Related themes or events happen in threes within a short time in this case when I encountered 3 ladies with BSc (Chemistry) degrees from Myanmar universities.
I was at Peninsula Plaza to visit Khin Khin who had rented a table space to start up her employment agency focused on Myanmar nationals (except maids) looking for jobs in Singapore. I congratulate her on finally doing her own business as she had passed the examinations to be licensed as an employment agency (except maids in the first year of operation).
LADY NO. 1. She was in her 50s and had submitted her papers to Khin Khin to look for an employer to do research in the chemistry field. Khin Khin asked me to read the papers. She was a Chinese and spoke the Hokkien dialect to me. Her English was not so good. I noted that she took 7 years to get her PhD degree and asked her why. She said she had to raise 2 daughters and therefore she took a long time while working for the government. It would be very difficult for her to get a job as she did not have proper documentation of her work experience or testimonials from previous employers. She said: "The government (of Myanmar) does not give testimonials to employees." Her daughter came to Peninsula Plaza later. She studied in Singapore and the father was working in Singapore on a "S" pass. She said: "Looking for job is her 2nd priority. Mum comes to visit the family in Singapore." Yet to me, Mum's first priority seemed to be looking for a job and be able to stay with the family in Singapore. Without a job, she could stay in Singapore for 2 months on a visitor visa
and then must go home.
LADY NO. 2. While talking to Lady No. 1, there was a young lady doing typing on a table near Khin Khin. Khin Khin said: "This lady has a BSc (Chemistry) degree too and her S pass had been rejected. So she is asking me to help her apply for an Employment Pass."
This lady is in her late 20s or early 30s, I can't really tell. Her oral English was good as she could communicate with me just like a Singaporean. She had worked 18 months in Singapore for an expatriate company under an S pass. But now, the MOM (Ministry of Manpower) said that her company did not have 4 Singaporeans to qualify for an S pass for one foreigner. So, her manager wrote a few sentences in a letter to apply for an Employment Pass. The MOM officer rejected this application saying she was not qualified.
So, she looked for an employment agency to help her do a proper job and that was where Khin Khin's employment agency was involved. I was just visiting her but Khin Khin wanted me to help her review her client's case. If I can help somebody to get a job, I will be most happy to do it.
Khin Khin's one-table desk was insufficient to provide the administrative support. So the young lady had to go out to another office to get her documents printed. Two and a half hours passed by so quickly and still she could not finish her paper work. I could now see why it is so difficult for a person just to apply for an S or E pass from the MOM as there are at least 6 procedures to be adopted and presented in writing.
One of them is testimonials from the previous employers and the other is a list of duties and responsibilities from the new employer. Now, she has the excellent testimonials from her previous two employers in writing. One was from a Myanmar hospital expatriate who wrote a good testimonial for her to get her job in Singapore. Then she got the S pass from this second Singapore employer 18 months ago but now her S pass would not be renewed by the MOM. It must be very stressful for her.
I advised her to get all the writing done as required by the MOM as updated details of her work, her promotion to assistant manager to qualify for the Employment Pass and testimonials, employment contract, details of her company's activities, recent invoices and contracts were required. Surprisingly, she has all these documents as her expatriate boss trusted her to do all the operations. So, she has a 50:50 chance of success to apply for an E pass, I told Khin Khin. So much more documentation needed to be done. Khin Khin wanted me to help and another 2 hours were spent. Still we had not completed the paper work as I had to ask her to edit and I had to proof read.
This case has all the supporting documents MOM wanted but it takes so much time to justify in English. I had to help as the written English of this young lady and Khin Khin would understandably be not be up to the MOM's standard of English to support the case. I hope this young lady will be successful as I discovered that she is energetic and has good communication skills as well as experience. This expatriate company with head offices in Hong Kong has the potential to create more jobs for Singaporeans but it needs the time to do it. It does not have 4 Singaporean employees as its jobs are highly specialised and professional engineers from overseas are used to do the technical work for the time being.
LADY NO. 3. She stays in Myanmar with her parents who run an electronic trading company. She asked me whether there are jobs in Singapore for her. She has a BSc (Chemistry). I advised her that she has to have a good command of English and the best way is to study English in Singapore seriously and get the certificates. At the same time, she may speak English better while in Singapore. Her parents would need to pay for her tuition and boarding expenses. But I guess this is difficult for her. She can work for a foreign company in Myanmar if she has good skills just like Lady No. 2 who worked in a Myanmar hospital in administration and IT and got her first testimonial from an expatriate there to get a job in Singapore. I advised this young lady to acquire IT skills in Myanmar and tourism skills if she is really interested. She would be around the same age as Lady No. 2 but Lady No. 2 was already working in Singapore for at least 2 years and getting more experiences.
In the end, much depends on the mindset and drive of young Myanmar single ladies with graduate degrees being proactive in seeking employment in a foreign company in Yangon first. The pay may be very low but it is a stepping stone to a better tomorrow.
Sunday, December 12, 2010
271. 4th surgery to remove cheek tumour in an old dog
Report is written by a 4th year vet student from Murdoch Univ doing internship at Toa Payoh Vets. I welcome different perspectives from interns.
Surgery Report for XXX (11 Y/O mixed breed male dog)
PRE-OP
History:
XXX was presented with a malignant tumour on the Right cheek. Tumour was persistent, with ill-defined margins and had a rough 7cm circumference. It also had a history of dermatitis with multi-focal exudative pustules and papules located primarily on the proximal fore and hindlimbs, with severe scaly and crusted regions of epidermis on the caudal elbow and knee joints. XXX was otherwise eating normally.
Physical Exam (PRE-OP):
On physical examination, XXX displayed an obdunted attitude. Heart, respiratory rate and temperature were within normal limits at 102 bpm, 30bpm and 39.2degrees Celsius respectively. Peripheral perfusion seemed normal with mucous membranes being moist and pink and CRT < 2 secs. Breath was malodorous (possibility of bacterial / fungal overgrowth inside the mouth).
Treatment Plan:
Palliative and curative.
To surgically excise the malignant cheek tumour via electrocautery and check for observable metastasis to regional lymph nodes under general anaesthesia.
OPERATION
Surgical and Anaesthetic details:
XXX was not sedated prior to anaesthetic induction as there was sufficient restraint to hold him down.
Catheterization was performed via a 22G needle into his left cephalic vein for easy intravenous (IV) access before anaesthetic induction with Diazepam (0.4ml) and Ketamine (0.4ml) totaling 0.8ml IV. Roy was deemed sufficiently induced after 10minutes and surgery proceeded. Surgical site was prepped with chlorhexidine and alcohol and a transverse incision across the tumour was made via electrocautery.
The epidermis above the tumour site was undermined to relieve skin tension and provide easier excision of the tumour itself. Roy was also given an IV drip of 5% dextrose wit 0.45% NaCl to compensate for electrolyte losses and to prevent dehydration and hypovolaemia.
Care was taken not to sever the facial nerve although part of it might have been as the tumour margins were large and irregular and the base of the tumour was located deep within the facial cavity, thus requiring aggressive surgical therapy. Upon tumour excision, tumour was found to have metastasized to the bone as well as the upper gingiva. As the effects of the induction drugs weared off, gaseous anaesthesia for maintenance was administered. 5% isoflurane was administered initially and slowly decreased over the course of the surgery up to 0.2% during the muscle, subcutaneous and skin closure at the excision site. 0.1% zoletil was also administered IV during the course of the surgery as Roy was still deemed too light. After 40 minutes, tumour was partially resected and wound closure commenced so as to decrease anaesthetic risk and toxicity. Muscle, subcutaneous and skin closure was performed using 2-0 synthetic polysorb, absorbable suture for all layers. Muscle and subcutaneous layers were closed using a simple interrupted pattern while the skin layer was closed using a mattress suture pattern.
POST-OPERATION
Surgical site was washed and swiped clean with sterile saline to reduce risk of sepsis and 1ml of Tolfenamic Acid (Tolfedine) was administered IV as post-op analgesia. XXX was then placed back in his cage and equipped with an E-collar while he continued to receive the remainder of the 5% dextrose and 0.45% NaCl at maintenance rates followed by another 500ml of Hartmann’s after, also at maintenance flow rates to prevent dehydration, hypovolaemia and to maintain electrolyte balance. Blood sample was taken for CBC and biochemistry while a tumour sample was also submitted to QuestLabs for histopathology.
DRUGS USED AND PRECAUTIONS
Ketamine:
- Mode of action: Acts at the N-methyl-D-Aspartic (NMDA) receptors and blocks central sensitization. It is useful for patients with chronic pains and patients that fail to respond to conventional analgesic therapy. Can also be used (mostly in combination with other drugs such as Xylazine and Diazepam) for sedation and anaesthetic induction.
- Precautions: AVOID the use of ketamine in patients with traumatic head injury as it increases cerebral blood flow and may increase intra-cranial pressure.
Diazepam:
- Mode of action: Diazepam is a benzodiazepine that binds to a specific subunit on the gamma-aminobutyric acid (GABA) receptor at a site distinct from the binding site of the endogenous GABA molecule. Therefore it works as an allosteric modulator of GABA, enhancing its effects and provides good anxiolytic, anti-convulsant, hypnotic and amnestic properties. Used especially in the management of seizure cases.
- Precautions: IV administration of diazepam should be performed slowly, particularly when injected into the smaller veins such as the cephalic vein because of the potential of thrombophlebitis and cardiotoxicity due to the propylene glycol base.
Diazepam may cause weakness, drowsiness and loss of motor coordination. In rare cases, it may result in paradoxical excitement, unexpected aggression or unusual behavourial changes.
Zoletil
- Mode of action: Combination of 2 drugs, tiletamine and zolazepam. Tiletamine’s mode of action is similar to that of ketamine as it is a NMDA receptor antagonist and blocks central sensitization as well. Zolazepam’s mode of action is similar to diazepam as it is a pyrazolodiazepinone derivative that is structurally similar to the benzodiazepine drugs.
- Precautions: Contraindicated in animals with CNS signs, hyperthyroidism, cardiac disease, pancreatic or renal disease, pregnancy, glaucoma or penetrating eye injuries.
REFLECTIONS
As tumour was incompletely resected, the chance of recurrence is very high. Prognosis of this dog is very poor as well as it is old and there has already been evident local metastasis to bone and gingival. Distant metastasis has not been diagnosed but is possible, which will further decrease its prognosis for survival.
In my opinion, if cost is not an issue for the client, I would recommend palliative treatment with NSAIDs such as acetaminophen, aspirin, meloxicam as well as prophylactic broad spectrum antibiotics such as Trimethoprim Sulphate (TMS) or Amoxicillin Clavulanate (Amoxy-clav) along with neoplasia excision again when the tumour grows again to a clinically significant size.
As the surgery had to be aggressive, part of the facial nerve might have been severed in the process which might have resulted in the post-op excessive salivation, drooping of the lip and ear on the ipsilateral side of the lesion. Dog should also be examined for signs of nystagmus, head tilt, asymmetrical pupil size dropping of food and ataxia to further confirm the suspicion of facial nerve paresis or paralysis. Part of the sublingual and mandibular salivary glands and/or their ducts might have also been severed in the process, resulting in excessive salivation. Due to traumatic injury to the glands and/or ducts, in my opinion, I would expect the dog to develop a sialocele which would then require further surgical intervention. Diagosis of this could be confirmed with fine needle aspirate should a SOFT, palpable mass develop near the mouth region. Needle aspirate can also help differentiate a sialocele from a neoplastic process.
On a separate note, the dermatological processes should also be looked into if the client is willing. Punch biopsies should be done on the pustules and papules, centered in the middle of the biopsy specimen. Punch biopsies should also be obtained from the scaly and crusted areas AS WELL AS from the normal skin. This is to allow comparisons of the epidermis and stratum corneum of the 2 sites by the pathologist. This is done to diagnose the nature of the skin lesions and to determine an appropriate treatment plan for XXX with systemic treatment such as injectable or oral cephalosporins, enrofloxacin etc. Adjunctive therapy could include topical treatments such as Chlorhexidine gluconate (Pyohex Dermcare) shampoos as well as benzoyl peroxide (Pyoben Virbac)
Done by:
Name of student
Surgery Report for XXX (11 Y/O mixed breed male dog)
PRE-OP
History:
XXX was presented with a malignant tumour on the Right cheek. Tumour was persistent, with ill-defined margins and had a rough 7cm circumference. It also had a history of dermatitis with multi-focal exudative pustules and papules located primarily on the proximal fore and hindlimbs, with severe scaly and crusted regions of epidermis on the caudal elbow and knee joints. XXX was otherwise eating normally.
Physical Exam (PRE-OP):
On physical examination, XXX displayed an obdunted attitude. Heart, respiratory rate and temperature were within normal limits at 102 bpm, 30bpm and 39.2degrees Celsius respectively. Peripheral perfusion seemed normal with mucous membranes being moist and pink and CRT < 2 secs. Breath was malodorous (possibility of bacterial / fungal overgrowth inside the mouth).
Treatment Plan:
Palliative and curative.
To surgically excise the malignant cheek tumour via electrocautery and check for observable metastasis to regional lymph nodes under general anaesthesia.
OPERATION
Surgical and Anaesthetic details:
XXX was not sedated prior to anaesthetic induction as there was sufficient restraint to hold him down.
Catheterization was performed via a 22G needle into his left cephalic vein for easy intravenous (IV) access before anaesthetic induction with Diazepam (0.4ml) and Ketamine (0.4ml) totaling 0.8ml IV. Roy was deemed sufficiently induced after 10minutes and surgery proceeded. Surgical site was prepped with chlorhexidine and alcohol and a transverse incision across the tumour was made via electrocautery.
The epidermis above the tumour site was undermined to relieve skin tension and provide easier excision of the tumour itself. Roy was also given an IV drip of 5% dextrose wit 0.45% NaCl to compensate for electrolyte losses and to prevent dehydration and hypovolaemia.
Care was taken not to sever the facial nerve although part of it might have been as the tumour margins were large and irregular and the base of the tumour was located deep within the facial cavity, thus requiring aggressive surgical therapy. Upon tumour excision, tumour was found to have metastasized to the bone as well as the upper gingiva. As the effects of the induction drugs weared off, gaseous anaesthesia for maintenance was administered. 5% isoflurane was administered initially and slowly decreased over the course of the surgery up to 0.2% during the muscle, subcutaneous and skin closure at the excision site. 0.1% zoletil was also administered IV during the course of the surgery as Roy was still deemed too light. After 40 minutes, tumour was partially resected and wound closure commenced so as to decrease anaesthetic risk and toxicity. Muscle, subcutaneous and skin closure was performed using 2-0 synthetic polysorb, absorbable suture for all layers. Muscle and subcutaneous layers were closed using a simple interrupted pattern while the skin layer was closed using a mattress suture pattern.
POST-OPERATION
Surgical site was washed and swiped clean with sterile saline to reduce risk of sepsis and 1ml of Tolfenamic Acid (Tolfedine) was administered IV as post-op analgesia. XXX was then placed back in his cage and equipped with an E-collar while he continued to receive the remainder of the 5% dextrose and 0.45% NaCl at maintenance rates followed by another 500ml of Hartmann’s after, also at maintenance flow rates to prevent dehydration, hypovolaemia and to maintain electrolyte balance. Blood sample was taken for CBC and biochemistry while a tumour sample was also submitted to QuestLabs for histopathology.
DRUGS USED AND PRECAUTIONS
Ketamine:
- Mode of action: Acts at the N-methyl-D-Aspartic (NMDA) receptors and blocks central sensitization. It is useful for patients with chronic pains and patients that fail to respond to conventional analgesic therapy. Can also be used (mostly in combination with other drugs such as Xylazine and Diazepam) for sedation and anaesthetic induction.
- Precautions: AVOID the use of ketamine in patients with traumatic head injury as it increases cerebral blood flow and may increase intra-cranial pressure.
Diazepam:
- Mode of action: Diazepam is a benzodiazepine that binds to a specific subunit on the gamma-aminobutyric acid (GABA) receptor at a site distinct from the binding site of the endogenous GABA molecule. Therefore it works as an allosteric modulator of GABA, enhancing its effects and provides good anxiolytic, anti-convulsant, hypnotic and amnestic properties. Used especially in the management of seizure cases.
- Precautions: IV administration of diazepam should be performed slowly, particularly when injected into the smaller veins such as the cephalic vein because of the potential of thrombophlebitis and cardiotoxicity due to the propylene glycol base.
Diazepam may cause weakness, drowsiness and loss of motor coordination. In rare cases, it may result in paradoxical excitement, unexpected aggression or unusual behavourial changes.
Zoletil
- Mode of action: Combination of 2 drugs, tiletamine and zolazepam. Tiletamine’s mode of action is similar to that of ketamine as it is a NMDA receptor antagonist and blocks central sensitization as well. Zolazepam’s mode of action is similar to diazepam as it is a pyrazolodiazepinone derivative that is structurally similar to the benzodiazepine drugs.
- Precautions: Contraindicated in animals with CNS signs, hyperthyroidism, cardiac disease, pancreatic or renal disease, pregnancy, glaucoma or penetrating eye injuries.
REFLECTIONS
As tumour was incompletely resected, the chance of recurrence is very high. Prognosis of this dog is very poor as well as it is old and there has already been evident local metastasis to bone and gingival. Distant metastasis has not been diagnosed but is possible, which will further decrease its prognosis for survival.
In my opinion, if cost is not an issue for the client, I would recommend palliative treatment with NSAIDs such as acetaminophen, aspirin, meloxicam as well as prophylactic broad spectrum antibiotics such as Trimethoprim Sulphate (TMS) or Amoxicillin Clavulanate (Amoxy-clav) along with neoplasia excision again when the tumour grows again to a clinically significant size.
As the surgery had to be aggressive, part of the facial nerve might have been severed in the process which might have resulted in the post-op excessive salivation, drooping of the lip and ear on the ipsilateral side of the lesion. Dog should also be examined for signs of nystagmus, head tilt, asymmetrical pupil size dropping of food and ataxia to further confirm the suspicion of facial nerve paresis or paralysis. Part of the sublingual and mandibular salivary glands and/or their ducts might have also been severed in the process, resulting in excessive salivation. Due to traumatic injury to the glands and/or ducts, in my opinion, I would expect the dog to develop a sialocele which would then require further surgical intervention. Diagosis of this could be confirmed with fine needle aspirate should a SOFT, palpable mass develop near the mouth region. Needle aspirate can also help differentiate a sialocele from a neoplastic process.
On a separate note, the dermatological processes should also be looked into if the client is willing. Punch biopsies should be done on the pustules and papules, centered in the middle of the biopsy specimen. Punch biopsies should also be obtained from the scaly and crusted areas AS WELL AS from the normal skin. This is to allow comparisons of the epidermis and stratum corneum of the 2 sites by the pathologist. This is done to diagnose the nature of the skin lesions and to determine an appropriate treatment plan for XXX with systemic treatment such as injectable or oral cephalosporins, enrofloxacin etc. Adjunctive therapy could include topical treatments such as Chlorhexidine gluconate (Pyohex Dermcare) shampoos as well as benzoyl peroxide (Pyoben Virbac)
Done by:
Name of student
270. Immunosuppressive drugs, oxalate urinary stones, cheek tumour dog cases
3 reports are written by the vet intern. They are:
immunosuppressive drugs, oxalate urinary stone management and 24-hour follow up on a surgery to excise the recurred right cheek tumour in a dog for the 4th time.
DRUG DETAILS:
Atopica® (Cyclosporine-systemic) 50mg soft caps
INDICATIONS: Normally indicated for perianal fistula, atopic dermatitis, feline necrotizing gingivitis, renal transplantation and other immune-suppressive purposes.
Dose rate (CANINE): 2-5mg/kg PO q12h OR 2-5mg/kg PO q24h if concurrent ketoconazole administration*
PRECAUTIONS: Ensure to adjust dose to attain good clinical response. Overdose or excessive use may cause nephrotoxicity (protein-losing nephropathy), gingival hyperplasia, anaphylaxis (type 1 hypersensitivity reaction) possibility with IV administration.
DO NOT use in dogs aged less than 6 months or weighing less than 2kg as efficacy and safety has NOT been assessed for the above-mentioned parameters.
Occasionally, Atopica may cause gastrointestinal disburbances such as vomiting, mucoid or soft stool and diarrhoea as well.
Imuran® (Azathioprine) 50mg tablets
INDICATIONS: This is an immunosuppressive agent, normally indicated for use in autoimmune diseases such as Rheumatoid Arthritis, immune mediated hepatopathies, pemphigus, polymyositis, myasthenia gravis, atopic dermatitis, Idiopathic thrombocytopenic purpura (ITP) etc.
PRECAUTIONS: DO NOT USE IN CATS as it is TOXIC. Ensure to monitor CBC, bone marrow suppression and biochemistry (to ensure that leukopenia and thrombocytopenia does not occur). Although incidence rate is rare, use of Imuran may occasionally result in hepatotoxicity.
NOTE recommended dose rates for Diazepam + Ketamine drug combinations for anaesthetic induction is 0.25mg/kg IV for Diazepam and 5.0mg/kg IV for ketamine
CASE STUDY 1)
UROLITHIASIS: This is essentially aggregates of crystalline and occasionally non-crystalline solid substances that form in one or more locations within the urinary tract
CLINICAL SIGNS: Signs normally vary according to the locations of the uroliths and normally include cystitis, stranguria, dysuria, haematuria and Urinary Tract Infection (UTI). Acute urethral obstruction may also occur. Hydronephrosis and sometimes renal failure also occur with nephroliths. Ureteroliths are normally accompanied by intense pain.
DIAGNOSIS: Based on clinical signs, palpation and diagnostic imaging.
UROLITH TYPES: There are generally 6 types of uroliths, which is basically made up of a central Nidus, coated with stone, followed by a shell and surface crystals
DIAGRAM NOT ABLE TO DISPLAY FROM WORD TO BLOGGER.COM
The types include:
Struvite
Calcium Oxalate
Ammonium Urate (Urates)
Cystine
Silica
Xanthine
Only Calcium Oxalate uroliths shall be discussed
CALCIUM OXALATE:
RISK FACTORS: Increased urinary calcium excretion DUE TO
- Increased GI calcium absorption (absorptive hypercalciuria)
- Renal-leak hypercalciuria (a tubular defect)
- Hypercalcaemia (of any cause, usually chronic)
- Hyperadrenocorticism (Cushings)
TREATMENT: Medical dissolution of calcium calculi is NOT possible so the only treatment is surgical removal, lithotripsy or hydropropulsion.
PREVENTION:
- Correction of hypercalcaemia if present
- A reduced protein, calcium and oxylate diet for absorptive hypercalciuria
- Urinary alkalisation with potassium citrate
- Consider thiazide diuretics in dogs with highly recurrent disease (eg. Hydropchlorothiazide at 2mg/kg q12h PO)
- Recurrence is common.
- THERE IS NO TREATMENT FOR RENAL-LEAK HYPERCALCIURIA
POST OPERATIVE Subjective, Objective, Assessment and Plan (SOAP) for XXX, 11 Y/O mixed breed male dog
Subjective: XXX was eating and drinking normally. No observed signs of anorexia, dysphagia or dysuria. His attitude was BAR (Bright alert and responsive).
Objective: On physical examination, XXX’s heart rate and respiratory rate were within normal limits at 72bpm and 30bpm respectively. Weight remained relatively constant at 9.5kg. Rectal temperature was at 38.8 degrees Celsius, mucous membranes were pink and moist with CRT <2s, displaying no abnormalities in peripheral perfusion.
Assessment: XXX was given 1 tablet Imuran (Azathioprine) 50mg PO and antibiotic and antifungal coverage with metronidazole* 10mg/kg IV slowly via fluid bag.
*Side effects of metronidazole may include vomiting, hepatotoxicity and skin hypersensitivity so use with caution and keep under close observation.
Roy was also given 500ml of 5% Dextrose, 0.45% NaCl fluid therapy overnight at maintenance flow rates to maintain electrolyte balance, prevent hypovolaemia and dehydration.
Plan: To assess again in the morning and to administer another dose of metronidazole given at 10mg/kg IV q8h. Ensure vitals, temperature and peripheral perfusion are within normal limits.
Done by
Name of student
4th year vet student, Murdoch Univ
Seeing vet internship practice at Toa Payoh Vets
Dec 6-10, 2010. One of the few interns who was hardworking to write up case studies seen. Most observe and do not write. University professors do require report writing from students seeing practice in some instances but this is not a consistent policy.
UPDATE ON SUN DEC 12,2010
4th year exam results are out for Murdoch Vet students. I hope this intern has good news.
XXX went home on Day 2. Imuran tablets will be given 1/4 tab/day. Antibiotics Baytril and multivitamins are given. Need to follow up. Prognosis very poor as this is the 4th recurrence of tumour. Tumour has spread to bones and gums.
immunosuppressive drugs, oxalate urinary stone management and 24-hour follow up on a surgery to excise the recurred right cheek tumour in a dog for the 4th time.
DRUG DETAILS:
Atopica® (Cyclosporine-systemic) 50mg soft caps
INDICATIONS: Normally indicated for perianal fistula, atopic dermatitis, feline necrotizing gingivitis, renal transplantation and other immune-suppressive purposes.
Dose rate (CANINE): 2-5mg/kg PO q12h OR 2-5mg/kg PO q24h if concurrent ketoconazole administration*
PRECAUTIONS: Ensure to adjust dose to attain good clinical response. Overdose or excessive use may cause nephrotoxicity (protein-losing nephropathy), gingival hyperplasia, anaphylaxis (type 1 hypersensitivity reaction) possibility with IV administration.
DO NOT use in dogs aged less than 6 months or weighing less than 2kg as efficacy and safety has NOT been assessed for the above-mentioned parameters.
Occasionally, Atopica may cause gastrointestinal disburbances such as vomiting, mucoid or soft stool and diarrhoea as well.
Imuran® (Azathioprine) 50mg tablets
INDICATIONS: This is an immunosuppressive agent, normally indicated for use in autoimmune diseases such as Rheumatoid Arthritis, immune mediated hepatopathies, pemphigus, polymyositis, myasthenia gravis, atopic dermatitis, Idiopathic thrombocytopenic purpura (ITP) etc.
PRECAUTIONS: DO NOT USE IN CATS as it is TOXIC. Ensure to monitor CBC, bone marrow suppression and biochemistry (to ensure that leukopenia and thrombocytopenia does not occur). Although incidence rate is rare, use of Imuran may occasionally result in hepatotoxicity.
NOTE recommended dose rates for Diazepam + Ketamine drug combinations for anaesthetic induction is 0.25mg/kg IV for Diazepam and 5.0mg/kg IV for ketamine
CASE STUDY 1)
UROLITHIASIS: This is essentially aggregates of crystalline and occasionally non-crystalline solid substances that form in one or more locations within the urinary tract
CLINICAL SIGNS: Signs normally vary according to the locations of the uroliths and normally include cystitis, stranguria, dysuria, haematuria and Urinary Tract Infection (UTI). Acute urethral obstruction may also occur. Hydronephrosis and sometimes renal failure also occur with nephroliths. Ureteroliths are normally accompanied by intense pain.
DIAGNOSIS: Based on clinical signs, palpation and diagnostic imaging.
UROLITH TYPES: There are generally 6 types of uroliths, which is basically made up of a central Nidus, coated with stone, followed by a shell and surface crystals
DIAGRAM NOT ABLE TO DISPLAY FROM WORD TO BLOGGER.COM
The types include:
Struvite
Calcium Oxalate
Ammonium Urate (Urates)
Cystine
Silica
Xanthine
Only Calcium Oxalate uroliths shall be discussed
CALCIUM OXALATE:
RISK FACTORS: Increased urinary calcium excretion DUE TO
- Increased GI calcium absorption (absorptive hypercalciuria)
- Renal-leak hypercalciuria (a tubular defect)
- Hypercalcaemia (of any cause, usually chronic)
- Hyperadrenocorticism (Cushings)
TREATMENT: Medical dissolution of calcium calculi is NOT possible so the only treatment is surgical removal, lithotripsy or hydropropulsion.
PREVENTION:
- Correction of hypercalcaemia if present
- A reduced protein, calcium and oxylate diet for absorptive hypercalciuria
- Urinary alkalisation with potassium citrate
- Consider thiazide diuretics in dogs with highly recurrent disease (eg. Hydropchlorothiazide at 2mg/kg q12h PO)
- Recurrence is common.
- THERE IS NO TREATMENT FOR RENAL-LEAK HYPERCALCIURIA
POST OPERATIVE Subjective, Objective, Assessment and Plan (SOAP) for XXX, 11 Y/O mixed breed male dog
Subjective: XXX was eating and drinking normally. No observed signs of anorexia, dysphagia or dysuria. His attitude was BAR (Bright alert and responsive).
Objective: On physical examination, XXX’s heart rate and respiratory rate were within normal limits at 72bpm and 30bpm respectively. Weight remained relatively constant at 9.5kg. Rectal temperature was at 38.8 degrees Celsius, mucous membranes were pink and moist with CRT <2s, displaying no abnormalities in peripheral perfusion.
Assessment: XXX was given 1 tablet Imuran (Azathioprine) 50mg PO and antibiotic and antifungal coverage with metronidazole* 10mg/kg IV slowly via fluid bag.
*Side effects of metronidazole may include vomiting, hepatotoxicity and skin hypersensitivity so use with caution and keep under close observation.
Roy was also given 500ml of 5% Dextrose, 0.45% NaCl fluid therapy overnight at maintenance flow rates to maintain electrolyte balance, prevent hypovolaemia and dehydration.
Plan: To assess again in the morning and to administer another dose of metronidazole given at 10mg/kg IV q8h. Ensure vitals, temperature and peripheral perfusion are within normal limits.
Done by
Name of student
4th year vet student, Murdoch Univ
Seeing vet internship practice at Toa Payoh Vets
Dec 6-10, 2010. One of the few interns who was hardworking to write up case studies seen. Most observe and do not write. University professors do require report writing from students seeing practice in some instances but this is not a consistent policy.
UPDATE ON SUN DEC 12,2010
4th year exam results are out for Murdoch Vet students. I hope this intern has good news.
XXX went home on Day 2. Imuran tablets will be given 1/4 tab/day. Antibiotics Baytril and multivitamins are given. Need to follow up. Prognosis very poor as this is the 4th recurrence of tumour. Tumour has spread to bones and gums.
Friday, December 10, 2010
Acute vomiting and bloody diarrhoea
"It is better to get an X-ray done," I advised the owner who brought back the dog after he was discharged. My associate vet deemed it not necessary to X-ray and sent the dog home after 3 days of hospitalisation and IV drip and treatment. His judgment was that the dog did not have foreign bodies and was in no need to have an X-ray, to save money for the owner. Unfortunately, the dog vomited at home and the young lady was not too pleased.
To prevent negligence complaint, I advised my associate vet to get an X-ray done. There was no "sausage roll" palpated to indicate an intussception which causes acute bloody diarrhoea.
IV drips and treatment drugs were given. The dog was hospitalised for 2 more days. X-ray showed lots of gas in the intestines. Some opaque grains which may be remnants of bones but the owner insisted that the dog did not eat any bones. Blood test showed low platelet count. A possibility of toxaemia from acute food poisoning.
This appeared to be a case of acute food poisoning. The dog recovered and there was no complaint after going home again. The owner was worried about vet expenses and many times, we try to save them some money. In the end, we may get sued or complained for incompetence and failure to take X-rays if the dog dies. Therefore, I have a system of requiring X-rays when the vomiting persisted more than 2 days or even earlier if abdominal palpation revealed foreign bodies. Negligence and incompetence rear their ugly heads when the dog dies. Therefore, preventive medicine is sometimes necessary.
To prevent negligence complaint, I advised my associate vet to get an X-ray done. There was no "sausage roll" palpated to indicate an intussception which causes acute bloody diarrhoea.
IV drips and treatment drugs were given. The dog was hospitalised for 2 more days. X-ray showed lots of gas in the intestines. Some opaque grains which may be remnants of bones but the owner insisted that the dog did not eat any bones. Blood test showed low platelet count. A possibility of toxaemia from acute food poisoning.
This appeared to be a case of acute food poisoning. The dog recovered and there was no complaint after going home again. The owner was worried about vet expenses and many times, we try to save them some money. In the end, we may get sued or complained for incompetence and failure to take X-rays if the dog dies. Therefore, I have a system of requiring X-rays when the vomiting persisted more than 2 days or even earlier if abdominal palpation revealed foreign bodies. Negligence and incompetence rear their ugly heads when the dog dies. Therefore, preventive medicine is sometimes necessary.
268. A very painful encapsulated abscess in the neck of a Shih Tzu. Complete Blood Count
10 Dec 2010.
CHUBBY – DOG – Shih Tzu
9 Y/O Male. A very painful encapsulated neck abscess
CBC interpretation:
Haematology Profile:
Description:
The CBC is commonly performed on an automated haematology analyzer using well mixed whole blood that is added to a chemical (EDTA – Ethylenediaminetetraacetic Acid) to prevent clotting.
A CBC is a group of tests used to quantify the number of RBCs, WBCs and platelets, provide information about their size and shape, measure the haemoglobin content of RBCs, determine the percentage and absolute number of the five white blood cell types, and identify early and abnormal blood cells.
These tests are performed simultaneously.
Analysis (Haematology):
Haematology Result Unit Ref. Range
Haemoglobin 18.4 g/dL 12.0 – 18.0
Red Cell Count 7.7 X10^12 / L 5.5-8.5
Total White cell count 8.3 X10^9 / L 6.0 – 17.0
Differential Count % Absolute V. Unit
Neutrophils 68.19 5.66 X10^9 / L
Lymphocytes 21.08 1.75 X10^9 / L
Monocytes 6.14 0.51 X10^9 / L
Eosinophils 3.49 0.29 X10^9 / L
Basophils 0.96 0.08 X10^9 / L
PCV 0.48 0.37 – 0.55
MCV 63 fL 60 – 77
MCH 24 Pg 20 – 25
MCHC 38 g / dL 32 - 36
RDW 15.7 %
Platelets 491 X10^9 / L 200 - 500
Haemoglobin: 18.4 g/dL
• This value is lightly above reference range but it should not be of much significance as the red blood cell count, PCV, MCV, MCH, RDW are all within normal limits.
• Haemoglobin concentration is normally used to diagnose anaemia, which can be caused by microcytic RBCs, which are smaller than usual in size and unable to carry sufficient Oxygen. Macrocytic anaemia usually occurs when the division of RBC precursor cells in the bone marrow is impaired. The most common cause of macrocytic anaemia are vitamin B12 deficiency, folate deficiency and liver disease.
Normocytic anaemia may be caused by decreased production of RBCs (any cause of bone marrow failure), increased destruction of RBCs (haemolytic anaemia) or loss of blood.
Total White Cell Count: 8.3 x 10^9 / L (within normal limits)
•
Normal white cell count usually indicates that the animal is not in any threat of infectious diseases and foreign bodies.
• An elevated white cell count usually occurs in infection, allergy, systemic illness, inflammation, tissue injury and leukemia.
• A depressed white cell count may occur in some viral infections, immunodeficiency states and bone marrow failure.
• The white blood cell differential count will reveal which WBCs are affected the most
• Neutrophils are the most abundant granulocytic cells and are phagocytic cells that aid in the removal of bacteria and antibody-coated antigens
• Lymphocytes are the 2nd most abundant monocytic WBCs and originate from the lymphoid tissues and are NOT phagocytic. They are responsible for initiating and regulating the immune response by the production of antibodies and cytokines.
• Monocytes are the largest monocytic WBCs and are phagocytic cells that process and present antigens to lymphocytes, an event required for lymphocyte activation
• Eosinophils are granulocytic WBCs that have cytoplasms filled with granules that contain peroxidise, hydrolases and basic proteins that aid in the destruction of phagocytised cells. They are increased in allergic and parasitic infections
• Basophils are granulocytic WBCs that contain large amounts of histamine, heparin and acid mucopolysaccharides. They mediate the allergic response by releasing histamine.
Platelets: 149 x 10^9 / L (Below reference range of 200-500)
• Platelets are disc-shaped structures formed from the detachment of cytoplasm from megakaryocytes. They aid in the coagulation process by attaching or adhering to the walls of injured blood vessels, where they stick together to form the initial platelet plug.
• A low platelet count may occur in patients with viral infections, lymphoma or animals taking certain drugs such as quinine and quinidine.
• Decreased platelet production is also a cause of thrombocytopenia, and may be due to aplastic anaemia, leukemia, lymphoma or bone marrow fibrosis.
•
A low platelet count can occur due to increased destruction and can result in antibody production that is often drug-induced (heparin treatment being a prominent cause)
• In relation to this case, Chubby’s decreased platelet count might be auto-immune, resulting in platelet destruction and decreasing his ability to clot blood and predisposing him to conditions such as TTP (Thrombotic thrombocytopenic purpura) and DIC (Disseminated intravascular coagulation).
BIOCHEMISTRY RESULTS:
BIOCHEMISTRY RESULT UNIT REF. RANGE
Total Cholesterol 4.75 Mmol / L
HDL Cholesterol 3.72 Mmol / L
LDL Cholesterol 0.20 Mmol / L
Cholesterol / HDL Ratio 1.28 Mmol / L
Triglycerides 1.83 Mmol / L
Glucose 4.1 Mmol / L 3.9 – 6.0
SGPT / ALT 59 U / L < 59
SGOT / AST 41 U / L < 81
Calcium 2.06 Mmol / L 1.50 – 3.60
Uric acid 0.01 Mmol / L
Wednesday, December 8, 2010
The old dog with the recurring cheek tumour goes home
2 days after surgery. The 11-year-old dog looks good and will be going home today. His pustules which spread all over his body had disappeared due to the intensive IV drip with baytril, metronidazole and a bit of dexamethasone.
I spoke to the young lady yesterday. "Spend time with your dog. Give him good food and water. It is unlikely that he will survive a 5th anaesthesia and operation. The tumours had spread to his lymph nodes."
I popped out a 1.5x1.0 cm popliteal lymph node which is usually not palpable to show the young lady. I said: "It is unlikely that the immuno-suppressive azathioprine 50 mg (1/4 tab/day for the next 14 days at 1.5 mg/kg/day initially). The drug will stop the fast growth of this tumour. The dog may be vomiting and not eating on this drug.
It is back to square one after excision of the cheek tumour for the 4th time. This time, the cancer had spread aggressively back into the gums and the bones of the lower jaw. "If chemotherapy works, his cheek tumour will not grow back again. It will be a miracle." It will be Christmas in 17 days' time. If miracles do happen, it will be known by Christmas day.
I spoke to the young lady yesterday. "Spend time with your dog. Give him good food and water. It is unlikely that he will survive a 5th anaesthesia and operation. The tumours had spread to his lymph nodes."
I popped out a 1.5x1.0 cm popliteal lymph node which is usually not palpable to show the young lady. I said: "It is unlikely that the immuno-suppressive azathioprine 50 mg (1/4 tab/day for the next 14 days at 1.5 mg/kg/day initially). The drug will stop the fast growth of this tumour. The dog may be vomiting and not eating on this drug.
It is back to square one after excision of the cheek tumour for the 4th time. This time, the cancer had spread aggressively back into the gums and the bones of the lower jaw. "If chemotherapy works, his cheek tumour will not grow back again. It will be a miracle." It will be Christmas in 17 days' time. If miracles do happen, it will be known by Christmas day.
266. Eat, Love, Pray & Warts
"Are you waiting for Dr Vanessa?" I asked the couple who popped in today while I was about to operate on the old Shih Tzu with the open wound in a left neck lump of around 1.5 x 1.5 cm.
The lady owner had scheduled this surgery after the dog suddenly had this crazy scratching of the enlarged lump some 2 weeks ago. I had treated the swelling which was 5 times the present size. Much earlier I had advised surgical excision but she did not want to do it. The lump had swelled and gone down over the last 2 years and so it was nothing to worry about. Till two weeks ago, when it exploded like a volcano (see image). I was surprised too. This will be another story.
Back to the couple with the old Miniature Schnauzer limping and biting the owner should they touch his left fore limb. "Actually, we want to see a vet immediately," the young trim lady in make up and green dress said softly.
So I had to abandon my surgery case to attend to this dog.
"He must be suffering from an ingrown toe nail like last time," the man in his 40s said. "Remember, you need a tranquiliser to trim his toe nail." I checked the records. It was done by Dr Jason Teo and the limb affected was right fore.
"This dog has lots of ear hairs and his ears are painful. Did the groomer pluck his ear hairs?" I examined the ear canal after muzzling the dog and noted that the left ear was dirty with wax. "Mum is the groomer, and she cannot do it."
I got the groomer to clip the dog's left fore paw under domitor sedation. He has a puncture wound in his pad which contained pus.
The man had been flying for the past 20 years internationally. "Did you take any pictures of the various cultures and people you meet?" I asked. "People like me don't get to see the world as it is too costly and time-consuming. You have the opportunity to document the fascinating diversity of people and culture."
"I will get a SLR to do it," the man said he did not do photography. "Travel stories with pictures are fascinating to many people," I said. "You may become rich if you author an interesting travel story that is made into a movie. Have you watched the movie "Eat, Love, Pray"?
"Bali," the girlfriend said.
"Bali is the place where the writer found her true love. Italy is the place where she eats good food and makes good friends without bothering about her weight gain. India is where she meditates and clears her mind."
I hope the man will take pictures and document his travels. It is very rare for a person to write travel stories but buying a camera is a start to create memories.
As for the old Schnauzer, I got the dog's left elbow wart (blackest one I had seen) excised. A papilloma behind the left shoulder was excised. I asked the intern to write the "surgery" of this case plus the one on the Shih Tzu with the neck abscess. He can write but like most interns of 4th year, they prefer not to document. Writing will help him in his forthcoming examinations as he sees real cases. Books and lecture notes can be most boring.
As for the Shih Tzu, he saw the operation when he came in after 10 am. He was fortunate as I wanted to complete the operation before 10 am if the couple with the Schnauzer had not stepped in. So, he could see and understand the principles of tumour and growth excision. How it is done and what is the post-op care. I asked him to write this record.
As for post-op injection, I asked him where to inject the tolfedine l.0 ml with half IM and half SC said: "My professor teaches me to inject in the dog's neck for IM."
I said sadly to him and to my assistant: "Sometimes two of you make me so angry because you said something which cannot be done." Obviously, the dog's neck had surgery and was bandaged up. So, there was no possibility of neck IM injection. "I usually inject IM in the back muscles," I showed the intern the location. This is the first time I hear dogs being given neck IM injection for sedation. Since the intern's Murdoch University does it as a routine, it must be OK. In racehorses, I use IM neck injection as the neck is muscular and large.
"I know of a Filipino vet graduate who injects IM into the muscles above the knee joint," I said to the intern. "So the professor in her university must have taught her that way." There are many ways of IM injection in the dog apparently. I stick to the backside muscles.
The lady owner had scheduled this surgery after the dog suddenly had this crazy scratching of the enlarged lump some 2 weeks ago. I had treated the swelling which was 5 times the present size. Much earlier I had advised surgical excision but she did not want to do it. The lump had swelled and gone down over the last 2 years and so it was nothing to worry about. Till two weeks ago, when it exploded like a volcano (see image). I was surprised too. This will be another story.
Back to the couple with the old Miniature Schnauzer limping and biting the owner should they touch his left fore limb. "Actually, we want to see a vet immediately," the young trim lady in make up and green dress said softly.
So I had to abandon my surgery case to attend to this dog.
"He must be suffering from an ingrown toe nail like last time," the man in his 40s said. "Remember, you need a tranquiliser to trim his toe nail." I checked the records. It was done by Dr Jason Teo and the limb affected was right fore.
"This dog has lots of ear hairs and his ears are painful. Did the groomer pluck his ear hairs?" I examined the ear canal after muzzling the dog and noted that the left ear was dirty with wax. "Mum is the groomer, and she cannot do it."
I got the groomer to clip the dog's left fore paw under domitor sedation. He has a puncture wound in his pad which contained pus.
The man had been flying for the past 20 years internationally. "Did you take any pictures of the various cultures and people you meet?" I asked. "People like me don't get to see the world as it is too costly and time-consuming. You have the opportunity to document the fascinating diversity of people and culture."
"I will get a SLR to do it," the man said he did not do photography. "Travel stories with pictures are fascinating to many people," I said. "You may become rich if you author an interesting travel story that is made into a movie. Have you watched the movie "Eat, Love, Pray"?
"Bali," the girlfriend said.
"Bali is the place where the writer found her true love. Italy is the place where she eats good food and makes good friends without bothering about her weight gain. India is where she meditates and clears her mind."
I hope the man will take pictures and document his travels. It is very rare for a person to write travel stories but buying a camera is a start to create memories.
As for the old Schnauzer, I got the dog's left elbow wart (blackest one I had seen) excised. A papilloma behind the left shoulder was excised. I asked the intern to write the "surgery" of this case plus the one on the Shih Tzu with the neck abscess. He can write but like most interns of 4th year, they prefer not to document. Writing will help him in his forthcoming examinations as he sees real cases. Books and lecture notes can be most boring.
As for the Shih Tzu, he saw the operation when he came in after 10 am. He was fortunate as I wanted to complete the operation before 10 am if the couple with the Schnauzer had not stepped in. So, he could see and understand the principles of tumour and growth excision. How it is done and what is the post-op care. I asked him to write this record.
As for post-op injection, I asked him where to inject the tolfedine l.0 ml with half IM and half SC said: "My professor teaches me to inject in the dog's neck for IM."
I said sadly to him and to my assistant: "Sometimes two of you make me so angry because you said something which cannot be done." Obviously, the dog's neck had surgery and was bandaged up. So, there was no possibility of neck IM injection. "I usually inject IM in the back muscles," I showed the intern the location. This is the first time I hear dogs being given neck IM injection for sedation. Since the intern's Murdoch University does it as a routine, it must be OK. In racehorses, I use IM neck injection as the neck is muscular and large.
"I know of a Filipino vet graduate who injects IM into the muscles above the knee joint," I said to the intern. "So the professor in her university must have taught her that way." There are many ways of IM injection in the dog apparently. I stick to the backside muscles.
Subscribe to:
Posts (Atom)