time, I converted to Buddhism."

This fortune teller had given her father an amulet or blessed cloth to keep him safe. Her father carried it with him every day.  "One day, a large truck smashed into the passenger side of his car, damaging the side door badly," she recounted. "Yet my mother was not injured a bit. My father took out his amulet and it was stained full of blood. Do you believe this story?"

"Blood appearing out of thin air?" I said. "This is not possible scientifically. But many things cannot be explained by science."  I recounted to her my experience of seeing blood drops appearing out of thin air when I helped a client to design a company logo. Only when the logo design was correct did blood stop appearing. She found this story unbelievable. 

"When I was a baby, I could not be wakened for 3 days," the lady said. "The doctor said I was dying or dead as I did not move. No baby could be alive without food or water. My father consulted several mediums. One gave him a packet of ash. He mixed it with water and put on my lips. I woke up.

"What was the cause?" I asked.
"It seemed that my father had cemented a big hole in front of our house. My shadow was covered up while cementing. So I could not wake up. After breaking open the cemented area, my shadow was freed."


This was an unbelievable tale. "Is the house still around? Where is it?" I asked.
"It had been demolished and is part of the PIE (Pan Island Expressway) now."

2500. A 9-month-old male Miniature Schnauzer has stranguria - a large swollen bladder

Sat Jul 18, 2015

"I don't know if you believe my story," the mother of two primary 4 and 5 boys said. "My younger son said that he was asked to buy this dog by my late father-in-law who had died of cancer. This is because my son had not been supporting my father-in-law financially and so we have to support this Schnauzer."

"It is hard for most people to believe" I said. "However, some incidents cannot be explained scientifically as in the following story."

"My 75-year-old friend had asked me to pose for a photograph with a diabetic and high-blood-pressure Singaporean going to visit his girl friend in Bangkok. My friend joked:  "This photograph of his last day in Singapore will be most valuable.".

This divorcee died around midnight in Bangkok on the day of arrival. At around 2 am, my friend's throat started to swell. He had difficulty in breathing. He drove himself to the emergency department of Tan Tock Seng Hospital and was treated. Could it be possible that the spirit of the dead man tried to "strangulate" him by swelling of his throat? How do you explain that occurrence?"

This 9-month-old Schnauzer had an obstructed urethra. Full of dirty brown urine inside the orange-sized bladder. The owner did not want blood test or X-ray. I catheterised the bladder for the next 2 days, unblock the bladder, lavaged the bladder for the next 2 days. An IV drip with antibiotic and spasmogesic was given on Jul 18, 2015. Some small stones of around 3 mm were picked up.

I would check the next day by bladder palpation for any large bladder stones. Ideally an X-ray would be best.

    

     

2499. A pyometra-spayed dog still comes on heat?

Jul 18, 2015

On Jul 17, I got a sms asking me how much I charge for ermoval of ovarian remnant and whether the dog needed to be hospitalised? I replied that I needed more information than before giving a quotation as every surgical case is different in complexity. So, it would be better to talk on the phone. The owner phoned and the following were some information.

A 7-year-old female Miniature Schnauzer with pyometra had been spayed by Vet 1 on "May 2015".  The owner went to Vet 2 whose Jul 16, 2015 ultrasound of the ovaries and uterus showed a 6-cm  left ovarian remnant caudal to the left kidney. Biopsy and histology of the removed ovary, ovarian remnant or if no visible ovarian remnant of the ovarian pedicle is advised. 

No distinct stump pyometra is visible between the colon and bladder. It could be small and difficult to identify. Both uterus were not present as the dog was spayed in "May 2014".  

The owner had said that this dog came into heat in February and August regularly and had just passed some bloody vaginal discharge on Jul 17, 2015.  Ultrasound was done on this day.


The owner had done her internet research, knowing about cytology to detect estrus, hormonal prevention of estrus and minimal invasive removal of the ovary.

An image of the swollen uterus and ovaries with clamps at the ovaries was available from Vet 1. It seemed that one clamp showed little of the ovarian tissues while the other clamp had the whole ovarian tissues being removed.

The image of the uterus and ovaries after spay did show one ovarian tissues clearly but the other ovarian tissues were obscured. The  the ultrasound and clinical signs of heat and lactation in Jun 2015, after the spay, pointed to the left ovarian tissues not being completely removed.

Friday, July 17, 2015

2498. INTERN Bladder and urethral stone cat and kidney failure. Angel the cat who meows hello to me.

 DRAFT

Time lines





Thursday, July 2, 2015


A cat sits on the litter box

Jul 2, 2015

Cat, MN, 3 years
Vomiting 1 day. Dysuria, pollakiuria, haematuria, urethral obstruction (urethral stones).


"Have you encountered such cases?" the lady with a baby asked me about her cat having great difficulty in peeing, sitting on the litter box all day long. He vomited twice yesterday, July 1, 2015.

"It is quite a common problem in male neutered cats," I replied. This cat eats only dry food and lives with two other female cats.

I palpated no enlarged kidneys but a big swollen bladder as big as an orange. The cat dribbled blood-tinged urine on the consultation table.
-----------------------------------------------------
---------------------------------------------




Under gas anaesthesia, the urinary cathether was not easily passed into the bladder, despite syringing normal saline. Some urine did flow out and the bladder was emptied 50%. I got the x-rays done and there were stones inside the bend of the urethra.








At home, 2 other female cats had no problem. One litter box and water bowl. Dry food only.

The owner gave permission for surgery. Dr Daniel did it in the afternoon. Body weight  4.8kg, temp = 38.3C.   Sedation xylazine + ketamine 0.1 + 04 ml IM. Maintenance with isoflurane and oxygen gas.
Cystotomy. Syringed saline into the urethra to get the 2 urethral stones into the bladder.

Warded. E-collar and urinary cathether. Antibiotics and pain-killers


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

Tuesday, July 14, 2015


2495. Angel the cat is admitted for dysuria




1. Monday, Jul 13, 2015. The cat was admitted as the owner said he had difficulty in peeing. Bladder and urethral stones were removed some 7 days ago. The cat was given IV drips on Jul 10 and 11 and I discharged him on Saturday Jul 11, 2015 since he was eating. I took out his stitched urinary catheter as it is not good for the cat to have it for more than 3 days, in my opinion, as it irritates the bladder.  However, he ate little at home, the owner said and was worried.

Dr Daniel and I discussed his treatment. Perineal urethrostomy will be the last resort.

"There is bound to be inflammation in his urethra as he had urethral stones stuck at the bend of the urethra," I said. "The bladder is not much swollen as before, not as big as an orange. Pain killers and antibiotics will be needed."
The cat was given gas anaesthesia. Dr Daniel lavaged the bladder by sucking out the bloody urine (video). An injection of painkiller and antibiotic was given.

2. Tues July 14, 2015. The cat meowed when he saw me. His bladder was not swollen. He preferred to sit inside the litter box where there is sand, than outside the box. He ate when my assistant hand- fed feline C/D with water. The owner came to visit around 6 pm and was happy to see him.

 
This is a case of the intense inflammation inside the bladder and urethra as the owner had delayed seeking treatment, base on blood test result showing kidney failure and the much swollen and red bladder (image).




HISTORY

Ju1 2, 2015    Cannot pee, blood in urine. Surgery. urethral stones and bladder stones removed.
Jul  5             Dr Daniel sent home 2 days after surgery.

Jul 8              Vomiting and dysuria. Had kidney failure based on blood test of high creatinine and urea. Given 2 days IV drips

Jul 11            I sent home as he was eating.

Jul 13          Warded. Bladder lavage. urine analysis. Catheter not stitched. 

Jul 15          Bladder swollen 1/3 size of orange. Cat eats when hand fed dry feline C/D + water. Bladder lavage. urine analysis. Catheter not stitched.  Alert.

Jul 16          Bladder small like ping pong ball, painful. --------------------------------
July 18, 2015  10am

Another bright sunny morning

Jul 18, 2015. Angel meowed to greet me as I checked on him. I lifted him out of the sand litter box which he plonked himself on instead of being out. I palpated his bladder which was small and not painful now. He had eaten all his dry and moist feline C/D overnight and had pooped. So, he should be fully recovered.

HISTORY
Angel, Cat, MN, 3 years

Jun 2, 2015  Stranguria (painful frequent urination in small amounts by straining. Muscle spasms of the urethra and bladder) for 2 days. Vomiting.  I palpated a big swollen bladder the size of an orange. Urinary catheter could not be passed into the bladder.

X RAYS
I advised X-rays which showed urethral stones and bladder stones (video).
Sharp brown stones






-----
Jul 2, 2015
BLOOD TEST
Urea  19.8  (7.2-10.8)
Creatinine 285  (71-160)
Total white cell count  21.4  (5.5-19.5)
N  95%  (35-75%).  Absolute  20.3  (2.5 -12.5)
   
Platelets  131 (300-800)

Blood test show kidney failure and bacterial infections of the blood. So, this is not a simple cystitis or FIC (Feline Interstitial Cystitis) case.
   

Jul 2, 2015
URINE TEST
red, turbid. pH 7 (5-8)  SG 1.015 (1.005-1.030)  Protein 3+ (negative), Glucose + (negative), blood 4+ (negative). Bacteria (Occasional), Crystals Nil

Surgery by Dr Daniel. Cystotomy. bladder and urethral  stone removal. Urethral stones flushed into the bladder and removed.




Jul 14, 2015
URINE TEST
yellow, turbid. pH 6, SG 1.038. Protein 2+, Blood 4+, No bacteria or crystals.  Health improves.



STONE ANALYSIS
Owner did not want stone analysis.  Small sharp brown stones, biggest 4 mm across. Probably calcium oxalate?


Jun 5.  Cat goes home.
---------------------------

Jun 8. Cat admitted. Vomiting and dysuria. Bladder is swollen. I diagnose kidney failure.
Bladder catheterised and lavaged with normal saline. 2 days of IV drip of Hartmann and dextrose saline to flush out toxins. Meloxicam oral for 4 days


Jul 11. I sent the cat home as he was eating and drinking. He was vocal, meowing to greet me.
Urinary catheter was taken out.
Owner to continue with hand feeding A/D and dry feline C/D. Leave C/D overnight.

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

Jul 19,  Ate food by himself. Sat outside the litterbox. That means he has recovered. Sent home.


FOLLOW UP FRIDAY JUL 24, 2015

I sms the owner as she did not answer the phone call:
10.36 am   "Is Angel back to normal urination? Dr Sing, Toa Payoh Vets?"

Her reply
10.58 am   "Hi Dr Sing, thank you for following up on Angel. He is coping well. Have a good day!"

11.24  I sms "Is he eating 100% the dry feline C/D and no other food or treats?"

11.37 am   "He is eating the CD mainly but I do feed him canned food once in a while."

11.46 am  My reply
"Try not to include other food as this affects the urine acidity and cause recurrence of urinary stones or cystitis."





Outcome good.
Case closed.                    



   

Thursday, July 16, 2015

2497. INTERN. NOCTURNAL PANTING. The chihuahua pants at night and sits upright with her front legs straight and head pointed to the sky

"Panring and sits on backside with front legs straight up. Her head tilts upwards with eyes staring," the lady in her 30s said to me today, Hari Raya last day. A bright sunshine day. 


On Jun 10, 2015, she boarded the 3-year-old female spayed Chihuahua. On the 7th day of boarding in a home, the chihuahua vomited saliva and had a slight cough. The boarding owner fed her own vegetarian diet and so the owner presumed a change of diet caused this problem. She brought the dog home on Jun 25.

On Jun 25, consulted Vet 1 who diagnosed heart disease based on X-ray (see below) and wanted to prescribe heart medication. The owner rejected this.

On Jun 27, consulted Vet 2. Also another visit on Jul 12. Vet 2 diagnosed a dietary change as the boarder came to give the owner free vegetarian diet for the dog. The boarding operator came on Jul 9 and the dog was fed this vegetarian diet for 3 days. "Could there be toxicity in the diet?" the owner postulated. So Vet 2 diagnosed the problem as dietary based on blood liver enzymes slightly elevated and low white cell count. 

But the dog continued with the same behaviour of panting at night and upright front legs.

On Jul 14, consulted Vet 3 who diagnosed heart disease based on X-ray of Vet 1 and prescribed one medication called invoril 5 mg.

On Jul 15, consulted Vet 4 who did an abdominal ultrasound to scan for tumour and wanted to refer her to a French specialist to do ECG test for the heart. The heart murmurs were grade 1.

Today, Jul 17, I was on duty in the morning. I confirmed Vet 1's and Vet 3's diagnosis of heart disease.  Left heart enlargement for a 3-year-old dog is rare but does occur. There was throat pain due to the owner force-feeding medicine by grabbing the dog's throat and syringing medication with a 3-ml syringe.

I thought her to use a 1-ml syringe and be gentle. The dog should be placed on a table.  Panting at night stresses out the career lady as she has to have a sound sleep. The lady is happy with the final diagnosis from me.

"I am in denial," she said when I asked her why she did not believe the first vet. "It is better than I have more second opinions! Will she be cured and how long will she live?"

"Well, the 3rd vet is an experienced vet with over 30 years of practice," I said. "Yet you do not believe him."

I opened my website and showed her X-rays of a 1-year-Pom with severe heart disease and how heart enlargement look like.
http://www.bekindtopets.com/animals/20110201dog-heart-problems-x-rays-toapayohvets-singapore.htm

http://www.bekindtopets.com/dogs/20090923Heart_Failure_Young_Pomeranian_ToaPayohVets.htm





"Your dog has a Grade 1 left mitral murmur on the left heart, the left sided heart enlargement is not too large and is due to congenital origin, that is from birth problem. It is hard to predict how long she will live. Much depends on the control of the heart disease, restriction of strenuous exercise and diet."

The dog went home. The owner phoned. "My dog vomited, peed and her front legs are now stretched out straight!"  I asked her to be patient as it was only 1 hour since she left the clinic.


 
CONCLUSION
It is very difficult to convince some owners about heart disease in young dogs. I used the previous case of a one-year-old Pomeranian to illustrate the heart enlargement in X-rays as shown above.
As you can see, the left heart occupies more than 1/3 of the pleural cavity and is therefore enlarged. the right heart is normal. The X-rays from Vet 1 are slightly tilted but the clinical signs are the main factors in coming to a correct diagnosis of heart disease. It is just that client education is very important as there is a need to "show and tell" rather than just tell.

The owner just cannot believe that such a young dog can get heart disease during boarding. The boarding operator surprisingly offered more of her home cooked vegetarian diet after boarding, confusing the owner. As to the dog showing improvement after the first visit to Vet 1, I told her that it could be the pain-killer cartophen that temporarily stopped the pain in the heart. But proper heart medication is the solution.



UPDATE ON SAT JUL 18, 2015

Jul 18, 2015. My SMS as I could not contact her by mobile
                9.50am     "Any front leg being upright in Wawa now?"



              
                     Her SMS
               1.10 pm  Hi doc, sorry I was busy with housework earlier, so missed your call.  She is not in upright posture anymore, but kept sleeping and mostly in a daze-like expression.

I phoned her. The dog had the most restful sleep without panting on Jul 17, after treatment. So did the owner. The dog had eaten a little bit of the chicken meat but avoided the H/D diet prescribed for heart-diseased dogs.   I advised her to persevere in feeding H/D with 90% of the present diet until H/D replaces the diet. As for the lethargy, it was most llikely that the dog is recuperating for over a week of night panting and deprivation of sleep. I advised a small teaspoonful of honey in case the chihuahua suffered from hypoglycaemia as some do.

"I have researched the internet and saw similar X-rays of left heart enlargement," the lady said. "What is the cause of this heart disease?  Will she be cured? Should she have an ECG?"

"The cause is presently unknown. Heart enlargement could be due to infection,  heart valve disease or from birth. Wait one month before doing the ECG and to get another review."  No blood work was done by me on that day as the other vet had done it.

UPDATE - July 22, 2015
The owner phoned me saying that the French vet who did an ECG on her cat had said that the dog's heart did not have abnormalities as there was no heart murmur or abnormal ECG. "I had told you that the heart disease was due to a slightly enlarged left heart when you had seen the X-ray of a 1-year-old pomeranian with a extremely large heart enlargement. The heart murmur was not serious. I have advised to take the antibiotics and heart disease medication for one month and then review the heart, doing ECG when necessary."

But the owner had the ECG done anyway on this 3-year-old chihuahua and found nothing abnormal from the 5th vet. "It is hard to pinpoint as to cause your dog to have the upright posture, night panting and difficulty in sleeping based on one-time X-ray," I said. "The dog could have a chest or heart infection which leads to a slight enlargement of the left heart. How is he nowadays?"

"He is good and normal," she now can sleep peacefully at night as the dog no longer had nocturnal respiratory distress.  She would complete the medication and get the dog X-rayed and reviewed one month later.     

2496. INTERN Aug 2014 Thousands of ticks in my face - Rottweiler

Video like:
https://www.youtube.com/watch?v=VgQO9Kbdid0


HOOK

BKTP


INTRODUCTION

Settings - City


MIDDLE

Setback - economic depression, real estate crush, property values fall


CONCLUSION


Tuesday, July 14, 2015

2495. Angel the cat is admitted for dysuria




1. Monday, Jul 13, 2015. The cat was admitted as the owner said he had difficulty in peeing. Bladder and urethral stones were removed some 7 days ago. The cat was given IV drips on Jul 10 and 11 and I discharged him on Saturday Jul 11, 2015 since he was eating. I took out his stitched urinary catheter as it is not good for the cat to have it for more than 3 days, in my opinion, as it irritates the bladder.  However, he ate little at home, the owner said and was worried.

Dr Daniel and I discussed his treatment. Perineal urethrostomy will be the last resort.

"There is bound to be inflammation in his urethra as he had urethral stones stuck at the bend of the urethra," I said. "The bladder is not much swollen as before, not as big as an orange. Pain killers and antibiotics will be needed."
The cat was given gas anaesthesia. Dr Daniel lavaged the bladder by sucking out the bloody urine (video). An injection of painkiller and antibiotic was given.

2. Tues July 14, 2015. The cat meowed when he saw me. His bladder was not swollen. He preferred to sit inside the litter box where there is sand, than outside the box. He ate when my assistant hand- fed feline C/D with water. The owner came to visit around 6 pm and was happy to see him.

 
This is a case of the intense inflammation inside the bladder and urethra as the owner had delayed seeking treatment, base on blood test result showing kidney failure and the much swollen and red bladder (image).




HISTORY

Ju1 2, 2015    Cannot pee, blood in urine. Surgery. urethral stones and bladder stones removed.
Jul  5             Dr Daniel sent home 2 days after surgery.

Jul 8              Vomiting and dysuria. Had kidney failure based on blood test of high creatinine and urea. Given 2 days IV drips

Jul 11            I sent home as he was eating.

Jul 13          Warded. Bladder lavage. urine analysis. Catheter not stitched. 

Jul 15          Bladder swollen 1/3 size of orange. Cat eats when hand fed dry feline C/D + water. Bladder lavage. urine analysis. Catheter not stitched.  Alert.

Jul 16          Bladder small like ping pong ball, painful.
































































2494. The most loved cat in the block has difficulty peeing

Previously able to run down 16 floors and climb up 16 floors after going outdoors. Last 2 months, would wait for the owner to come to look for her, maybe at the 3rd floor.
"Why would a cat climb up and down 16 floors of the apartment?" I was surprised.  The slim lady owner in her late 50s do that. That was why.

Today, Jul 14, 2015, her busy son took her and the cat to me for treatment. The cat could not pee on the litter box, just squatting but could pee on the bed and blankets when lying down.

What was the problem?




1. Everybody loves this cat as he meows when fed and meows to "thank" the giver after eating. "Other cats would just eat and go silently," the woman had never stayed apart from this cat.

2. "This cat has a good memory of going to the vets," she told me. "He would avoid getting into the car."

Monday, July 13, 2015

2493. Animal Welfare. The smartest street dog in Singapore

Jun 11, 2015

"She gave birth to 2 litters," the woman who was active in trapping stray dogs and bringing them to SOSD showed me a cross-bred. "My husband and I just cannot get her! She will  run away at the first hint of suspicious activity to trap her with a collar.  Do you have the sleeping tablets? The last time you prescribed one was ineffective! "

"You did not stay long to see the effect," I said. "The effect starts 30 min to one hour after eating the tablet."
"Well, another stray dog barked. She was feeling drowsy after taking the tablet. On hearing this barking, she bolted into the dense forest!"
 
The couple wanted to catch this dog to spay her so that no litters would be born. 1/6 (a white one) of the puppies were adopted as they looked handsome, with the long nose of the bull terrier and the face of the Golden Retriever.
The wife stated that the shelter would not accept more sick dogs for medical treatment.
"There is a limit to the money any shelter will have," I said. "In any case, you sent one day at night for treatment. Heartworm was diagnosed". How much was the bill?"
"
"Your $1,250 bill from the vet could have paid for treatment of other strays." I admonished her.
 

Saturday, July 11, 2015

2492. The daughter-in-law does not want the shih tzu in her HDB

Sat Jul 11, 2015

"The daughter in law does not want the shih tzu to be inside the apartment," the matronly lady brought her dog for vaccination and said that the dog demanded a lot of time to be cared for. "She does not want any dog hairs inside the apartment as she has a baby."  The son and his girlfriend bought the puppy but now leave him to mum.

"A bit fat but well cared for," I said in Hokkien as that was her dialect. "Some tartar in the back teeth. Next year, will need dental scaling." The dog was groomed regularly. Only that the groomer did not express the anal sac. Full of dark brown smelly oil.

2491. A kind family adopted a Beagle

Saturday, July 11, 2015.

As part of the adoption agreement, the family brought the neutered Beagle under the care of Voices For Dogs to Toa Payoh Vets for a check up. I showed Intern Gin the procedures involved as her 2nd semester in Melbourne Univ Animal Health course will have a module "Animal Welfare". 

If she gets straight As in the 2nd semester as in the first, she should have no problem being admitted to the Vet course.

2490. A kind cat owner with a caterwauling "spayed" cat.

Sunday Jul 7, 2015.


This lady was very kind as she did not sue the vet who spayed her cat. A few weeks after spaying, the cat caterwauled. The vet gave her a strip of Ovarid tablets to be given whenever the cat makes noises. This happened around 4 times per year and after 2 years of medication, the cat became fatter.

The lady was worried about prolonged use of hormones such as kidney failure.
"You have only one alternative to hormonal control of heat," I said. "Surgery to open and look for the ovary or ovarian tissues which are near the kidney or kidneys. When the cat is on heat, as she is now, it may be easier to spot the ovarian tissues and take them out."

"What if the cat still caterwauls?" the Sec 4 daughter asked.
"No more caterwauling, if the ovaries are removed entirely."  .

The mother signed the Informed Consent form and op will be done tomorrow

Dr Daniel advised ultrasound to see whether the ovarian tissues can be found and near which kidney. Op is delayed till next heat.


HISTORY

1.  Around Nov 2012, Vet 1 spayed this cat.  In 2013, consulted Vet 1 as caterwauling started a few months after spay. She prescribed some Ovarid tablets, to give 1/4 tablet when caterwaul on Day 1 and Day 3.


2. Cat caterwauls 4x/year and next 2 years. Given tablet. Cat puts on weight. Sometimes clear vaginal discharge.

3. Last Ovarid given some months ago. Cat on heat now, Jul 12, 2015

2489. A Rottweiler has a few thousand ticks - VIDEO FOR INTERNS

Sunday Jul 12, 2015

Unusual to see a young Rottweiler with a few thousand adult and  nymph ticks attached to the face and body.

Sedation needed. 35 kg. 4-year-old dog.
Given 1/3 formula ie. Dom + Ket at 0.4 ml + 0.5 ml IV. Able to clip bald.

The owner had applied Frontline Plus spot on. The pest control man applied a white insecticide wash yesterday. So, all ticks were dead but the mouth parts clamp to the face and body skin. Took over 2 hours to clip and remove the dead ticks. Goes home on same day. This dog had a left dislocated hip repaired by another vet (closed reduction) when he fell into a drain.  He is OK now but still, the vet must be careful in case the hip dislocates and the owner blames the vet.


DE-TICKING AT TOA PAYOH VETS.
Dog safety and staff safety.
This dog looked thin and was probably poisoned by both Frontline Plus and Pest control man's insecticide.  The owner wanted the dog's ticks extracted from  the face and body. Looked horrible. One groomer suggested that euthanasia.

SEDATION. Minimum yet sufficient. This is hard to assess in a weakened toxic dog.
Formula: I gave 30% of the calculated dosage for this 35kg Rott.   0.4 ml + 0.5 ml Dom + Ket IV.
No top up. Dog muzzle when ticks plucked from face as he tends to bite.
"Topping up may kill the dog," I explained to Naing who was not so happy with the dog trying to get up and bite him. "Just muzzle him."   



FOLLOW UP ON JUL 13, 2015
The dog ate but was not as active.
QUARANTINE FROM ANOTHER DOG (X-bred F, 7 years rescued as a puppy from the Defu Industrial Park with cement-covered body).
The lady owner said the Rott had a few small ticks seen and was told to remove them manually. I did the clipping but no further tick wash as the dog had Frontline Plus 7 days ago and the pest control had applied insecticide on his body the day before.

The Rottweiler was enclosed in a playpen of 7 fences in a circle (diagram) on the car porch.
"He could just push away the fences, being such a strong dog," I said.
"No, he dared not go near the play pen," the lady replied.  Probably he had a lasting imprint of fright as a puppy when the playpen fence collapsed on him. So he dared not go near. That was good for the owner to quarantine him.

The other dog was quarantine but had few dead ticks.

PEST CONTROL
Yesterday
1. Sprayed insecticide mist on grass, walls, floors of car porchs, play pens, perimeter of home, and not indoors as there was no ticks indoors.  Lady said about 95% effective as she saw few ticks.

2. Advised to tell the mum not to eat the papayas and pandan leaves in the garden as they will be contaminated with spray and from soil.

EPIDEMIOLOGY
Both dogs have no ticks for past 7 years.
Rott does not go outdoors except to the vet when he had right hip dislocation and surgery. On the follow up visit, the owner saw a large adult female tick which was removed.
X-bred, never visit vet since puppyhood 7 years ago. She goes out 3X/day by herself for 10 minutes. But no ticks for past 7 days. No more use of Frontline since 4 years ago for this X-bred. Rott never had any Frontline Plus. Both roam around the garden but the X-bred seemed immune. Given Frontline Plus on Jul 5 to both dogs, when Rott discovered to  have ticks from the Vet clinic. X-bred had dead ticks on inspection after Frontline Plus on
When Rott had ticks at 2nd follow up visit some 3 weeks ago, Frontline Plus given to both dogs. But Rott's face became infested with ticks. Whole body and neck area plugged with grey adult female ticks around 1 cm x 0.8 cm.

OWNER TREATMENT OF ROTT
1. Advantix 2 X at once a month after seeing ticks from Vet clinic.
2. Frontline Plus 1X
3. X-bred clear of ticks. Rott has some small ticks, now plucked off.


Friday, July 10, 2015

2488. 13-year-old cat has a recurring below right eye abscess -microbiological exam

Jul 3, 2015

Culture

Moderate growth of Lancefiled Group G Streptococcus
Susceptibility Results

Resistant to tetracycline
Sensitive to amoxycillin+clavulanic acid, erythromycine, penicillin, clinadmyain, azithromcyin, ampicillin, ofloxacin,clarithromycin.

2487. An FIV cat meowed and passed away at 6.34pm

Jul 10, 2015

The cat was diagnosed FIV +ve on Jun 23, 2015. The owner visited every evening at around 5.30 pm.Today, she panted rapidly, meowed once to the owner and passed away at 6.23pm.The lady owner said that the cat waited for her before passing away. Private individual cremation was her request so that the ashes would be the cat's.

A 14-year-old Jack Russell has canine lymphoma

Jul 10, 2015

TP 16462

Female JR, 14 years
All lymph nodes enlarged (video) but active and eating.

Blood test
Hb 12.3  (12-18)
Red cell count 5.4 (5.5-8.5)
Haematocrit  (PCV)  0.34  (0.37-0.55)
Platelets  217 (200-500)

Total WCC   11.5   (6-17)
N = 45.3 % (60-70%)     Absol 5.21
L  = 26.6%                         Absol 3.06
M  =23.5%                        Absol  2.7
E  = 2.5%                          Absol  0.29
B  = 2.1%                          Absol 0.24




Hb & RBC - lower than normal ---  anaemia coming
                      bone marrow biopsy

Tests:  lymph node biopsy or excision biopsy, bone marow biopsy, x-rays chest and abdomen


Standard chemotherapy   3 drugs + pred, 25 weeks. IV. Weekly visit to vet.   Costs more than $7,000 done by another vet practice. Advised not a cure. Remission.
Immuran + pred?

Wednesday, July 8, 2015

2485. Email from the Netherlands about dental work without anaesthesia

I got an email from a Netherlands vet today.




 Dear Dr. Sing, 

I read your report on the extraction of teeth on an old Pomeranian without general anesthesia (http://www.asiahomes.com/book2/20100664dental_extraction_16-year-old-Pomeranian_dogs_singapore_ToaPayohVets.htm). I have a few questions about this case. Please keep in mind that, as a veterinarian, I am just very interested in this case – I am not trying to “catch you out” or criticize your treatment!

First question is: have you used any kind of analgesia? I can’t find it in your report. I would be very apprehensive to perform extractions of teeth without anesthesia, but even more so without any kind of analgesia.
Second question is: how did the dog react to the procedure? I can only imagine that it must have been stressful. Extractions hurt, regardless if you have to use luxators or if the teeth is so loose that it can be plucked.
Question three: Weren’t you afraid of getting bitten? I have had some nasty infected scratches from working with bad teeth, so I’m careful. I have at least 25 years to go in this profession, I have to look out for my fingers. Even under general anesthesia I see some pretty powerful jaw reflexes, although more in cats than in dogs.   

I have performed lots of dental work on patients of all ages. I always use general anesthetic and to no ill effects, on geriatric dogs and cats. I usually advise the owner that living with such bad teeth causes so much pain that it’s inhumane to not do the dental work. In my opinion, it’s the quality of life that counts, not the duration (within reasonable limits of course). Also, I hold the owner accountable for state of the teeth, after all, he/she should have taken care of their animal. So if they don’t want anesthesia, I ask them if they would be comfortable to have their teeth pulled without anything. That usually does the trick. :-)

Furthermore, I have had very reliable results in anesthesia of geriatric patients, many of whom have either mitral valve disease, kidney dysfunction, or both. I provide analgesia with pre-op buprenorphine, anesthetic induction with midazolam/ketamine and surgical plane anesthesia with isoflurane. I supply a drip with Ringer’s lactate, and a low dose of furosemide for heart patients (and catheterization so they don’t flood the operating table). Before starting the extractions, I provide regional nerve blocks to minimize post-op pain, and always provide four day take-home analgesia in either NSAID or Tramadol. I would be glad to supply you with dosages if you’d like. 


Thanks for te time you took to read this e-mail and I look forward to receiving your answers.


Kindest regards,



Drs. Peter de Frankrijker-Schiphorst DVM,

BeterBeest Dierenartsen
The Netherlands




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REPLY DATED JUL 9, 2015

Thank you for your email and interest in this case study.


In reply to your questions:
1. No analgesia was used in this case.
2. The dog's teeth were very loose. There was some reactions when the loose teeth were extracted..
3. The Pomeranian was the gentle type and did not attempt to bite me.  

I give anaesthesia and analgesia in all my dental work except for this case.  This was the only case, since I graduated in 1974 that I did tooth extraction without anaethesia. The owner was much worried about that her 16-year-old dog would die on the operating table. I had promised her that I would extract the loose teeth without anaesthesia and she trusted me. 

I reject another case of a younger dog when the owner did not want anaesthesia for dental scaling being worried about death on the op table. Patient safety under anaesthesia is my top priority

I shall be grateful if you will provide the dosages of drugs you use for geriatic patients.  Best wishes.

Dr Sing Kong Yuen
Toa Payoh Vets
Singapore 

Monday, July 6, 2015

2484. FIC - Feline Interstitial Cystis - A mother phoned to say her cat is now normal

Jun 6, 2015

Some 4 weeks ago, this career woman was much depressed as her cat would sit on the litter box trying to pee, affecting her sleep. She wanted to put the cat to sleep if this continued as she needed to work.

I drove to Smith Street to give the ACP anti-spasmodic tablets 12.5 mg to be given 1/4 tablet 2 x /day and painkiller meloxicam orally at 0.03 ml for 4 days. Antibiotics would be given if the first two medication did not work.

The cat should be given her own space, litter box, water and feed bowl, separated away from the other female cat.

Follow up on Jun 6, 2015.
She was most happy that the cat is back to normal.
"How did you persuade your cat to eat the Feline C/D diet?" I asked her.
"I feed him the canned C/D when I am home from work and leave the dry C/D and not feed him other food.  So he eats when he is hungry."

Many cat owners do not know what to do to change the diet and so the disease FIC recurs. She told me she did not need to use the antibiotics.

The cat had been warded by the first vet for 5 days some 4 months ago for bladder obstruction but the dysuria recurred 2 months ago. I palpated that there was no painful or swollen kidneys and bladder and so diagnosed FIC. The dysuria and polliakiuria recurred some 7 days later and the mother had considered euthanasia.  I rushed to Smith Street to hand over the above-mentioned medication to her son who worked as a bar tender. So, the medication worked and there was no need to do X-rays, blood test or urine test in this case.

Thursday, July 2, 2015

Angel - A male cat sits on the litter box

Jul 2, 2015

Cat, MN, 3 years

"Have you encountered such cases?" the lady with a baby asked me about her cat having great difficulty in peeing, sitting on the litter box and vomiting twice yesterday.

"It is quite a common problem in male neutered cats," I replied. This cat eats only dry food and lives with two other female cats.

I palpated no enlarged kidneys but a big swollen bladder as big as an orange. The cat dribbled blood-tinged urine on the consultation table.

Under gas anaesthesia, the urinary cathether was not easily passed into the bladder, despite syringing normal saline. Some urine did flow out and the bladder was emptied 50%. I got the x-rays done and there were stones inside the bend of the urethra.




At home, 2 other female cats had no problem. One litter box and water bowl. Dry food only.

The owner gave permission for surgery. Dr Daniel did it in the afternoon. Body weight  4.8kg, temp = 38.3C.   Sedation xylazine + ketamine 0.1 + 04 ml IM. Maintenance with isoflurane and oxygen gas.
Cystotomy. Syringed saline into the urethra to get the 2 urethral stones into the bladder.

Warded. E-collar and urinary cathether. Antibiotics and pain-killers

 

Wednesday, July 1, 2015

2482. How to be an excellent vet in Myanmar - talk to final year students - draft for video production

Myanmar is rapidly developing with property prices increasing very high in 2015 . New veterinary clinics for pet dogs and cats are set up in Yangon just as in Singapore.



Comfort zone - work overseas









EMPLOYEE BEHAVIOUR
A sense of responsibility
Respect for elders, the boss
Respect for self
Strong work ethic

DESIRES OF SINGAPOREAN GENERATIONS

1-2-3-4   (1 wife, 2 children, 3-room apartment, 4 wheels). Generation born in the 1930s.
5 C's   (Cash, car, condominium, credit card and country club). Generation born in the 1950s after the second World War
Work-life balance and different desires. Generation born in the 1970s 

Is there hunger in your belly? No weekend work, no shift work, no evening work, more pay. 
Migrants work hard and long hours

Stress. Burnt-out. Take holidays. Appointment system.

Pro-active
Skills and experience - welfare cat and dog sterilisation
Continuing education, other skills like digital photography, case recording and research


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GIVING BACK TO SOCIETY
More animal welfare groups formed to advocate for the care of stray dogs, cats and wild animals. TRN - trap, neuter and spay in Yangon.  RABIES CONTROL in Yangon and Bali by vaccination of at least 70% of community dogs instead of culling them.

Giving back to society by Toa Payoh Vets - education of the pet owners. Be Kind To Pets project
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HOW TO BE AN EXCELLENT VET IN MYANMAR  LECTURE 2015
Lecture 2014 given in:

Part 1:  https://www.youtube.com/watch?v=Tco7lmAId3Y&feature=youtu.be

Part 2:  https://www.youtube.com/watch?v=IqzcEL2Tw6s&feature=youtu.be

Part 3:  https://www.youtube.com/watch?v=qxWrYm6FsCs&feature=youtu.be



1. PERSONALITY OF A VET
2. GIVING BACK TO THE COMMUNITY


Pl extract some footage from the following video:
https://www.youtube.com/watch?v=H0iuMV5vsxI
(About Dr Thein Tun Aung).






PERSONALITY OF A VET -  MOTIVATION  TO EXCEL          
1. 18:08 - 22:31   SACRIFICES AND HARD WORK TO ACHIEVE EXCELLENCE
                            GET OUT OF YOUR COMFORT ZONE (image).




                            GET OVERSEAS VETERINARY EXPERIENCE AFTER GRADUATION.
                            Insert subject  "About Dr Thein Tun Aung's 20 years of veterinary experience in Singapore".
                            Write subtitles for Naing to narrate in the Myanmar language as this was not done.



2.  8.27 - 11.50                             PASSION, HARD WORK, SACRIFICES AND PERSEVERANCE.
                           For example, Dr Aung used his day off to observe Dr Sing's case of a bone lodge between the dog's gullet and stomach.

Naing to narrate in Myanmese

3.  0.49 - 3.34
                           VOLUNTEER TO ACQUIRE MORE EXPERIENCE FROM A MENTOR. Dr Thein Tun Aung volunteered his time off to assist Dr Sing in a house-call



                           THE CASE OF THE FEARLESS VET - NEEDLE IN A CAT'S THROAT.
                           There are subtitles. Naing will narrate in Myanmar.




GIVING BACK TO SOCIETY by Dr Thein Tun Aung

                               GIVING BACK TO YOUR COMMUNITY AND UNIVERSITY
1.  11:56 - 14:05      TALK TO YEZIN FINAL YEAR STUDENTS IN AUG 2014










      15:25 - 16:55     DEMONSTRATING SURGERY TO YEZIN FINAL YEAR STUDENTS IN AUG 2014




2.      GIVING BACK TO THE VETERINARY COMMUNITY by Dr Sing Kong Yuen


2.1   TALK TO YEZIN VET UNIVERSITY FINAL YEAR STUDENTS IN AUG 2014
Organised by Myanmar Veterinary Association and sponsored by Royal Asia Veterinary Surgery.

A rare opportunity for Dr Sing to meet a fisherman in Naypyitaw collecting his fish traps and to appreciate the pretty landscapes of Yezin Dam, near the University in August 2014.

 


 





2.  See "Corporate Social Responsibility" for video of BE KIND TO PETS and extract video footages

https://www.youtube.com/watch?v=wMlY4XcxHW0&feature=youtu.be

extract the following footage and combine

00 -- 2:52   How Dr Sing started the Be Kind To Pets project. Persevere to record case studies since 1991 when the world wide web was started to 2015. 

5:34 to 6:45  Writing case studies and making videos make you review your case and learn how to better deal with another similar case in future. This will make you a better vet.


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PATIENT SAFETY IS OF UTMOST IMPORTANCE AT TOA PAYOH VETS
Singapore pet owners worry much about anaesthetic deaths as they hear such stories from friends and read online articles.  Pets are family members all over the world and news of anaesthetic deaths may mean no more referrals to the practice, litigation and non-payment of fees.



For example,
1.  Dr Aung of RAVS uses the  Ap Alert  during an anaesthetic. It alerts him with a sound each time the patient takes a breath and also when the patient has not taken a breath.

2. Toa Payoh Vets use the Capnograph. This machine enables us to monitor an animals respiration rate, heart rate, blood oxygen levels, carbon dioxide levels, blood pressure and the amount of anaesthetic agent during an anaesthetic.







Image shows the veterinary operating table and anaesthetic machine of Toa Payoh Vets.

1. Isoflurane gas machine and oxygen are expensive but will be most important if the vet wants to get good outcomes from long surgeries such as Caesarean section (VIDEO)  and urinary stone removal.  (VIDEO). Every small animal veterinary practice is Singapore is mandated to possess such machines before they can be licensed.

This 2.5-hour perineal hernia surgery cannot be done with injectable anaesthesia without causing death. Gas anaesthesia was used.



Bilateral perineal hernias in a 10-year-old silkie terrier. The repair took 2.5  hours. With IV anaesthetics, the dog may die.  











Illustrate your complicated surgical cases for future references on "how the surgery was done" for old dogs and what anaesthetics were used.
Such records are made available on the company website for teaching of younger vets.
In this case  1 Maxon monofilament was used for the deep hernial repair. 3 layers of2/0 PDS were used.  A more expensive option will be to use the wire mesh.

(VIDEO).
Edit and shorten video with narrator's voice used  https://youtu.be/XjvYOjumAZw


2. An oxygen generator may be used instead of ordering oxygen cylinders.
3. An autoclave to sterilise instruments is important. (VIDEO)
4. Anaesthestic monitoring machines are useful for long surgeries. (VIDEO).
Edit and shorten video with narrator's voice used  https://youtu.be/XjvYOjumAZw

5. Injectable anaesthetics - IV and IM.


Edit and shorten this video
https://youtu.be/XjvYOjumAZw


For small practices without gaseous anaesthesia, IV anaesthestics like thiopentone may be used in Caesarean sections. The vet must top up the thiopentone and the dam and puppies may die as such surgeries take a long time. Therefore, such vets may not accept elective Caesarean section




5.1  In Toa Payoh Vets, I find that injectable anesthetics are safe for procedures like spay and neuter. I maintain with isoflurane gas + oxygen if necessary.

5.2 For young healthy cats less than 2-3 kg, I give xylazine 0.1 ml + ketamine 0.4 ml IM. For heavier cats of 3 - 4 kg, xylazine 0.15 + ketamine 0.6 ml IM. Heavier cats get xylazine 0.2 ml + ketamine 0.8 ml.


TABLE OF DRUG DOSAGE V. BODYWEIGHT

For young healthy dogs of 10 kg, my formula is domitor 0.4 ml + ketamine 0.5 ml IV. I find this formula very safe and effective in spaying of a young dog. However, the vet must be speedy in spaying by proper planning such as clipping the hairs of the surgical site before injection. Spaying should be completed within 20-30 minutes after injection.


TABLE OF DRUG DOSAGE V. BODYWEIGHT

For dogs older than 3 years, I give 50% of the formula and top up with isoflurane gas + oxygen, if necessary. (VIDEO. 8-year-old Husky X - ear irrigation, back area ringworm clipping and dental scaling).

5.3  Veterinary University's teachings. When I studied veterinary anaesthesia in 1973 (4th year of Glasgow University), the professor recommended sedation with acetylpromazine IM first, then thiopentone IV induction followed by halothane gas maintenance. Atropine is given to prevent bradycardia. In 2015, I note that the same procedures are taught. (VIDEO  Yesin Vet University)




5.4  Zoletil 100 anaesthesia. I find this drug very effective and safe for tumour removal surgeries in dwarf hamsters and the rat.  Dosage for dwarf hamsters is 0.01 ml IM and for the pet rat, 50mg-70mg/kg IM. Maintenance with isoflurane gas + oxygen is needed. (VIDEO of hamster anesthesia and rat mastectomy pre-op, op and post op using Zoletil 100 + gas mask).










Conclusion
Safe and effective anaesthesia usually lead to good anaesthetic outcomes.  You get more referrals and retain your clients in the intensively competitive field. In 2015, there are more than 70 vet clinics in Singapore. Singapore pet owners are better educated and have high expectations.



Without a gas machine, you lose out on growing your revenue as your client needing elective Caesarean sections has to go to the competitor with the machine!

Some competitors will tell your client not to use your services as they are better equipped!






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INFORMED CONSENT


SOP
Systematic  in treatment

Meticulous anaesthetic and surgical records - litigation


FINANCIAL MANAGEMENT
Without rich parents' investment, the following tips may be useful for small practices;

1.  Outsourcing the x-rays and blood tests are advised. However, some clients who prefer a fully equipped practice will not come anymore.

Account management
net profits   savings  SARS  MERS











---------------------------------------------------
PERSONAL CHOICES - Homeless








A single person may be more useful to the company's bottom line if he has strong work ethic and a sense of responsibility. 








SUPPORT THE ARTS
Various art forms - performing, visual, literary, contemporary and traditional

Value the arts and culture in your society. You need to support it as artists need an audience.

1.gives you a better understanding of people from different backgrounds
2. helps you to express your thoughts, feelings and ideas
3. inspire you to be more creative in your work or studies
4. nurturing creativity and innovation




STRESS
Anxiety, Depression
FIC in a cat.


----------------------------------------------------------
  Standard Operating Procedures (SOP)
Speedy, Accuracy, Completeness
in Veterinary Surgery.  This requires a SOP so that there is a systematic process in anaesthesia, surgery. E.g Electro-cautery pad and machine ready

Hamster with leg wart video - Edit it, try put in some narrator's voice
Credit: Operating surgeon : Dr Daniel Sing


Evidence-based medicine






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






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Narrate as follows:

The police looks for evidence to solve a crime. In this case, a tourist coach was locked and parked in the hotel car park overnight. The next morning, the coach driver discovered the doors were unlocked and his sunglasses and some water bottles were stolen.  The police came to investigate (Images of police car and police woman)  




The packaged tourists left the hotel, thinking that the burglar must have used duplicate keys to enter the coach. After a few minutes of driving, the safety vent on the roof of the coach flew off!



The tourists scanned the expressway for the safety vent. The coach driver retrieved the vent from the road. This was the "evidence" for the crime scene investigation.

 In veterinary diagnosis, evidence must be gathered to help in solving the problem of the pet. This evidence includes blood and urine tests, X-rays, ultrasound as illustrated in the following case of a cat having difficulty passing urine (dysuria). In Ascites, you need to gather evidence as to the cause of ascites.

 



Digital X-ray machine



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WORK-LIFE BALANCE


 IMAGE -- YEZIN UNIVERSITY OF VET SCIENCE 2014 FINAL YEAR STUDENTS



IMAGE OF NEW GRADUATES  SINGAPORE




Family responsibility. The father needs to work to support the family.



IMAGE - Mother goes on holiday with child and parents.

After you graduate, you will find that career, family and society take up a lot of time. Families usually do not have the time of the workacholic who wants to be successful in his profession or business.






If you cannot balance these three demands, you will suffer burn-out, divorce (if married), depression, chronic diseases and early death. Some commit suicide as they cannot cope with the stresses of living.







Some solutions are:


1. Focus on the most important aspects of your work and do it well. Write a priority list of what you have to do for the day.

2. Let your employer know if you cannot cope with the caseload or find a better employer. Most employees prefer high pay and less work so as to spend time with the family and friends.  Be realistic as the company needs to make money to survive in a very competitive world.

3. For self-employed vets, have an appointment system to prevent over-work and str Gess in yourself and the staff. More than 40 small animal cases per vet per day may be considered too many.  The quality and standard of care will be poor if everyone has no

time to rest, eat well and exercise.  Staff will resign and new staff need to be trained.

4. Take at least 30 minutes/day to exercise or meditate.  Make new friends rather than just hang around with your group. Enjoy your hobbies like photography.



5. Eat healthy foods to prevent high blood pressure and dying from diabetes and kidney diseases.    




6. Be interested in how other professionals become successful. For example, in my tour, I met a  French artist selling his paintings at the market. He works around 6 months per year, so that he has time for his family. He told me how he markets his paintings through his website and got buyers from China.  I bought a small painting from him.





7.  Have a hobby and learn how to be good at this hobby. My hobby is digital photography. I met this fisherman near a Naypyitaw police station. This police signboard looks like a framed painting. I have not seen such a pretty signboard in Singapore. 





Here are some intesting photographs I took in Myanmar. A rice-field fisherman wearing similar shirt pattern as me. Another interesting photograpoh of a smoking woman in Yangon.  The pretty landscape of the Yezin Dam and 2 boats near the Vet University in August 2014.





 





Support the Arts. For example, appreciate paintings and support the artists.











Friendship, romance, marriage, motherhood and career - It is very difficult to balance it all. You have to decide on what goals you want to achieve in your life after graduation. Be a stay-at-hoe mother or father if that is what you want.


Conclusion

To be successful in being a very good vet - sacrifices are needed as you focus on acquiring skills and expertise in your profession. It is hard to acheive a work-life balance if you want to be the best veterinary surgeon in your field. 

The image shows a car accident from Naypyitaw to Yangon in August 2014. I was fortunate that it was not a serious accident for me and my friends. On the road from Naypyitaw to Yangon, there is a road side signboard in English. It says: "Life is a Journey. Complete It."

Your life after graduation to retirement is like a journey. Have a strong work ethic and a sense of responsiblility. Be honest. Do not get involved in drugs and cheating people. Or you will end up in a police station. De-stress with a hobby like travel photography. You will enjoy more of life and learn more about other culture. My digital image of of Myanmar police station is shown. It must be the prettiest police station signboard in Myanmar.






Be humble. Respect your seniors. Know how to communicate with your clients.  You will be able to complete your journey as a good veterinarian.   





CREDITS

Follow the same as in 2014 Talk. See the Part 2 of the 3 videos.


This is the 2nd Talk to Final Year Yezin Vet Students
Video of tThe 2014 Talk is at:
https://www.youtube.com/watch?v=Tco7lmAId3Y&feature=youtu.be  - Part 1


https://www.youtube.com/watch?v=IqzcEL2Tw6s&feature=youtu.be  - Part 2


https://www.youtube.com/watch?v=qxWrYm6FsCs&feature=youtu.be   - Part 3





MORE VETERINARY EDUCATION VIDEOS AT:
toapayohvets.com/videos.htm



2014 TALK TO FINAL YEAR STUDENTS