Your Pet's Best Friend

Stool Specimens (Part 3)

We've talked about what to bring, and where to find it.  I didn't mention what we do with it after it gets here, though.  There are so many fecal specimens run through our laboratory every day that I just take it for granted.  I shouldn't be doing that, though. 

Here's what happens:  about a teaspoonful of poop gets dissolved in a half-ounce of concentrated zinc sulfate solution.  This will make the microscopic worm eggs float to the top, just like those people you see bobbing on the surface of the Great Salt Lake or the Dead Sea.  Then, the whole mess gets filtered through some gauze into a plastic tube, like those in the foreground. [Yes, that is a messy, nasty job.] The tubes go into the centrifuge, where spinning at high speed puts the heavy poop-stuff down in the bottom of the tube, letting all the cute little eggs float to the top by themselves.  Then you look at the top drop under the microscope.    All the eggs in the whole sample are in that one little drop, so you should be much more likely to find them than if you just took a smear of poop and looked at that under the microscope.

There are some protozoa (microscopic one-celled animals) that are destroyed by the salts in the flotation process, so we do check a smear under the microscope, too.  Overall, though, that's like checking a handful off a truckload -- maybe that truck is full of soybeans, maybe it's full of motorcycles.  You don't know.  That's why we ask for a bigger sample than the tiny smear.

This is Dr. Don Schmidt (one of nature's noblemen), who taught me all of the above about 30 years ago.  That's the way I've always done it.  The centrifuge in the first picture was purchased in 1979 and the old war-horse is still going (the centrifuge, not me... well, me, too, I guess).

Imagine my surprise when I attended the gastro-intestinal disease seminar last week and the presenter was selling this as a new idea.  He didn't exactly say it was new; in fact, he said "We've known this since the seventies".  What was news to me was how few veterinarians have apparently been doing it.  You can just look at smears, or you can just let the little eggs float to the top without centrifuging.  You miss half of what you're looking for, but you could do that. Dr. Todd Tams is a GI specialist, and the chief medical officer for the VCA-Antech chain of corporate veterinary hospitals.  He made flotation with centrifugation standard practice in the chain just five years ago.

Dr. Schmidt told me what to do, and I've been doing it ever since.  Unlike some of my other education, which has been superseded by new information, I find I've been ahead of the curve by just doing what I learned 30 years ago.  How weird is that?

Stool Specimens (Part 2)

Some people tell me that they just can't find where their dog goes to the bathroom.  If they live on a huge farm, then I'm not surprised.  Sure, I'm disappointed, but I'm not surprised.  When they tell me that "Yes, the yard is fenced", but they still can't find it, I've got to wonder just how big this yard is.  If it's that huge, they probably have servants to take care of it.  Perhaps one of the servants could follow the dog around for a day.

Then there are folks who live in little subdivisions, with little houses and little yards, all in a row.  When they tell me that the dog doesn't go in their yard and they just "don't know where he goes", I'm thinking that there is somebody in the neighborhood who does know where he goes.  I'm also thinking that that somebody is not only anxious to show the owner that location, but also to talk to him about it... vigorously!

They should call The Poop Detective.  The video may be a little silly, but the message of being considerate of your neighbors is right on the money.  Leaving fresh crap all over is inconsiderate, unsanitary, and just gross.  Not to mention that it does not make dog-lovers out of the previously undecided group of voters.  If you love your dog, don't help him make enemies.

That's why I've had this sign in my kennel for years.  The deodorizer spray next to it works a lot better than the sign, though.

Stool Specimens

Warning: Bodily Functions are Disgusting

So, the client brings in a ziploc bag with a few leaves just as bright green as these.  "I think that my dog has diarrhea from eating these plants."  "Have you seen him eating some like these?"  "Not like these, these plants right here. See how wet they are? They must have gone right through him."  "Trust me, lady, I'm a professional.  If these plants had gone all the way through your dog's digestive tract, they wouldn't be this bright green."  Of course, the dog had eaten the weeds and vomited them up.  I'm not kidding about that different color thing. I'm not kidding about being a professional, either.

I advise you not to click on this picture to blow it up.  The title "Fecal Scoring System" could also be "Know your s__t".  I never use this chart with clients, though maybe I should.  Typically, when the client says the pet has diarrhea, I ask if the consistency is watery, or like paint, or applesauce.  Sometimes this works... sometimes they swear off applesauce.  In livestock country, you can ask if it's "cow-pie" consistency, but few of our clients have been up close to a cow, much less a cow-pie. 

Here's a picture of a cow.  Here's a picture of a cow-pie.  Happy now?

We always ask clients to bring a stool specimen as part of the pet's examination.  People think I have some kind of poop fetish, because I always ask if they've  brought it.  As I've mentioned in a previous post, a microscopic exam of the stool is best way to check for most intestinal parasites.  Color and consistency can also give you clues about some other types of digestive ailments.

People are reluctant to even talk about the excrement, much less pick it up.  If they do bring a specimen, it's "his job", "a present for you", "his homework" [my favorite].  Many clients (in fact, most clients) would rather not bring in the specimen.  Sure, I could fish some out, but you get a pretty tiny sample that way, and you can miss things just because your sample is so small.  With just a smear, you have the equivalent of pulling a handful off a truck-load -- maybe that truck is full of soybeans... maybe it's full of motorcycles.  You don't know.  Really, we need about a tablespoonful, and we need it the same day it's passed -- within 12 hours; it doesn't have to be steaming (thank goodness).

It's always interesting to note the different responses to my request for the specimen.  Virtually nobody brings in a tablespoon-full.  You might get a smear on a Kleenex or a coffee-can full.  There are people who just forget (and I understand that: it's the kind of thing you'd be happy to forget).  "The secretary didn't tell me to bring one." [Yes, she did.] Then there are other people who just tell you flat out that they are not going to pick up poop and bring it in.  Fair enough, though it may handicap me a little.  And then there are the folks who are sure not going to bring you a sample, but they feel bad about it, because they love their pet and they know they really should.  These are the folks who slap their forehead and say, "Oh, I had one, but I left it sitting on the kitchen table."  In the butter dish, no doubt.

My favorite is the client who lets me fish a specimen out of the dog's exhaust pipe and go through the whole exam.  As we finish, I say, "Now, if you can bring me a bigger specimen, we can do a more accurate check for intestinal parasites."  "Oh... I've got one."  He's had it in his pocket the whole time.   What if I hadn't asked for it?   How long would he have saved it?  Why?  We know how I lost my capacity to feel dirty, but what happened to this guy?

Pet Wellness Exams

The "wellness exam": what is it? It's a good physical examination, plus or minus some diagnostic tests, when you think you're in good shape and don't need it.

In terms of my own health, my insurance company pays for bloodwork each year, sends me a survey to fill out, and then advises me of what they consider to be my risks of developing common diseases for guys in my age group.  I usually see my physician each year because I can't stay at Scout camp without a current physical.  Do I really need a check-up that often?  After a good check-up might I still have a prostate infection or a heart-attack, despite what my risk factor assessment says?  Yeah, maybe.  But what if we find something that keeps me from waking up with the plumbing shut off?  Yeah, that would be good.

When you're young, you have contempt for the frailties of the old.  The older you get, the more obvious it becomes that your body is not as bullet-proof as you thought it was thirty years ago. Sixty doesn't seem nearly as old when you're fifty-four as it did when you were twenty-one. You think that maybe it's okay to let old people keep on living for a while. On the other hand, despite doing a cardio workout every day and lifting weights twice weekly, taking my vitamins -- stuff still happens.  If that "stuff" doesn't get better pretty quick, I will call my doctor.

Animals have a tendency to conceal their problems: it's not very pro-survival to advertise how weak and helpless you are.  We've talked about the tendency of older animals to have more problems.  Why should your apparently healthy pet get a check-up?  The National Pet Wellness site has lots of reasons for you.  Of course, that could be just some marketing gimmick cooked up by veterinarians and drug companies.

On the other hand, maybe you could use some help in assessing your pet's health. 

This week a lady brought in her cat for "a second opinion". This 12-years old cat had been treated with antibiotics for a respiratory infection last week by another doctor, but she was feeling worse again.  Since I had never seen the pet, it took a while to get the complete history.  I start with "When did you get her?" and work through where she stays, what she eats, how many pets in the household, previous medical problems and treatments, and "When was her last check-up?".   "Oh, I never take them to the veterinarian.  My pets live a long time. They don't need check-ups." 

The cat was greater than ten percent dehydrated, and weighed six pounds when she should have weighed eight.  If that were a person, think 160 pounds down to 120 pounds, and shriveled up like a raisin.  This weight loss had been apparent for at least one month.  Now the cat would hardly eat anything.  Something was going on here besides a snotty nose.

We gave her fluid therapy to rehydrate her, and started diagnostic tests the next morning.  Her kidneys were failing, and she had diabetes mellitus (sugar diabetes).  IF she can be successfully managed at this point, we're talking a major project of intensive care in the hospital.  Balancing her fluid needs, and her insulin needs, and getting her to take in food -- not easy...not cheap, either.  Things would have been a lot simpler a month ago, not to mention say, six months ago, before she started "looking sick".

I'm not saying that your observations of your pet are missing as much as this lady was, but I will say that a lot of "wellness exams" turn up findings that show the pet is not so "well" as you thought it was.  I think it's a good idea.

Blood in the Urine...One thing I forgot to mention

In a previous post I discussed the presentation of dogs and cats who have blood in their urine.  I mentioned various causes and diagnostic tests available, but I left out the current scenario.

Some years ago, a client called saying "Fuzzy has another one of those bladder infections." (She had previously had two episodes of cystitis, with a bacterial bladder infection.) "She's passing blood in her urine again."  "Is she squatting and straining a lot, like before?"  "Well, no... but I'm sure it's the same thing." "I'm not.  I need to see her." On examination I didn't see anything out of the ordinary, but something just wasn't right.  Patients with bladder infections feel like they have to go, and they feel that way all the time.  They do a lot of squatting and straining, and Fuzzy wasn't. [Don't get me started on that "Fuzzy-wuzzy wasn't fuzzy, was he?" song now.]

So, if you have blood in your urine, but no inflammation, what's the deal?  Could be a tumor, could be trauma, could be a bleeding problem.  So, I miraculously made the correct choice of which test to run first.  We did a complete blood count, which revealed that the cat had no platelets.  You need platelets.

Without platelets, you tend to bleed pretty freely.  While there are many proteins and complex factors in the blood-clotting process, it's the little blood cells called platelets that provide the initial plugging of the hole.  Without some sort of "scaffolding", the clotting proteins don't really have a place to lodge and get to work, even if they're working great.  Put some of that blood in a test-tube and it will clot in a normal time period.  Make a little cut on the patient, and it will just keep on bleeding.

Curly Sue is a big old dog who just had "a little blood in her urine" last Wednesday.  "Probably has a bladder infection", thought her owner.  On Thursday her urine was about twenty percent blood, and it was all over the garage.  Since she's an older dog, my initial thought was that she might have one heck of a bleeding tumor in there. Physical examination showed that her gums were a little pale (and you've got to be down to half your normal complement of red blood cells for that to happen).  She's pretty furry, so her skin was hard to see. On a hunch, I shaved her tummy, and found little hemorrhages all over.   She looked like a dog with Rocky Mountain Spotted Fever, except she only had the spots (no swollen lymph nodes, no fever, and no history of tick exposure, although sometimes folks don't see the tick).  She also had no platelets.

Now when you don't have platelets, either you're not making them, or something is destroying them.  If they aren't being made in the bone marrow, then we most likely have a cancerous disease damaging the bone marrow or an auto-immune disease, where the body's own defenses are destroying the stem cells that make the platelets.  This auto-immune reaction, this malfunction of the body's defenses, can be destroying the platelets later in the game as well.  Sometimes this type of reaction occurs secondary to infections or drug administration.  Most of the time we really just don't know why it happens.

So with both Fuzzy and Curly Sue, I got lucky.  I can't say that they got lucky, because having auto-immune thrombocytopenia (a lack of platelets, due to the body destroying them) is not a lucky thing.  I feel lucky, because I did the right diagnostic test, they had a treatable disease, and the treatment worked.  Both individuals responded to big doses of prednisone to temporarily suppress the body's defenses and stop the cycle of platelet destruction.

The medical end is a little more complicated than that, but the bottom line is that we have to look at the whole patient, the history, get our diagnostic tests, and do some thinking to get it right.  Sometimes your first impression can be wrong.  When the data don't fit your theory, you need a new theory.  If you don't bother to get any data, you wouldn't know that, would you?

What kind of dog is this?

I spent the summer of 1973 working at the Central Missouri Humane Society, back in my pre-veterinary days.   People would call asking, "Do you have any purebred dogs with papers?"  Occasionally, we actually did.  Most of the time we had the canine "wretched refuse of your teeming shore" (to borrow from Emma Lazarus).  While there are dogs who are given up for adoption due to extenuating circumstances, the vast majority of folks giving up their pets stated simply: "Don't want him anymore." 

Under those circumstances, the dogs rarely come with pedigree, and many are of no immediately recognizable breed.  So you write "mixed breed" on their paperwork.  I will tell you that while "mixed breed" sounds a lot nicer than "mutt" or "mongrel", it is not an acceptable answer to the prospective adoptor in search of a dog.  When they ask "What kind of dog is this?", they want an answer, and they don't want the answer to be "I don't know."   The shelter employee must become creative.  Fortunately, you spend a lot of time looking at that chart with pictures of all the AKC recognized dog breeds.  There are certainly a lot of possibilities. With a modicum of imagination, you can conjure a plausible pedigree.  "I think he's probably a cross between an Irish Water Spaniel and a Bouvier des Flandres."  Yeah, right.  That may not sound all that plausible to you, but people want an answer.  When all else fails, small dogs can be a "terrier mix" and large dogs can be a "shepherd mix".

That's why I know that the new Wisdom Panel MX test is going to sell.  It won't be available before September, 2007, and we don't know what it will cost, but I know it's going to sell.  Inquiring minds want to know, especially what kind of dog this is.   I love this idea, but the test certainly has its limitations.  Supposedly, with a blood sample for your dog's DNA, they are going to check it against genetic markers for 130 breeds.  "You've got an uncle who was half Dachshund and half Collie". [Don't laugh -- I've SEEN that cross, and the Dachshund was the father.  Talk about  a missed opportunity for America's funniest home videos, or YouTube, anyway.]

The kicker is that it's not offered for purebreds.  You're not going to prove that your dog is really a purebred Arkansas Giant Bulldog, or prove that it's NOT a Pit-Bull where they are outlawed. 

The other funny thing (to me, anyway) is that it's offered by Mars Veterinary Care.  You know, Mars, the candy bar people.  Of course, in addition to M&M's, they also make pet foods.  It's corporate diversity.  I think this may be a little too much corporate diversity.

I love this quote from their frequently asked questions: What research is the Wisdom Panel MX based on?  "Wisdom Panel MX is the result of years of extensive research."  Pardon me, but does that actually say anything?  It reminds me of the interview with the Japanese minister of justifying whale-slaughter.  "We need to kill whales for research."  What kind of research? "Scientific research."  Yeah, right.

There will definitely be a market for this, whether or not the results mean more than me juggling the breed chart in my imagination.  Think how popular it was to order your "Family Coat of Arms" back in the seventies.  I think that this test may wind up with some sort of disclaimer at the bottom, like the old TV psychic ads: "For entertainment purposes only."  It will be fun, though, if it's not too expensive.

Which test should you do first?

Sometimes that seems obvious.  If a patient is having blood in the urine, you ought to examine a urine specimen.  So the folks bring their baby in, and she takes a little walk outside with our top urine-catching technician, and back they come with a dandy sample.  She's emptied her bladder and you've got a great specimen to analyze.  Whoops! The analysis shows rafts of weird cells along with the blood cells when you look under the microscope.  We need to perform an ultrasound scan of the bladder, and for that, we need the bladder to be full...you know, the bladder we just emptied.  Nuts.  This happened yesterday, and we wound up keeping the dog overnight and performing the ultrasound this morning.  The scan confirmed my suspicion of a tumor in the urinary bladder.  Fortunately, we were able to remove it surgically with no trouble (though pathology results may very well send us to chemotherapy follow-ups).

Last month, a huge Rottweiler comes in with complaints of occasional blood in the stool.  He looks great and seems to feel great otherwise.  Stool exam shows nothing out of the ordinary.  The owner says she can't afford a lot, so we start with a broad-spectrum de-worming (Panacur/fenbendazole), and a course of metronidazole (an antibiotic that has an anti-inflammatory effect on the colon wall, while killing bacteria that thrive without oxygen, as well as killing many giardia, the one-celled intestinal parasites).

That didn't work.  We've got persistent (if intermittent) blood in the stool.  We need to do a colonoscopy. We love that, especially the multiple enemas needed to clean him out first.  Oh, well, at least he's so big that it will be hard to deal with the size of the mess.  Wait... that's not a positive.  Anyway, we get it scheduled.

He comes in today, and we find that he no longer feels great.  He hasn't eaten for the last two days.  He still looks great, though he's lost a couple of pounds (from his big 120 fighting weight).  We give him a couple of enemas, then take an X-ray to see if he's empty.  He's empty, and we don't see much remarkable.  Next step, light anesthesia for the colonoscopy.  Hey, I think I'll just take a quick peek around his abdomen with the ultrasound before we send the scope up the back way. 

So we have him asleep, on his back, and I smear some gel on his tummy.  Well, now, I've tried to examine his abdomen on previous visits, but this is the first time he's really been relaxed enough for me to get a good touchy-feely on his tummy. I feel something big and hard and not-supposed-to-be-there.  You can't really see it on the X-ray, so it must be about the same density as normal tissues. No colonoscopy for you, pal.  It's time for exploratory surgery.  Jeez, if I'd only anesthetized him to feel his abdomen on the first visit I could have skipped all these other tests.

Have you ever heard that silly question, "Why is it when you're looking for something, it's always in the last place you look?"  What we'd like is for the first place we look to also be the last place you look (when you find it, naturally, you stop looking).  The bottom-line take-home message here is that the only way for me to know which test to run first would be for me to already know what the problem is.  Of course, then I wouldn't need to run the tests.

It takes us back to how much testing is enough?  You can't have irony-poor blood in this profession.

Von Willebrand's Disease

This is Roxxi.    She looks a little woozy because she got spayed today (a complete ovario-hysterectomy, i.e. the removal of the entire puppy works).  People tend to think of this surgery as routine because it is performed so commonly.  Of course, it's never routine for the dog -- for her it's a once-in-a-lifetime major surgery.  Most of the time it is routine for the doctor.  I've done lots of them, most dogs are put together in pretty much the same arrangment internally, I know what I'll do first, what I'll do second, etc.  It's not like an exploratory surgery where you're "making it up as you go".

Roxxi is a little different, though.  She has a bleeding/clotting disorder called Von Willebrand's Disease.  She doesn't make enough of a particular blood-clotting protein.  We discovered this when she had her ears cropped at ten weeks of age.  Interestingly, there was no excessive bleeding during her surgery (performed in the morning), nor was she oozing any during the day.  When I came back at 10:00PM to give her pain medicine, everything looked fine.  The next morning, we arrived to find that, while she wasn't bleeding at the moment, she had bled a significant amount during the night. ["significant amount" = AAAGH!!! There's huge puddle of blood under the grate in her cage!]  Fortunately, the rest of her recovery was uneventful.

We took blood to test for clotting disorders and found that she had Von Willebrand's Disease.  The Doberman Pinscher is one of the breeds that is known to have this in their genes.  The disease is inherited, but it has incomplete penetrance, meaning that many individuals are carriers, but are not themselves affected with the bleeding problem. 

Another neat thing is that these dogs are not "free bleeders" under everyday circumstances.  It's mostly only when they get some seriously traumatic event like being hit by a car, or surgery, that they have problems.  So when they need their clotting ability the most, that's when they have it the least.  Bad timing.

If you read the VWD article in VeterinaryPartner.com, you'll get a lot more technical information, if you're interested.  One thing they mention is performing a "bleeding time" test pre-surgically.  Aside from the fact that it would add another $20 test to every surgery, I guess I've just been fortunate to see very little of this disease over the years (this is number two since 1978).  I've gotten complacent about checking for it ahead of time.

Normal test results for the VWD factor range from 70 to 180 at our lab.  Anything less than 60 is considered a potential bleeder.  Roxxi tested out at a big 7.  Since this is hereditary, she obviously should not be bred.  Ah, but what about doing surgery?  Won't she bleed to death?  Yeah, she might...UNLESS she gets a transfusion of clotting factors (cryoprecipitate) before the operation.

It turns out that you can buy this from Midwest Animal Blood Services all ready to rock and roll.  They ship it to you frozen on dry ice and you just thaw and serve (through an IV over about an hour, that is).  There's really only one hitch: it costs about $240.00 (including the overnight shipping).  That was enough to cause Roxxi's folks to "think about it for a while".

Unfortunately, while they were thinking about it, Roxxi attained puberty, slipped out and got bred.  Whoops!  Now we're looking at a potential hemorrhage during the birthing process, or during an abortion, just as we might fear during surgery.   So, they decided to take care of business, and Roxxi is doing just fine (though a bit groggy with pain meds tonight).

Senior Care/Geriatric Workups, Part 3: "He's been so healthy until today."

Three times in the last week I have been presented with a pet who was gravely and terminally ill, and the people felt the illness had come on suddenly.  I looked at the pet and saw things like being twenty percent underweight, bones "sticking out", dehydration, sunken eyes, swollen abdomen.  These are things that didn't happen overnight. 

It is certainly true that animals have a tendency to conceal their illnesses to whatever extent possible.  It's a survival thing: you don't want to advertise what a helpless target you are.  It is also true that a long hair-coat sort of fills in the gaps, concealing early weight loss (like someone wearing a bulky sweater: you don't know if they're fat, thin or what).

Also, the body has a lot of reserve capacity built in.  Your heart normally beats at about half-speed, resting the other half of the time.  You have two lungs, but could get by with one.  Two kidneys, but you could get by with half of one.  The liver has lots of excess capacity.  This means that long-term, chronic, ongoing destruction of the organ's function can go on for quite a while, and you still look okay.  It's only when the reserve is all gone and you're down to losing the nitty-gritty that you start looking sick.

On the other hand, when questioned, these owners readily volunteered things like "Oh, yeah, he hasn't been eating well for a long time.  He doesn't move around much either.", or "She has been eating everything she could find and still was losing weight.  She drinks a ton of water, too, way more than she used to." , or  "We had been noticing that big belly for a few weeks."

Does that sound like some of the things on yesterday's checklist?  You bet it does!  Even though the pets had been operating at a level the owners had come to consider "normal" just a few days before, there was nothing normal about it.  They had been sick for weeks or months, but it had been dismissed as (you guessed it) "just getting older".

Many veterinary hospitals (including KVC) have "Senior Care" packages.  When your older pet (or younger one, for that matter) is showing some of the clinical signs on yesterday's checklist, we bundle a wide array of screening tests into a package that saves you about twenty percent over the cost of running them separately. [The savings derive from getting a package deal from an outside lab, and from only having to handle the patient and the paperwork one time.]  It's not a bad idea for older pets to have periodic screenings, even if they don't have obvious clinical signs of disease.  As a dog or cat ages, one calendar year really does equate to seven "human  years".  A lot can change in that time for an aged pet.

What difference can it make?  It's a tale of two dogs.

"E" had high liver enzymes when she had her senior check-up, leading to an ultrasound exam showing a tumor.  The tumor went to surgery, but could not  be completely removed.  However, at 13 years old, she is 18 months past surgery, leading a happy life with oral chemotherapy at home. 

"K" came in at 12 years old with a really swollen abdomen.  It had been a couple of years since her last check-up.  It seemed to her owners that she had just "suddenly become sick".  Her ultrasound exam showed her liver riddled with tumors, with practically no normal tissue left.  Her owners felt that euthanasia was the only practical and humane choice.

You don't have to invest a lot of money in diagnostic testing for your pet.  If you have an older pet, why not invest a little time in reviewing that checklist?  You might be able to add years (good years) to your friend's life.

Senior Care/Geriatric Workups, Part 2: The Checklist

It is amazing to me how many clinical signs of disease are dismissed as "just getting older".  It is certainly true that old age will bring about some degenerative changes that we cannot remedy.  On the other hand, many diseases of the older pet are very treatable. 

I have listed common signs of disease that should be recognized as needing further handling, rather than being dismissed as "just getting older".  They are listed in four categories (and some will show up in multiple categories): Quality of Life (Pet's), Quality of Life (Owner's), Pain, and Shortened Life Span.

Quality of Life (Pet's): Can't see well, can't hear well, itchy skin, greasy skin, flaky skin, too thin, overweight, difficulty rising, difficulty walking, difficulty climbing, difficulty jumping, sleeps excessively, restless or sleeps poorly, poor endurance, incontinence (wets herself), diarrhea, constipation, thick or scaly footpads or nose, gets lost, confused, disoriented, less interaction with family, mattery eyes, crusty nose

Quality of Life (Owner's): Odor from mouth, odor from ears, odor from skin, odor from rear, vomiting, spitting up, diarrhea, incontinence (wets the bed), "accidents" in the house, excessive barking, whining, scratching constantly, decreased responsiveness, less playful, excessive shedding, confused, disoriented, doesn't greet, skin is dry or flaky or greasy or just "looks bad", sleeps all the time, restless or poor sleep, excessive urination

PAIN: Difficulty rising, difficulty walking, limping, difficulty jumping, difficulty climbing, bad odor from mouth, restless, sleeping poorly, coughing, gagging, excessive panting, heavy or difficult breathing, tremors or shaking, less enthusiastic greeting, less playful, decreased responsiveness, grumpy disposition, mattery eyes, squinting, barking, whining, moaning, poor appetite

Shortened Life Span: Vomiting, diarrhea, constipation, coughing, gagging, lumps, tumors, excessive water drinking, excessive urination, excessive appetite, poor appetite, weight loss, poor coat condition, hair loss, unusual shedding, bad odor from mouth, poor endurance, circling, repetitive movements

Tomorrow in Part 3 I will discuss the practical application of these principles.