1458. Skin disease & urinary stone cases

TOA PAYOH VETS toapayohvets.com Date:   14 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Skin disease & urinary stone cases Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   14 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Thursday, June 13, 2013 1458. Two skin disease & two urinary stone cases TWO SKIN DISEASE CASES   June 13, 2013  7.35 pm review I may or may not work in the evenings as Dr Daniel would be present. However, on June 13, 2013,. Dr Daniel had gone to a "Dirty Dancing" concert at Marina Bay Sands and so I handled the cases after 6 pm. Surprisingly two dogs had intense ear and skin itchiness were brought in by two couples in their 30s. I used the UVL to show and tell. One dog was an aggressive Jack Russell. The other was a Shih Tzu. Both ringworm-infested hair shafts fluoresce apple-green while the normal hair showed plain lighting. This was quite impressive to the owner. I asked intern Ms Toh to video the UVL procedure but I know it is difficult to capture the real images owing to our lack of experience in videography.  "Lots of hard rubbing of the skin and ear irrigation and medication is needed," I emphasized to the two couples. "Review in 3 weeks." Case 1. The ferocious Jack Russell that all vets avoid The first couple had seen a few vets and skin scrapings were negative. "The main problem is the painful itchy left ear," I said. "There is a red circular skin patch in front of the left ear of 4 cm across. It would be ringworm . Also, the left inguinal area is extremely red while the right is normal white. Therefore, I can say that this is not a case of contact dermatitis although some vets will say it is ventral contact dermatitis. In such cases, both the left and right inguinal areas are inflamed. Your dog only has the left side blood red, now obvious after clipping the whole body bald." The couple had brought the dog in the morning. I gave him immediately a Dom + Ket 0.1 ml + 0.11 ml IM and the dog was sedated for dental scaling and hair clipping without biting my assistant and me.  The owner came in the evening after work to take the dog home and I had a lengthy discussion with them as generalised skin diseases are not so easily treated by owners despite seeing several vets. "If you see 10 vets, you will have 10 different opinions as to the cause of the skin disease. "From my observation, the dog uses his left hind paws to scratch vigorously the left inguinal area because the left ear is extremely painful. Most owners will wonder what the left inguinal area's itchiness has to do with the left ear being infected? There is a nerve connection and you will see the dog's hind leg moving whenever the same sided ear is itchy. Only in this dog, the leg scratches the inguinal area. Normally it scratches the flank and belly area." The Jack Russell shook his head sideways and this was a clue that he has ear problems. As to which ear he scratches more, the couple did not know. "I saw both ears being scratched," the husband said. I would say it is the left ear as the inflamed skin was present mainly on the left ear base and the left inguinal area. Only the dog knows and he cannot talk! Case 2. The timid Shih Tzu is a tiger at home. As for the Shih Tzu, he bites the owners but was docile at the consultation table. He did not bite me or my assistant. I advised: "Feed the anti-fungal and antibiotic medication tablets inside cheese balls when he is hungry. Irrigate his ears with ear drops downstairs away from his home base as he may be more docile. "Do you sell muzzles?" the wife asked me. "This Shih Tzu is hard to muzzle as he has a flat face," I said. "Use the net from the oranges for sale to cover his face but I doubt it will work."  I muzzled the dog with my muzzle but it was too long. "More for a Jack Russell with long nose," the wife laughed. Still the owner must work hard on the ear to resolve the problem. Going downstairs to clean the ears may be successful as the dog appears timid in the clinic but ferocious at home.  In the Jack Russell, it is unusual as the left inguinal and scrotal area were very red. Neck skin and paws also were red. One paw showed fluorescence at the pad junction but the dog wanted to bite me when I tried to lift the paw up to shine the UV light. The wife was convinced. In the Shih Tzu, the neck showed a large circular patch of 5 x 4 cm which fluroesce green in certain parts, confirming ringworm. The wife was quite impressed with this show and tell. The chin was inflamed too. Ear surface were rough but not much pain when I pressed both ears. In this case, the main area of itchiness was inflamed by ringworm and the belly, flank and inguinal area were OK.      THREE URINARY STONE CASES. Case 1. Urine crystals 3+ but no stones in the X-rays. This morning, I got a 2-year-old female cross X-rayed as her urine test showed triple phosphate 3+ crystals. X-rays did not show any stones.  S/D diet for 2 months advised by Dr Daniel. Case 2. 10 little stones Yesterday's X-ray of the male, overweight older Jack Russell, emptied bladder and catherised showed at least 6 bladder stones of 3 mm across. Dr Daniel operated today and removed 10 stones. Urine test showed Calcium oxalate. The dog is resting as I typed this report and is given IV drip. "His bladder bleeds and tears whenever I stitch the tissues," Dr Daniel says. "His bladder wall is thin as he is not badly infected for some time. There is little inflammation and so there is a difficulty in stitching with 3/0 monosyn."   As for me, I used 3/0 absorbable braided with smaller needle but the monosyn comes with a bigger needle. Each vet has his or her own preferences. Case 3. Update on blood in the urine   6189 - 6192. Female dog urethral catherisation and 30 ml of air into bladder provides excellent contrast X-rays. Against Medical Advices Female Poodle with one big bladder stone and small kidney stones. The owner phoned for appointment tomorrow Friday for surgery. I will be operating. This case was infected as the total WCC was high at 25 but now the dog is OK and active. Case is at: Against Medical Advices. So, my operation can proceed tomorrow, Jun 14, 2013.   Update will be on this webpage: www.sinpets.com/F5/20130613 skin_diseases_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 14, 2013 Toa Payoh Vets

1457. Emptied bladder shows 9 calcium oxalate stones (X-ray)

Kidney ok
Blood in urine two times

1456. Two You tube videos - canine i/v placement & cherry eye tucked in

I/V catheter placement in a dog
http://www.youtube.com/watch?v=wt_K1beUZEI


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TOA PAYOH VETS toapayohvets.com Date:   13 June, 2013   Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Cherry Eye in 2 Dogs in 2002 and 2010 Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Case 1 written: 20 Sep 2002 Case 2 written: 01 Sep 2010 Updated: 13 Jun 2013 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Case 1: Cherry Eye in a Cocker Spaniel puppy in 2002 Case 2: Cherry Eye in a English Bulldog in 2010 8 years had passed since I documented the cherry eye in the Cocker Spaniel case above. In 2010, there are over 200 pet shops and more than 10 approved puppy breeders in Singapore. I got a referral of a cherry eye recently. The man said: "The seller told me to wait till the other eye develops a cherry eye before going to the vet for the surgery." I operated on this puppy and excised the gland. There was no complaint from him since 3 months ago. He did not want any recurrence or popping out of the cherry eye if I did the "tucked in surgery" which costs much more and which is not guaranteed. Many Singapore pet owners are cost-conscious and therefore do not follow up or wish to pay for repeat surgery which may occur in the "tucked in surgery".  Some get very upset at having to repeat the surgery.  Therefore, the vet has to be understanding and practical. Any surgery over $200 seem to meet a resistance level from pet owners in Singapore. In such cases, the vet has to snip off the cherry eye although it is said that the dog may develop dry eye if the cherry eye has been cut off. Using the cheaper method of excision, the veterinary treatment of the excision of the cherry eye in the dog is discussed below:   CHERRY EYE EXCISION SURGERY IN THIS BRITISH BULLDOG PUPPY 1. Gas mask isoflurane - no problem 2. Local anaesthestic subconjuctiva below the cherry eye 3. Clamp for a few seconds 4. Remove clamp unless there is space below the clamp to perform step 5. 5. Ligate central vertical area where blood supply to the cherry eye is located 6. Excise gland with scalpel 7. No bleeding post-operation using this procedure   ALTERNATIVE TO ABOVE-MENTIONED SURGICAL EXCISION APPROACH As above, but no ligation. Profuse bleeding post-operation is temporary. I find that this approach is satisfactory.  Excise as little of the cherry eye as possible as it is said to produce 30-40% of the tears. NO EXCISION APPROACH - CHERRY EYE TUCKED IN METHOD The re-positioning of the cherry eye and suturing it is usually advised but this approach is costly and does not guarantee that the cherry eye will not prolapse. Extra veterinary costs for additional surgery is not be acceptable by many Singapore pet owner. The vet cannot guarantee a successful treatment outcome in this approach and so the owner is reluctant to pay more for this surgery. The culture for most Singaporean pet owners and travellers is to go for the cheapest although there are more sophisticated ones in 2013 wanting to know more about the quality than quantity of service.   Jun 13, 2013. Cherry eye tucked in surgery videos from You tube 1.  Cherry eye tucked in surgery video seen on You Tube Electro-excision, continuous sutures,  local anaesthestic, two sutures knots away from the cornea. 7 days later to remove knots. http://www.youtube.com/watch?v=Xsaq8ks2Jg4 Well filmed video. The suture used is likely to be 2/0. 2. http://www.youtube.com/watch?v=SvXybSHaZ9w A video by Neartown Animal Clinic - a vet used absorbable 5/0 and use scissors instead of electro-excision to cut and undermine the conjunctival surface away from the cherry eye. She cuts out the conjunctiva covering the cherry eye. Then she used a continuous suture to close the wound after tucking in the cherry eye. This piece of conjunctiva cut off is shown in the video. Her procedure is described in 4th edition of the Small Animal textbook edited by T W Fossum. She used a corneal shield availabe from Ellman, Item H781. Sutures are placed away from the cornea on the outside skin of the eye area. 3. http://www.youtube.com/watch?v=EAu2QpxpdBA Cherry eye surgery at Shinki Vet Hospital 4.  http://www.youtube.com/watch?v=uBmCpekwpcc Suture anchoring tack method. Sharing of knowledge from the video producers benefit many pet owners and vet surgeons as each party provides new ideas and tools about veterinary surgery. Updates will be on this webpage. URL is: http://www.sinpets.com/dogs/cherryeye.htm   Advertisement Asia USA Realty (Singapore) asiahomes.com Pte Ltd   VARIOUS UNITS ARE FOR RENT AT VARIOUS TIMES: Tel: +65 9668 6468, Email: judy@asiahomes.com Asia USA Realty More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129

Toa Payoh Vets Clinical Research

1455. AMA - Against Medical Advices - A case study

TOA PAYOH VETS toapayohvets.com Date:   14 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Against Medical Advices (AMA) Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   14 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 "Vet 1 did not advise me to get an X-ray to check whether the cause of blood in my dog's urine is due to urinary stones," the owner said to me. I had reviewed Vet 1's medical records of this poodle and Vet 1 had not written his advices to get X-rays done. Earlier, I had asked Vet 1 whether he did advise X-ray since the owner told me he was not told. "I always advise X-ray and urine test when a dog passes blood in the urine," Vet 1 said to me. "The owner wanted to wait and see after a course of antibiotics." A urine test was done as there was a report which showed "No crystals in the urine." I told the owner that I had written "owner does not want radiography" on the urine test report as I had reviewed this case done by Vet 1 and had asked him why he did not advise X-ray during the consultation. Vet 1 had said that the owner did not wish to have X-ray. However there was no AMA in his medical report and I had not pursued the matter further. I was present when the owner came as his dog had passed blood in the urine after the course of antibiotics.  Sometimes, I don't record every medical advice to the owners too and this can be held against me when there is a negligence complaint to the authorities or in litigation. It is one man's word against another. Who to believe? I got the owner's permission to do a blood test, X-ray and urine test. I asked my assistant to use "Whats App" from his mobile phone to send him all the 3 results. The owner replied instantly with queries and this showed that he was much concerned about his old dog's health. Many old dogs are family members. This case shows that the vet must be proactive and consistent in his veterinary process, protocols and systems to provide evidence-based medicine. Many times we want to save money for the owner by not doing tests. But such kindness could turn against the vet if the dog dies. By recording AMA (Against Medical Advices) in the medical records during consultation, no ambiguity arise when there is litigation or complaint to the vet authorities. I usually write as I talk to the owner. Some vets do their writing at the end of consultation and this is where he or she forgets to record medical matters and advices. If the owner has been given the X-rays or lab test reports, this should also be written down in the case sheets.  Nowadays, Singapore owners are more sophisticated, veterinary competition is more intense. Vets have to deliver results or justify their treatment and this can be done by being meticulous and aware of the need to have a proper process, system and protocols in veterinary diagnosis and treatment of diseases in pets. This case illustrates the importance of AMAs in the practice of medicine and the need to practise defensive and evidence-based medicine in a developed country like Singapore.    P.S. The dog will be operated by me today, Jun 14, 2013 after another course of antibiotics and when she eats and is active. The blood tests showed a high total white cell count of 25 and very high number of neutrophils indicating a bacterial infection at the time of consultation with me. Urine test this time showed struvites crystals. X-rays of the female dog with urethral catherisation and 30 ml of air showed a big urinary stone and no bladder tumour. The owner has been told that kidney stones are also present in the left bladder. Only the bladder stone will be removed in today's surgery. Every old dog anaesthesia is high risk and this dog is 10 years old and much loved by the family. Pressures are high for any vet as nobody can guarantee no anaesthetic death on the operating table.           6189. Female dog urethral catherisation and 30 ml of air into bladder provides excellent contrast X-rays Update will be on this webpage: http://www.sinpets.com/F5/20130614 against_medical_advices_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 14, 2013 Toa Payoh Vets

1454. Myanmar stories - The man from Rangoon

Yesterday Jun 11, 2013, I visited Khin Khin. She was subletting half her office at $850 to another person as the employment agency business had gone downhill with the Singapore Government's clamp down on the hiring of foreigners by Singapore employers. During the election, the foreigners were a hot issue, said to deprive Singaporeans of jobs and lowering the salaries. So, nowadays, many applications are rejected as compared to liberal approvals over 2 years ago. Other countries like the UK and USA also have restricted foreigners from gaining employment.

I met a tall slim dark skinned man who had resigned from working in a recycling company after 2 weeks of work. He had this black hair creamed and curved into a wave at the left side, just the style some 50 years ago. He could speak some English and I asked why he resigned.

"Shouting and shouting by the manager," he put his left hand on his heart area. "Every time shout. If I put the wrong item into the container, I have to re-do again. For example, if I put aluminium can into the steel container, I have to start and sort all again. More shouting. I just can't take this anymore."

"Where are you from and how old are you?" I asked.
"I am from Rangoon. I am 38 years old."

I was surprised he said "Rangoon" instead of "Yangon".

His father had passed away and his mother is a retired civil servant who has pensions.
He is a Myanmar graduate in Zoology. I felt sad for him as he must have spent a lot of money coming here and now he is looking for another job.

"I was new to this job," the Rangoon man said. "If they give me 3 months, I will be more experienced. But the manager shouted and shouted at me all the time. I have to work for the forklift driver and the others too. But they all shouted at me."

"What are your working hours?" I asked.
"7.30 am to 6.30 pm and sometimes to 7.30 pm when the delivery truck comes late."
"Do you work on Sundays?" I asked.
"Every Sunday but I get one weekday off a week."


"It is not so easy to find another employer as you have no experience and Singapore employers are not allowed to hire freely as before," I knew of many applications rejected by the MOM although the employer has the required quota. "You may face shouting employers again. Will you then resign again?"

"I will not resign," he said.
I asked him to contact Bernard the agent who got him this job.
He took out his Zit phone which looked like the very ancient Nokia phone without camera and frills and dialled the number. Nobody answered. I dialled the same number on my phone and Bernard said that the S Pass had been cancelled and he had one month to go home or find another employer.
"I thought he said he had given a month's notice," I said.
"No need," Bernard said. "He was on probation and since he resigned, he would not need to give notice."

It is too late. In addition, this man would lose 50% of his agency fee if he loses his job within 6 months, according to the MOM rules and regulations.But he did not get sacked. He resigned and therefore he could lose all. There were 4 other foreign workers in this recycling firm and they were Chinese Nationals. Sometimes, they could be ganging to oust him by scolding a novice and getting him to work faster and be more productive. I don't know.