These Stones Aren't Rolling

It was Christmas eve day 2006. With the families coming for dinner & present opening in a few hours, I was preoccupied with cleaning and cooking so didn't notice that Marta didn't leave her sleeping spot under the covers even when we got up, or that she was quieter than usual. Late that afternoon Bill came to me with the words I hate to hear..."I don't think Marta feels good."

Just as I do every day for my patients, I did a physical exam on Marta. Subdued but responsive, hydration ok, coat & skin ok, ears/eyes/nose/throat ok, teeth & gums ok, heart & lungs ok, kidneys ok, intestines ok, bladder... Bladder not ok. Marta's urinary bladder was moderate sized & very firm. She was noticeably uncomfortable as I palpated this area. Feeling a firm bladder was not unknown to me, it was the classic feeling of a male cat with a urinary obstruction. But wait, Marta was a female, females don't obstruct!

Never having seen or even heard of and obstructed female cat, I treated Marta for urethral spasms, hoping that in a few hours she would be back to herself. As with most of my male patients with a urinary obstruction rather than merely spasms, there was no improvement. I knew she had to be worked up. With our clinic closed for Christmas, this meant a trip to the Emergency Clinic. As the families arrived, I headed out with Marta, telling everyone to start without me.

The Dr. at the Emergency Clinic came to the same conclusion...it felt like an obstruction. Marta's urinalysis showed no cystals, her x-rays showed no signs of stones, yet she was blocked. An ultrasound of her bladder showed what might be a mass but wasn't conclusive. She would need more tests later that night, but what she needed right away was a catheter to allow the urine to leave her bladder. It had been many years since I had catheterized a female cat, but that was more experience than the Emergency Clinic Dr. had, so I was chosen to do this. With the catheter in place and Marta awake, I returned home to Christmas dinner and presents, but all the while worried about Marta. Like I have written in an earlier post, I wondered, is this "it"? Has her Feline Leukemia become active, is this lymphoma? Or was this the more typical bladder tumor, transitional cell carcinoma ? Neither were good.

A late night call from the Emergency Clinic was my best present that evening. Marta's blood tests were normal, and the special x-ray studies showed that the blockage was not a tumor, it was a stone. This wasn't "it", this was curable and surgery would be performed as soon as the emergency schedule would allow.

The next call I received came in the early hours of Christmas day, the surgery was a success and Marta was recovering well. Just like the spirits in Charles Dickens' "A Christmas Carol" the Emergency Clinic had done it in one night.

On Christmas day, Bill and I drove to the Emergency Clinic to receive yet another present, Marta. She has not had a repeat of her urinary stone, which was confirmed as urate, the type that occurs only 6% of the time, which isn't seen readily on x-rays, and which I've diagnosed at most 1/2 a dozen times since I've been in practice. And in 20 years of practice, she remains the only blocked female cat I know of.

Bladder stones, also known as uroliths or cystic calculi occur when minerals in your cat's urine crystalize, mix with organic material (usually mucus-like) and form stone-like masses in it's bladder.

Cats can have several types of bladder stones. The two most common types are struvite (magnesium ammonium phosphate or "triple phosphate") and calcium oxalate, account for approximately 90% of all cat bladder stones and are found in both male and female cats. Age and diet play important roles in the formation of these stones. Struvites form in neutral or alkaline(high pH) urine and are more commonly seen in younger cats; while Calcium oxalate stones form in acidic (low pH) urine, and are more commonly seen as age increase. In the past, the most common type was struvite, but over the years, the number of calcium oxalate uroliths has increased. Now, the two types occur with almost equal frequency.

Less commonly seen are Urate stones, which account for approximately 6% of bladder stones.

Stones can be present without causing any symptoms, but more often, they are associated with hematuria (blood in the urine), pollakuria (increased frequency of urination) and dysuria (difficulty passing urine). Many cats with bladder stones will urinate outside of their litterbox. While most stones remain in the bladder, some stones may pass into the urethra (the tube leading from the bladder to outside the body). Because the male cats urethra is much narrower than the female, a stone is more likely to cause partial or total obstruction so that little or no urine can pass. Obstructions are painful and often are life-threatening emergencies. Other bladder problems such as urinary crystals (without stone formation), infection, tumor or an inflammatory condition such as Interstitial Cystitis; or non-bladder problems, such constipation, may result in similar symptoms, so it is important to have your cat evaluated.

While urinalysis is helpful to determine if a urinary problem is present, but is often not enough to diagnose a bladder stone.

Many stones can be detected by x-rays, however, some (urate stones) don't show up well or may be too small to be seen. In these cases, a bladder ultrasound is the best method of detection. When ultrasound is not available, special x-rays involving instilling a contrast agent into the bladder in order to see the stone more clearly can be done.

Management of stones depends on the numbers, size & type of stone; as well as the cats condition.

In cases where struvite stones are suspected, or an owner wishes medical management of their non-obstructed cat first, the cat is fed a stone-dissolving diet and x-ays and urinalysis are monitored for response to treatment. This may take several weeks, and the cat may be at risk for becoming obstructed. Oxalate and urate stones will not dissolve with diet.

Small stones that are not causing blockage may be removed in a flushing procedure called voiding urohydropulsion. Any stone(s) flushed from the bladder can be sent to a laboratory for evaluation to determine the type of stone.

If there is an obstruction, immediate emergency treatment to relieve the obstruction is required. Obstructed cats are often dehydrated, have electrolyte and acid-base imbalances, and increased levels of waste products in their bloodstream. These problems can lead to heart and kidney problems as well as bladder damage, and even death if left untreated. Just as with Marta, the urethra is catheterized to restore flow of urine and fluid therapy is started. Blood and urine tests are done to determine the cat’s status and guide further treatment

Surgery is needed if the cat continues to re-obstruct. Also, removing the stones allows for faster resolution of the stone(s) and pain. As with hydropulsion, the stone(s) recovered can be analyzed.

Antibiotics are prescribed if a bacterial infection was part of the problem (which is uncommon) or if the cat was catheterized to relieve an obstruction.

Cats that have had crystals or stone are at risk to develop them again. Fortunately, most cystals & stones can be prevented by dietary management. Struvite management diets typically help to produce an acidified urine, while calcium oxalate management diets produce a slightly alkaline urine. The Cat Care Clinic carries commercially prepared diets to help treat and prevent urinary crystals and stones.

Double clicking on photos will enlarge them.

These stones have very sharp edges

This stone is smooth and rounded












This is an ultrasound of a bladder stone




This stone was not seen on x-rays. It shows up on the double contrast study like a photographic negative. It is the dark area in the center of the bladder, it is surrounded by the dye which appears white around it.










These small stones were flushed out by voiding urohydropulsion

Another kind of hip hop

With almost an hour drive time between work and home, I have a lot of time to listen to the radio. One of the commercials I hear lately tells the story of a man who's arthritic hip is causing him enough pain that he can't enjoy his usual activities (golf) and causes him to walk with a noticeable limp. His children call the limp his "hip hop". The ad educates us about the benefits of seeing a particular hospital's Orthopedic Surgical Department for arthritis diagnosis, education and treatment.

Degenerative joint disease occurs in cats too. It is more commonly known as osteoarthritis, or just plain arthritis. Arthritis is commonly present in shoulders and elbows; hips, stifle (knee), hock (ankle) and lower spine. So, you may see more than just a "hip hop" when a cat has arthritis.

When I was a veterinary medical student,we were taught that cats did not get arthritis. Years later, I read an article about new studies indicating arthritis was more common than was previously assumed, yet the number of cats with arthritis was nonetheless still incredibly low. The most recent study we have has now revealed that over 90% of cats 12 years and older actually show arthritic changes on x-rays. Studies also now show that arthritis isn't even limited to elderly cats! While arthritis is most commonly an older cat disease, it is now often seen in much younger cats.

Amazingly, most cats with arthritis will not limp or refuse to use the painful limb(s). In fact, some cats with arthritis show no obvious signs at all!

Ok, I know what some of you are thinking right now..."of course they don't show signs, how can they show signs when they sleep 18 hrs a day?"

In my post about the Veterinarian as Detective, I explained how veterinarians pick up clues through observation. You can do this too.

Observing your cat's body language and knowing what to look for can help. Is your cat is slower or stiffer when he or she first gets up after a nap or sitting on your lap? Does going up or down the stairs take longer than it used to, or your cat just doesn't go up or down as often? Will your cat stand up in the litter box when he or she used to squat? These may be important clues in our diagnosis.

Moreover, even when you observe changes that please or displease you, they may be important in our diagnosis. When Fluffy doesn't jump up on the counters like she used to, you might be so happy with this change you don't realize she doesn't jump because it hurts her to do so. Just the opposite, you might be frustrated with the fact that Boots isn't using his litter box as often without realizing that it's because it's too painful for him to bend his hips & knees to get over the high sides. The normally affectionate Sweetie is now irritable and bites when petted or picked up because arthritic joints hurt. "Grizabella the glamour cat" might look pretty ragged these days because painful joints won't let her reach the places she needs to in order to keep that coat well groomed. So, be sure to tell us about all behavioral changes you see.

What should you do if you think your cat has arthritis? See your veterinarian. A thorough exam that includes an orthopedic exam is a good start. Such an exam may reveal swelling or crepitus (the medical term for the creaks and cracks we hear when your cat's joints are moved). Range of motion (an evaluation of how well or poorly the leg can be bent or extended) may show poor range or discomfort. X-rays may not detect very early arthritis changes, but are helpful to rule out other diseases. With increasing frequency I am finding obvious changes on x-rays. I never cease to be amazed at how severe some of the x-ray findings are in a cat that only has the mildest of limps.

Arthritis is a chronic condition, and while it may not be curable, there are a few things that you can do to help your cat live a more comfortable life. Weight management is something everyone can do and it is important in order to decrease stress on arthritic joints. Controling your cat's weight is also one of the few things you can do to help prevent or delay arthritis development.

You can also make changes in your cat’s environment at home so that your cat's life will be easier and more comfortable after diagnosis of arthritis. This can include adding ramps to allow your cat to reach higher areas (beds or furniture) without having to jump, providing litter boxes with lower sides to make it more comfortable to get in and out; and having a box on each floor so that your cat doesn't have to go up & down stairs as often..

Medical management has come a long way from the early days when we treated symptoms with aspirin and hoped for the best. We now have supplements such as Dasuquin and Adequan that help support joint health. Omega 3 fatty acids, and anti-oxidants such a SAM-e can decrease inflammation. When supplements alone are not enough to decrease discomfort, there are an increasing number of pain relief medications such as buprenorphine or gabapentin that are now available that can help. Other non-traditional treatments such as Acupuncture or Massage can also decrease your cat's arthritic discomfort.

Recognizing and treating arthritis can make a difference in your cat’s quality of life. And while your cat may not be a golfer like the gentleman in the radio ad, diagnosing and treating your cat's "hip hop" can help them enjoy many if not all of the things they used to do.

This cat has severe arthritis in both hips. The normally smooth ball and socket hip joints are not smooth, and are flattened instead of rounded as they should normally should be. The red arrows show additional bony deposits resulting from arthritis.

The red arrows point to arthritis changes in this cat's knee joints. None of these structures would be here in a cat without arthritis.

This large extra bony deposit confirms shoulder arthritis.

June is Adopt-A-Cat Month

Adopt-A-Cat Month
June 1, 2010

Approximately 4 million cats end up in shelters every year, including thousands born every spring and summer during “kitten season.” To help promote adoptions of these fun, affectionate animals, American Humane celebrates Adopt-A-Cat Month each June.
Your local shelter is brimming with cats of every breed, age and personality just waiting for a loving home. Whether you prefer young and frisky or mature and mellow, you’re sure to find the perfect cat companion during Adopt-A-Cat Month!

Happy Birthday Marta

Statistics state that 60% of Feline Leukemia positive cats die within 2 years of diagnosis, the number goes up to 85% by 3 years. That was the first thought to go through my mind when Heather, a clinic client, called to ask if I might be able to give a Feline Leukemia positive (FeLV+) cat a home.

Heather had called me in the past knowing that I had a FeLV+ cat at home and had given a home to several similar kitties over the years. She was fostering a FeLV+ momma and her new kittens. Having their own non-FeLV kitties to care for meant keeping the 2 groups separated. This is not always an easy task. My heart felt for the momma and kittens, but sadly, I had to say no, I was not able to add so many more cats to the household.

With time the virus took it's toll and one by one, momma and the kittens died. Now alone, her family gone, and hearing people and cats on the side of the door where she couldn't be, the 2 year old cat meowed her loneliness. Again, my heart felt for her.

This time it was one cat not several. This time I could see my own FeLV cat was lonely for a feline friend. This time I could say yes, but... the statistics ran through my mind.

My own "statistics" (it sounds so harsh when speaking about cats I loved so dearly) were worse. The 2 FeLV+ females that preceded this cat each lived only 15 months, my first FeLV+ male lived just past 2 years, my current FeLV+ male was just reaching 1 years old. Did I really want to take on a 2yr old FeLV cat, especially with my history? Did I really want to take on a cat that would break my heart at any time? Could I really ask my husband, who loved the cats as much as I did, to do it all again?

For any of you who have seen the movie, "Risky Business", you may recall the memorable quote by Joel's father "Sometimes you just gotta say what the heck". Maybe you recall Joel's friend Miles telling him the same thing only more graphically.

It was time for me to say "what the heck". For those of you who know me, this is not done easily or often, but I said it. I had a cat that needed a friend, there was a cat that needed love and a family, and I had plenty of love to give. What the heck.

Heather brought her to the clinic for for an exam and vaccines, and to introduce us. Her name was Marta. She was a 2 year old brown tabby and white short haired cat. She was overweight due to her lifetime of restriction to a single room, but otherwise healthy. She was a sweetheart.

At the end of the day Marta, along with her favorite toy, a flexible styrofoam rod, came home with me. She was quiet during our ride home, and quiet as she explored the new room that was to be her new home as she acclimated to her new life.

Marta's next few days were spent under the bed, coming out only when Bill or I were there with her. Soon, we found her snoozing on the bed or up on the perch we had set up for her to look out the window. During this time, Butters, my FeLV+ cat, stood watch at the door curious at the new kitty on the other side. From time to time, paws reached under the door from both directions.

When we thought she was ready, we opened the door to let her meet Butters and to begin to explore the rest of her new home. Butters adored Marta, Marta did not share his feelings but tolerated him. Marta preferred the safety of the familiar room but began to venture out and explore the bottom level. She spent her days gazing out the sliding glass door.

Milestones occurred...she took her first cautious steps on the stairway and a month after coming home, made her 1st appearance on the middle level. Soon afterward, she gathered the courage to climb the open stairway to the top level. The entire house was now her domain. Butters was accepted.

Summer came and went, giving way to winter. Marta helped put up her first Christmas tree. Winter gave way to summer, and as the sun moved farther south in the sky, the sunny spots in the house changed and Marta moved with them. Sadly, Butters became one of the 60% of FeLV cats that die within 2 years of diagnosis. Marta beat the odds, Marta turned 3, then she turned 4, and 5, and kept going.

Like most cats throughout their lifetime, Marta would show signs of illness. A vomiting spell, a period of decreased appetite, a bout of coughing. But she wasn't like most cats, she had Leukemia. Each time I feared the worst, was this "it"? And each time she recovered.

On Christmas eve day 2006 Marta wasn't herself. Always the Veterinarian, I examined her and felt a very large firm bladder. I recall telling Bill that if she were a male cat, I'd be concerned about a urinary blockage. As our families were arriving for Christmas, Marta and I were on our way out the door to the Emergency Clinic for Animals. The Dr. agreed with my assessment, so blood and urine tests were ordered. A quick ultrasound was performed on her bladder didn't find any stones but it looked like there may be a mass in her bladder, more tests were needed. I returned home to continue with Christmas activities but my thoughts were with Marta and her bladder mass. Lymphoma is a type of cancer associated with Feline Leukemia...was this an unusual presentation or did she have the still uncommon but more typical bladder tumor...was this "it"?

Late that night I received the diagnosis..special x-ray studies had confirmed that it was a bladder stone, not a mass. This was great news, the stone could be removed surgically. Would I authorize surgery on a 5 year old FeLV+ cat that had lived well past the time most cat do? Would I authorize surgery on a cat that potentially could die of leukemia at any time? Absolutely. What the heck.

Marta had an ammonium urate stone. This type of stone accounts for only 5% of bladder stones found in cats. Leave it to Marta to have a rare stone AND to be the only obstructed female cat I have seen in 20 years of practice, she's beaten the odds again!

Marta still has the occasional spell of vomiting and decreased appetite but her most recent lab tests look good. She has to contend with summer thunderstorms which she hates, and the addition of Gator, our Catahoula/Lab mix puppy adopted in January. She now has to duck under a barricade to get to her litter box and jump up to the counters to eat, but otherwise life is good.

Days are spent dozing in the sunbeams or gazing out the 3rd story windows watching the birds and animals that make their homes in our 5 acres of woods and prairie. Every jump up to the counter is rewarded with favorite treats, and brushing occurs as often as she'll allow. Evenings are spent on laps as we watch TV or work on the laptop. Nights are spent sleeping on the bed with us, starting out on Bill and moving to the pillow where she sleeps ON my head.

Over the last year, she has expanded her "duties" and has become "Nurse Marta". Marta rarely left Bill's side as he recuperated from his broken hip suffered last Memorial Day weekend in a bicycling accident (we joked that Nurse Marta was applying heat therapy because she insisted on laying on the broken hip) and did the same when the rod & pin were removed this May. After I was diagnosed with a blood clot in my leg and told to lay with my legs higher than my heart, Nurse Marta settled in on my lap, ensuring that I wouldn't move for fear of disturbing her.

Today, June 1, is the date that 9 years ago was designated as her birthday. Today she continues to beat the odds. Everyone who knows me, has heard me refer to her as my "miracle girl". Words can't express how grateful I am that 9 years ago Heather
called one more time to see if I could give her a home, and that I said "what the heck". Words can't describe how comforting it is to fall asleep to the sound of purring every night, even if it is on my head; and how stress melts away when petting her soft silky coat. I love to watch as she gets so excited watching the birds or see her completely as peace sleeping in her favorite sunny spots.

Happy Birthday Marta, I love you with all my heart.



Marta on her sunny spot on the stairs

Let the Facts Lead You to the Conclusion

One of the duties of a judicial law clerk is to help the Judge write his or her decisions. To do this the law clerk will review and summarize the facts of the case, research existing law in similar cases, write a draft of the decision and present those to the Judge for discusion, editing and publication.

When my husband Bill was a Law Clerk, he was given his first assignment to research case law for a recently finished trial. Not knowing how to even start, he asked the Judge who should win. The Judge gave Bill the advise he follows to this day as a Judge himself; "Let the facts lead you to the conclusion not the other way around." It sounds obvious, but sadly, it is not unusual for some judges to have a pre-conceived idea of what the final outcome should be and look for facts that lead to the decision they want to make rather than letting the facts lead to the conclusion they should make. By promoting their own ideas of how things should be rather than deciding the case on its merits, the Judge does a disservice to justice.

Every day, we Veterinarians find ourselves in a similar position. In my previous post I wrote how we are like Detectives sorting though the facts of a case. Just as it is important for the Judge to let the facts lead them to a conclusion, it is important for us to do the same. We develop our differentials list(the list of possible causes) based on the patient's medical history and our exam findings. Additional testing such as blood & urine tests, x-rays and/or ultrasound help us put the differentials higher or lower on the list. This, in effect, leads us to a conclusion, or in our case, a Diagnosis.

If we presume to judge a case by choosing only to use the history, exam or test findings that support our "diagnosis", we are not doing justice to our clients and patients. We need to use all of the information and let it lead us to wherever the diagnosis lies.

Why might we even choose to pre-diagnose and use the tests to lead us to what we want to find? There are many reasons. Perhaps because it is the quickest or easiest way to finish the case or maybe because we think we are doing our patient or client a favor by providing a quick answer, or saving them money, or sparing them from a diagnosis they don't want to hear. Ultimately, we are doing them a disservice by providing the wrong treatment and delaying or missing the opportunity to provide the correct treatment.

I'd like to share Bubba's story with you.

I met Bubba and his owners on April 16. His owners were concerned about his recent weight loss. Also, they observed that some of the urine clumps in the cat litter box were larger than they were in the past, and that one of the cats was vomiting every other week.

During my exam, I found that Bubba had lost almost 1 1/2 lb since last August, his right kidney was smaller than the left and he had a tooth with a resorptive lesion (similar to a human tooth cavity in it's effects on the tooth, but not due to the same cause).

I suspected that kidney or thyroid disease, diabetes, intestinal disease, pancreatitis or cancer were possible causes for his symptoms. I ordered initial testing including blood & urine tests and x-rays to give me additional information.

Results showed that Bubba had degenerative changes in his kidneys. His thyroid hormone level suggested that he had an overactive thyroid. Because the test results fit 2 of the diseases I suspected, I could make a case for starting treatment. However, to do so, I would have had to ignore other test findings and history. I needed to let the facts lead me to a conclusion.

So, I ordered additional testing. Abdominal Ultrasound and a recheck of thyroid hormone levels was performed a few days later. Bubba's weight continued to decline and his appetite was lower than normal. Ultrasound showed that there were irregularities in his kidneys, as well as changes in his intestines which can be seen with an overactive thryoid or intestinal disease. Again, the results matched diseases on my differentials list but given the fact that the changes were mild, I decided to set aside the information and re-test.

Repeat thyroid hormone testing was normal...confirming that I would have done a disservice to my patient if I had started treatment based on fitting the facts to a quick and easy "answer".

All of the facts lead me to conclude that Bubba did have chronic kidney disease and that he needed to start a special diet. However, when searching for the cause of decreased appetite and weight loss, the facts were not leading me to a conclusion that was on my list so I had to go back to the start.

Up to this point, I had focused on weight loss due to several causes, and had put taking care of Bubba's teeth on hold. After all, it was only 1 bad tooth and lots of cats show no ill effects from a single bad tooth. But the fact is, a painful tooth CAN cause decreased appetite, and decreased appetite CAN lead to weight loss, and intense pain CAN cause vomiting. As skeptical as I was that this one tooth was the source of the remaining problems, it was time to address his dental disease. Bubba needed an oral exam, dental x-rays and dental work. I had to let the facts lead me to a conclusion.

My surgery technician completed her dental probes and cleaning and was the first to see Bubba's x-rays. I was stunned to see the extent of his dental disease. It wasn't just the one tooth with a cavity-like hole in the enamel, there was also a loose tooth and both lower canines had roots that were being eroded away and were surrounded by large areas of abnormal jaw bone. Most likely I was seeing osteomyeleitis, bone infection, but was concerned about the possibility of bone cancer. My technician cleaned Bubba's teeth, I treated the tooth with the resoprtive lesion, I removed the loose tooth and the remaining parts of the lower canine teeth, and took biopsy samples from the diseased bone. I treated Bubba with antibiotic and painkillers during the dental procedure and he went home.

Bubba responded well. He ate. He gained weight. At his recheck earlier this week, I could see that the extraction sites were healing nicely.

Bubba is fortunate to have 2 very loving and committed owners who allowed me to use the advice given to my husband by a very wise mentor. Let the facts lead you to a conclusion. Had I stopped when I had enough facts to fit my initial suspicions, I would have been doing Bubba a great disservice and would have treated medical problems he didn't have while failing to treat him for the painful medical problem he did have.


This is a photo of Bubba's normal looking lower canine teeth


This is the x-ray of Bubba's lower canine teeth (what's left of them)

Normal x-ray appearance of lower canine teeth

The Veterinarian as Detective

We all wear many different hats throughout the day...spouse, child, parent, co-worker, friend, neighbor, sounding board...and your Veterinarian is no different.

A veterinarian may already know what the diagnosis is when initially presented with a sick patient, ...an owner may have walked into the room just as her cat swallowed the last string on the pot roast sitting on the counter (foreign body), or there may have been vomited plant material near a shredded diffenbachia leaf (the toxins mostly act as oral and GI irritants).

But what about a patient that has vague symptoms, or symptoms that are common to any number of conditions? Simple. We can ask, and we can listen to what we're being told.

Dr. Dolittle could talk to and understand animals in their own language but we can't. Fortunately for us, it's the rare cat that comes to the veterinary clinic unaided by a human who can help tell their story.

I was surprised to learn that Dragnet's detective Sargent Joe Friday never said "Just the facts ma'am." exactly. Nevertheless, that's how we all start our own detective work. It's called the medical history. By listening to the owner, and asking our own questions, we receive the first pieces of a complicated puzzle. For example, a casual remark from an owner about how she found ants at the spot her cat urinated (true story) was just the clue that I needed to check her cat for diabetes (bingo!).

The next step in our detective work comes during our physical exam. It is here where we make use of ALL of our senses to determine what our patients body is telling us.

While Dr. Cal Lightner on TVs "Lie to Me" isn't a detective, he's hired by law enforcement to do detective work in the form of interpreting clues gained through careful observation of body language, voice changes and expressions.

You all know basic cat language. You can distinguish the difference in your cats "feed me" meow from the one that says "I really don't like this car ride." You can recognize the difference between your cats straight up happy tail and a straight up fearful tail.

An experienced Veterinarian often picks up more subtle signals. For example a suddenly "finicky cat" may have a particular and recognizable lip licking that often accompanies nausea even if the cat isn't otherwise viually sick.

Sight, sound, touch,and yes, even smell give us clues.

An experienced Veterinarian will go where most owners dare not to go, into the mouth, to find a broken tooth that is so painful that our patient will eat it's canned food but not kibble. A stethoscope allows us to hear a heart murmur, for example, prompting us to check for heart disease, anemia or high blood pressure. We will palpate the abdomen and may feel an empty colon and that lets us know that our patient is not constipated as the owner had thought, but is empty because the cat isn't eating. We then need to look further to discover why. What was dismissed as "kitty breath", may actually be ketoacidosis, a complication of diabetes; an indication that uremic toxins are building up in the bloodstream due to kidney failure, or an infected tumor.

We've just scratched the surface up to this point and often need more clues to reach a diagnosis. Blood & urine tests, x-rays and in some cases, even more special testing round out our fact gathering. Hmmmm, do I sense another hat here? Just like the archeologist, as we dug deeper, and by doing so discover more about our subject.

We've gathered the facts and have used our observational skills and senses. We've gathered more clues with diagnostic testing. We've generated our differential list. Now we're ready to be the ultimate detective, Sherlock Holmes, and sort though the jigsaw pieces, and to put them all together to reach a diagnosis.

"I got worms in me"

Before sitting down to write my previous post, I turned on the TV and started channel surfing to find something to watch as I typed. I came across "Untold Stories of the ER" on TLC. I had missed the beginning, but became intrigued with the story about a woman who kept repeating "I got worms in me".

I watched as the perplexed ER physician tried to make sense of what this meant...she had intestinal parasites? how did she know? she swallowed worms? why?....and I, like him, was surprised as he discovered that his patient had actually placed earthworms under her skin in several locations. No doubt, this was the last thing on his mind as he ran though his differential list for a patient telling him she had worms in her!

It reminded me of the day a client had called our clinic saying that her cat had worms coming out of his abdomen. With the client still on the phone, the same process the ER physician went through was begun. What could "worms coming out of the abdomen" mean?

Knowing that tapeworm segments can be passed out of the intestinal tract in stool or on their own, and knowing they can move like inch worms once out of the body, we asked if there might be a small worm or worms moving on her cats fur....no, these were coming out of the skin. Having seen only 2 cases of maggots (and hoping never to see another case) we asked if the cat had cuts or sores on the abdomen...no, just the worms coming out of the skin. Might these be something other than worms...no the worm heads were sticking out of the skin. Unable to determine what we were dealing with without seeing the cat, an appointmet was made.

The worried owner and her nervous-at-being-at-the-vet but otherwise happy & healthy appearing cat arrived. Wishing to end the suspense, I eagerly began my exam. Several minutes later I happily reported to the concerned owner that I saw no evidence of worms coming out of the abdomen, her cat was fine. Skeptical, she proceeded to point out 8 "worms" evenly spaced, 4 in a row each on the left and right sides of her cats abdomen.

Have you guessed it by now? Sure you have. I let her know not to worry, these were nipples and very normal looking ones at that. She was quite surprised to hear my diagnosis, and skeptical of my diagnosis, pointed out to me that this was a MALE cat. Seeing that she was wearing a wedding ring, I gently asked "have you ever seen your husband with his shirt off?" and waited for her to make the connection.

A sheepish owner left the clinic with an anatomy lesson that will never be forgotten. A cat left the clinic with a diagnosis of good health and nothing more than a good "massage". And I reaffirmed my belief that a diagnosis can't be made over the phone, the patient needs to be seen.