Simba

"He's doing fine, no coughing, sneezing or diarrhea... just drinking more, and occasionally peeing outside the box... which he has always done"  This was the run-down from the veterinary assistant as I was about to go see Simba and his brother for their yearly physicals and vaccines.  The owner, as many owners do these days, had expressed financial concerns before even making the routine appointment.  Luckily the owner had decided to make the sacrifice and get a thorough  exam and vaccinations for her cats despite her financial situation.  In this economic climate, it is a rare week that we don't have someone tell us that "we don't need an exam, we just need shots".

It is a shame that the physical exam is the most underrated and overlooked diagnostic in veterinary medicine.  Somehow, we as a profession have failed to communicate the benefit of or necessity for physical examination in pet healthcare.  In our enthusiasm for products (vaccines, flea preventatives, dewormers, drugs) our services (physical exams and procedures) have been unintentionally minimized.  When we send out reminders for vaccinations, we reinforce this mindset.  People almost always call because "Fluffy" needs shots, not because "Fluffy" needs a physical exam.

I digress... The point of this story is to illustrate just how strikingly useful physical examination can be for the detection of disease.  Simba's occasional poor litterbox habits did not set off any alarm bells in my mind as I put my stethoscope around my neck.  Many cats occasionally pee outside the box and there can be a myriad of reasons, many of which are fairly benign but difficult to diagnose.  Drinking more water, however, can be a bad sign in cats.  

I examined Simba's brother, Bear, first.  He was a stray that had adopted the owner as his new provider.  The owner was interested in getting him neutered... As (poor) luck would have it, he was cryptorchid (had an undescended testicle).  For anyone who does not have an excess of money to spend, that is bad news.  A routine cat neuter is a relatively simple procedure.  A cryptorchid surgery is at best much more complicated, and at worst an invisible easter egg hunt.  I broke the news to the owner and started explaining what she was into.

Simba was next, and while the owner was digesting the news about his brother, I started going through Simba's history with the owner looking for clues.  He was finicky with his food.  He was drinking more water.  He seemed irritable when she picked him up.  I listened intently as I conducted my physical head to toe.  When I came to abdominal palpation, something felt very wrong.  Just as I felt a hard mass in his cranial abdomen, he turned around to bite me.

I had my assistant scruff Simba as I went back to feeling his abdomen.  Sure enough, there was a big hard something in his abdomen that most certainly did not belong there, and he did not want me touching it.  Now, this was a difficult situation.  I knew that something was desperately wrong with Simba, but also knew that diagnosing and treating this was going to be an issue.  I explained to the owner what I felt, and offered to run the ultrasound over his abdomen to see what was there.  She agreed, and we took Simba to the back.

The ultrasound was unrewarding... the ultrasonic waves do not travel through air well, and there was gas interference from his guts.  I decided to take an x-ray.  What I saw on radiographs I could not begin to explain.  I had the other two doctors feel him and look at the x-rays.  No one could tell what was going on.  Right in the cranial abdomen was a big globoid something that looked like it was full of radio dense worms or spaghetti (neither of which would show up on an x-ray like that).  I showed the owner, and told her that I didn't know what it was but was confident that it didn't belong and most likely needed to come out.

The owner agreed and we scheduled surgery for early the next day.  That afternoon we started taking bets on what it was.  I felt that it was in fact a mass of intestinal worms (perhaps mildly calcified) in the stomach (where they don't belong).  Other bets were cancer, foreign body, and cyst.

The next morning, as the owner waited in the lobby, I conducted an exploratory surgery on Simba.  After I entered the abdominal cavity, a large hard stomach just about jumped out of the incision.  I could feel hard densities contained within and knew that I found my target.  Upon opening the stomach, I was greeted by a tangled mass of rubber hair-ties filling the tubular organ.  Removal of the ties was trivial, and closing the stomach and body wall was routine.

The owner was surprised when I explained my findings.  Simba had eaten those months ago.  Luckily, they had not yet made it past the pylorus into the small intestine.  Once there, they could have caused all kinds of unpleasantness and even death.  Simba went home later that day, and was up eating normal wet cat food within 24 hours.

I guess the moral of this story is that while vaccines, deworming, and tick/flea products may seem like the "reason" to go to the veterinarian, they are really just the icing.  The real meat and potatoes of your pets' visit is the physical exam.  Most veterinarians are experts at physical examinations.  The reason is that the physical exam is sometimes our only modality for detection of disease.