Wednesday, July 15, 2020

3372. Covid-19 stories. The 83-year-old tissue selling aunty. Tissue seller

COVID-19 STORIES Dr Sing Kong Yuen, BVMS (Glasgow)

An 83-year-old tissue seller wore her face mask incorrectly

Tuesday Jul 14, 2020

“There is no need to worry,” the 83-year-old wheel-chaired, leathery faced tissue seller assured me that the mask wearing enforcers would not bother her as she had her face mask hanging loose around her neck. “Where have you been? I have not seen you for a long time!”


“You had been selling tissues since April 7 when the Covid-19 lockdown started?” I asked. “The government officers wheeled me home when they stopped me selling. I have started around 10 days ago.”

“You ought to wear your mask properly,” I told her that her mask's right ear loop was broken. It was knotted so that she could re-use it. She would not be protected from infectious Covid-19 viral droplets and aerosols from the various passers-by at this traffic junction. “Not to worry. You sounded like the enforcers!”

I gave her two new red disposable masks and money. She thanked me and wished me prosperity and good health. I had thought that she would not be selling tissue papers anymore after 3 months of lockdown, but here she was. Her eyes were tired but she told me she would rather not stay at home and stare at the four walls. Besides, the welfare bodies gave her $200 per month which was insufficient.  In this job, she could meet people.



There were kind people who would give her $2.00 to buy a packet of tissue. Some gave her money.
One man usually bought her lunch. She suffered from paraplegia after an emergency intestinal surgery when she developed vomiting and diarrhoea after eating some food from the hawker stall.









The aunty did change to a new disposable face mask but did not use my two red ones.




Mask wearing is mandatory when outdoors until the end of the Covid-19 pandemic which is probably next year. The penalty for not wearing the face mask outdoors, unless permitted, is a $300 fine.





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Tuesday, July 7, 2020

4132. An old dog has a fast growing head tumour - trichoblastoma. - histology


DRAFT SCRIPT for video production.


HOOK

Use footage   0:00 - 0:55 as hook and narrate the following below. 

For the past 11 years, the Silkie Terrier had a small skin lump on her head. It slowly grew bigger over the years. 

However, in the past 2 months, it grew much more. It became inflamed. See the big  pinkish lump (pause this footage in the video).

The lump had changes in its cell structure as it grew bigger. Hence, it become extremely itchy. 


The owner consulted Dr Daniel of Toa Payoh Vets on Dec 18, 2014. 




 
PAUSE 

This is a 




Singapore is an island state of around 700 sq km. Small breed dogs are most popular as around 80% of the residents live in high-rise apartments. 




Tiong Bahru apartments are over 60 years old


Singapore Postman



Tiong Bahru market

Silkie terriers used to be a favourite breed as pets
in the past 10 years. Skin lumps develop as small papules and then nodules as the pet grows older. 

However, many of the baby boomer generation of owners do not have time to get their pets health checked after puppyhood as in this case study.   
Fruit stall in Tiong Bahru market





"My dog rubs her head tumour against the sofa many times!" the lady owner spoke loudly as was her usual habit. "She just can't stop doing it."  
(Animation of dog rubbing sofa?)😢😢😢😢😢


"The head of the lump is inflamed or red now," the vet explained. That inflammation cause itchiness. It can be a benign tumour like a  cancerous tumour like basal cell carcinoma or an abscess.




"Surgery to cut it off is the only treatment. 

"After cutting out the skin lump, send the lump to the laboratory for histology. Histology is the microscopic examination of the tissue cells to check whether it is cancerous or not. 

"A fast growing tumour in an old dog may be basal cell carcinoma. This is a cancerous tumour." 

The lady owner, in her late 40s, consented to the blood test, anaesthesia, surgery and histology.  


SURGERY
Use footage 0:00 - 0:32 as you narrate. 
https://www.youtube.com/watch?v=dJRFqvtEFW4

The blood test did not show any abnormalities. The dog was fit for anesthesia. Dr Daniel used a scalpel to cut out the skin lump and sent it for histology. 





HISTOLOGY is important to check: 

1.  whether the lump is cancerous or not. It was not cancerous. 
2.  whether it has had been completely cut out. In this case, 
the surgery completely removed it as Dr Daniel cut with 1-cm margin.


(Show the histology report and read:)
 
The tumour is completely excised. No overt malignancy is present.
Diagnosis: Suggestive of a trichoblastoma, not involving the resection margin.

(Pause the footage to let viewer see report in video).  




What is a trichoblastoma?

The trichoblastoma is a benign cutaneous tumor that may derive from the hair germ of a developing follicle. It is common in dogs. 

(SHOW AN IMAGE OF IT FROM THE VIDEO FOOTAGE) 

Trichoblastomas are usually present on the face and head as non-ulcerated nodules or papules.  They are very rarely pigmented or cancerous. 

Trichoblastoma may be inflamed and become itchy as in this Silkie Terrier.

On histology, trichoblastomas are large circumscribed basaloid tumors, located in the middle to lower dermis, without epidermal connection.

Tips and advices: (narrate image)


Prognosis for trichoblastoma is good with surgical removal as most do not become cancerous. However, there are rare cases of some being cancerous. 

Trichoblastic carcinoma may appear similar to trichoblastomas clinically. However, on histology, there is significant asymmetry of the architecture, atypical mitotic figures, necrosis, and substantial infiltration of the tumor into the subcutaneous fat and muscle evident in trichoblastic carcinoma.

Hence early excision saves your pet's life.  


Credits:








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Toa Payoh Vets google page images














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HISTOLOGY CAN TELL WHETHER THE HEAD NODULE IS CANCEROUS OR NOT. 

Basal cell carcinoma and trichoblastic carcinoma may appear similar to trichoblastomas clinically. 

Basal cell carcinomas are malignant, proper diagnosis and management is important. 

On histology, trichoblastomas are large circumscribed basaloid tumors, located in the middle to lower dermis, without epidermal connection. 

The use of immunohistochemistry to show the staining patterns. 

Histologically there are retraction spaces, atypia, and single cell necrosis in basal cell carcinoma. In addition, basal cell carcinomas do not stain for cytokeratin 20 and CD34 antigens. They also have diffuse staining of bcl-2 compared to peripheral staining seen in trichoblastomas.

Basal cell carcinomas do not stain for cytokeratin 20 and CD34 antigens. They also have diffuse staining of bcl-2 compared to peripheral staining seen in trichoblastomas.


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RESEARCH NOTES
TP 45715


Dec 18, 2014 Case consultation and operation videos
Dog, F, 11 yrs

Pt 1

Difficult to give tablet after surgery - excision of skin lump by Dr Daniel today. It is best to get small skin lump removed by your vet as some of them do turn malignant or irritate the dog. This dog was rubbing the skin tumour above the neck against the bed etc. for many years.





4131. CHLOE TO MAKE VIDEO. A 7-year-old Golden Retriever has a gigantic elbow lump. -


July 17, 2020
Chloe. 

Title : A GR had a large elbow "hygroma" twice the size of a Thai mango.
Do 3 good videos.  Diagnosis, treatment, Follow up 


This case study will teach you a lot of veterinary medicine and surgery if you know how to find the parts (e.g. laboratory aids to diagnosis - cytology by Vet 1 (see report), ultrasound (footage in You tube, download and use it), 

radiography (2 images....learn how to describe it), histology..(read and show the slides of cancerous cells....), 






surgery (complete excision not possible, what is complete excision? bone involvement etc. plasty to close such a big hole hence the other vets were reluctant to perform surgery and referring the owner to Vet 3 with CT scan). What is CT scan? Read up and write.  


USE THE 3D'S FORMAT
1. Details (Hook and introduction). BKTP Images.
2. Dialogue
3. Discovery  (Include credits etc).
all wrapped in drama

I will write this case for you as an example. You need to reduce the word count by 50% (try).

DETAILS for Part 1
HOOK (with video footages and images)

Big breeds like the Golden Retriever do suffer from elbow swellings due to lying down on hard surfaces like hardwood floors, tiles or concrete. Repeated trauma causes the skin over the elbow joint to form a soft swelling to protect the elbow joint. This is an elbow hygroma.  Many dog owners who do internet research will diagnose an elbow hygroma which is not cancerous. No big deal. No hurry to consult the vet. 


However in this Golden Retriever, the elbow swelling started to grow bigger and bigger in March 2020. She phoned her vet, but was told that the Singapore lockdown from April to June 2020, to stem the spread of Covid-19 viral infections had not permitted surgery to remove "skin lumps". In July, the elbow swelling was twice as big as the Thai mangoes. She consulted 2 vets in July but they advised cytology, ultrasonography, radiography and then a CT scan at the 3rd Vet who will perform surgery (excision).

The medical costs were mounting. A quotation of more than $5,000 for the surgery caused her to seek advice from her Golden Retriever Club. A member referred her to Toa Payoh Vets.   

DIALOGUE is by WhatsApp and phone conversations. 
Jul 5, 2020

The owner WhatsApp Images to Dr Sing Kong Yuen.

Small "elbow hygroma" before lockdown

Gigantic elbow tumour (sarcoma) in July 2020








Cytology done by Vet 1.
Owner went to Vet 2 who did ultrasound (video footage in Youtube) and X-rays (Images below)


Tuesday, 9 July 2020, Dr Sing advised bringing the dog to Toa Payoh Vets for examination.

Cytology report, ultrasound video clip, X-rays were submitted by Vets 1 and 2 to Dr Daniel.
(Chloe, to Interpret the documents).

 The owner did not want a blood test for health screening before anaesthesia and surgery by Dr Daniel Sing. Dr Daniel had diagnosed a possible sarcoma. He would operate the next day.


July 8, 2020.  Day 1 post-op. WHATSAPP BY DR SING TO OWNER.
Dog eating well and wanting to pee and poop.


Jul 17, 2020. All ok. Some stitch break down.



POST OP
DAY 1


DISCOVERY
1. Early treatment saves lives. Small tumour can be excised completely This means no cancerous cells at the margins.

2. Histology is important. 








3. Delays - cancerous ones like sarcomas will not be completely excised. Recurrence. Leg amputation may be needed. Most owners against  amputation. 

4. Outcome for this dog.    Follow up -- another video


POST OP IMAGES FROM THE OWNER




















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SETTING (Singapore images and happenings) to be introduced in Part 1.
As it was not done, do it in Part 2. Intern to script a narrative using the following images  in Jul 6, 2020 to introduce the setting (Singapore). Singapore Covid-19 lockdown - APR 7 to Jun 30, food couriers, mandatory mask wearing, 2020 elections



SETTING - Singapore high rises - a modern new Housing Development Board apartments
Funan Shopping Mall.  Sg Malls closed for over 2 months

Deliveroo Food couriers work harder as more people stay at home to avoid Covid-19 infections

food courier    mask wearers in the background

2020 Elections
2020 Elections.  Yio Chu Kang single member constituency
Progress Singapore Party vs. People's Action Party

Prime Minister Lee Hsien Loong of the People's Action Party

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Male, neutered, 7-year-old Golden Retriever



Small elbow mass spotted in March 2020. Singapore lockdown  starting from April 7, 2020 with devastating impact on this Golden Retriever as vets were prohibited to operate on tumours. This tumour did not stay small....grew explosively to be a gigantic mass.  Vet 1 prescribed medication which was ineffective. Vet 2 did not operate and referred to another Vet for CT scan.   (USE IMAGES WITHOUT TEXT - SEE BELOW)
















Likely to be a sarcoma. Owner is happy that Dr Daniel will operate as Vet 2 did not want to perform such surgery. 

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HISTOLOPATTHOLOGY REPORT

Tumour from the left front leg (arm). 1 x pot.
2.8 x 1.9 x 1.4 cm.

Summary of the report. Over 80% of the cutaneous mass, left front leg has undergone severe coagulative necrosis. Where is mass is still intact, there is no normal tissue present as cells are neoplastic.

Diagnosis:
Cutaneous mass: Poorly diferentitated sarcoma. Cells are consisttent with sarcoma. Diferentials include soft tissue sarcoma, histiocytic sarcoma or less likely a neoplasm arising from the bone. If the invasion or involvment is not from the underlying bone, this is likely a high-grade soft tissue sarcoma. 


TIPS AND ADVICES

Early detection and surgical excision will be best if your pet has a small elbow lump. It may not be the benign hygroma (elbow swelling with fluid) as suspected by the owner in this case. Early surgery may permit complete excision of this malignant tumour.


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3 FINAL VIDEOS ARE COMPLETED BY THE INTERNS

1. Diagnosis by Chloe


2.  Treatment by Chloe


3. Follow-up 





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ORIGINAL IMAGES