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 

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.    

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.



   

2502. The dwarf hamster. Impacted cheek pouch and eye abscess/head tilt (2 cases). Everted cheek pouch.

CASE 1. IMPACTED CHEEK POUCH AND EYELID ABSCESS
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 nurse it at home with opening the incision wound, cotton bud to express the pus, daily.

2. Left 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.

3.  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)

4.  FINAL VIDEO:
https://www.youtube.com/watch?v=XaADnNrC_PM&t=7s

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.

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



CASE 1. IMPACTED CHEEK POUCH AND HEAD TILT

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

CASE 3. EVERTED CHEEK POUCH IN A DWARF HAMSTER

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.

VIDEO

https://youtu.be/0F4mzWrzSkM

CASE 4. EVERTED CHEEK POUCH IN A DWARF HAMSTER
VIDEO
https://youtu.be/Abp4Dd5ZLyQ


CASE 5. EVERTED CHEEK POUCH IN A DWARF HAMSTER
VIDEO SHOWING CHEEK POUCH EXCISED

https://www.youtube.com/watch?v=0wLvKaPKq8E

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

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

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.

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.                    



   

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