I had an appt for Whiskers to have an echocardiogram today. I made the appt. at the place where he was hospitalized overnite about a week ago when he was having difficulty breathing. It is both a regular Vetrinary Centre and the local emergency hospital -open 24 hours a day. I hadn't asked for any particular Dr - I just said I wanted to schedule the echo. When I got there, the Dr I had the appt with told me that he was not a board certified Cardiologist, but he could do the echo, or there was another guy there that would be better and he would work Whiskers in within the next few hours. He suggested that the Dr could tell fairly quickly if there were any major heart problems and if he did not see any he would stop and just charge me a minimal fee. He pointed out that if thats what happened, then I still would not know the cause of the breathing difficulty (occasional episodes of open mouthed breathing that last a long time - like maybe 20min) - but then the next step would be to see an Internist or a board certified Cardiologist. I thought it sounded like a good plan so I agreed and left Whiskers there.
So I guess the better thing that would happen would be that the Dr did not see any of the 3 major heart problems - Dilative cardiomyopathy, Hypertrophic cardiomyopathy or Restrictive cardiomyopathy - and that I still have to figure out what's going on, right? Well, that is what happened - but I am a little confused - and I would appreciate any input anyone might have? Here are other things that Dr told me today, please let me know what you think:
1. the ultrasound didn't show the 3 major heart problems, RCM, HCM or DCM.
2. there might be some enlargement on the right
3. there are leaky valves
And they had already told me he had Pectus Excavatum and "a thoracic vertebral malformation that reduced the thoracic cavity size. Compared to previous lung x-rays taken, there may have been increased interstitial pattern[iin the caudal lung fields."[/i] [NOTE: I don't know what that means - It was in the Dr's report of his emergency visit last week, which I just picked up today]
They say his sternum pushes on his heart. [DOES ANYONE HERE HAVE ANY EXPERIENCE WITH THIS? Like especially - what is the Best Position to lay him down, or prop him up?]
Anyway, he gave me the name of a board certified Cardiologist, who happens to be in the same center where the neurologist Whiskers has seen is. Evidently he knows him. He told me to let him know if I am going to see him so he can call the guy first.
Then he bothered me a bit by asking me something like, what am I hoping to achieve here? I took that to mean something like Why am I keeping him alive? He had caught me off guard with that and I don't think I gave much of an answer - but basically Whiskers is like he has been the whole time I've had him. Yes, he's quadriplegic - but he eats great, urinates and poops very well( I have to hold him over the box - but he does the rest himself), enjoys being petted and rubbed, all of his limbs respond to touch - he just can't make himself walk! He has just had a few episodes of something new --But we don't know what that is yet!?, right?
Please let me know what you think!
Karen
Whiskers' update
Re: Whiskers' update
Hi Karen,
Your appointment was useful and already you have some good information. Leaky valves can cause shortness of breath. I work late today but can write a longer answer either on my dinner hour or tonight. I am guessing he is more comfortable lying on his right side than on his left side. I don't know about propping him up. Can you recall what side he was lying on the times he was short of breath?
Your appointment was useful and already you have some good information. Leaky valves can cause shortness of breath. I work late today but can write a longer answer either on my dinner hour or tonight. I am guessing he is more comfortable lying on his right side than on his left side. I don't know about propping him up. Can you recall what side he was lying on the times he was short of breath?
Re: Whiskers' update
Karen:
I think I would go ahead with the board certified cardiologist and have him do another echo since heart problems/respiratory problems are not something to fool around with and yes, I would definitely want answers rather than risk this happening again. "Interstitial" refers to the space between the tissue. I know they examine the lungs for abnormal patterns including the interstitial pattern but I do not know what the increased interstitial pattern means and there could be a number of reasons for an abnormal pattern but I am not sure if the doctor is saying the lung pattern is abnormal. I know sometimes an enlargement of the right ventricle of the heart is associated with respiratory problems. The last time Simon was in the cardiologist thought his right ventricle enlargement was due more to asthma---and I do not know if this is a possibility with Whiskers. With valve problems I guess I would expect them to hear a murmur and they should be able to identify valve problems with the echo. I don't think the prognosis is very good with valve problems and I think you basically manage these for signs of congestive heart failure. I have limited experienced with heart problems and wish I knew more but like I said I think I would go ahead with having the cardiologist take a look at Whiskers. Please keep us updated. Diana
I think I would go ahead with the board certified cardiologist and have him do another echo since heart problems/respiratory problems are not something to fool around with and yes, I would definitely want answers rather than risk this happening again. "Interstitial" refers to the space between the tissue. I know they examine the lungs for abnormal patterns including the interstitial pattern but I do not know what the increased interstitial pattern means and there could be a number of reasons for an abnormal pattern but I am not sure if the doctor is saying the lung pattern is abnormal. I know sometimes an enlargement of the right ventricle of the heart is associated with respiratory problems. The last time Simon was in the cardiologist thought his right ventricle enlargement was due more to asthma---and I do not know if this is a possibility with Whiskers. With valve problems I guess I would expect them to hear a murmur and they should be able to identify valve problems with the echo. I don't think the prognosis is very good with valve problems and I think you basically manage these for signs of congestive heart failure. I have limited experienced with heart problems and wish I knew more but like I said I think I would go ahead with having the cardiologist take a look at Whiskers. Please keep us updated. Diana
Re: Whiskers' update
Hi Karen,
I was looking back over your messages, and one thing I wanted to comment on was the idea that his ribcage might be deformed due to his paralysis. I would be more likely to assume the pectus deformity is genetic, and the shape of the ribcage is not merely due to lying around. Humans can have pectus deformities and it has nothing to do with lying around in humans, it is purely genetic. A lot of times if the sternum is deformed (pectus excavatum or carinatum) then you also see a ribcage deformity (for example rib flare or the ribs being shaped differently on the left and right sides) and scoliosis (curvature of the spine) or kyphosis (stooped shoulders). I imagine his fused thoracic vertebrae (thoracic means chest) are part of the whole picture of ribcage/spinal/pectus deformity. And for some reason, when you see skeletal deformities including pectus deformity, it is not uncommon to find cardiac involvement.
I am not a vet, this is only my
as a layman. There are a couple of things I can think of that could be causing the shortness of breath, either the valve problem or an arrhythmia.
I'm assuming all they found was leaky valves (no hole in the heart, no aneurysm). You did not say which valves, that part is important. The other important thing is how leaky they are. The idea is that blood is supposed to flow forward through the heart, going from one chamber to the next, and the thing that keeps it from accidentally flowing backward when the heart beats is valves closing. If the valves aren't closing all the way, then some of your blood is going to flow backward, reducing the amount of oxygen going out to the body. That can make you short of breath.
The other thing that can happen with leaky valves is a tendency for blood clots to build up inside or on the rough edges of the valves, which can be thrown loose during forceful heartbeats, and then the clot travels through the bloodstream until it lodges somewhere causing a stroke or worse. And another problem is, a heart with leaky valves can become infected with bacteria (endocarditis) more easily than a normal heart. They used to recommend prophylactic antibiotics before dental work for people with mitral valve prolapse. The idea was that during dental work, bacteria from the teeth were likely to go into the bloodstream and you wanted to avoid infecting the heart. And finally, the other thing that can happen with a leaky valve is that because the blood tries to move forward through the heart but instead sloshes backward, the chambers of your heart can eventually stretch out. You mentioned possible right side enlargement, that would fit with a leaky valve and backflow.
In humans they can go in and replace a leaky valve or put a reinforcement around it, but most people cannot afford that kind of surgery for a pet, assuming it is even available where they live. You may have heard that former first lady Barbara Bush had aortic valve replacement recently. When you have a problem with the aortic valve, it is pretty serious. Garrison Keillor (Prairie Home Companion) had his mitral valve replaced several years ago (and he had a stroke this week). A leaky aortic valve will give you really bad symptoms and needs to be fixed, a leaky mitral valve is something you may be able to live with for years and possibly never need surgery, or in any case you have time to plan for it, it is generally not an emergency. It makes you tired or very tired and short of breath, but is usually not life threatening. (At least in humans.)
You may be able to improve the efficiency of the heart with medication, your cardiologist will know if that is an option. It could possibly help a lot. In my limited experience of heart pills for 2 cats and myself, they always tend to be either small or really teeny tiny, so they are very easy to give.
The most important thing to me right now is, you do not know what is going on. Normally when a cat is panting and the heart is is involved, you are afraid there is congestive heart failure (fluid builds up in the chest) and that is an emergency, but I did not see you mention anything about lasix or draining fluid off of his chest, so that is good. It sounds like he was not in congestive heart failure when you took him in, that is the best news.
I wonder if he could be having an arrhythmia. Palpitations are something that will come and go. They may easily last for 20 minutes. They can be helped with medication.
The thing is, how do you diagnose an arrhythmia that may come and go? If the doctor cannot hear it with his stethoscope or catch it on an EKG during an office visit, then they send the patient home with a holter monitor to wear. It records the heart beat for 24 hours. Hopefully you will have an episode during the time you're wearing the monitor, and they will be able to diagnose the arrhythmia. I know they do that for dogs, not sure about cats, and again you are getting into more expense. Possibly they could try him on some medication without all that.
As a practical matter, your question about the best way for him to lie is such a good question. I do not know the answer for sure but I imagine it does make a difference. Speaking for myself, I can't sleep on my left side at all, and a cat has the heart on the left like human so my first guess would be he'd do better lying on his right side. But on that, the best thing to do is probably just to try different ways and really observe which position seems most restful for him. I think you will see tension if he is in a position that is making it hard for his heart to beat or affecting breathing, even if he isn't panting. You will know.
In some people eating a full meal will trigger palpitations, you might want to monitor if he has his episodes after a big meal and possibly feed him smaller meals.
I think you are wonderful for taking care of him like this, as you have done. You are right, if he is happy and loves his meals and being petted and all of that, he has a good life. I do hope in your efforts to help him, you will not be rewarded by any rudeness from anyone. You're doing a good thing, I think it's wonderful what you've done for him.
I was looking back over your messages, and one thing I wanted to comment on was the idea that his ribcage might be deformed due to his paralysis. I would be more likely to assume the pectus deformity is genetic, and the shape of the ribcage is not merely due to lying around. Humans can have pectus deformities and it has nothing to do with lying around in humans, it is purely genetic. A lot of times if the sternum is deformed (pectus excavatum or carinatum) then you also see a ribcage deformity (for example rib flare or the ribs being shaped differently on the left and right sides) and scoliosis (curvature of the spine) or kyphosis (stooped shoulders). I imagine his fused thoracic vertebrae (thoracic means chest) are part of the whole picture of ribcage/spinal/pectus deformity. And for some reason, when you see skeletal deformities including pectus deformity, it is not uncommon to find cardiac involvement.
I am not a vet, this is only my
as a layman. There are a couple of things I can think of that could be causing the shortness of breath, either the valve problem or an arrhythmia. I'm assuming all they found was leaky valves (no hole in the heart, no aneurysm). You did not say which valves, that part is important. The other important thing is how leaky they are. The idea is that blood is supposed to flow forward through the heart, going from one chamber to the next, and the thing that keeps it from accidentally flowing backward when the heart beats is valves closing. If the valves aren't closing all the way, then some of your blood is going to flow backward, reducing the amount of oxygen going out to the body. That can make you short of breath.
The other thing that can happen with leaky valves is a tendency for blood clots to build up inside or on the rough edges of the valves, which can be thrown loose during forceful heartbeats, and then the clot travels through the bloodstream until it lodges somewhere causing a stroke or worse. And another problem is, a heart with leaky valves can become infected with bacteria (endocarditis) more easily than a normal heart. They used to recommend prophylactic antibiotics before dental work for people with mitral valve prolapse. The idea was that during dental work, bacteria from the teeth were likely to go into the bloodstream and you wanted to avoid infecting the heart. And finally, the other thing that can happen with a leaky valve is that because the blood tries to move forward through the heart but instead sloshes backward, the chambers of your heart can eventually stretch out. You mentioned possible right side enlargement, that would fit with a leaky valve and backflow.
In humans they can go in and replace a leaky valve or put a reinforcement around it, but most people cannot afford that kind of surgery for a pet, assuming it is even available where they live. You may have heard that former first lady Barbara Bush had aortic valve replacement recently. When you have a problem with the aortic valve, it is pretty serious. Garrison Keillor (Prairie Home Companion) had his mitral valve replaced several years ago (and he had a stroke this week). A leaky aortic valve will give you really bad symptoms and needs to be fixed, a leaky mitral valve is something you may be able to live with for years and possibly never need surgery, or in any case you have time to plan for it, it is generally not an emergency. It makes you tired or very tired and short of breath, but is usually not life threatening. (At least in humans.)
You may be able to improve the efficiency of the heart with medication, your cardiologist will know if that is an option. It could possibly help a lot. In my limited experience of heart pills for 2 cats and myself, they always tend to be either small or really teeny tiny, so they are very easy to give.
The most important thing to me right now is, you do not know what is going on. Normally when a cat is panting and the heart is is involved, you are afraid there is congestive heart failure (fluid builds up in the chest) and that is an emergency, but I did not see you mention anything about lasix or draining fluid off of his chest, so that is good. It sounds like he was not in congestive heart failure when you took him in, that is the best news.
I wonder if he could be having an arrhythmia. Palpitations are something that will come and go. They may easily last for 20 minutes. They can be helped with medication.
The thing is, how do you diagnose an arrhythmia that may come and go? If the doctor cannot hear it with his stethoscope or catch it on an EKG during an office visit, then they send the patient home with a holter monitor to wear. It records the heart beat for 24 hours. Hopefully you will have an episode during the time you're wearing the monitor, and they will be able to diagnose the arrhythmia. I know they do that for dogs, not sure about cats, and again you are getting into more expense. Possibly they could try him on some medication without all that.
As a practical matter, your question about the best way for him to lie is such a good question. I do not know the answer for sure but I imagine it does make a difference. Speaking for myself, I can't sleep on my left side at all, and a cat has the heart on the left like human so my first guess would be he'd do better lying on his right side. But on that, the best thing to do is probably just to try different ways and really observe which position seems most restful for him. I think you will see tension if he is in a position that is making it hard for his heart to beat or affecting breathing, even if he isn't panting. You will know.
In some people eating a full meal will trigger palpitations, you might want to monitor if he has his episodes after a big meal and possibly feed him smaller meals.
I think you are wonderful for taking care of him like this, as you have done. You are right, if he is happy and loves his meals and being petted and all of that, he has a good life. I do hope in your efforts to help him, you will not be rewarded by any rudeness from anyone. You're doing a good thing, I think it's wonderful what you've done for him.
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MissWhiskers
- Posts: 276
- Joined: Sun Nov 25, 2007 11:34 pm
- Location: Reston, VA
Re: Whiskers' update
Thank you Carol, for taking all the time to explain all of that to me. So it sounds like the Cardiologist IS the best, next Doctor to see? I was hoping that since that one Dr. didn't see any major problems that I could rule the heart out. And actually that visit was kind of a waste of time and money as I still have to go see a cardiologist and have an echo done! - which is what I thought I was doing the other day!?How frustrating! I would have skipped that trip and gone straight to A real cardiologist, had I known! Hopefully the Dr who saw Whiskers on Tuesday will ask the actual cardiologist to deduct from his bill what I already paid him!? And worse, that has just delayed getting Whiskers the help he needs!
Tomorrow I will set up an appt with the real Cardiologist and I will definitelly keep you posted.
I am amazed at how lucky I am to get to benefit from your knowledge and personal experience with these things! I can't thank you enough....
Karen
Tomorrow I will set up an appt with the real Cardiologist and I will definitelly keep you posted.
I am amazed at how lucky I am to get to benefit from your knowledge and personal experience with these things! I can't thank you enough....
Karen
Re: Whiskers' update
Hi Karen,
If you are able to see a cardiologist, that would be great. If it is an arrhythmia, some arrhythmias are dangerous, some are not, it would be worth trying to find out if possible. That would probably involve a veterinary EKG. I did not see anyplace where you mentioned they did an EKG when he was hospitalized. Can you ask about that? It would be great if they caught his rhythm on tape while he was having problems.
As far as the echo being wasted, I know what you are saying, sometimes you save money in the long run by going straight to a specialist. Your vet said to let him know if you are consulting a cardiologist so he can talk to him in advance before you go. I imagine he is going to explain what he did and did not find on the current study, and possibly save you some time and testing and money that way by telling the cardiologist what has already been ruled out. At least you now know a number of things that are not wrong.
In humans they record the echo, I don't know if they do that in vet hospitals now. You might ask the clinic if the echo was recorded. If it was, it could be sent to the cardiologist to look at. If the equipment and technique were good, he may be able to make some assessments from it, but in my experience doctors often want to redo imaging on their own equipment, it would have to be up to him.
There is someone here who would know more about this, I will send her a PM and possibly she will be able to shed some light. Again, I think you are wonderful for everything you are doing for him. If it gets to be too expensive, why not ask them what options there are for treatment right now with what you do know.
If you are able to see a cardiologist, that would be great. If it is an arrhythmia, some arrhythmias are dangerous, some are not, it would be worth trying to find out if possible. That would probably involve a veterinary EKG. I did not see anyplace where you mentioned they did an EKG when he was hospitalized. Can you ask about that? It would be great if they caught his rhythm on tape while he was having problems.
As far as the echo being wasted, I know what you are saying, sometimes you save money in the long run by going straight to a specialist. Your vet said to let him know if you are consulting a cardiologist so he can talk to him in advance before you go. I imagine he is going to explain what he did and did not find on the current study, and possibly save you some time and testing and money that way by telling the cardiologist what has already been ruled out. At least you now know a number of things that are not wrong.
In humans they record the echo, I don't know if they do that in vet hospitals now. You might ask the clinic if the echo was recorded. If it was, it could be sent to the cardiologist to look at. If the equipment and technique were good, he may be able to make some assessments from it, but in my experience doctors often want to redo imaging on their own equipment, it would have to be up to him.
There is someone here who would know more about this, I will send her a PM and possibly she will be able to shed some light. Again, I think you are wonderful for everything you are doing for him. If it gets to be too expensive, why not ask them what options there are for treatment right now with what you do know.
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MissWhiskers
- Posts: 276
- Joined: Sun Nov 25, 2007 11:34 pm
- Location: Reston, VA
Re: Whiskers' update
Hi Carol,
I have been trying to assimilate all the info I've gathered. I'm on the verge of making an appt. with the Cardiologist, but, and I got this idea from one of the Drs that saw him the other day - the one that I had made the appt for the echo with, but who told me when I got there that there was another Dr. who would be better to do it - tho neither are board certified cardiologists. His idea was that that Dr would start the echo and that he would quickly be able to see if there were any MAJOR heart problems(I guess that meant HCM, RCM, or DCM) and that if there weren't those then perhaps I should see an Internist. And the Dr did NOT see those. He said "there might be some enlargement of the right side (ventricle? I think.) and "there are leaky valves". So, the guy did do an echo, but he only charged me $100. I think they just were trying to help me rule out major heart problems. I had paid $798.00 at that same hospital just days earlier. Maybe they felt sorry for me? and were being kind - because I had been told on the phone that an echo was $375.00 and I went there that day expecting to have to pay that. Of course the person who made the appt did NOT tell me that it was not a Cardiologist doing it.
And I had got to thinking the same thing you said, that the reason the Dr who did the echo said for me to call him if I go to this cardiologist was so he could tell him what he had done and seen and maybe that will make a difference in cost.
Part of my problem is: I don't know how bad those things are( murmur and possible enlarged right side) versus the other things that may be causing the problem. I guess that is like the Pectus Excavatum and the Thoracic Vertebral Malformation, which together gives him less space for his lungs & heart. Are those things an Internist might advise me on?
I realize he probably should eventually see a cardiologist, but perhaps for his recent problem an Internist would be better to see first? What are your thoughts on that?? Anyone and everyone?!
Carol and Dianne - thank you so much for taking the time and sharing your experience.
Karen
I have been trying to assimilate all the info I've gathered. I'm on the verge of making an appt. with the Cardiologist, but, and I got this idea from one of the Drs that saw him the other day - the one that I had made the appt for the echo with, but who told me when I got there that there was another Dr. who would be better to do it - tho neither are board certified cardiologists. His idea was that that Dr would start the echo and that he would quickly be able to see if there were any MAJOR heart problems(I guess that meant HCM, RCM, or DCM) and that if there weren't those then perhaps I should see an Internist. And the Dr did NOT see those. He said "there might be some enlargement of the right side (ventricle? I think.) and "there are leaky valves". So, the guy did do an echo, but he only charged me $100. I think they just were trying to help me rule out major heart problems. I had paid $798.00 at that same hospital just days earlier. Maybe they felt sorry for me? and were being kind - because I had been told on the phone that an echo was $375.00 and I went there that day expecting to have to pay that. Of course the person who made the appt did NOT tell me that it was not a Cardiologist doing it.
And I had got to thinking the same thing you said, that the reason the Dr who did the echo said for me to call him if I go to this cardiologist was so he could tell him what he had done and seen and maybe that will make a difference in cost.
Part of my problem is: I don't know how bad those things are( murmur and possible enlarged right side) versus the other things that may be causing the problem. I guess that is like the Pectus Excavatum and the Thoracic Vertebral Malformation, which together gives him less space for his lungs & heart. Are those things an Internist might advise me on?
I realize he probably should eventually see a cardiologist, but perhaps for his recent problem an Internist would be better to see first? What are your thoughts on that?? Anyone and everyone?!
Carol and Dianne - thank you so much for taking the time and sharing your experience.
Karen
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MissWhiskers
- Posts: 276
- Joined: Sun Nov 25, 2007 11:34 pm
- Location: Reston, VA
Re: Whiskers' update
Carol,
I just read your last post more carefully and I will check into whether an EKG was done while he was in the throes of respiratory distress that day. At either hospital! Thanks again,
Karen
I just read your last post more carefully and I will check into whether an EKG was done while he was in the throes of respiratory distress that day. At either hospital! Thanks again,
Karen
Re: Whiskers' update
Hi Karen,
If he is talking about an internist, it sounds like he thinks this is not heart-related and is looking elsewhere for the cause. It was awfully nice of the vet to charge so litle for the echo. I do think he is trying to get you a correct diagnosis as quickly as possible, and if he thinks an internist is the best choice at this point, I trust he has your cat's best interest in mind. Perhaps you could ask him what he thinks the internist might check for, and if it is confirmed, will there be anything that can be done about it. I'd want to know what they will charge just for the consultation, you've spent a lot already. I wish I could be more help.
If he is talking about an internist, it sounds like he thinks this is not heart-related and is looking elsewhere for the cause. It was awfully nice of the vet to charge so litle for the echo. I do think he is trying to get you a correct diagnosis as quickly as possible, and if he thinks an internist is the best choice at this point, I trust he has your cat's best interest in mind. Perhaps you could ask him what he thinks the internist might check for, and if it is confirmed, will there be anything that can be done about it. I'd want to know what they will charge just for the consultation, you've spent a lot already. I wish I could be more help.
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MissWhiskers
- Posts: 276
- Joined: Sun Nov 25, 2007 11:34 pm
- Location: Reston, VA
Re: Whiskers' update
You HAVE been so much help already!!
Since my last post I called the Dr who came up with the gameplan. Dr. Hyatt, the one I met Tues morn when I took Whiskers in for the echo. He had said he could do it, but there was another guy who was better, Dr Voell (who is evidently well acquanted with the cardiologist I would go to) if I didn't mind waitting to be fit into his schedule that day. Dr Hyatt is the one who came up with the idea that if the other Dr. Voell started the echo and didn't see MAJOR heart problems he would stop and I might want to see an internist. See I never met Dr Voell - I only spoke to him on the phone. I actually don't know if he knew the plan which Dr. Hyatt had suggested to me. I would think he did? but I decided to call Dr Hyatt instead of Dr. Voell and ask him to get a feel for the situation for me! Kind of confusing but I think it might be a good idea.
Meanwhile Whiskers seems to be doing fine. He is such a sweet boy!
I am going to start researching local internists and I hope Dr Hyatt calls me tomorrow to help me clarify which way to go first.
Thanks to everybody for their support!
Karen
Since my last post I called the Dr who came up with the gameplan. Dr. Hyatt, the one I met Tues morn when I took Whiskers in for the echo. He had said he could do it, but there was another guy who was better, Dr Voell (who is evidently well acquanted with the cardiologist I would go to) if I didn't mind waitting to be fit into his schedule that day. Dr Hyatt is the one who came up with the idea that if the other Dr. Voell started the echo and didn't see MAJOR heart problems he would stop and I might want to see an internist. See I never met Dr Voell - I only spoke to him on the phone. I actually don't know if he knew the plan which Dr. Hyatt had suggested to me. I would think he did? but I decided to call Dr Hyatt instead of Dr. Voell and ask him to get a feel for the situation for me! Kind of confusing but I think it might be a good idea.
Meanwhile Whiskers seems to be doing fine. He is such a sweet boy!
I am going to start researching local internists and I hope Dr Hyatt calls me tomorrow to help me clarify which way to go first.
Thanks to everybody for their support!
Karen