I have attached a document on the case studies I have
seen on the 2nd day of internship, 18 December 2011. Is
this what you want of the daily case studies or does it
have to be more detailed?
Yours Sincerely
Name of Intern
REPLY FROM DR SING DATED DEC 19, 2011
Thanks for email. During internship, one case study per
day is to be recorded for me to review and discussed
with you. Otherwise, being a bystander standing around
the vet will not enable you to appreciate the diverse
aspects of vet medicine and surgery and its varied
clinical presentations and challenges to a correct
diagnosis.
Evidence-based medicine and knowing how to arrive at a
correct diagnosis is not so easy in some rare cases as
in this Sheltie whose condition may be mis-diagnosed as
ringworm when the actual cause of the hair loss is due
to hormonal factors.
One Case study should be written with the following
format using the Sheltie you saw yesterday Sunday as an
example. You re-write your case study with as much info
of the case under the following headings:
CASE NO. 1 DATE:
1. Description of patient - breed, gender, age, colour.
Not spayed.
2. Chief complaint - hair loss. Other complaints -
3. History - Hair loss for the last 5 years. Hair grows
back after the heat and problem of hair loss recurs. Not
fully recovered. Seen 2 vets.
4. Presenting sign: Vulval enlarged over 20X normal.
Hyperpigmented black.
5. Examination and tests (blood, urine, skin etc).
6. Diagnosis
7. Treatment/Advice
8. Review/Outcome/Follow up - 2 weeks later. Date to be
written on medical record.
8. Against Medical Advices - to be written down
As reviewed by me, what should have been included in
this case were:
1. Where were the medical records of other vets? This
should be recorded if the owner does not bring them. If
owner said "Blood test of other vet is OK," the vet
should not take the owner's word for it and ask for the
blood test results. Some owners do NOT want to pay for
another blood test and this should be recorded under
"Against Medical Advices".
2. When was the last heat? This should be asked.
From my review of the above case, the main diagnosis
would be a case of hyperestrogenism rather than fungal
infections of the dog. Fungal infections are present but
the dog's problem will not be cured even if the ringworm
is eliminated. So, the owner goes to another vet later
for a 4th opinion or just accept that nothing can be
done. The dog was put on a hypo-allergic diet by the
previous vet for one month. This would be too early to
eliminate dry food allergy as a cause of the hair loss.
Record all
observations in your medical record including
enlargement of the vulva and the history of
estrus.
The owner had given a clue for hyperestrogenism:
"The Sheltie's hairs grow back after the end of
heat but 6 months later, the hairs drop off
again". This clue indicates that the hair loss is
associated with the hormonal cycle of the female
dog. Examination of the grossly enlarged vulva
would be another clue. This time, the clue comes
from the dog
Now, the
Presenting Sign of a swollen vulva 3 months after the
end of heat and its presence for over the last 5 years
point to a high probability of hyperestrogenism. The
solution for this owner is to spay his dog after the
skin infections are resolved in around 4 weeks' time.
However the dog is old and there are high anaesthetic
risks. This case is quite rare. I had seen less than 10
cases over the past 30 years of small animal practice.
So a mis-diagnosis can easily be made as the skin signs
of recurring hair loss distracts from the PRESENTING
SIGN. A blood test for hormonal levels should be advised
in theory and as part of the practice of evidence-based
medicine.
P.S
What the intern on his 2nd day of internship, wrote
quite a good report considering the fact that he did not
study Biology during his A levels:
Day 2 of internship at
Tao Payoh Vets (18 December 2011)
Case 1
A 12 years old dog that has
been having skin problems for the past 5 years.
There is dandruff all over the dog’s body. The dog
also has dry skin. Fungus is also growing on the
skin of the dog and it gives off a bad odour. It
is suspected that the dog’s hormones caused the
skin problems. There is also a pressure sore in an
area as the dog kept lying on one side. Medicated
wash was given to reduce the fungus growth.
Conditioner was given with the medicated wash as
medicated wash tend to make the skin very dry.
There will be a follow up in the case to determine
the main cause of the problem.
3 Images: Two lateral views and the back view
pictures were in his .png file which could not be
downloaded. The mobile handphone pic were blurred.
The intern will learn more about digital
photography as he has more hands-on case writing.
TOA
PAYOH VETS
