NO NEWS IS GOOD NEWS
"The owner's previous male cat had the same problem of dysuria (difficulty in passing urine)," I said as I presented a 3-year-old male cat to the Senior Veterinarian, Dr Foo for radiography which is an X-ray of the bladder and kidneys. "He died a few weeks later."
Dr Foo frowned. He had performed at least a thousand cases in forty years of small animal practice and had a solid surgical reputation in my opinion. Deaths from urinary bladder obstruction would occur as no veterinarian could save every case and many owners had not complied with instructions to take medication, change to a calculolytic diet or go for a follow up. In most cases, the cat refused to take medication or accept a new diet and the owner could not do much.
I elaborated, "The owner did say that she had left the post-operative care of her first case to her mother as she was overseas. The cat would not take the medication and her mother had not consulted any veterinarian. The cat then died. Probably due to urinary bladder rupture and or kidney failure."
"No point taking X-rays," Dr Foo said. "Nothing will be seen as the cat with urolithiasis do not have solid stones."
"There may be obstruction by stones further up the bladder, in the ureter or in the kidneys," I said. "Although urethral obstruction in the cat is usually caused by an organic matrix which would not be seen clearly on X-rays, sometimes there may be crystals."
No urinary stones seen on X-rays
X-rays add to the veterinary costs and in the dog-eat-dog veterinary practices of Singapore, it was the least cost that attract the average pet owner. Overheads are high and if there are no clients, there will be no revenue and the practice will have to close within a year or two.
Dr Foo had been long in practice to understand that Singaporeans want cheap and good services. The competitor was nearby. Younger veterinarians in new practices underprice their services, a common situation in the private sector.
He was experienced but he could not command higher fees because the pet owners were not sophisticated enough yet to pay a premium for veterans. In fact, his fees were in some cases lower than the competition!
The mean age (50% of the cases) for urolithiasis in cats is 7 years old and the range 1 - 22 years old, but this cat was only 3 years old. He was a gentle slim cat with a "M" in his forehead, nervous about going outdoors and much loved by the equally trim and fit lady owner, a career lady who worked long hours into the night. She had said, "I hope you don't need to neuter him during treatment as I wanted him to be a father."
The cat was tranquilised and treated. It was difficult to dislodge the organic plug inside the urethra. After some five minutes, the urine shot out onto his hands.
The obstruction was cleared and the bladder was pressed to allow more urine to flow out. It was a relief as if we had urinary bladder obstruction. Nurse Ann's joy was short-lived. The urine flow stopped suddenly. The male cat urethra is very narrow and it was blocked again.
More work at dislodging the urethral plug. Dr Foo inserted a catheter into the urethra to let the urine flow out. Strong ammonia smell mixed with blood. Infected smelly urine. The urine had a strong ammonia smell as if it was kept for several days inside the bladder.
A neck collar was worn to prevent the cat from biting off the catheter which was sutured to the skin. Dr Foo said that the cat could go home with medication and that would mean least cost. But would that be in the interest of the cat? It was not easy for most Singapore owners to medicate a cat.
It would have been better to keep the cat for the next 3 days to observe and checked that his urinary obstruction and bleeding in the bladder had stopped. But the practice would be known as "expensive" and that would out price the competitors.
I had given him antibiotic and dextrose saline injections to flush out any "sand" inside his bladder. Two hours after surgery, he passed a large amount of smelly blood-stained urine. Seventeen hours later, his urine passed the smell test. It was not smelly and that was good.
Would his catheter get blocked? The owner brought the cat back the next day as I did not want her to incur more boarding costs.
The owner, being a doctor, would know what to do with medication and a change from dry cat feed to a low magnesium diet. The urine and the uroliths inside the urine were not sent for laboratory examination or bacterial culture because that would increase the cost of treatment.
In private practice all over the world, the average pet owner usually goes for the cheapest doctor.
Well, telephone consultations are free. I phoned the doctor five days later to enquire about this gentle cat. I left a message on her busy mobile phone for her to call me back. No call. I got her on her phone but she was busy at consultation.
"I can't talk now," she said.
"Is your cat OK?" I had to ask as this was the only chance since I did not expect her to return calls.
"Yes," she said and that was all. There were no return calls from her despite leaving messages on her mobile phone. Singaporeans seldom return phone calls unless they need to as they usually lead a hectic life.
It was best not to persist. No news is good news, that is the saying. I hope the cat had recovered well.
A Cat Can't Pee On Labour Day
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 04 May, 2011
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
The above-mentioned case, probably recorded in 2000, was fished out from my archives as I am keeping all my cat's urinary tract problem cases under
http://www.sinpets.com/cats/20110433cats-urinary-tract-urethra-obstruction-infections-toapayohvets-singapore.htm for ease of reviews and for clinical research.
On Sunday, May 1, 2011 (Labour Day in Singapore), I was manning the front desk while Dr Vanessa Lin was doing the consultation. A man in his early 50s phoned me as his cat could not urinate normally for the past two days. I had a discussion with Dr Vanessa Lin on the management of this case as I would be having the afternoon off as each vet handles a case of urethral obstruction differently. When the patient recovers, everybody is happy. But should the patient gets worse or dies, litigation and complaints may occur and I don't want that to happen to Toa Payoh Vets.
There are certain standard operating procedures I will want to advise the owner and be recorded in case of medical negligence litigation and I had to inform my associate vets as I was taking the afternoon off. These are:
1. urine collection for analysis of crystals, bacteria and blood - mandatory. Some vets do not do this and may be sued for possessing a lower standard of care if the cat dies since the vet has no defence of urine or blood tests.
2. blood collection for health screening is strongly advised esp. to check whether the kidney is affected and whether there is a severe bacterial infection. Fever may or may not be an indicative sign of this infection. If the owner does not want to pay for this test, this objection must be recorded in the case sheets.
3. As to whether the urinary catheter should stay in this cat for 2 days, I left that option to her. However, I said: "Usually I don't stitch the catheter after thoroughly irrigating the bladder if the urethra obstruction is a recent event as in this case".
For long-standing cases, I do stitch the catheter for 2 days and may irrigate the bladder again. See my procedures at: The hissing cat has difficulty peeing again
CAUSE OF THE URETHRAL OBSTRUCTION/URINARY TRACT INFECTION?
In this cat, there was no urethral obstruction as the catheter passed into the bladder easily. I spoke to the owner the next day as he came for the cat. Monday, May 2, 2011 was a public holiday as May 1 (Labour Day) happened on a Sunday.
What was the cause of this cat's dysuria problem?
"FLUTD (Feline Lower Urinary Tract Disease) usually occurs in a male neutered cat over 5 years of age," I was thinking that this cat could have some injury or infection.
"My cat is only one and a half years old and he is not neutered!" the IT man said to me.
"5-years is the average age," I said. "Some cases happen in younger cats. Is your cat busy mating with other cats and thereby suffering from traumatic injury?"
"Well, my other cat keeps humping him every month. But this has been going on for several months and there has been no problem with urination."
I try not to be antagonistic and impatient. I said: "Many events don't happen until they are performed often enough. For example, people don't get prawn allergies till they are eat prawns for many times. It is possible that your cat has traumatic injury to the penile area."
I don't want to appear soliciting for business by advising neutering of the humping cats and therefore let sleeping dogs lie. This cat's dysuria is likely to be a case of traumatic injury. The cat owner will give canned food instead of dry food. I will follow up on the cat's urine and blood test results.
TOA PAYOH VETS' URL
http://www.asiahomes.com/singaporetpvet/0707cat_urolithiasis.htm
Wednesday, May 4, 2011
Tuesday, May 3, 2011
425. Lick granuloma in a gentle Golden Retriever. What to do?
His owner said: "I have been to your Surgery before but that was a long time ago. Vet 1 gave me a tub of cream to apply but the lump will not go away. What do you advise?"
I checked my records. I had vaccinated the Golden Retriever as a puppy and that was 5 years ago. Now this gentle dog has a big lump on the lower side of his right elbow.
"This is a case of a lick granuloma," I said. "It is hard to cure. I will manage your case with Dr Vanessa," I got the dog into the consultation room and informed Dr Vanessa that the owner wanted me specifically to handle the case. I would do the case with her since the owner did not object but I would be in charge.
"The elbow is a famous for hygromas," I said. "But this is not a hygroma. It is a lick granuloma. It can't disappear with the application of creams as it is quite large."
In the consultation room, I gave the owner 2 treatment options. One was steroid injection and the other was surgical excision. "I have not seen an elbow lick granuloma before," I said to the owner. "Lick granulomas are not common in dogs in my many years of practice. This elbow lick granuloma is a rare case for me. But I have seen other lick granulomas and have successfully treated two with steroid injections."
Singapore has nearly 90% of small breeds and lick granulomas are said to be more common in big breeds such as the Golden Retriever. I must organise my clinical research cases to show the conditions before and after treatment but time is so short.
P.S. Successful treatment of lick granuloma with chiropractic therapy, see:
http://www.avca.com.au/library/lick_granuloma.pdf
I checked my records. I had vaccinated the Golden Retriever as a puppy and that was 5 years ago. Now this gentle dog has a big lump on the lower side of his right elbow.
"This is a case of a lick granuloma," I said. "It is hard to cure. I will manage your case with Dr Vanessa," I got the dog into the consultation room and informed Dr Vanessa that the owner wanted me specifically to handle the case. I would do the case with her since the owner did not object but I would be in charge.
"The elbow is a famous for hygromas," I said. "But this is not a hygroma. It is a lick granuloma. It can't disappear with the application of creams as it is quite large."
In the consultation room, I gave the owner 2 treatment options. One was steroid injection and the other was surgical excision. "I have not seen an elbow lick granuloma before," I said to the owner. "Lick granulomas are not common in dogs in my many years of practice. This elbow lick granuloma is a rare case for me. But I have seen other lick granulomas and have successfully treated two with steroid injections."
Singapore has nearly 90% of small breeds and lick granulomas are said to be more common in big breeds such as the Golden Retriever. I must organise my clinical research cases to show the conditions before and after treatment but time is so short.
P.S. Successful treatment of lick granuloma with chiropractic therapy, see:
http://www.avca.com.au/library/lick_granuloma.pdf
Monday, May 2, 2011
424. Neutering a big breed - scrotal haematomas
Neutering is such a common surgical procedure in all veterinary practices. I was surprised that the other veterinary clinic did not want to neuter this gentle Golden Retriever as the vet rejected large breeds.
One cause of the other vet's reluctance could be the complications of neutering. One complication would be post-surgical scrotal haematoma due to haemorrhage as the dog licked and traumatised the wound. Over 48 hours, the scrotum became swollen to as big as a tennis ball in big breeds. Such cases are rare but had happened to me too.
What's the prevention advice. Basically, double ligation and sufficient post-operation pain-killers. One such case with no post-op problem is shown here, in 3 images.
One cause of the other vet's reluctance could be the complications of neutering. One complication would be post-surgical scrotal haematoma due to haemorrhage as the dog licked and traumatised the wound. Over 48 hours, the scrotum became swollen to as big as a tennis ball in big breeds. Such cases are rare but had happened to me too.
What's the prevention advice. Basically, double ligation and sufficient post-operation pain-killers. One such case with no post-op problem is shown here, in 3 images.
423. Sunday May 1, 2011 Interesting Cases - The 2nd case of a hissing cat
May 1, 2011 is a bright sunshine Sunday. Monday will be a holiday as May 1 is Labour Day. So, there would be a long weekend for leisure and the causeway to Malaysia would be clogged with cars from Singaporeans desperate to escape the concrete jungles of Singapore.
As I had spent 2 hours (not joking) inside a tour bus from Singapore to Johor Bahru (a 3/4-mile causeway) during one of such weekends to tour Malacca last year, I don't bother to waste so much time now to go on holidays to Malaysia on long weekends.
Things come in 3s sometimes. I had recently written about the case of the hissing cat with urethral obstruction. No news from the owner for the last few days after my follow up 24 hours after leaving Toa Payoh Vets. I presume they are happy with the outcome and I don't want to pester them since they have been asked to phone me if they have queries.
So, on this bright sunshine morning at 9.30 am, I was surprised to hear a cat hissing at my assistant, Mr Min. He was trying to get the cat spayed by Dr Jason Teo yesterday out of the cage to go home. The mother and adult daughter had come to pick up the cat to go home. The daughter helped by putting her hand in to take the cat out. A sudden swipe of the daughter's hand and she got a scratch.
So, what should Mr Vin do. Remember my report on Mr Vin being bitten on both hands by a cross-bred while helping Dr Teo to treat the maggot wounds? He was trying to muzzle the dog which was already tranquilised by Dr Teo. The dog bit him twice as he swung the muzzle onto the dog's face. Let sleeping dogs lie? I had to get him treated by the doctor and to teach him that he ought to use a big towel to cover the sedated dog's head instead of trying to muzzle. This dog was muzzle-shy as some dogs are gun-shy.
Now, he encountered a cat that swung her right paw out and hissed at him as he tried to get her out of the crate to put her inside the owner's top-opening carrier.
The cat hissed louder as he tried again. What should he do? "Thinking on your feet" is not easy for Mr Min as he still has many years of experience to know what to do. So he was bravely trying to get the cat out. His present procedure of opening the crate door and getting the cat out, if possible, would only get him wounded and the cat escaping. Becoming more ferocious. New clients would be arriving and witnessing such incident. I could foresee such a scenario. It would be a waste of time on this public holiday and time-wasting is not good for anyone.
"Has the owner a carrier that the cat can walk into?" I asked. The carrier was top opening and I don't expect a cat to just saunter into it.
"My daughter can get the cat out," the mother said.
"No, she can't", I said. "The cat had scratched her hand!"
This was the type of situation that required thinking on my feet.
What to do without traumatising the cat and the owners?
To make a long story short, I asked Mr Min to take a big towel to cover the crate's front and top. Then bring the crate with towel to the client's car. Put the crate inside, sit inside the car and go back with the client to their home. He took off the towel when he had the crate inside the car. "No, just cover the crate," I said. "The cat would feel more secure without seeing you."
As some clients don't bring back borrowed crates and bags, I had Mr Min to accompany the clients home. He came back soon as the clients were living nearby in Kim Keat.
He was unhurt and I hope he learnt something from me. Provoking an angry cat by trying to grab her out is not the solution. Unfortunately, it takes experiential learning to know what to do and everyone has to do it. Read widely. Some wisdom is also acquired from reading what others do and from asking the senior vets whom you have worked well with.
As I had spent 2 hours (not joking) inside a tour bus from Singapore to Johor Bahru (a 3/4-mile causeway) during one of such weekends to tour Malacca last year, I don't bother to waste so much time now to go on holidays to Malaysia on long weekends.
Things come in 3s sometimes. I had recently written about the case of the hissing cat with urethral obstruction. No news from the owner for the last few days after my follow up 24 hours after leaving Toa Payoh Vets. I presume they are happy with the outcome and I don't want to pester them since they have been asked to phone me if they have queries.
So, on this bright sunshine morning at 9.30 am, I was surprised to hear a cat hissing at my assistant, Mr Min. He was trying to get the cat spayed by Dr Jason Teo yesterday out of the cage to go home. The mother and adult daughter had come to pick up the cat to go home. The daughter helped by putting her hand in to take the cat out. A sudden swipe of the daughter's hand and she got a scratch.
So, what should Mr Vin do. Remember my report on Mr Vin being bitten on both hands by a cross-bred while helping Dr Teo to treat the maggot wounds? He was trying to muzzle the dog which was already tranquilised by Dr Teo. The dog bit him twice as he swung the muzzle onto the dog's face. Let sleeping dogs lie? I had to get him treated by the doctor and to teach him that he ought to use a big towel to cover the sedated dog's head instead of trying to muzzle. This dog was muzzle-shy as some dogs are gun-shy.
Now, he encountered a cat that swung her right paw out and hissed at him as he tried to get her out of the crate to put her inside the owner's top-opening carrier.
The cat hissed louder as he tried again. What should he do? "Thinking on your feet" is not easy for Mr Min as he still has many years of experience to know what to do. So he was bravely trying to get the cat out. His present procedure of opening the crate door and getting the cat out, if possible, would only get him wounded and the cat escaping. Becoming more ferocious. New clients would be arriving and witnessing such incident. I could foresee such a scenario. It would be a waste of time on this public holiday and time-wasting is not good for anyone.
"Has the owner a carrier that the cat can walk into?" I asked. The carrier was top opening and I don't expect a cat to just saunter into it.
"My daughter can get the cat out," the mother said.
"No, she can't", I said. "The cat had scratched her hand!"
This was the type of situation that required thinking on my feet.
What to do without traumatising the cat and the owners?
To make a long story short, I asked Mr Min to take a big towel to cover the crate's front and top. Then bring the crate with towel to the client's car. Put the crate inside, sit inside the car and go back with the client to their home. He took off the towel when he had the crate inside the car. "No, just cover the crate," I said. "The cat would feel more secure without seeing you."
As some clients don't bring back borrowed crates and bags, I had Mr Min to accompany the clients home. He came back soon as the clients were living nearby in Kim Keat.
He was unhurt and I hope he learnt something from me. Provoking an angry cat by trying to grab her out is not the solution. Unfortunately, it takes experiential learning to know what to do and everyone has to do it. Read widely. Some wisdom is also acquired from reading what others do and from asking the senior vets whom you have worked well with.
Sunday, May 1, 2011
421. Twelve Golden Rules
Friday, April 29, 20911
REAL ESTATE AGENCY (REA) PAPER 3. Real Estate Agency Practice & Regulations
Ethics & Client Care
I remembered this lecture more than the 12 Golden Rules of the CEA (Council for Estate Agencies). The lecturer was showing a power point presentation slide to illustrate Rule No. 8 which is Ethics & Client Care - Advertisement.
The slide showed two advertisements of an agent before and one week after the CEA was formed. The advertisement showed the agent's photo on the left and her viewings of the HDB flat.
The lecturer said: "This is a top agent. Every 15 minutes from 5pm to 7.15pm, she had an apartment for sale viewing. There were 10 viewings every 15 minutes on one Saturday afternoon."
The mature students would have been exhausted by this 3-hour-long lecture of power point slides and after slides did not comment. 7 Golden Rules had been preached and must be memorised for the dreaded examinations. We had several housing and property rules to remember too.
To lighten the solemn mood, I asked: "Is she good-looking?". What I meant to communicate to the class was that this was a well posed professionally taken photograph (angle of body slightly tilted unlike most agents' face-direct photography), long hair to below the shoulders and a comely smile.
"What do you mean," the lecturer turned and looked at me with atomic eyes that could annihilate me. "I am already so old! She can be my daughter!"
I was shocked at his response. Had I implied that he was having some hanky panky? Or was there a clash of cultures, he being nearly 7 decades old and deadly serious in affairs of the heart?
I kept silent but it seemed the classmates paid more attention.
The lecturer said: "See the heading of the first advertisement. It says 'XXX International Top All Around No. 1 Achiever For Year 2009 - XXX USA.'"
We focus on this impressive claim. In the second advertisement one week later, the heading was not presented. What was the reason? I checked my lecture notes of Estate Agency Act & Practice, Ethics & Client Care, 8/12 Rule:
CEA Regulation of Rule 8:
"ALL FORMS of an advertisement must be supported by proof".
Then the lecturer pointed to the bottom of the first advertisement which stated:
"Senior Marketing Director" and then to the second advertisement which stated: "Senior Team Director". Why?
CEA Regulation of Rule 8:
ALL FORMS of an advertisement must be supported by proof
If necessary, VETTED/APPROVED by the Estate Agent.
I would infer that the Estate Agent did not now approve of the position of "Senior Marketing Director".
The 3rd change he showed was "Just Sold by ..." in the first advertisement was replaced by "My Achievement for the Year 2010". Why?
CEA Regulation of Rule 8:
All advertisements to be REMOVED if withdrawn/sold/rented e.g. website. The lecturer's notes did not give newspapers as an example but this type of trumpet-blowing advertisements of past properties that had been sold had been a common practice by the more successful agents.
Going into more details as I write this report to attempt to retain some knowledge for the exam, there is another CEA Regulation of Rule 8 which states:
Advertising/Promotion/Letter MATERIALS must have
1. Name/Contact number same as in the CEA Register
2. Registration/Licence NUMBERS
3. If necessary VETTED/APPROVED by estate agent.
The 2nd advertisement did not show the Registration/Licence Numbers. So, is the R and L numbers compulsory in every advertisement?
If we cannot remember all the 12 Golden Rules, I hope my classmates can at least remember Rule No. 8 due to the reaction of the serious lecturer who would be their father for many of them, due to the age gap.
To summarise for my revision for the May 2011 exam, here are the 12 Golden Rules:
1. Knowledge of and compliance with applicable laws, practice, circulars and guidelines (laws of agency, contract, tort).
2. Due diligence and compliance with law and statutory requirements.
3. General duty to clients and public (mislead, misrepresent, lack of integrity and honesty, unethical practices).
4. Not to bring discredit or disrepute to real estate industry (I will write on an case of touting in a lawyer setting up a real estate referral company, as reported recently in the Straits Times)
5. Duty to clients in relation to signing of documents (explain meaning and consequences, seek professional advice).
6. Obligations in respect of agreements (all in writing, no blank spaces and accurate recording).
7. Conveying offers, counter offers etc. (Counter offer is not legally an offer or part of a contract).
8. Advertisement
9. Interpretation or translation if necessary (record interpreted by...).
10. Duty to avoid conflict of interests
11. Recommending professional advice where appropriate.
12. Safeguarding confidential information (e.g. distress sales).
Many of the rules of ethics and client care can be applied to the veterinary practices too. For the real estate agent, he or she must be careful of mis-communication between clients and agent (all relevant contracts and services to be in writing- Rule 6). In particular, regarding Rule No.8, there should be no misleading advertisements (property not accurately described), misrepresentation (impersonating as buyer in flyers and newspapers) or advertise without proof (e.g. claiming to be a HDB specialist).
REAL ESTATE AGENCY (REA) PAPER 3. Real Estate Agency Practice & Regulations
Ethics & Client Care
I remembered this lecture more than the 12 Golden Rules of the CEA (Council for Estate Agencies). The lecturer was showing a power point presentation slide to illustrate Rule No. 8 which is Ethics & Client Care - Advertisement.
The slide showed two advertisements of an agent before and one week after the CEA was formed. The advertisement showed the agent's photo on the left and her viewings of the HDB flat.
The lecturer said: "This is a top agent. Every 15 minutes from 5pm to 7.15pm, she had an apartment for sale viewing. There were 10 viewings every 15 minutes on one Saturday afternoon."
The mature students would have been exhausted by this 3-hour-long lecture of power point slides and after slides did not comment. 7 Golden Rules had been preached and must be memorised for the dreaded examinations. We had several housing and property rules to remember too.
To lighten the solemn mood, I asked: "Is she good-looking?". What I meant to communicate to the class was that this was a well posed professionally taken photograph (angle of body slightly tilted unlike most agents' face-direct photography), long hair to below the shoulders and a comely smile.
"What do you mean," the lecturer turned and looked at me with atomic eyes that could annihilate me. "I am already so old! She can be my daughter!"
I was shocked at his response. Had I implied that he was having some hanky panky? Or was there a clash of cultures, he being nearly 7 decades old and deadly serious in affairs of the heart?
I kept silent but it seemed the classmates paid more attention.
The lecturer said: "See the heading of the first advertisement. It says 'XXX International Top All Around No. 1 Achiever For Year 2009 - XXX USA.'"
We focus on this impressive claim. In the second advertisement one week later, the heading was not presented. What was the reason? I checked my lecture notes of Estate Agency Act & Practice, Ethics & Client Care, 8/12 Rule:
CEA Regulation of Rule 8:
"ALL FORMS of an advertisement must be supported by proof".
Then the lecturer pointed to the bottom of the first advertisement which stated:
"Senior Marketing Director" and then to the second advertisement which stated: "Senior Team Director". Why?
CEA Regulation of Rule 8:
ALL FORMS of an advertisement must be supported by proof
If necessary, VETTED/APPROVED by the Estate Agent.
I would infer that the Estate Agent did not now approve of the position of "Senior Marketing Director".
The 3rd change he showed was "Just Sold by ..." in the first advertisement was replaced by "My Achievement for the Year 2010". Why?
CEA Regulation of Rule 8:
All advertisements to be REMOVED if withdrawn/sold/rented e.g. website. The lecturer's notes did not give newspapers as an example but this type of trumpet-blowing advertisements of past properties that had been sold had been a common practice by the more successful agents.
Going into more details as I write this report to attempt to retain some knowledge for the exam, there is another CEA Regulation of Rule 8 which states:
Advertising/Promotion/Letter MATERIALS must have
1. Name/Contact number same as in the CEA Register
2. Registration/Licence NUMBERS
3. If necessary VETTED/APPROVED by estate agent.
The 2nd advertisement did not show the Registration/Licence Numbers. So, is the R and L numbers compulsory in every advertisement?
If we cannot remember all the 12 Golden Rules, I hope my classmates can at least remember Rule No. 8 due to the reaction of the serious lecturer who would be their father for many of them, due to the age gap.
To summarise for my revision for the May 2011 exam, here are the 12 Golden Rules:
1. Knowledge of and compliance with applicable laws, practice, circulars and guidelines (laws of agency, contract, tort).
2. Due diligence and compliance with law and statutory requirements.
3. General duty to clients and public (mislead, misrepresent, lack of integrity and honesty, unethical practices).
4. Not to bring discredit or disrepute to real estate industry (I will write on an case of touting in a lawyer setting up a real estate referral company, as reported recently in the Straits Times)
5. Duty to clients in relation to signing of documents (explain meaning and consequences, seek professional advice).
6. Obligations in respect of agreements (all in writing, no blank spaces and accurate recording).
7. Conveying offers, counter offers etc. (Counter offer is not legally an offer or part of a contract).
8. Advertisement
9. Interpretation or translation if necessary (record interpreted by...).
10. Duty to avoid conflict of interests
11. Recommending professional advice where appropriate.
12. Safeguarding confidential information (e.g. distress sales).
Many of the rules of ethics and client care can be applied to the veterinary practices too. For the real estate agent, he or she must be careful of mis-communication between clients and agent (all relevant contracts and services to be in writing- Rule 6). In particular, regarding Rule No.8, there should be no misleading advertisements (property not accurately described), misrepresentation (impersonating as buyer in flyers and newspapers) or advertise without proof (e.g. claiming to be a HDB specialist).
Saturday, April 30, 2011
421. Put Non-Profits on the road to sustainability
Sat Apr 30, 2011 National Library Victoria St
I spend some time to read the book "ROI for Nonprofits" by Tom Ralser, 2007 as I am interested in non-profit organisation.
I don't have much time to read nowadays, due to my having to study for the CEA REA real estate course exam in May 25, 2011 (3 evenings, 2 hours, 5/8 questions, passing the exam does not mean getting the licence according to my lecturer).
Tom Ralser is a Chartered Financial Analyst (CFA) and taught finance and investments to college seniors for 7 years.
ROI (return on investment).
I spend some time to read the book "ROI for Nonprofits" by Tom Ralser, 2007 as I am interested in non-profit organisation.
I don't have much time to read nowadays, due to my having to study for the CEA REA real estate course exam in May 25, 2011 (3 evenings, 2 hours, 5/8 questions, passing the exam does not mean getting the licence according to my lecturer).
Tom Ralser is a Chartered Financial Analyst (CFA) and taught finance and investments to college seniors for 7 years.
ROI (return on investment).
Wednesday, April 27, 2011
420. The hissing cat has difficulty in urination. Initiating cause due to amitriptyline?
Sunday, April 24, 2010. Bright sunshine, blue skies. Should be outdoors. I was at work at 9.30 am. 3 clients came in but they were my associate vet's clients and so I told him they had to wait as she comes in at 11 am. Suddenly a couple with a cat carrier came in at 10.15 am. They would be 4th in the queue and by the time, they get attended by my associate, it would be past 12.30 pm which meant a 2-hour wait. As they have no preference, I took over the case, thinking it was a simple case of a cat that can't pee. A commonly presented case, usually of an older male cat fed on dry food.
HISTORY. Cat, Male, Neutered, 7 years old. Could not pee 2 weeks ago. Vet 1 relieved urethral obstruction, gave one "2-week-lasting" SC injection. Cat went home. OK for first 2 days. Then difficulty in peeing. Squatted but no urine. After for around 2 weeks, the couple in their 30s consulted me for a second opinion on Sunday April 24, 2011, 10 am. "Be careful," the husband warned. "The cat is very ferocious since the visit to Vet 1." According to the wife, Vet 1 had used anaesthesia to catherised the cat at the first time. However, the second and third bladder irrigation via the catheter was done without sedation as witnessed by the wife who was called to help. The wife was unhappy at seeing her cat traumatised. "Now the cat hisses whenever he is taken to the vet," the wife said. "The vet may think that it is risky to give sedation/anaesthesia again," I said. "The cat may die from the sedation and that would be disastrous." I don't do repeat bladder irrigation but each vet has his own ideas.
Now the cat warned me with a loud hiss as I examined his backside and palpated his abdomen. There was no point traumatising the cat. So, I gave a sedation and asked the owner to wait. Was this a recurrence of the urethral obstruction?
SEDATION & EXAMINATION Weight: 6kg, xylazine 0.15ml ketamine 0.5ml. Catheter passed in smoothly. No obstruction. But the unusual problem was that the penis of the cat could not be extended. The prepuce had swollen to a ball-shaped lump. An unusual case. I took a picture.
After some massage, it was possible to extend the cat's penis and insert the catheter. There was no penile inflammation. Bladder palpation. Bladder was swollen to twice the ping pong ball size. Urine collected for analysis. No crystals. Blood, white cells and red cells, bacteria + present.
DIAGNOSIS. Feline Lower Urinary Tract Disease (FLUTD).
The owner was not prescribed oral antibiotics by Vet 1 but the wife said to me: "The cat had been given a "2-week-lasting antibiotic injection". Therefore, there was no need for oral antibiotics. However, Vet 1 prescribed an anti-depression oral medication which the cat objected forcefully. So the owners did not give him the amitriptyline after two tablets. This drug licensed use in people is for depressive illness, bedwetting (nocturnal enuresis) in children aged 6 years and over.
Vet 1's X-ray show that the bladder is large and distended. No urinary stones seen, according to the owner.
4109 - 4111. The cat can't pee again. He hisses at the owners and at me (the 2nd vet). Why? Is there a permanent cure for feline lower urinary tract disease (FLUTD)? The hissing cat has difficulty peeing again
One of the adverse side effects of amitriptyline is "difficulty in passing urine" and this is reasonable since it is used to prevent bedwetting in children. I don't use it in cats or dogs and so I have no experience with this drug. But after two tablets, the owner observed that the cat had difficulty peeing! So was this the effect of amitriptyline or not? The cat continued to have dysuria for the next 10 days and that was when on this bright sunshine Sunday morning, I encountered this interesting case. Interesting only to veterinary knowledge on the use of amitriptyline, not to the owners as it had been traumatising for them and their cat.
To make a long story short, the cat did not have urethral obstruction as the catheter went into the bladder smoothly. He was warded for 2 days. The diagnosis was feline lower urinary tract disease confirmed by urine analysis. This was an intelligent cat as he sat on the litter box all the time while warded for 2 days in the surgery. If you understand that a cat wants to be clean, he is leaking urine via the catheter and so, by sitting on top of the litter box, he does not mess up the surrounding area. Even after removal of the catheter, he still sat on top of the litter on day 3 when the owner came to take him home.
When the owner came to take him home, he hissed at the owner! So, the couple patiently took time to get him to relax and put him inside the crate. In the morning I had sedated him (xylazine 0.1 ml + ketamine 0.4 ml IM) to remove the 6/0 stitches tying his catheter to his prepuce in 4 places and take rectal temperature (fever 39.8 deg C) and to weigh him. I treated his fever with baytril and tolfedine injections SC.
According to the wife, at Vet 1, the e-collar had been taken out once and the cat pulled off his catheter but with the sutures still knotting one end to the prepuce. Therefore, she asked whether I had put an e-collar all the time. Better to use oral pain-killers for cats post-treatment as the cat is very difficult to medicate and will claw you.
In any case, I don't usually put catheters in cats after bladder irrigation, except in some cases such as this case and only for 1-2 days. I don't bladder irrigation more than once but some vets do, without sedation.
The cat will be on oral antibiotics for 12 days. I don't believe in giving one single injection lasting "2 weeks" as Vet 1 did, but if the owner can't medicate at home, this may be the alternative. Pound medicine into powder and add to sugary paste. Spread on cat's body or paws without the cat knowing it. But cats may be too smart and flick away the medicated sugar.
Close monitoring of water intake and canned food, urine analysis in 2 weeks. Change to sand litter. Continue canned SD diet for 1-3 months and urine test monthly for 1-3 months. Then canned food. No shampoo for the first week. The cat is shampooed once a month as the owners find its coat oily. "Cats seldom get bathed in Singapore," I said. I did not take blood test so as to lower the veterinary costs.
However, urine tests are important for diagnosis of FLUTD and this was done in this case as the owner wants to know what is happening. Bacterial antibiotic sensistivity tests of the urine was not done in this case but would be done if there is another episode, so as to save the owners some money as they had spent quite a large sum at Vet 1.
P.S.
1. Cause of the FLUTD
I said to the owner on the second day: "You must have given dry food after treatment by Vet 1, thus leading to difficulty in urination."
"No, I did not," the husband said.
Then he remembered that Vet 1 had given him the dry food of Hills' Prescription SD as canned ones were out of stock. So, there was a dry food involved. Could it be the dry food? Could it be the action of amitriptyline retaining the urine in the bladder and permitting bacterial infection? Could it be the sharp pelleted litter injuring the prepuce and causing it to swell and prevent ease of urination? Could it be the re-infection of the bladder after going home? Was Vet 1's "long-term guaranteed to last 2-week" antibiotic injection of Synulox (clavulanic acid and amoxicillin) ineffective since it was apparently given once only? There are so many factors causing the urinary tract infection presented to me now and so it is hard to specify one causative factor.
It is a mystery but a urine analysis is important and must be done as part of the vet's duty of care. Certainly there was bacteria and white cells in the urine, indicating urine retention had led to cystitis or was a cause of cystitis. The SD diet had acidfied the urine apparently as the urine pH was 6.5 in the test.
It is quite painful for the couple to see their cat going to the litter box many times, tried to pee and not able to do so on the 3rd day after going home from Vet 1's treatment. They decided to seek another opinion and I was present on this bright sunshine blue-skies Sunday that I would like to spend at the Botanic Gardens.
2. Follow-up 24 hours after going home on Tuesday, April 26, 2011. I phoned at around 4 pm on April 27, 2011 as the cat had a fever of 39.8 deg C on Tuesday morning (when I took out the catheter and checked the rectal temperature under sedation). I had informed the husband of the fever and asked him to observe the cat closely. I had given tolfedine injection which would reduce the fever.
The husband said: "Everything is OK. The cat ate a lot and drank a lot on reaching home. Then he became quiet and not moving much. My wife smeared the baytril antibiotic in brown sugar onto his body and he licked it off."
This was one of the tips of medication I had given to the handsome couple in their 30s.
I replied: "It is possible that she is very tired after spending two stressful nights at Toa Payoh Vets which is a new environment for her.
"She is also not hungry after eating a lot. Check whether she has fever by feeling her lower abdomen with the hand but this is not accurate. Let me know if the cat is not eating. You have the anti-fever tolfedine tablets ready. Have you bought the sand litter?"
The owner had not and would do so. I expect this case to stabilise and that the emotional coaster-ride of the couple would fade away. The veterinary costs of two vets would be over a thousand dollars but this could not be avoided since there were so many procedures and tests.
The management at home is most important as there are many causes involved in the development of FLUTD (Feline Lower Urinary Tract Infection). The causes include uroliths (stones), urethral obstruction (plugged-penis syndrome and blocked cat syndrome), infectious causes and others (unknown causes in about 60% of the cases, physical trauma to penile area, tumours of the urinary tract, congenital abnormalities, neurological problems and intentional urinary retention (common behaviour seen in cats not given a litterbox or dirty litterbox).
In this case, the sophisticated owners told me the cat was shifted to a new house and that would be the cause.
The risk factors would be
1.1. Age. Uncommon in cats less than one year old but most common in cats 2-5 years old. This cat is 7 years old).
1.2 Sex. Male and neutered cats are at greater risk of urethral obstruction as their urethra is longer and narrower.
1.3 Neutering.
1.4 Dehydration.
1.5 Dry food high in magnesium or other minerals and high in pH.
1.6 Obesity.
All the above factors are present in this case. Dehydration could be due to the lack of adequate water intake as the cat was adjusting to the new house environment. Most cats on dry cat food do NOT get FLUTD. The causes are many and therefore, amitriptyline was not the only cause of the recurrence of the dysuria. Good management at home and regular veterinary check ups are very important to prevent recurrence of the dreaded Feline Lower Urinary Tract Disease (FLUTD).
Updates and more pictures of this webpage for my blog readers:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm
HISTORY. Cat, Male, Neutered, 7 years old. Could not pee 2 weeks ago. Vet 1 relieved urethral obstruction, gave one "2-week-lasting" SC injection. Cat went home. OK for first 2 days. Then difficulty in peeing. Squatted but no urine. After for around 2 weeks, the couple in their 30s consulted me for a second opinion on Sunday April 24, 2011, 10 am. "Be careful," the husband warned. "The cat is very ferocious since the visit to Vet 1." According to the wife, Vet 1 had used anaesthesia to catherised the cat at the first time. However, the second and third bladder irrigation via the catheter was done without sedation as witnessed by the wife who was called to help. The wife was unhappy at seeing her cat traumatised. "Now the cat hisses whenever he is taken to the vet," the wife said. "The vet may think that it is risky to give sedation/anaesthesia again," I said. "The cat may die from the sedation and that would be disastrous." I don't do repeat bladder irrigation but each vet has his own ideas.
Now the cat warned me with a loud hiss as I examined his backside and palpated his abdomen. There was no point traumatising the cat. So, I gave a sedation and asked the owner to wait. Was this a recurrence of the urethral obstruction?
SEDATION & EXAMINATION Weight: 6kg, xylazine 0.15ml ketamine 0.5ml. Catheter passed in smoothly. No obstruction. But the unusual problem was that the penis of the cat could not be extended. The prepuce had swollen to a ball-shaped lump. An unusual case. I took a picture.
After some massage, it was possible to extend the cat's penis and insert the catheter. There was no penile inflammation. Bladder palpation. Bladder was swollen to twice the ping pong ball size. Urine collected for analysis. No crystals. Blood, white cells and red cells, bacteria + present.
DIAGNOSIS. Feline Lower Urinary Tract Disease (FLUTD).
The owner was not prescribed oral antibiotics by Vet 1 but the wife said to me: "The cat had been given a "2-week-lasting antibiotic injection". Therefore, there was no need for oral antibiotics. However, Vet 1 prescribed an anti-depression oral medication which the cat objected forcefully. So the owners did not give him the amitriptyline after two tablets. This drug licensed use in people is for depressive illness, bedwetting (nocturnal enuresis) in children aged 6 years and over.
Vet 1's X-ray show that the bladder is large and distended. No urinary stones seen, according to the owner.
4109 - 4111. The cat can't pee again. He hisses at the owners and at me (the 2nd vet). Why? Is there a permanent cure for feline lower urinary tract disease (FLUTD)? The hissing cat has difficulty peeing again
One of the adverse side effects of amitriptyline is "difficulty in passing urine" and this is reasonable since it is used to prevent bedwetting in children. I don't use it in cats or dogs and so I have no experience with this drug. But after two tablets, the owner observed that the cat had difficulty peeing! So was this the effect of amitriptyline or not? The cat continued to have dysuria for the next 10 days and that was when on this bright sunshine Sunday morning, I encountered this interesting case. Interesting only to veterinary knowledge on the use of amitriptyline, not to the owners as it had been traumatising for them and their cat.
To make a long story short, the cat did not have urethral obstruction as the catheter went into the bladder smoothly. He was warded for 2 days. The diagnosis was feline lower urinary tract disease confirmed by urine analysis. This was an intelligent cat as he sat on the litter box all the time while warded for 2 days in the surgery. If you understand that a cat wants to be clean, he is leaking urine via the catheter and so, by sitting on top of the litter box, he does not mess up the surrounding area. Even after removal of the catheter, he still sat on top of the litter on day 3 when the owner came to take him home.
When the owner came to take him home, he hissed at the owner! So, the couple patiently took time to get him to relax and put him inside the crate. In the morning I had sedated him (xylazine 0.1 ml + ketamine 0.4 ml IM) to remove the 6/0 stitches tying his catheter to his prepuce in 4 places and take rectal temperature (fever 39.8 deg C) and to weigh him. I treated his fever with baytril and tolfedine injections SC.
According to the wife, at Vet 1, the e-collar had been taken out once and the cat pulled off his catheter but with the sutures still knotting one end to the prepuce. Therefore, she asked whether I had put an e-collar all the time. Better to use oral pain-killers for cats post-treatment as the cat is very difficult to medicate and will claw you.
In any case, I don't usually put catheters in cats after bladder irrigation, except in some cases such as this case and only for 1-2 days. I don't bladder irrigation more than once but some vets do, without sedation.
The cat will be on oral antibiotics for 12 days. I don't believe in giving one single injection lasting "2 weeks" as Vet 1 did, but if the owner can't medicate at home, this may be the alternative. Pound medicine into powder and add to sugary paste. Spread on cat's body or paws without the cat knowing it. But cats may be too smart and flick away the medicated sugar.
Close monitoring of water intake and canned food, urine analysis in 2 weeks. Change to sand litter. Continue canned SD diet for 1-3 months and urine test monthly for 1-3 months. Then canned food. No shampoo for the first week. The cat is shampooed once a month as the owners find its coat oily. "Cats seldom get bathed in Singapore," I said. I did not take blood test so as to lower the veterinary costs.
However, urine tests are important for diagnosis of FLUTD and this was done in this case as the owner wants to know what is happening. Bacterial antibiotic sensistivity tests of the urine was not done in this case but would be done if there is another episode, so as to save the owners some money as they had spent quite a large sum at Vet 1.
P.S.
1. Cause of the FLUTD
I said to the owner on the second day: "You must have given dry food after treatment by Vet 1, thus leading to difficulty in urination."
"No, I did not," the husband said.
Then he remembered that Vet 1 had given him the dry food of Hills' Prescription SD as canned ones were out of stock. So, there was a dry food involved. Could it be the dry food? Could it be the action of amitriptyline retaining the urine in the bladder and permitting bacterial infection? Could it be the sharp pelleted litter injuring the prepuce and causing it to swell and prevent ease of urination? Could it be the re-infection of the bladder after going home? Was Vet 1's "long-term guaranteed to last 2-week" antibiotic injection of Synulox (clavulanic acid and amoxicillin) ineffective since it was apparently given once only? There are so many factors causing the urinary tract infection presented to me now and so it is hard to specify one causative factor.
It is a mystery but a urine analysis is important and must be done as part of the vet's duty of care. Certainly there was bacteria and white cells in the urine, indicating urine retention had led to cystitis or was a cause of cystitis. The SD diet had acidfied the urine apparently as the urine pH was 6.5 in the test.
It is quite painful for the couple to see their cat going to the litter box many times, tried to pee and not able to do so on the 3rd day after going home from Vet 1's treatment. They decided to seek another opinion and I was present on this bright sunshine blue-skies Sunday that I would like to spend at the Botanic Gardens.
2. Follow-up 24 hours after going home on Tuesday, April 26, 2011. I phoned at around 4 pm on April 27, 2011 as the cat had a fever of 39.8 deg C on Tuesday morning (when I took out the catheter and checked the rectal temperature under sedation). I had informed the husband of the fever and asked him to observe the cat closely. I had given tolfedine injection which would reduce the fever.
The husband said: "Everything is OK. The cat ate a lot and drank a lot on reaching home. Then he became quiet and not moving much. My wife smeared the baytril antibiotic in brown sugar onto his body and he licked it off."
This was one of the tips of medication I had given to the handsome couple in their 30s.
I replied: "It is possible that she is very tired after spending two stressful nights at Toa Payoh Vets which is a new environment for her.
"She is also not hungry after eating a lot. Check whether she has fever by feeling her lower abdomen with the hand but this is not accurate. Let me know if the cat is not eating. You have the anti-fever tolfedine tablets ready. Have you bought the sand litter?"
The owner had not and would do so. I expect this case to stabilise and that the emotional coaster-ride of the couple would fade away. The veterinary costs of two vets would be over a thousand dollars but this could not be avoided since there were so many procedures and tests.
The management at home is most important as there are many causes involved in the development of FLUTD (Feline Lower Urinary Tract Infection). The causes include uroliths (stones), urethral obstruction (plugged-penis syndrome and blocked cat syndrome), infectious causes and others (unknown causes in about 60% of the cases, physical trauma to penile area, tumours of the urinary tract, congenital abnormalities, neurological problems and intentional urinary retention (common behaviour seen in cats not given a litterbox or dirty litterbox).
In this case, the sophisticated owners told me the cat was shifted to a new house and that would be the cause.
The risk factors would be
1.1. Age. Uncommon in cats less than one year old but most common in cats 2-5 years old. This cat is 7 years old).
1.2 Sex. Male and neutered cats are at greater risk of urethral obstruction as their urethra is longer and narrower.
1.3 Neutering.
1.4 Dehydration.
1.5 Dry food high in magnesium or other minerals and high in pH.
1.6 Obesity.
All the above factors are present in this case. Dehydration could be due to the lack of adequate water intake as the cat was adjusting to the new house environment. Most cats on dry cat food do NOT get FLUTD. The causes are many and therefore, amitriptyline was not the only cause of the recurrence of the dysuria. Good management at home and regular veterinary check ups are very important to prevent recurrence of the dreaded Feline Lower Urinary Tract Disease (FLUTD).
Updates and more pictures of this webpage for my blog readers:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm
Subscribe to:
Posts (Atom)