It can be frustrating for pet parents to deal with their cat peeing outside of the litterbox without knowing why it is happening. There may be an underlying behavioral or medical problem, and a visit to your veterinarian can help distinguish the two. Sometimes, treatment is easy and the issue resolves, but other times it can take some time and patience.
Feline Lower Urinary Tract Disease (FLUTD)
FLUTD is a term describing all of the urinary issues that can be attributed to a medical cause. Urinary tract infections, bladder stones, bladder inflammation, or urethral obstruction can all result in urinary issues. You may notice your cat urinating more frequently, passing blood in the urine, or straining to urinate. Your cat may even cry out when urinating or fail to pass urine at all! If you are noticing any of these signs, you should seek veterinary care.
Once at your veterinarian, he or she will do a thorough physical exam, collect a urine sample, and perform imaging, such as an x-ray or ultrasound. If these tests show that bacteria and inflammation are present within the bladder, your cat will be given anti-inflammatory and antibiotic medications followed by a urine recheck one week later. If the urinary tract infection is not resolving, it may be necessary to collect a sterile sample to better target antibiotic therapy. If bladder stones are seen, surgery may be necessary to remove them. Obstructions may be relieved by passing a urinary catheter or in severe cases, surgery may also be necessary. Cats with obstructions must be hospitalized for several days.
Once the underlying cause has been addressed and resolved, switching your cat to a diet formulated for urinary health and reducing stress in the environment may be recommended for long-term management.
Once all possible medical reasons have been ruled out, behavioral modification may be necessary. Cats can become easily stressed or anxious especially in multi-cat households where there may be conflict. Altering the environment through renovations or addition of a new baby can also cause stress to your cat, which can manifest as inappropriate urination. A few strategies can be helpful to try to eliminate these behaviors.
Feliway products, such as diffusers and spray, can be used. They emit calming pheromones which can reduce anxiety, fear, and stress in your cat. I also recommend having one more litterbox than the number of cats in your household. For example, if two cats live in your home, you should have three litterboxes each placed in a different area of the home. Providing vertical space, such as with shelving or cat trees is also helpful to keep cats active and engaged.
Inappropriate urination can be frustrating for pet parents. The first step in getting to the bottom of this behavior is to see your veterinarian who will be happy to discuss possible causes and treatment options.
It’s the usual summer busy season
in veterinary hospitals. On top of that, we are still in the season of COVID-19,
so add those together and you get complete chaos on some days! As a newer grad,
I am still learning the ins and outs of daily life in practice. I have found
more confidence as the weeks progress, but I still wake up some days with anxiety
about what the day may bring and if I will be good enough for my patients. I am
hoping with more experience those feelings will subside, but in the mean time I
believe I am growing as a person and as a doctor.
I recently had a fully booked day of
appointments with several patients needing diagnostics and treatments done. In
addition, we had about twelve drop-offs added to the schedule that morning. Needless
to say, I was quite busy, and at one point I was managing six hospitalized
cases- a diabetic dog getting a glucose curve, a dog with hemorrhagic
gastroenteritis, a dog with pancreatitis, a blocked cat, a dog with chronic
kidney disease, and a dog with a brachial plexus avulsion. That is quite the variety!
It was one of those days I couldn’t wait to be over so I could breathe.
The demands of daily practice, especially
during this time, can be overwhelming. We are a profession of compassionate
caregivers. We push ourselves and replay cases over in our heads wondering if
we made the right choices. We strive to be perfect and get discouraged when we
can’t possibly live up to that standard. That is too heavy a load to carry even
for the most seasoned veterinarians! Trust me, I need to remind myself of this daily.
It’s okay to not be perfect. It’s
okay to make mistakes and then learn from them. It’s okay to ask for guidance,
and it’s okay to give yourself grace because we are only human and can only do
so much. At the end of the day, what matters is that we’ve done our best to
advocate for our patients. All we can do is our best, and that is enough.
Summer is upon us, and that means more pets are arriving to the animal hospital with allergies and corresponding clinical signs. Oftentimes, their itchy skin and hair loss is related to fleas. These small parasites are frequently found outdoors and can jump on your dog while he or she is sunbathing, taking a walk, or playing ball. An allergic reaction to the saliva can occur in sensitive dogs when a flea bites, leading to intense itching, hair loss, and inflamed skin. This can be incredibly uncomfortable!
If your dog is experiencing itchy skin or losing hair, it is best to see a veterinarian for a thorough physical exam. A flea comb will be used to identify any live fleas or flea dirt (feces of fleas). The most common distribution of hair loss and inflamed skin secondary to flea allergies is on the rear end near the tail base and down the hind legs. Absence of fleas or flea dirt does not necessarily rule out flea allergy dermatitis. When your dog goes outside, a flea can still jump on, bite, and trigger a reaction. However, the flea will not stick around and cause additional issues if your dog is current on monthly prevention.
Flea prevention is essential year-round to prevent infestations and these secondary signs in your dog. Products that work to kill fleas and ticks rather than repel them are preferred. A couple products in this category include Bravecto or Credelio. In addition, using a household cleaner specifically formulated for fleas will help eliminate any infestation present within your dog’s home environment that can wreak havoc. This is an essential step in resolving the issue. Be sure any other pets in your household are also up to date on flea prevention! Fleas can be difficult to treat due to their extended life cycle. However, this is a treatable condition with a good prognosis. For dogs that are particularly itchy, anti-histamines or steroids can be given to provide relief while any fleas are being eliminated.
I have been seeing numerous patients suffering from allergies recently. Environmental allergies are seasonal and occur most commonly in the spring and summer when there is an abundance of pollen and other allergens. This condition is medically referred to as atopic dermatitis.
First, it is important to differentiate atopic dermatitis from food or flea allergies. To learn more about these other allergies, you may read my previous blog post. Atopic dermatitis usually affects a dog’s belly, paws, muzzle, or ears. Dogs suffering from this condition are usually brought to the animal hospital because they have started to itch, lose hair, or chew their paws. Additional presenting complaints may include watery eyes, sneezing episodes, or malodorous skin. Common environmental allergens are pollen, dust, molds, hay, and grass, among others.
There are specific tests available through your veterinarian to pinpoint the exact allergens your dog is sensitive to. One test is serological and consists of submitting a blood sample to detect antibodies against more than a dozen potential allergens. Intradermal skin testing is also an option, which consists of injecting a small volume of allergen within the skin and assessing whether any swelling or redness results.
Many treatment options are available to provide your dog
relief from allergies. In dogs that are only mildly affected, antihistamines or
medicated shampoos may be effective. Diphenhydramine (Benadryl), hydroxyzine, and
cetirizine (Zyrtec) are all commonly prescribed antihistamines but be sure to
get veterinary guidance before administering anything to your dog. These
medications reduce the histamine response that occurs from allergies but must
be administered frequently to maintain their effect. Medicated shampoos can have
anti-inflammatory, anti-pruritic, and antimicrobial properties. Often, they are
used in combination with another therapy.
Steroid injections can provide immediate relief from itchy
skin and inflammation. The relief is usually short-lived and lasts about two
weeks. Steroid injections should not be given repeatedly because they have a
wide array of side effects. However, they can provide relief while you
determine a long-term treatment strategy.
Two medications–Apoquel and Cytopoint— have been
specifically formulated to combat allergies. Cytopoint is a subcutaneous
injection that starts working within 24 hours and lasts 4-8 weeks. It is very
safe and works to block a specific inflammatory cytokine involved in the itch
pathway. Apoquel is an oral medication that also targets the itch pathway and begins
working within 4 hours. Monitoring bloodwork with long-term use of Apoquel is
In severely affected dogs, immunotherapy injections may be
recommended. They can provide long-term relief since they slowly build up
tolerance to specific allergens. This therapy consists of a series of
subcutaneous injections that each contain increased doses of the allergen.
Injections are continued until an adequate dose is given to provide
immunotolerance. This means your dog’s immune system will no longer react to
the allergen causing issues. The goal of this therapy is similar to that of
vaccines, which primes the immune system against certain disease.
The prognosis for dogs affected by allergies is good, but it
can require lifelong treatment to reduce clinical signs and ensure your dog is
Hypothyroidism in dogs occurs when there are decreased levels of thyroid hormones present within the body. It is common in middle-aged to older dogs. These hormones are important for maintaining heart rate, a healthy hair coat, energy levels, ideal body condition, and normal body temperature.
What causes it?
The pituitary gland secretes thyroid stimulating hormone (TSH) which stimulates the thyroid gland to produce T3 and T4 (thyroid hormones). When there is a problem along this pathway, low levels of thyroid hormone can occur. The most common cause of hypothyroidism is lymphocytic thyroiditis, which means that the immune system is attacking the thyroid gland and causing inflammation and destruction. Atrophy of the thyroid gland may also occur as dogs age. A tumor within the pituitary gland that prevents TSH from being produced is another possible cause, but it is much less common than primary thyroid disease.
What are the clinical signs?
Since thyroid hormones are important for metabolism, dogs typically experience weight gain despite a normal diet. Hypothyroid dogs will often have fat accumulating along their hind ends, shoulders, or neck regions. Low heart rate, lethargy, and abnormal hair coat (shedding, hairless areas, dandruff, thickened skin) are often found. Hypothyroid dogs also cannot regulate their body temperature as efficiently and are often heat-seekers.
How is it diagnosed?
Often, this disease is detected through annual wellness bloodwork when T4 levels are checked. If results indicate a low T4, hypothyroidism should be considered. However, many non-thyroidal illnesses can cause low T4 levels so it is important to decipher these based on clinical signs and additional testing. In dogs where hypothyroidism is suspected due to a low T4, a comprehensive thyroid panel is submitted. If the values in this panel match what we would expect to see in a hypothyroid dog, your veterinarian can make the diagnosis. High cholesterol and high triglyceride levels are often found on bloodwork as well.
What is the treatment?
Treatment consists of supplementation of thyroxine (T4). This is a relatively inexpensive medication that is given orally every day. Hypothyroid dogs must be regularly monitored while receiving this medication to ensure the dosing is appropriate to maintain normal thyroid hormone levels.
What is the prognosis?
The prognosis is generally good for dogs receiving supplementation. As long as regular monitoring is performed via bloodwork and veterinary visits, most dogs can go on to live normal lives.
Vaccines are administered to prevent specific diseases throughout your dog’s life. Core and non-core vaccines are important to ensure your dog stays protected and healthy!
Rabies Rabies is a zoonotic viral disease that is transmitted through the saliva of infected dogs, specifically when they bite. It causes severe neurological dysfunction and death. It is important that your dog stays up to date on this vaccine to protect him or her. If a dog is not kept up to date on the rabies vaccine and is exposed, he or she may need to be euthanized or undergo strict quarantine for a period of time to ensure the disease was not contracted while susceptible. The rabies vaccine is given to puppies between 12-16 weeks of age. The first vaccine is good for one year. Every booster after that is good for 3 years.
Distemper (DAPP) Canine distemper is also a viral disease that causes gastrointestinal, neurological, and respiratory signs. It is spread through bodily fluids, and young, unvaccinated puppies are most susceptible. The distemper vaccine is given between 6-9 weeks of age and boostered every 3 weeks until your dog is 16 weeks of age. We vaccinate so frequently because maternal antibodies are still present in young puppies and can interfere with their immune responses to vaccines. By 16 weeks of age, all the maternal antibodies should have disappeared, and your puppy will have mounted a sufficient immune response to be protected. The distemper vaccine is administered again at one year of age and then every 3 years.
Bordetella Bordetella is a type of bacterium that can cause infectious tracheobronchitis (kennel cough) in dogs that come in contact with each other, such as during grooming, daycare, or boarding. As the name describes, this disease results in upper respiratory signs. It is administered in dogs 10 weeks and older. The first dose is given intranasally for a localized immune response, and boosters are given either intranasally or subcutaneously thereafter. Boosters are done every 6 months-1 year depending on your dog’s exposure level and your veterinarian’s preference.
Leptospirosis Leptospirosis is a type of spirochete bacterium that is transmitted through contact with infected wildlife urine or puddles. It is zoonotic and most commonly causes kidney and liver disease. This vaccine can be combined with the second distemper vaccine booster or given individually. It is boostered 3-4 weeks after the initial dose and then yearly. It is only given to at-risk dogs.
Lyme Lyme disease is caused by a bacterium known as Borrelia burgdorferi. It is transmitted by tick bites and causes kidney and joint disease. This vaccine is administered at 12 weeks of age with a booster 3-4 weeks later. It is then given yearly to at-risk dogs.
Influenza There are currently two strains of influenza seen in dogs. Influenza causes upper respiratory signs similar to what we see in people. It is highly contagious among dogs coming in close contact with one another. The vaccine can be administered at 8 weeks of age and then is boostered 3-4 weeks later. It is then given yearly to at-risk dogs.
Coughing can be caused from a variety of medical conditions.
We will discuss the most common reasons why you may have noticed a cough
develop in your dog or cat recently.
Let’s first discuss heart disease, which can be congenital or acquired. Hearing a heart murmur can provide the first clue that heart disease is present. Murmurs occur when there are valvular abnormalities within the heart. Over time, the heart can become progressively damaged and lead to congestive heart failure. If the left side of the heart is affected, fluid may back up into the lungs and produce a wet or productive cough.
Dogs and cats that have contracted heartworm disease may also develop a cough. This can be due to an anaphylactic reaction to heartworm microfilaria or progressive damage to the pulmonary artery and right atrium, where heartworms become lodged.
Parasites and inflammation are a few lung issues we can see in our patients. Coughing may worsen during spring and summer when environmental allergens cause inflammation within the bronchioles (bronchitis). In cats, asthma is fairly common and results in difficulty breathing and a non-productive cough likely secondary to environmental allergens as well. In addition, primary lung tumors or metastatic disease can reduce lung capacity and lead to breathing abnormalities and coughing that may expel blood.
Dogs and cats can contract bacterial, fungal, or viral infections
that may lead to upper respiratory signs. Pneumonia results in lung
consolidation and a productive cough, whereas many viruses result in a dry cough.
Unvaccinated dogs are at risk for contracting kennel cough or distemper by
coming in contact with a virus and/or bacteria. Cats may also develop upper
respiratory tract infections due to underlying viral or bacterial disease.
Upper Respiratory Disease
Older, large breed dogs can develop laryngeal paralysis, which is a nerve defect that causes the larynx to become partially closed. This results in noisy breathing and a dry cough. In contrast, small breed dogs are predisposed to tracheal collapse where the cartilage within their tracheas weakens and the lumen becomes smaller. A “honking” cough is characteristic of this disease and can often be elicited upon tracheal stimulation.
As you can see there are many possible causes of the
coughing that is occurring in your pet. Your veterinarian can perform
diagnostics, such as bloodwork and chest radiographs (x-rays) to determine the
underlying cause and formulate an appropriate treatment plan.
When you take your dog to the veterinarian for vaccines, you may wonder why he or she needs a leptospirosis vaccine. Leptospirosis is a zoonotic disease, which means it can transfer from animals to people and cause similar sickness in both species.
What is it?
Leptospirosis is an infection caused by a type of spirochete bacteria. Dogs most commonly contract this disease by coming into contact with infected urine of other dogs and wildlife. It may be transmitted by contaminated surfaces in the environment as well. The spirochetes cause infection by penetrating mucus membranes or damaged skin and then spreading to tissues via the bloodstream. They replicate rapidly within many different organ systems, and serum antibodies will typically clear the infection. However, even when antibodies are present, the spirochetes can persist and replicate within the kidneys for several years, remaining infectious when eliminated in the urine.
What are the clinical signs?
Infected dogs often have fevers early in the disease process. Other clinical signs may include muscle pain, lack of appetite, vomiting, uveitis (eye inflammation), hematuria ( blood-tinged urine), fever, increased thirst and urination, or petechia (small skin hemorrhages). In advanced stages, outward signs of liver and kidney disease may be seen, including the presence of icterus (yellowing of the mucus membranes and sclera) and poor perfusion or inflammation of the blood vessels.
How is it diagnosed?
When leptospirosis is suspected, dogs should be placed in isolation to avoid the spread of disease while a diagnosis is confirmed. Your veterinarian will want to perform bloodwork and check the urine for signs of infection. We may see increased kidney and liver values, changes in white blood cell counts, and low platelets depending on the stage of disease. A SNAP test or serum titers can be performed to check for exposure to and antibodies against leptospirosis, respectively. However both of these tests do not tell us whether your dog has an active infection. They simply tell us that exposure has occurred at some point in his or her life. Performing PCR on the urine can detect an active infection and is most useful in diagnosis.
How is it treated?
Penicillin can be administered to eliminate the acute phase of infection for 3-5 days. This treatment is followed by an additional antibiotic, such as doxycycline, for 3-5 weeks to eliminate the bacteria that remain within the kidneys. In some cases, your dog may need to be hospitalized on fluid therapy to help flush the kidneys and to replenish any fluid losses that may have occurred through increased urination or vomiting. Infected dogs will need to be isolated until the infection has fully cleared.
Is it zoonotic?
Leptospirosis is zoonotic, which means it can be transmitted from infected animals to humans. This mode of transmission is less common than people becoming infected from environmental exposure, but it is still possible. The infection may cause fever, joint pain, and other flu-like symptoms in humans. It can also cause abortions in pregnant women. Treatment is largely supportive care with hospitalization on intravenous fluids, antibiotics, and liver protectants.
Is it preventable?
Since there is a zoonotic risk, it is important to vaccinate your dog against this infection to protect both of you. Vaccinations should be updated annually for full protection in at-risk dogs. In addition, reducing your dog’s exposure to puddles or other areas where wildlife or canine urine may be present can help prevent this infection.
We recommend wellness exams every 6 months to one year depending on the age and condition of your pet. At these visits, we perform a thorough physical exam and take a history on how your pet has been doing since his or her last visit and see if any new concerns have developed. During the physical exam, we check your pet’s eyes, ears, nose, mouth and teeth, lymph nodes, skin and coat, heart, lungs, abdomen, joints, and temperature. A thorough exam allows us to catch any abnormalities that may have developed and inform you of our findings. Based upon these findings and the history, we may recommend additional testing.
Ideally, bloodwork should be performed at least yearly and within a month of any anesthetic procedures. Bloodwork can tell us a great deal of vital information about the health of your pet. There are two large blood panels that are commonly performed during a wellness visit if we deem them appropriate. You may have heard of a Complete Blood Count (CBC) or a serum chemistry panel.
A CBC provides information on your pet’s cell counts, including red blood cells, white blood cells, and platelets. This test allows us to detect signs of infection, anemia, low platelets, dehydration, stress, and blood parasites, just to name a few. A serum chemistry panel provides a look at internal organ function, including kidneys and liver. We can see the levels of electrolytes, detect muscle damage, diagnose endocrine dysfunction, and recognize kidney or liver disease with this test.
Heartworm antigen tests are also a common component of wellness visits. Heartworm disease is a preventable disease and identified with a few drops of blood. This test is done at least yearly but preferable every 6 months. This is because it takes about 6 months for an adult heartworm to produce the microfilaria that we detect using this test. This is more useful in dogs where disease can be identified and treated. Cats have more occult infections that may be difficult to detect. This is why year-round heartworm prevention is extremely important in both cats and dogs.
Urinalysis may also be performed at a wellness visit, especially for geriatric patients. We can detect urinary crystals, urinary tract infections, and signs of endocrine or kidney dysfunction with this test. We can also test the acidity and detect blood, bilirubin, hemoglobin, or myoglobin in the urine.
You can see that a wellness exam provides a wealth of information and establishes a relationship between you, your pet, and your veterinarian. Because your pets cannot speak to us and tell us something is wrong, wellness and preventative care is essential to catch any abnormalities early on and treat them to help your pets live long, healthy lives.
It was the
morning of my first rotation in my clinical year of vet school, and I had woken
up with fluttering butterflies in my stomach! I was assigned to Internal
Medicine, which has a reputation for working long hours, being stressful, and juggling
multiple critical patients at once. On the first day we were to assign
ourselves to a hospitalized patient. The patients’ names and presenting
complaints were listed on the giant dry erase board on the wall of the rounds
room. As I entered the room, my eyes immediately fixed upon the words “diabetic
ketoacidosis.” In simple terms, this was basically an extremely critical
diabetic patient with dangerously high blood sugar and metabolic imbalances
(among other concurrent issues). Continuous monitoring in the intensive care
unit (ICU) was essential for this patient’s recovery. I knew instantly that I
wanted to take over care of this dog. (This stems from the fact that my husband
has Type 1 Diabetes, so diabetic patients always tug at my heart strings.) I
signed my name next to hers and met with the student who was currently treating
her. We discussed when she had been admitted to the hospital, what her
treatment plan was, and how she had been doing thus far.
I went to our ICU
to meet her and instantly became attached! Despite being so sick, she lifted
her head and gazed at me with big chocolate eyes, and her tail began to thump
softly. I started her treatments and made sure she was resting comfortably.
When I had finished, I called her dad and gave him an update on her current
condition and what I had done that morning for her. He asked if he would be
able to come visit her that afternoon, and of course, I said that was no
problem. I finished updating her medical record and speaking with the attending
Shortly after, I heard my name being called on the overhead pager. I quickly walked up to the lobby of the hospital and introduced myself to her dad, an older gentleman who looked to be a farmer. We walked back to the ICU together, and she was sleeping peacefully. I could not help but smile when he started talking to her and she immediately perked up and started wagging her little tail nub. You could just tell there was a special bond between those two. We talked for a short while before he turned to her and said, “You need to get better so we can go home. Mom’s waiting to see you,” just before pulling out a Ziploc bag of beef jerky treats from his pocket. Her nose caught the strong aroma, and her tail wagged harder. He hand-fed her each piece but stopped when a couple pieces remained in the bag. He told me those were her favorite treats at home, and she would probably like if I fed her some when he left. Since she had not shown much interest in food while being hospitalized, I happily obliged.
continued through the rest of the week. He would drive one hour both ways for
his daily visits, even if some days he could only stay for ten minutes. He
shared his favorite stories of her, and his visits became the highlight of my afternoons.
She slowly improved each day, and we scheduled a time for her to be discharged
the following Tuesday.
I continued my treatments through the weekend and arrived at the hospital Monday morning looking forward to her continued recovery. However, as I reviewed her chart and looked at her overnight blood glucose readings and condition since Sunday, my heart sank. Her blood sugar had rose through the day despite appropriate treatment, and she no longer even lifted her head when I spoke to her. She had been moved to an oxygen kennel because her breathing had declined.
Treating very ill diabetic patients is incredibly difficult. Oftentimes they have concurrent disease that hinders their responsiveness to treatment. They can improve one hour and quickly decline the next. In this case, she had multiple other health issues that had begun to work against our best efforts. Still, we persevered and held out hope. Her dad made his usual visit that afternoon. Throughout the night and the next morning, she continued to decline and was just really not in good shape. After completing my treatments on Tuesday morning, I made a phone call to her dad and urged him to come to the hospital. This time his wife had also joined him. She was a soft-spoken older woman with saddened eyes. I walked them both back to the ICU, and we spoke about her quick decline and poor prognosis. The attending veterinarian came by, and we discussed possible options. Due to her current condition, we could no longer comfortably discharge her. We could continue administering treatment though her quality of life was poor or make the difficult decision to euthanize. I sat with the family for over an hour as they deliberated what they believed was best for their dog. I could see the pain in their faces as they processed the news. Today was supposed to be the day they were able to finally bring their dog home—a day of celebration. It was most certainly not supposed to include this difficult decision.
My eyes began to
well up with tears alongside theirs as they contemplated what to do. She was
their loyal companion, and they had a bond that could not be broken. In the
end, they chose to not be present for her euthanasia. She had been through
enough, and they just hoped for her peace. They had already experienced this
process with another dog and couldn’t do it again. I let them say their
good-byes and escorted them to the lobby, giving them my sincere condolences. I
took a deep breath and started walking back to the ICU, fighting back the tears
with every step. I started gathering supplies I needed and found another soft,
cozy blanket for her. By that time, I could barely mutter to the resident that
we were ready to go as the tears streamed down my cheeks.
I wrapped my arms around her and put my head next
to hers. I whispered that things would be okay…that she was a good dog…that I
was sorry I had failed her. Things weren’t supposed to be this way. I was
supposed to save lives. I wasn’t supposed to be standing here in tears next to
my very first patient watching her slowly drift away. It is the worst feeling
in the world to feel so helpless.
On my way home that day, I stopped at Walgreens and picked up a sympathy card. When I got home, I scoured the internet for inspirational poems. I came across the classic Rainbow Bridge Poem. I printed it off, folded it neatly, and wrote a heartfelt message in the card before putting it in the mail, hoping it would provide some comfort as they dealt with their loss.
A couple weeks later, I went to check my mailbox at school and noticed a light blue envelope inside. Wondering what it could be, I carefully opened the flap. Inside was a thank you card that read “Thank you very much for your loving care of our dog. Your kindness makes such a difference.” A soft smile grew upon my face, and one tear trickled down my cheek. In the midst of heartbreak, this couple had chosen gratitude. In the midst of a stressful week of clinics, I was given reassurance that I was doing okay. My first patient will always have a special place in my heart. She will always remind me to focus on the good and to never underestimate the power of a small act of kindness. It may be just what someone needs on his or her worst days. When that’s not enough, a little beef jerky never hurt anyone!