779. Internship - Presenting sign of hyperoestrogenism in an old female Sheltie

2011/12/18 lim ..@hotmail.com>

Dear Dr Sing

I have attached a document on the case studies I have seen on the 2nd day of internship, 18 December 2011. Is this what you want of the daily case studies or does it have to be more detailed?

Yours Sincerely
Name of Intern

REPLY FROM DR SING DATED DEC 19, 2011

Thanks for email. During internship, one case study per day is to be recorded for me to review and discussed with you. Otherwise, being a bystander standing around the vet will not enable you to appreciate the diverse aspects of vet medicine and surgery and its varied clinical presentations and challenges to a correct diagnosis.

Evidence-based medicine and knowing how to arrive at a correct diagnosis is not so easy in some rare cases as in this Sheltie whose condition may be mis-diagnosed as ringworm when the actual cause of the hair loss is due to hormonal factors.

One Case study should be written with the following format using the Sheltie you saw yesterday Sunday as an example. You re-write your case study with as much info of the case under the following headings:

CASE NO. 1 DATE:

1. Description of patient - breed, gender, age, colour. Not spayed.
2. Chief complaint - hair loss. Other complaints -
3. History - Hair loss for the last 5 years. Hair grows back after the heat and problem of hair loss recurs. Not fully recovered. Seen 2 vets.
4. Presenting sign: Vulval enlarged over 20X normal. Hyperpigmented black.
5. Examination and tests (blood, urine, skin etc).
6. Diagnosis
7. Treatment/Advice
8. Review/Outcome/Follow up - 2 weeks later. Date to be written on medical record.
8. Against Medical Advices - to be written down

As reviewed by me, what should have been included in this case were:
1. Where were the medical records of other vets? This should be recorded if the owner does not bring them. If owner said "Blood test of other vet is OK," the vet should not take the owner's word for it and ask for the blood test results. Some owners do NOT want to pay for another blood test and this should be recorded under "Against Medical Advices".
2. When was the last heat? This should be asked.

From my review of the above case, the main diagnosis would be a case of hyperestrogenism rather than fungal infections of the dog. Fungal infections are present but the dog's problem will not be cured even if the ringworm is eliminated. So, the owner goes to another vet later for a 4th opinion or just accept that nothing can be done. The dog was put on a hypo-allergic diet by the previous vet for one month. This would be too early to eliminate dry food allergy as a cause of the hair loss.

Now, the Presenting Sign of a swollen vulva 3 months after the end of heat and its presence for over the last 5 years point to a high probability of hyperestrogenism.

The solution for this owner is to spay his dog after the skin infections are resolved in around 4 weeks' time. However the dog is old and there are high anaesthetic risks. This case is quite rare. I had seen less than 10 cases over the past 30 years of small animal practice. So a mis-diagnosis can easily be made as the skin signs of recurring hair loss distracts from the PRESENTING SIGN. A blood test for hormonal levels should be advised in theory and as part of the practice of evidence-based medicine.




Update at:
http://www.sinpets.com/dogs/20111219hyperestrogenism-old-female-Sheltie-internship-singapore_ToaPayohVets.htm

778. Myanmar stories from Peninsula Plaza - Lost a useful contact - case study

My thoughts and tips of the younger generation - the google generation.

Lady 28 years, single, Myanmar National

Had working experience of 2 years in Malaysia and 8 months in Singapore on a "S" pass. Her Singapore company was acquired and she was retrenched. She worked in the administrative side of both companies and has a good command of English and works hard. Presently she pays $500 to attend a diploma in business course but the college told her that the course would be 2 years. That is a lot of money as she is from a poor family.

My advice to her and all young people, including Singaporeans are:

1. Acquire important IT skills like a detailed knowledge of how to use Excel, Word,
video production and digital imaging. Real depth of knowledge of these software in database management and accounting. Not just superficial as many young people even from the Junior Colleges have. This makes you useful to prospective employer.

2. Willing to work hard and the longer hours. Yes, she does.

3. Can converse in English well. Yes. Written English is not so good as to be expected.

4. Positive outlook and lots of energy. Yes, as expected of a young person.

5. Get the testimonials of previous employers esp. the Singaporean company.

6. Unique Strength - Myanmar culture and language and speaking good English.

7. Be proactive. Do your own search and write to hundreds of employers (target 14 per week for example). Do not give up hope.

8. Resume must be up to standard and relevant. This needs outside professional help.

As "S" pass now require $2,000 payment by the employer, it is much more difficult to justify employing new graduates from Myanmar. But much depends on the education and skills and the demands of the relevant industry.

9. Do not job hop. Last month, I met a Filipino who switched to a Korean company for more pay. "However, I have to work on Sundays too," she told me as she visited Khin Khin Employment Agency to look for a job before her visa expires. It was too late. She had a earlier job which satisfied her work hour demands but the money was not there compared to the Korean company which told her that there would be no Sunday work. So this young lady resigned and without another employer, looked for a new employer. This is quite common. But her visa expires and her skills are common (administrative and sales). So, she had to go home.

10. Also save your network phone numbers in duplicate. This girl lost her old phone and all contact numbers esp. of the Accountant in the Singapore company. The Accountant was happy to give her and help. As is the case for young people, such contacts are not valued and phone number had disappeared. I advised her to be more proactive in searching for this mentor who could find jobs for her.

11. Many young people just do not bother with networks and people who will be of great help in their future job search. In conclusion, this case illustrates the importance of duplicating network contacts and being organised and careful. Young people with no specialised degree like accountancy will need to be more alert and pro-active in seeking work attachments and testimonials. New employers want testimonials and character references. "The Accountant told me that I can contact her anytime if I need help," she told me today as I met her at Peninsula Plaza while looking for a Myanmar travel agent. But she lost the phone.

12. Try and get along well with Singaporean colleagues of old job. Some may provide character references for you.

13. "Get married to a rich husband," I said to the young lady. Many Singapore wives stop work to look after their families if their husbands earn a good income. So this is what I advise her. "You are already 28 years old," I said. "How's your Italian boyfriend who contacts you daily from the UK?"

"It is not that easy," she told me. As I am more than twice her age, she does not feel offended in my advices. She needs to be more proactive in finding an employer who will apply for her the "S" pass.

777. Dog lame after Vet 1 injected his thigh

"Whether your injection is the cause of the lameness or not is hard to say," I advised Vet 1. "The dog owner had alleged that your injection was the cause as the dog was not lame before the injection and was lame some hours after the injection! Listen to the complaint and try not to antagonise the owner!

775. No dog

Friday Dec 17, 2011 was a significant day. Dr Vanessa's dog had not been brought to the surgery. On Thursday, I nearly fell as I slipped while going to a crate in the back Animal Handling Room to show a client another Shih Tzu with tarsorrhapy. Her dog peed a big puddle on the floor and did not see it. Obviously I don't look for urine in my own Surgery. This dog had a habit of letting go of large puddles of urine when let loose in the back room. My assistant Min had to clean up and that should NOT be his job. I don't see Dr Vanessa cleaning up and I had given her instruction NOT to let the dog loose anymore. The staff will inform me if she does not heed the instruction.

The dog barks at Min and at me whenever we go to the consultation room to talk to her about the cases. Dr Vanessa would just keep quiet and not discipline the dog as I had advised her. So the dog became bolder and barked to drown out any talk from me or Min. I just can't understand why she would permit such behaviour. This is just not appropriate behaviour for a vet.

The dog also barked at clients. Some Muslim clients cannot be near this dog but he was let loose and so wandered to sniff them or their cats.

It is over one year tolerating this dog's behaviour and copious urination. I hav e to decide as to whether to terminate Dr Vanessa's association with Toa Payoh Vets. Just last month, her dog charged at me when she and I were discussing a case of a dog warded. I just could not believe that she did nothing. Not even a word of scolding at this dog. She just held back the dog in time.

This story is so incredible that readers may think I have a fertile imagination.

774. Friday Dec 16, 2011. Ear canal resection in an old Cocker Spaniel

Dec 16, 2011
A young man who had completed his A levels started first day as intern till his National Service in May 2012. He surprised me by turning up at 9 am today as I told him I had an ear operation on a dog and he would be welcome to see how it is done.

"This ear canal resection surgery is seldom performed as most Singapore owners don't want to do it," I told this young man. "So, a vet undergraduate who studies 5 or 6 years may not have seen such an operation performed in real life. It costs money and that is why many Singapore dog owners don't want to do it."

Since he appeared keen by being present so early, unlike most of my interns who would be clock-watching, I shared with him some tips. He recorded the following for me:

Dear Dr Sing

Sorry to have to send you an email at such a time as I only got home by 10 p.m.. I have attached a report for 16 December 2011. The following is the timeline of the dog ear electrosurgery operation.

Dog Ear Operation (Electrosurgery)
Age: 10 Years Old Weight: 9.5kg Temperature: 38.5 Degree Celsius
10.15am: Clean flush the ear
11.13am: Sedation of the dog ( D and K)
11.23am: Isoflurance
11.35am: Electro incision
11.37am: 1% isoflurance
11.46sm: Stitching Right Ear
11.47am: 1% isoflurance
11.50am: 1% isoflurance
11.55am: 1% isoflurance
12.00pm: 1% isoflurance, 30 rr per minute
12.05pm: 1% isoflurance, 24 rr per minute
12.08pm: Finish Suture
12.10pm: Weat Exercise
12.11pm: Eye Blinking
12.11pm: increase to 4% isoflurance
12.11pm: Two clamps on the left ear
12.13pm: 1% isoflurance
12.15pm: electro incision
12.17pm: 2.5% isoflurance
12.19pm: 1% isoflurance
12.20pm: First Stitch on the left ear
12.22pm: 24 rr, per minute
12.25pm: 1% isoflurance
12.30pm: 0.5% isoflurance
12.34pm: 0.25% isoflurance
12.35pm: 0% isoflurance, remove electrode
12.39pm: End of stitch, End Of Operation

I did not edit his email report. rr=respiratory rate. isoflurance = isoflurane + O2 gas. D=domitor IV K=ketamine IV

From the above, it could be seen that two-ear canal resection surgery in an old dog with skin disease started from 11.35am and ends 12.39 pm. Total is around 1 hour just for the surgery.

I will record my surgery for the benefit of others. The vet surgery textbook can only give the theory but the practice of vet surgery is so much different in old dogs with generalised skin diseases.


EAR CANAL RESECTION IN AN OLD COCKER SPANIEL
Cocker Spaniel, 9.5 kg
Generalised skin diseases for many years. Scratching whole body, neck. Dandruff. Oily skin. The busy owner would send to the vet for treatment but the skin disease re-appears again after a few months. I believe that no vets had suggested ear canal resection to him. This was the cause of the skin disease, in my opinion. Ear infection --- painful, itchy. Dog scratches ears and neck, bites flanks - skin trauma, bacterial infections, more body itchiness, more scratching --- whole body skin inflamed. Finally, left ear had a big ear wart. Dog bites. Nobody at home cleaned the ear canals. Pus, bacterial, dampness as ear flap floppy covers ear canal --- no ventilation -- dampness inside ear canals -- bacteria grows ---pain and irritation --- dog scratches ear neck and bites flank. Uses back paws to scratch flank and chest --- oily infected red skin all over the body including forehead. Will post some images later.

1. PRE-OP PREPARATION
Dog with serious skin diseases was warded for over 2 weeks for treatment and fed proper food to gain weight. Monitored. Good appetite. Skin condition less dandruff but still oily. No yeast inside ear canal (ear canal smear). Owner gave permission for ear surgery. On day of op, dog bites esp. when left ear is touched. So my assistant only bathed him.

PLANNING PRE-OP
1.1 Sedate with Domitor and Ketamine at 50% of calculated dose IV. Very weak. Sedated within 2 minutes.
1.2 Put dog on table and flush, irrigate ear canals vigorously.
1.3 I washed his outer ear skin area thoroughly with cloth and antiseptic myself.
The oily skin was scrubbed well. I did not permit my assistant Min to do it in this bad skin diseased case as I must be sure that the area is cleaned.
1.4 Dog went to surgery room. Mask with isoflurane and O2 for <2 minutes. Intubated with size 8.5 endotracheal tube. This size fitted tightly so no leakage of gas during surgery.

1.5 Ensure set up of electrosurgery machine, big towel, moist saline on swab for indifferent plate, cotton bud, marker pen and surgical equipment and suture. "Check isoflurane level inside the machine," I said to Min after checking oxygen amount. He had to top up the isoflurane liquid.

ELECTROSURGERY
1. Full power setting for electro-incision. I fitted the electrode into the handle.
2. Towel covers steel operating table to prevent electric shocks to staff and vet
3. Marker pen defined lowest level of vertical canal.
4. 2 forceps clamp either vertical side of canal.
5. Electro-incision of skin
6. Skin flap elevated and cut.
7. Arterioles shoot out blood into me. Clamped arterioles. Venous bleeding controlled by clamp.

SURGICAL PROCEDURE
Described in detail in www.toapayohvets.com, goto DOGS, goto EARS. 3/0 nylon 2 packets used in this surgery for 2 ears.

PRODUCTIVITY
How long it takes to do the surgery? Should be around 1 hour for both ears. More experience and planning carefully, less than 1 hour in younger dogs with no skin diseases. Good assistant to monitor vital signs and the vet is to keep proper anaesthetic record

POST-OP CARE
Tolfedine 1 ml + Baytril 1 ml SC
Wash ear bleeding thoroughly at end of op and not wait.
Post-op medication.

CONCLUSION
Dog OK. Woke up with no need for Antisedan reversal. Will check on Day 2 (Saturday 9.44 am as I write this report). This surgery ought to be done for dogs with recurring ear infections and floppy ears, when the dog was much younger, e.g. 3 years old but most Singapore owners will not do it. Breeds commonly affected are Cocker Spaniels and Miniature Schnauzers with hairy ears. Some Shih Tzus. Other breeds seldom have chronic otitis externa that can't be cured.

Fluorescein eye stain test - Silkie rubs its eye vigorously

Generalised greenish as can be seen as follows:

772. Ward dog for 3 days after tarsorrhapy

When the left eye was injured, the owner agreed to her dog being warded for 3 days at Toa Payoh Vets and the eye was well cared for. So, no complaints.

When the right eye was injured and treated by tarsorrhapy by Vet 1, the owner wanted the dog home AGAINST medical advice. On day 2, she phoned me to say that the eye was swollen and bleeding. I advised immediate bringing the dog to Toa Payoh Vets for me to check. She did not do so. Around Day 7, she said the suture had broken down and the eye was swollen and bleeding. This time she brought the dog down and was very unhappy as the first left eye with tarsorrhapy recovered without problems.

"There is no guarantee that every surgery is going to be successful everytime," I said. "I do have cases where there are similar problems. In the first case of the injured left eye, I did advise NOT taking the dog home for 3 days but you did not accept my advice."

There was a lot of unhappiness and blame onto the vet when the owner does not heed medical advice. Vet 1 is not to be blamed as the dog's eye was not well cared for post-op by the maid and mother. The dog was not confined but left to wander around the house and could have rubbed his eyes against sofa sides and beds, leading to stitch breakdown and bleeding.

I advise a repeat tarsorrhapy as the ulcers were deep and would need to be covered up to heal. Or a second opinion from another vet as to whether to leave the eye alone. If the owner has her way, she would rather not have tarsorrhapy. If the eye cornea subsequently ruptures or get pus infection, she would again blame the consulting vet for not having given proper advice! All advices must be RECORDED in the medical records nowadays although sometimes my vet just will not do it.

I will perform tarsorrhapy on Dec 14 and follow up.
More images and update will be at:
http://www.sinpets.com/dogs/20111214tarsorrhapy-stitch-breakdown-7days-dog-at-home-tips-singapore_ToaPayohVets.htm

771. How are eye injuries treated at Toa Payoh Vets

HOW ARE EYE INJURIES TREATED AT TOA PAYOH VETS?

Dr Sing Kong Yuen, BVMS (Glasgow).

 1. General examination of the dog and eyes. 

2. Detailed examination of the eye injury.

3. Pupil examination - Pupillary light reflex - direct and consensual.

4. Cornea examination - Fluorescein stain strip on both eyes and inform owner of the extent of the green stain.

5. Record and illustrate extent of ulcers (green stain) and advices on treatment in the medical record. 

6. Diagnosis – For example, superficial keratitis, ulcerative keratitis, descemotocoele as shown in images below.

7. Advices on treatment and costs.

7.1 Extremely itchy eye. E-collar and eye drops. Eye irrigation of 3rd eyelid if acute conjunctivitis, under sedation is strongly advised.

7.2 Corneal ulceration surgery. Tarsorrhaphy under general anaesthesia. 

7.3 Corneal ulceration surgery. Tarsorrhaphy and 3rd eyelid flap under general anaesthesia.

7.4 Corneal ulceration surgery. Conjunctival graft. Needs 7/0 sutures under general anaesthesia.

8. Digital images before & after treatment preferred or illustration to be recorded in the medical record.

9. Post-op warding in Toa Payoh Vets for 3 days mandatory for tarsorrhapy and conjunctival flap. Owners who insist on bringing the dog home are strongly advised not to do so. The "Against Medical Advice" instruction is to be clearly recorded in the medical record to avoid disputes of post-op stitch breakdown. 

10. Pre-op preparation for surgery. Ensure area is shaved clean. Bigger facial area to be clipped short on both eye area. Eye lashes to be clipped short. 

11. Eyelid eversion and irrigation must be done.

12. Sub-conjunctival injection of gentamycin may or may not be done, depending on the vet. 

13. Advices: Treat the cause of corneal ulcerations. Traumatic injury caused by the protruding eyeball in the Shih Tzu, Pug, Pekinese ensures that such eye injury cases are common in the three above mentioned breeds in Singapore and elsewhere. Another cause is nasal fold hairs irritating the eyeball and nasal fold excision surgery is recommended. Ectopic cilia is another cause of eye corneal irritation and ulceration. 


Case studies at Toa Payoh Vets:
1. Perforated corneal ulcer in a pug
http://www.sinpets.com/dogs/20110315pug-male-7months-perforated-corneal-ulcer-deep-ulcerative-keratitis-toapayohvets.htm

2. Descemetocoele in a Shih Tzu
http://www.sinpets.com/dogs/20100660eye-injuries-rubbing-shih-tzus_dogs_singapore_ToaPayohVets.htm

3. Most of Dr Sing's case studies will be filed at:
Eye problems seen at Toa Payoh Vets:
http://www.bekindtopets.com/animals/20081201PAGE3_Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm

 

IMAGES OF CASES SEEN AT TOA PAYOH VETS ARE SHOWN BELOW:

SUPERFICIAL ULCERATIVE KERATITIS

DEEP ULCERATIVE KERATITIS

CORNEAL ULCER PERFORATION

DESCEMETOCOELE

TARSORRHAPHY 

CONJUNCTIVAL GRAFT

This blog address:
https://2010vets.blogspot.com/2011/12/771-sop-for-eye-injuries-at-toa-payoh.html

EYE INJURIES

Superficial ulcerative keratitis 

Deep ulcerative keratitis (blood and fluid seen)

Descemetocoele (protrusion of the eye basement membrane)

SURGICAL TREATMENT

Tarsorrhaphy is the joining of part or all of the upper and lower eyelids so as to partially or completely close the eye. Temporary tarsorrhaphies are used to help the cornea heal or to protect the cornea during a short period of exposure or disease. The procedure is done at Toa Payoh Vets. Images of a case study is shown below.

EYELID IRRIGATION

Eyelid eversion is used to expose the superior palpebral conjunctiva and fornix, so that foreign matter can be identified in these areas. Eyelid eversion and irrigation are frequently done together to ensure that both particulate material and chemical irritants are removed from the entire ocular surface. 

SURGICAL TREATMENT
Conjunctival graft. A strip of conjunctiva is freed and rotated so that it covers the ulcer, then stitched into position using very fine dissolvable suture material. The conjunctival graft provides a blood supply and physical support to the ulcer to allow it to heal.

Typically, the cornea will heal in 6 to 8 weeks. A follow-up appointment is necessary to monitor your pet's healing.

A VIDEO ON EYE ULCERS IN THE DOG

770. A cat with stinky right ear

"The right ear is very smelly. Have you considered ear irrigation?" I asked the lady whose cat scratched her whenever she tried to put ear drops into the right ear. "The vets gave me the ear drops and asked me to do it," she said. "But I can't do it."
So she consulted me as the problem had become worse.

As vets, we often prescribe ear drops and ask the cat owner to do it herself and often they manage. Owners who consult us again when they can't do it should be advised about ear irrigation. Otherwise the owner just go to another vet for a solution to her cat's ear problem.

"If ear irrigation fails to resolve the problem, there is the ear canal opening surgery," I said. "We will try ear irrigation first and see if it works."

The 4-kg cat was given xylazine 0.1 and ketamine 0.4 ml IM in one injection. The day before, I gave him 50% of the above formula and it didn't work. Sedation was given as low as possible as this cat was not in good health due to the chronic ear infection and it is always good to be careful.

"In ear irrigation, there must be a correct way of irrigation. Otherwise, nothing would be flushed out of the ear canal," I said to my assistant Min. I demonstrated to him my technique. He could see the big brown mass appeared out of the ear canal. I took a picture in case the cat owner was interested as Min did not keep the "evidence".

When the owner took the cat home, I said: "The cat had a lot of dead cells and wax flushed out of the ear canal. You will need to use this ear ointment to continue."

An ear ointment again? From a vet again? The lady shook her head. Why can't the vet understand that her cat would scratch her. Didn't the vet listen sufficiently?

"The ear ointment is to be applied 2 weeks later," I soothed her anxieties of being scratched. "The drugs and injection would bring down the pain, swelling and infection and you should have no problem applying the ear ointment to clear any leftover infection."

She left and I had not heard from her for over one week. If I don't see her again, I presume all are OK. Unless she went for a 4th opinion. I ought to phone her to follow up.

WEBSITE AT TOA PAYOH VETS
http://www.sinpets.com/cats/20111212ear-stinky-irrigation-cat-singapore-toapayohvets.htm

769. Sunday's interesting case. Post-op spay swelling

Sunday Dec 11, 2011

1. Post-spay complications do occur now and then to all vets performing spays in female dogs. It is hard to prevent every case.

Post-op 7 days later, an active Jack Russell came with swelling and inflammation at the spayed area. It looked as if the dog had irritated the spayed area due to itchiness as the owner said he had never taken out the e-collar. The dog was warded. There was no complaint till recently. The dog had pain-killers and antibiotics post-op.

2. 18-year-old cat with 2 large sores on back spinal area. "Would you advise euthanasia?" the owner asked me. "This cat was paralysed last year and treated by you," the owner said. "He could walk later."
"How long it took to walk normally?" I recorded injury T10-L3, jumped upon by the Golden Retriever. I was much surprised that he could be alive.
"A year of walking on front legs and then all 4 legs,.

"It is up to the owner to decide," I said. "Is the cat eating?"
The owner said: "Yes,".
"Many times it will be the children who are against euthanasia," I said.
"No euthanasia," the pre-teen child who listened intenly decided.
I don't advise euthanasia and it should be the owner's decision as treatment may or may not cure. But euthanasia denies a chance of living.
Gave the old cat a warm bath after Min had clipped bald. Got a kettle of water boiled and bathe this aged feline who went into fits when I touched the two big scabs on his back, somewhere on either side of the T10-L3 area Had fleas. Needed grooming and ear cleaning.


3. 4-year-old Schnauzer with globular skin tumour around 8mm x 8mm on right neck
"Any drugs to make it disappear?" the lady in her 30s asked me.
"Not advised," I said. "This is a skin growth. It may or may not be cancerous."
"How much?"
"Anaesthesia and surgery and medication estimated around $250," I said. "Do you want to know whether it is cancerous or not. If you want to know, I will send to the lab for histopathology."
"What if the growth is cancerous?" the husband asked. "Is there a cure?"
"It is not guaranteed," I said. "Depends on type of malignancy."
So, it was decided that the lump be removed and dental scaling be done at the same time to save on costs.

4. Paralysed Shih Tzu.
This Shih Tzu could lift his head but would not stand on his four legs as 2 days ago. His tongue was peculiarly a dark pinkish red. I took him outside the Surgery at 1.10 pm for review. He peed, looked at me. Later he pooped a large amount of soft brown black stools.
Same eye reflex as before when I shone the bright light on both eyes. The left one was dilated while the other constricted on light shone on the pupils. The left one dilated lesser amount than 2 days ago. I asked Dr Vanessa to pinch the front toes of both front paws. Both paws showed withdrawal reflex.

Blood sample taken to check for infection. Glucose, duphalyte and IV drip given. "It takes a long time to recover," I said to Dr Vanessa. "It is not going to be so soon."