I followed through today by phoning the owner. Some 5 days ago, his wife brought a container of semi-wet greenish stools, a medical swab of blood-stained vomit to me.
"My dog vomited blood", she had also told me she was a nurse and her husband was a doctor. They don't self-treat their own dog. The two samples were useful. I got the stools sent to the lab and the blood tested.
That was some 5 days ago. "Farting for so many months is not a normal thing for a dog or human being," I said. "There is something wrong with the stomach and intestines. So you get gas production and then smelly stinky smell in the room. If not treated, the intestines can get much irritated leading to "telescoping of one segment into another (intussusception) or rectal prolapse,"
This appeared to be a simple case of vomiting of blood. But the main problem could be the gastrointestinal system causing flatulence for very long time.
I gave the dog a 500 ml IV drip, antibiotic and anti-spasmodic and boarded overnight. I recommended the Prescription i/d canned diets for 1 month. No treats and any other food. Just the i/d 1.5 cans per day.
Now 5 days later, the husband answered my phone at 4 pm (Air Asia plane to Bali delayed as it was to leave at 4 pm, so I typed this story).
The husband said first: "The stools are solid for the first time. Where can I buy it? It is not sold in the shops."
Performance counts. This is what I always tell my younger vets. Stop the vomiting and flatulence. I did not give anti-vomiting injection at all. Just treat for chronic enteritis. You get good clinical outcome after the visit, you get referrals. As simple as that.
The stool sample showed blood but no white cells or parasites. The blood test was not significant. I/d for one month and go on good quality food and treats. The cheap treats sold at Singapore's pet shops should not be fed to your dogs as they are cheap for one reason.
Saturday, January 28, 2012
847. MYANMAR STORIES - An 82-year-old father in Yangon can't sit up at all. Renal Cortical Carcinoma.
28 Jan 2012.
Basically, I checked the drugs given to him asking her to google for info since a doctor in Peninsula Plaza told her that he did not know about the drugs given to her dad. Tramadol, Lyerica and celophrix (non-steroidal anti-inflam). No wonder he could not sit up as the first two cause drowsiness. Being so old, his body could not eliminate the drug fast like a young person!
With this knowledge, what did Khin Khin do? Nothing. So today, before I left for Bali on Air Asia, I followed through and phoned her to ask the father to stop taking the 3 drugs if he has no more pain (CT scan catheter in Yangon via femoral vein had hit the kidney and cause intense pain, Khin Khin said).
If pain returns, take the Tramadol first and consult the doctors for a review. For 2 weeks, the poor father could just lie down the whole day and night and had no appetite. I asked Khin Khin to speak to him over the phone. He could not answer me promptly as if his throat was choked. Most likely water in the lungs had returned. But there was some medicine to reduce the phlegm and none to remove the lung oedema. The CT scan said there was an atypical RCC (Renal Cortical Carcinoma).
If her father could sit in the wheel chair, his daughter would spare no expense to fly him to Singapore for a second opinion. I had met the father in Yangon when he was in good health.
He was a very intelligent educated man, working during the old British colonial days of Yangon in a bank.
It is so sad that he could not sit up for a minute and was vomiting and drowsy and did not enjoy his life. That was why he had not want to go to the Hospital but his daughter got him there. Now he can't walk!
FURTHER TESTS in Yangon showed he had kidney cancer. He passed away later.
Friday, January 27, 2012
845. An unusual complaint about puppy vaccination at Toa Payoh Vets
Yesterday, Jan 26, 2012, I received a phone call from a home breeder saying that her buyer had brought a 8-week-old gold/white Shih Tzu puppy to me on Jan 25, 2012 for vaccination. I had told the buyer that the puppy was 5 weeks old and therefore too young to vaccinate. "I delivered the puppies myself," the breeder said. "They are 8 weeks old but the buyer said you told her she is 5 weeks old."
I was surprised as I do not age a puppy so accurately as being 5 weeks. No vet can do this because it is not possible to pin-point the exact age just by looking at the puppy's teeth. There is a range and 8 weeks is plausible. So, I told her I would check Jan 25 cases and none of the 4 vets had such a puppy presented on that day.
The home breeder's message to me:
Dr Sing, indly assist to investigate the following:
Name and tel of buyer given
She claimed she had brought the puppy shih tzu, female, gold/white, 2 mths old to your clinic appointment on 25 Jan, for puppy's lst vaccination and microchip. However she had informed me yesterday that your vet told her the puppy is only 5 weeks old.
I suppose in that instance no vaccination or microchip done? N what is the assessment for no vaccine for the puppy? That constitutes to the buyer claiming your vet said so. If this is the case, I will make report and take action accordingly.
The puppies were born on 28 Nov 2011. I was the one who helped my dog gave birth to the puopies. I would like your assistance to investigate and clarification to this matter soonest. Thank you.
----------------------------------------
My reply to the breeder:
On 25 Jan 2012, none of the 4 vets including myself had a case of a female shih tzu puppy, gold and white, 8 weeks or 5 weeks for vaccination. I have checked all cases done on that day. Give me her tel number to verify with her.
-------------------------------------------
I have not contacted the buyer yet. This is quite an emotional issue and it is best not to rush into phoning the buyer since she had not come on Jan 25, 2012. How to handle this case since the buyer had stopped responding to the breeder's phone call?
Based on this case, home breeders who are concerned about their puppies sold may find it important to give a paper of birth when they sell their puppies.
I was surprised as I do not age a puppy so accurately as being 5 weeks. No vet can do this because it is not possible to pin-point the exact age just by looking at the puppy's teeth. There is a range and 8 weeks is plausible. So, I told her I would check Jan 25 cases and none of the 4 vets had such a puppy presented on that day.
The home breeder's message to me:
Dr Sing, indly assist to investigate the following:
Name and tel of buyer given
She claimed she had brought the puppy shih tzu, female, gold/white, 2 mths old to your clinic appointment on 25 Jan, for puppy's lst vaccination and microchip. However she had informed me yesterday that your vet told her the puppy is only 5 weeks old.
I suppose in that instance no vaccination or microchip done? N what is the assessment for no vaccine for the puppy? That constitutes to the buyer claiming your vet said so. If this is the case, I will make report and take action accordingly.
The puppies were born on 28 Nov 2011. I was the one who helped my dog gave birth to the puopies. I would like your assistance to investigate and clarification to this matter soonest. Thank you.
----------------------------------------
My reply to the breeder:
On 25 Jan 2012, none of the 4 vets including myself had a case of a female shih tzu puppy, gold and white, 8 weeks or 5 weeks for vaccination. I have checked all cases done on that day. Give me her tel number to verify with her.
-------------------------------------------
I have not contacted the buyer yet. This is quite an emotional issue and it is best not to rush into phoning the buyer since she had not come on Jan 25, 2012. How to handle this case since the buyer had stopped responding to the breeder's phone call?
Based on this case, home breeders who are concerned about their puppies sold may find it important to give a paper of birth when they sell their puppies.
844. Character and Competence of interns and new employees
To: The young interns and employees
Please note that you may want to do everything in a project at once according to your "better" way and your timing with no limits. That is the mark of your internet generation. But that takes lots of times and in the end, you take so much time that "opportunity costs" (if this is the correct word) have passed you by.
What I usually suggest to my younger interns at Toa Payoh Vets is to produce results within 3 days by doing smaller segments of the project.
For example, in doing a stock inventory of drugs, I have this young man, Mr Lim who has taken 2 months and has not been able to produce the complete list of unit pricing etc. This is because he tries to do all categories at one time. I have asked him to do one category at a time e.g. "Prescription Diets", then "Eye Drops" and that should be the way to produce results to show to your boss that you have achieved some results for discussion and editing.
The google generation will always switch on their computer to do the writing. Sometimes, a piece of paper and pencil achieve faster results.
I hope you will be open to receiving instructions to adopt the existing processes and not try and do new things for the time being.
By "opportunity costs", I mean that the opportunity to make money has slipped by if a person takes a long time to produce results like trying to get every information about a big project in place.
In the commercial world, performance counts and time is money. For the youths, time is eternal and I note that many simply waste their time daily in not being productive, efficient and able to accept instructions from old fogies whom they think are outdated and close-minded.
Old fogies have learnt from the hard knocks of life and some processes and systems have been produced through trials and errors that are not explained to the interns instantly, due to lack of time, pressure of work and the need to assess of the intern's motivations and diligence.
It takes a lot of time to explain the rationale of why the processes and systems are being used and unless the intern or youth has shown character and competence, there is so much the old fogies have to perform such that there is little time to just talk about the history of why certain tasks need to be performed in the present situation.
If there are improvements and innovations, the youths can propose later. But first, the new intern or employee must learn to adopt existing processes first and become productive. Performance and prompt results count in the commercial world and this is not taught in the junior colleges and universities, in my observations of the interns and new employees.
Please note that you may want to do everything in a project at once according to your "better" way and your timing with no limits. That is the mark of your internet generation. But that takes lots of times and in the end, you take so much time that "opportunity costs" (if this is the correct word) have passed you by.
What I usually suggest to my younger interns at Toa Payoh Vets is to produce results within 3 days by doing smaller segments of the project.
For example, in doing a stock inventory of drugs, I have this young man, Mr Lim who has taken 2 months and has not been able to produce the complete list of unit pricing etc. This is because he tries to do all categories at one time. I have asked him to do one category at a time e.g. "Prescription Diets", then "Eye Drops" and that should be the way to produce results to show to your boss that you have achieved some results for discussion and editing.
The google generation will always switch on their computer to do the writing. Sometimes, a piece of paper and pencil achieve faster results.
I hope you will be open to receiving instructions to adopt the existing processes and not try and do new things for the time being.
By "opportunity costs", I mean that the opportunity to make money has slipped by if a person takes a long time to produce results like trying to get every information about a big project in place.
In the commercial world, performance counts and time is money. For the youths, time is eternal and I note that many simply waste their time daily in not being productive, efficient and able to accept instructions from old fogies whom they think are outdated and close-minded.
Old fogies have learnt from the hard knocks of life and some processes and systems have been produced through trials and errors that are not explained to the interns instantly, due to lack of time, pressure of work and the need to assess of the intern's motivations and diligence.
It takes a lot of time to explain the rationale of why the processes and systems are being used and unless the intern or youth has shown character and competence, there is so much the old fogies have to perform such that there is little time to just talk about the history of why certain tasks need to be performed in the present situation.
If there are improvements and innovations, the youths can propose later. But first, the new intern or employee must learn to adopt existing processes first and become productive. Performance and prompt results count in the commercial world and this is not taught in the junior colleges and universities, in my observations of the interns and new employees.
Thursday, January 26, 2012
843. Dressing casually as a vet or veterinary staff
This year 2012, I will not try to be flexible as in the past years. I will not tolerate casual dressing by my vets or the staff or intern.
Sandals, T-shirts and jeans are out. Those who persists will likely get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.
Dressing casually is out in 2012 and those who insists on dressing casually will need to look for another job.
Sandals, T-shirts and jeans are out. Those who persists will likely get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.
Dressing casually is out in 2012 and those who insists on dressing casually will need to look for another job.
Wednesday, January 25, 2012
842. Chinese New Year 3rd day - follow-up 3 cases
National Library, Jan 25, 2012 7.42 pm
Dr Daniel Sing's first day at work
3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.
That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."
Case 1.
Jack Russell. Male, 12 years old.
After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.
The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.
As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.
For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.
But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.
Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.
There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."
I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.
What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.
He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.
Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.
Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.
Dr Daniel Sing's first day at work
3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.
That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."
Case 1.
Jack Russell. Male, 12 years old.
After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.
The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.
As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.
For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.
But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.
Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.
There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."
I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.
What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.
He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.
Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.
Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.
841. Email advice about a fast-growing hamster leg tumour
On Tue, Jan 24, 2012 at 4:44 PM, ...@yahoo.com> wrote:
Dear Doctor,
I need your advise regarding my daughter's winter white hamster.
It is abt 2years 2mths old and had a tumour on the right leg. We
noticed this tumour last year and its about a pea size.
Had brought her to a vet in Jan 2011 and advise against surgery due to old age.Within 2 weeks in Dec 2010 the tumor had grown very fast to a walnut size. She is eating and drink fine only her movement is rather slow and she keep bitting the tumour.
Is it too late to have the tumour remove now? If surgery is possible how much does it cost?We really love her sooo much, how do we know if she is in pain?
Would really appreciate your advise.
Thank You.
Regards
Owner's name
Thank you for your email. I am Dr Sing from Toa Payoh Vets
There is only one option to prevent death by infections and great pain from the growing tumour and that is surgical excision. Pain is shown by self-biting and being not active or eating in hamsters.
There is always an anaesthetic risk of death on the operating table for the older pet. You have to decide yourself. Cost is approximately $150-$200 for surgery and anaesthesia.
Coincidentally, I just saw a case of a dwarf hamster with a big growth on the back leg near the ankle. The lady had been advised by my associate vet Dr Vanessa to do leg amputation. But she did not want to as she did not want her hamster to be 3-legged. The tumour grew fast into a fatty ball of around 1 cm in diameter. Just as she arrived in a taxi to consult me, the hamster passed away. She could have saved this 1-year-old by permitting surgery 2 weeks earlier.
Therefore, decisions are made by the owner. The vet should give the proper advice and in your case, the advice from your vet was good. Pl make appointment at 6254 3326 if you decide on surgery. Best wishes.
Dear Doctor,
I need your advise regarding my daughter's winter white hamster.
It is abt 2years 2mths old and had a tumour on the right leg. We
noticed this tumour last year and its about a pea size.
Had brought her to a vet in Jan 2011 and advise against surgery due to old age.Within 2 weeks in Dec 2010 the tumor had grown very fast to a walnut size. She is eating and drink fine only her movement is rather slow and she keep bitting the tumour.
Is it too late to have the tumour remove now? If surgery is possible how much does it cost?We really love her sooo much, how do we know if she is in pain?
Would really appreciate your advise.
Thank You.
Regards
Owner's name
Thank you for your email. I am Dr Sing from Toa Payoh Vets
There is only one option to prevent death by infections and great pain from the growing tumour and that is surgical excision. Pain is shown by self-biting and being not active or eating in hamsters.
There is always an anaesthetic risk of death on the operating table for the older pet. You have to decide yourself. Cost is approximately $150-$200 for surgery and anaesthesia.
Coincidentally, I just saw a case of a dwarf hamster with a big growth on the back leg near the ankle. The lady had been advised by my associate vet Dr Vanessa to do leg amputation. But she did not want to as she did not want her hamster to be 3-legged. The tumour grew fast into a fatty ball of around 1 cm in diameter. Just as she arrived in a taxi to consult me, the hamster passed away. She could have saved this 1-year-old by permitting surgery 2 weeks earlier.
Therefore, decisions are made by the owner. The vet should give the proper advice and in your case, the advice from your vet was good. Pl make appointment at 6254 3326 if you decide on surgery. Best wishes.
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