If only we could just get to the Star Trek stage where you could wave one of those little handheld gadgets over a pet (or us) and get an entire profile of everything happening within without intruding and poking.

Evet May 2nd, 2009 12:06:29 PM

We hear so much about CBC reports and blood work in our canine cancer forums that I'm happy to finally get a better understanding about it all from this post. Thanks! I've added a link to this in our Ask A Vet discussion forum.

tripawds.com May 2nd, 2009 12:18:19 PM

Generally, when my vet suggests blood work, whether for a specific reason or just "routine" blood work, I say yes. On the rare occasions that I have felt really, really strapped, and the only reason for the blood work was "she's here and we have the opportunity" and I have said no, it has been a mistake. On one occasion, I had brought my two older cats, ages eleven and twelve, in together, and our vet suggested routine "senior" blood work on both of them, and I was really, really broke and yet her argument seemed inarguable--so we decided to do the older girl then, and the younger in six months.

The younger one got very sick a couple of months later--diabetes and congestive heart failure. We'd have caught the diabetes, most likely, if we'd done the blood work on her rather than my older girl, who is now sixteen. And if we'd caught the diabetes and already been treating it, when her heart started to go, she'd have been in better overall health.

The end result of not doing the blood work on her when first recommended, was that I spent a lot more money later and in the end had to euthanize her. Meanwhile, routine blood work on  my remaining girls has meant that my oldest, now sixteen, had her early stage kidney failure diagnosed before she showed any symptoms except a few ounces of weight loss.

And I would never want one of my animals to have surgery without pre-op blood work.

Lis May 2nd, 2009 12:31:11 PM

I know how important it is to have bloodwork before dentisty.  We are on an every 6 month schedule now for bloodwork for my one 9 y/o kitty whose kidney values are barely inside normal range, same for her urine specific gravity.  She's scheduled for a dental and the vet knows I'm concerned about the effect on her kidneys.  She will be doing bloodwork before starting and calling me if anything is significantly worse than her last full panel and we will discuss whether to go forward with the dental.

I guess the other two 9 year olds should be on semiannual as well, although their bloodwork was so fabulous last time that the vet hasn't yet recommended it.

Stefani May 2nd, 2009 12:54:01 PM

I wish I could wave a magic device over the clients (to open their minds) who are adamant that their senior pet get vaccinated for everything, but don't need bloodwork "because they're fine."   If your pet hardly ever goes anywhere, except outside to pee or to the vet's, the risk of getting parvo (just an example), is much less than developing some internal problem that you can't see any signs to until it's too dang late.  With some clients, who have money issues, I truly wish that idea of 'they'll only come in for shots, so we better give them and hope we can convince them of other things when they're here' would be replaced with 'let's discuss health issues and nutrition every year, and do vaccines if necessary' kind of visits.  (I hope I said that sensibly.)

Of course, maybe because I have more interest in nutrition and health issues, especially because I have older dogs, maybe I'm biased.  I realize that if vaccinations hadn't been so successfully sold to the majority of people, that more animals would die of those diseases, but I hate seeing so many senior pets come in for shots and owners refusing dentals and bloodwork (whether tied together or not), because they don't think those are important until their pets are really sick.  And then not being able to afford the care, which now costs a lot more and they lose time with their pets that they might have had if they'd just paid attention to the same things their humans doctors were doing in their healthcare. 

'Sorry, I just had to watch two clients today say no to bloodwork for their senior pets, but insist on vaccinations, and it irks me to no end.

KateH May 2nd, 2009 02:24:57 PM

Sometimes it pays to ask the vet if there is anything specific they are looking for based on the symptoms the critter is presenting. We do this when money is tight and the critter isn't scheduled for surgery. Sometimes the answer is "Not really" because we can't put the symptoms together enough and a blood test will help narrow it down. Sometimes the answer is "Well, maybe we can..." just check this or that, often in-house. We see the comprehensive blood test as an excellent baseline, too. Yeah, it is expensive, but it is quick and can tell a lot more in less time.

PaulaO May 2nd, 2009 03:29:25 PM

KateH

A lot of us, guradians, not only agree to a CBC any number of times the vet deems necessary, but we pay for the most exotic and expensive tests in an effort to diagnose our geriatric companions. Results of such tests often aren't interepreted correctly or are ignored with fatal outcomes. . .

Asproolee’s Story

Fotini May 2nd, 2009 03:31:18 PM

Hey let's watch it with that "critter" talk. I ain't no critter!

Meowwwwww

Evet May 2nd, 2009 03:44:57 PM

KateH: The major problem is that for decades, veterinary clinics have been overselling vaccines and convincing the public how necessary they are! Huge mistake to continue the mantra, when it was becoming obvious that the tide was turning and still the clinics lagged.

Well, now the damage has to be undone, and what are you going to say? Not to mention that some clinics are still in the vaccine sale mode...

People leave with their pet thinking, "hey I got all of Fido/Fluffy's shots, that's good for another year!"

I'm going to do a blog post on a vaccine "spin" today.

Barbara A. Albright/NH May 2nd, 2009 04:09:27 PM

Though I'm not made of money, (read: student) I'm a big believer in bloodwork. That said.. I'll be honest- I don't subject young, otherwise healthy animals to a yearly panel, though everybody gets the pre-anesthetic, regardless of age. Our 6 and 8 y/o cats receive regular bloodwork for monitoring purposes (6 y/o has recovered from Menu-related ARF, 8 y/o has numerous issues). The 7 y/o will be getting a yearly starting this summer. He hasn't quite reached the age where most of the vets in our area start pressing for bloodwork (9-ish), but he comes from the same gene pool as the 8 y/o (who clearly got the short end of the stick in the health department), so.. yeah.

Should I ever have to move, one of the features I'll look for when clinic-shopping is the ability to run in-house bloodwork. In addition to the fact that it's generally much more affordable, the immediate results have made it possible for us to start treating certain things (ARF, DKA in young feral cat with undiagnosed diabetes) right away instead of having to wait. The boys are big on weekend emergencies, and sometimes, when it's obvious on Saturday morning that something is amiss, having to wait until Monday to find out what can be risky. (I suspect neither cat- both of whom have made full recoveries despite what were initially very guarded prognoses- would have fared so well if we'd waited to treat.)

It was also really useful in terms of making end-of-life decisions for one of our cats. We were able to obtain concrete evidence that treatment was failing to improve A's condition (not unexpected) in a matter of minutes, as opposed to forcing her to suffer through the weekend so the lab could confirm that things were indeed hopeless. Given her condition, I suspect I would have euthanized that afternoon anyway (I'm in the I'd-rather-risk-doing-it-a-week-early-than-a-day-late camp, and it seemed to me that she was ready), but that confirmation eliminated the 'what if' factor, which was a real blessing at the time.

Ramen Connoisseur May 2nd, 2009 04:14:19 PM

I've always found that a big obstacle in getting clients to understand the importance of bloodwork, especially pre-anesthetic bloodwork, is that it doeesn't appear to be standard of care in human medicine.  I'm always amazed at how many people undergo anesthetic procedures without any kind of pre-op testing. 

I'm also always surprised that while most pet owners are afraid of anesthesia, they still opt out of pre-anesthetic bloodwork even after you tell them that it's one of the best ways to ensure that anetsthesia can be as risk-free as possible.

Ingrid King May 2nd, 2009 05:26:24 PM

Excellent post and in a nice easy to understand form...I copied it for use at work so we can all learn how to explain labwork in understandable terms.

Teri and the cats of Furrydance May 2nd, 2009 06:03:09 PM

Ramen Connoisseur: Regarding in-house vs. lab testing: We offer the least expensive comprehensive lab tests I've ever heard of. That's because we negotiated with a local veterinary lab that runs comprehensive panels on ALL our yearly patients. It's been a win-win all around. The lab gets more volume and we get more staff time, more reliable results (generally speaking, that's true for most hospitals) and a better price than we can offer with our in-house machines. Our patients get better care, too. The only down-side is the not-so rapid-response (24 hours). But for only an extra $15 they can have it done in under 90 minutes. 

Ingrid: I've had surgery thrice and every time they asked for a CBC and a chemistry. I was under the impression that it WAS standard of care. Weird not to require something so basic. 

Dr. Patty Khuly May 2nd, 2009 06:03:34 PM

Great topic, Dr. K, and great comments too!  KateH - I completely agree.

I would LOVE to see annual bloodwork replace the mantra of annual vaccines.  Imagine how much healthier the animal population would be!

Even more pressing though, in my opinion, is the need for more DVMs who not only understand the need for routine bloodwork, but also TRULY understand what each test means, the difference between tests (T4 vs. T4 EqD vs. full panel) and the reasoning behind each option, and most importantly how to read and interpret results correctly.

For dog owners out there, I strongly recommend a copy of Wendy Volhard's "Holistic Guide for a Healthy Dog" in every personal library.  Even if you never read the book, or read it and disagree with it in its entirety (there's plenty in it I disagree with, to be honest) the chapter on laboratory tests has proved literally lifesaving on multiple occasions.

Recently a friend's dog was diagnosed with a severe parasite infection.  After a few questions, something didn't sound quite right about the diagnosis.  I had them send me over a copy of his bloodwork, and it was glaringly obvious that the dog was suffering from advanced renal failure, was losing blood somewhere internally (ulcers were my first guess, although I did turn out to be wrong about the cause), and possibly liver issues to some degree.  This is a dog with a normal appetite, great weight, vomiting occasionally and had been "off" for the past few weeks.  There were no symptoms to back up the vet's assumption of parasites (no parasites found on fecal).

When I called her and suggested she get the dog to an ER *right now!!* for fluids and some additional testing (bloodwork indicated he was extremely dehydrated and should have had subQ on the spot!), she heeded my advice.  The vet at the ER confirmed my initial impression, although the liver issues were questionable without further tests and appeared to simply be values affected by the other two problems.  The liver issue turned out to be nothing, but the two vets consulted did agree that further testing was indicated.

We contacted the regular vet the next day to have the files transferred to MY vet, and she noted that yes, she had noticed that the kidneys were not functioning properly, but until we treated the (non-existant) parasites, she couldn't really say for sure what she was looking at.  At NO TIME did she mention the kidney values OR the liver values being off.  At NO TIME did she recommend further testing, or suggest fluids, or even a change in diet.

The owners were stunned - how was it that me, armed only with a copy of the bloodwork, a few books and the Google could get a better interpretation than their vet?  Since then we've heard MULTIPLE stories about this particular vet along the same lines.  Of course, we have this kind of thing happen all the time, this is just the most extreme example I've ever been a first party to.

My last issue with bloodwork that needs to be addressed?  The failure of vets to routinely provide a copy of ALL test results to their clients.  Dr. K - perhaps you can enlighten me here.  Is this simply a money saving issue?  Or is this an issue of the majority of DVMs not wanting to be second guessed by the Google?  Don't get me wrong, I understand - if I had a dollar for every bit of misinformation provided to me with the line "I read it on the internet" I'd... well, you know.

Not only do vets not offer a copy of these tests, but I've encountered everything from mild annoyance to outright anger at the suggestion - as if by asking for a copy I was automatically calling into question their abilities as a practitioner.  In fact, the majority of the time I simply want a copy for their records, should we ever require a trip to the ER.  Of course, I will readily admit, I do still look over every profile and make sure that I'm comfortable with the answers provided.

Kim May 2nd, 2009 06:08:50 PM

Just don't use Grey's Anatomy as a model of professional behavior and you'll be fine.

Evet May 2nd, 2009 06:40:14 PM

I've added in a few examples of relatively common diseases or disorders we can pick up or confirm/support with the findings of the CBC. I hope you find these helpful.

• anemia
• dehydration
• autoimmune diseases (like autoimmune hemolytic anemia)
• blood cancers (certain lymphomas, for example)
• kidney disease (as with chronic renal failure)
• tick-borne diseases (like Ehrlichia or Lyme)
• bacterial infections
• viral infections (like Parvo or Panleukopenia)
• bone marrow diseases 
• parasitic diseases (like hemobartonella in cats)
• poisoning (Tylenol or onion toxicity, for example) 

Dr. Patty Khuly May 2nd, 2009 06:43:19 PM

Kim I agree receipts don't help an emergency vet much if your vet is closed. 

Evet May 2nd, 2009 06:43:58 PM

Our Vet's fine with copy's of "paperwork" if requested.  She knows we aren't Vet chasers.

Evet May 2nd, 2009 06:48:37 PM

Gee whiz, Kim, I sure don't disagree. And do you really think that the vets you are talking about, don't understand the significance of the values?

Dr. Khuly, Instead of a brief overview, how about an expansion of each CBC value & indicies and the significance of how it can be used to diagnose the above list ? 

Barbara A. Albright/NH May 2nd, 2009 07:46:30 PM

I am very enthuseastic about doing blood work for any patient when thorough physical examination and history indicate a problem. I can also see value in occasional screening studies for older pets and/or particularly vulnerable breeds.  However, I have three nagging doubts. (1) How often, in actual fact, is the course of events changed by "blind" testing such as is done with routine dental treatment? When I have asked colleagues, many cannot remember even one case where they deferred elective surgery or dentistry; or modified their protocol because of blood test results. (2) What about the "curse of dimensionality" with panels? The "reference range" reported is usually the 95% confidence limits derived from a sample of assumedly healthy patients. This means that 5% of normal samples (2.5% above and 2.5% below) should fall outside of these limits and, therefore, be reported as abnormal.  This is much less of a problem with symptom-driven choice of tests, because only a few such tests will be considered. With a panel of 20 tests, the liklihood of some abnormal value being reported by statistical chance becomes much greater -- almost inevitable. (3) On the other hand, some tests that might give more useful information about risk for anesthesia are rarely done -- perhaps because the practice is not equipped for it.  As one example, I rarely hear of respiratory function testing (FRC, ventilation/perfusion studies, diffusion coefficient) as part of pre-anesthetic screening. Peri-anesthetic blood pressure measurement is also relatively uncommon in "my neck of the woods." My grandmother, of blessed memory, used to tell us kids a story about a man who was seen crawling around under a lamp-post. On questioning why, he said he was looking for keys he had dropped. On further questioning, it came out that he had dropped them up the street, but was looking here because the light was better.  Sometimes I get the feeling that we may be doing a certain group of tests becasue those are what our lab (or in-house machine) have available rather than those that are most clearly indicated by the clinical need. 

Dr. Steve Dubin May 2nd, 2009 08:16:37 PM

Only three of the vets I've ever - wait, make that four - vets I've worked with (although 1 was the vet who did some of the work with the education birds of prey I worked with, not my own pets), ever really went into what the test results were.  Everyone else just said, "Everything looks okay" or noted that one or two things might be a bit higher or lower than usual, except for the dog with the sudden onset of unspecified menengitis, in which case several things were messed up and the dog was paralysed, so euthanasia was happening soon anyway.  Now, before anyone yells, the times when vets didn't go into the results, my animals were being tested for either pre-op stuff or the vague ADR, so I didn't really think "I don't see anything wrong" was really egregious on the part of the vet.  The three vets who did go into results in detail, well, one was a long-time vet tech who'd gone back to school, and worked her way through vet school at 48, and her dedication saved my dog's life.  She was as gun-ho as any new grad, but her years of experience as a tech made a difference in how she looked at things, and she was so careful in explaining the results because I think the other vets were judging her a bit differently, so she was so careful to get everything right. 

The other two vets are different in how they view me, as both a client, and as someone who actually is interested in - and capable of - learning 'scientific stuff' which other vets generally assume is over a clients head, so to speak.  Even the vet I work for (who's known me, on and off, for 17 years), is mostly astonished when I say 'scientific stuff' correctly, and often thinks I wouldn't want to know things that I already actually know. 

I think that that's a big reason why many vets don't give clients lab result printouts - they think the info won't mean anything to most clients.  This might very well be true in a majority of cases (at least at the clinic I'm at, the majority of clients don't seem to have much interest in the 'scientific stuff'), but I think that can be connected with a lack of interest in science in general by so many people in the US. 

KateH May 2nd, 2009 08:35:41 PM

Well, Barbara - I'm not sure which is worse... the idea that they don't understand, the idea that they're lying to inflate their bottom line, or they're omitting information that may cause the owner to opt for euthanasia instead of continued treatments and tests.

A good example is the last time we had one of our senior dogs blood run - a simple senior wellness panel.  The vet (not our regular vet, a stand in for the day) tried to convince me that the dog had elevated kidney enzymes and required a long list of treatments, testing and diet changes - ultrasounds were even discussed.  My DH and I went to discuss how to proceed, and I requested a copy of the bloodwork to look over for myself. 

Once again, it didn't take a degree to interpret the bloodwork - it was a hot summer day and we had shown up to our appointment accidentally early.  We went for a walk to a local park, and since I wasn't planning on the jaunt we didn't bring water with us for the dogs.  We went back into the exam room, I looked over the dog again, and cornered the vet - isn't it possible that the dog is simply slightly dehydrated?  I mean, the values were simply on the top end of range - not even out of normal.  In addition, this particular dog has always had values that have been in the higher end of the value range - it's what we considered normal for him for the previous six years. 

He had no good answer, and so we went home after booking an appointment to see our regular vet the next day.  Not only did he agree that dehydration was the answer, but he re-ran the panel for free just for our own piece of mind after the previous vet had shaken us up.  Lo and behold, his values were back to normal.

Barbara - I can't accept that this vet was simply trying to expose my dog to a handful of unnecessary tests for financial reasons any more than I can accept that the vet in my previous example realized the dog was in ARF and simply didn't care.  How could I continue to take the word of any vet if this was the case?  Nope, I prefer to think that they just didn't understand.  The first vet focused on the internal bleeding and immediately assumed it was parasites even though other results disagreed - and values that are generally affected with parasitic infections were not affected.  The second jumped all over a slightly elevated value that could have been (and WAS) nothing at all.  Err on the side of caution, yes, of course - but in this case I think caution involved repeating the test after a few bowls of water.

I could give you a dozen more examples of these kinds of incidents - and I'm sure other readers have similar stories where bloodwork was misinterpreted.  I realize it's upsetting to consider that these doctors can't read simple test results - but I find the alternative far more disruptive to my outlook.  ;O)

Kim May 2nd, 2009 08:41:20 PM

Dr. Dubin - very, very, very interesting perspective. 

My rebuttal to you, however, would be that a practitioner skilled in interpreting blood results is not going to panic over a single value being out of range.  They are going to (hopefully) look at the WHOLE picture and read the book cover to cover, not just each page seperately, as it were.

In addition, by doing frequent bloodwork (annually, semi-annually) you have those baseline values to refer to.  You can also plot trends that may be occuring.  A dog who is eight or nine years old and is being screened for unknown illness may very well have values that are "normally" outside normal range - However, as a prudent owner who has done regular testing you would already be aware of what is "normal" for that individual. 

I disagree with your statement regarding "blind" testing - as we are all aware, organ function must be severely impaired before the dog or cat becomes symptomatic.  Cats in particular are exceptionally good at hiding illness.  "Blind" testing can spot these issues before they become so severe that they are symptomatic.  In fact, it's how we discovered our retriever's liver failure when he was 2.5 years old.  A Pb test evolved into a full chemistry profile/CBC and undoubtedly saved his life.

Kim May 2nd, 2009 08:52:44 PM

I think you're asking a lot of your clients to pay for annual bloodwork in the absence of any problem. I understand the pre-anesthesia bloodwork, a single draw on a healthy cat to establish a baseline, or regular focused testing for a sick animal, but sometimes that requirement has consequences: for example, the extra $100 bloodwork charge (on top of $200 for simple dentistry) means that my cats don't get their teeth cleaned each year. And, if my vet expected me to pay for annual bloodwork for every cat, no matter how young or healthy, my cats wouldn't be going in for a checkup each year. I compare it to my health care: the only time I would have blood drawn was if I were feeling really sick--the last time I had a blood workup, it was 10 years ago when I had mono. Similarly, my cats only have their blood tested if there's a really good reason. It's a family "policy" that's worked for more than 30 years and 15+ cats.

Sarah May 2nd, 2009 10:13:59 PM

Kim: What on earth would be the sense of doing a senior or junior wellness exam to include a CBC and chem, if the professional interpreting the results can't do so? OMG, who's obtaining degrees, passing exams, and obtaining licenses here? It makes a mockery of everything, if basic understanding of 101 education can not be applied, don't you think? Or pretty darn scary!

Barbara A. Albright/NH May 2nd, 2009 11:08:51 PM

labs diagnose more diseases than not in human or veterinary medicine. go to the library and pick up a hematology book...you'd be amazed at how much i (as a lab tech) can tell you from a peripheral blood smear stained from a single drop of blood. the instruments are better and better which is why your veterinary labs cost as much as the human ones do. in fact, it's sometimes the same equipment that runs the tests. sure, it might make some money for your vet's practice BUT they are also invaluable in making diagnose and monitoring treatments (and the cost of the instruments and reagents are ridiculous!). how much does a human doctor determine from physical exam versus the countless lab tests? the best care costs money.

sarah May 3rd, 2009 12:00:37 AM

Dr. Dubin, my vet sends out samples for any tests they can't do inhouse. Yes, that costs more. It also means I have the assurance of the right tests getting done when we agree they should be done, and not deferred just because my regular vet doesn't have every single bell and whistle inhouse.

Regular, routine annual blood screening identified my older cat's early stage renal failure long before she would have shown any obvious symptoms. If I'd had the same "blind" testing done on the cat that died four years ago, likely we'd have caught the diabetes earlier, before it had done significant damage to her and before her heart progressed to the point where the combination removed nearly all our options.

Routine testing means we know what's normal for all my animals now. That means the vets can look at new test results, and say "this is normal for her" or "this is quite high for her." Or low. Or whatever. Knowing what "normal" looks like for each of them makes it easier to to recognize not-normal when we see it.

Lis May 3rd, 2009 12:37:49 AM

Dr. K-

Access to same-day results, whether through a lab or a neighboring clinic willing to run a panel would be just fine.. and I'd definitely be willing to spend a little extra for it. (It's more an issue of availability than of money.) Basically, I'd just want to know that the option is there if indicated.

Re: deferment due to lab findings..

I have seen a few cases deferred (not my pets) due to bloodwork. One was a nine-year-old cat who appeared perfectly healthy, but whose bloodwork revealed a T4 value that was off the charts (vet elected to address hyperthyroidism before performing dental).. the others were younger pets with pre-spay/neuter PT/PTT abnormalities that suggested the possibility of a bleeding disorder. (I know that at least one of these abnormal readings was determined to be a matter of lab error.) I know it's rare, and that bloodwork offers an incomplete picture (The Lemon's cardiomyopathy probably presents his greatest anesthesia risk at this point, and despite the reams of lab results in his record, we'd have no idea it even existed if not for a medication reaction he suffered last year).. but I still think it's better than nothing.

Personally, I just like having the baseline. I wish I had a baseline on the ARF cat. He was neutered as a feral we didn't intend to keep, so we passed on the extra diagnostics. Now, post ARF, his BUN remains slightly elevated (~2 mg/dl, everything else WNL).. wish I knew whether to attribute that to the poisoning, or if it's just him.

Ramen Connoisseur May 3rd, 2009 12:49:02 AM

Also, agreed on the 'normal vs. not normal' for individual patients.

If you have that baseline, a slight deviation that might otherwise be ignored or perhaps followed up on at the next yearly physical becomes more meaningful, allowing for early detection of problems.

It's also useful in an ADR situation, where questions might arise as to whether or not that slight deviation might have clinical significance with regards to the problem. Years ago, I adopted a cat whose exterior was grossly abnormal as a result of prior injuries. The vet we were using at the time balked at my insistence on baseline x-rays (cat was doing well, but if the outside was that visibly messed up, you just knew there were going to be internal deviations, too).. but these wound up being absolutely invaluable two years later when she started having problems. As it turned out, there were a number of abnormalities on the films, and the new vet was unable to pinpoint whether or not some of them were related to old injuries or whatever new disease process was taking place. Those baseline films ultimately wound up answering a lot of questions and saving us thousands in diagnostics. Not bloodwork, I know.. but I'm always in favor of having a baseline.

Ramen Connoisseur May 3rd, 2009 01:06:44 AM

Dr. K: 

What about electrolytes?  What prompts electrolytes testing?

Fotini May 3rd, 2009 01:09:26 AM

I want to remark on the statement, "as we are all aware, organ function must be severely impaired before the dog or cat becomes symptomatic."  That is a very general and sweeping judgement which may be misleadiing.  Certainly not all organs nor yet every function is so affected.  Experimental ablation studies in carnivores show that 75% of kidney tissue may be removed before creatinine and BUN blood levels are elevated along with symptoms of increased thirst and urinary volume.  This "reserve" of function is why people can donate a kidney for transplant and still live normal lives.  On the other hand, at least 80% of the liver can be ablated (with much more surgical difficulty!) and full recovery of function (even some volume) will usually occur. Yet the "liver enzymes" we often measure can show major --  often rapidly reversable -- changes with only minor insult.  While blood testing in the absence of symptoms in young apparently healthy patients may sometimes point to hidden disease, it might also lead to more invasive blind alleys.  I am reminded of an episode of "House" where a patient had raised alk phos on routine blood work. This led to liver biopsy, haemorrhage, transfusion, mismatch, renal failure, multiple attempts at transplant and ultimately death.  Probably more frequent on "House," but not at all unknown in real life. 

Dr. Steve Dubin May 3rd, 2009 07:14:22 AM

Dr. Dubin: Interesting discussion. I don't disagree that frequent screening is unnecessary if it's not going to change how the veterinarian or the client approaches the patient's problem. But I do frequently change my anesthetic protocols--and defer anesthesia altogether--when I find evidence of a variety of issues. Yes, it sometimes annoys my clients to have "had to stress their dog out and starve him for nothing" if the results aren't back until game day, but everybody eventually understands and the pet ultimately gets what she needs--a more detailed workup.

I'm a big believer in the "if you do not look you will not find." 

Dr. Patty Khuly May 3rd, 2009 08:59:10 AM

Last trip to the vet I agreeded to a senior panel, expecting it to be in the $100 or so range like blood work has been in the past.  Man was I surprised when I checked out and found out that it was $270!!!  At least the vet suggested we could skip the yearly thyroid panel (also in the $100 range).  Needless to say - I am not able to do that test semi-annually.  And pretty much all the test said was that his BUN was a bit high - which I could have told them (I feed raw - BUN tends to be a bit higher than kibble fed dogs).

I wish he had at least warned me that the senior panel was so much more expensive than I expected.  

I am temped to start taking the cat (with no current medical problems) to Banfield.  I like the vet at my local one, and with the packages, so much is covered, there will be fewer surprises at routine visits.

teri May 3rd, 2009 10:10:11 AM

And that the biggest mistakes come from not looking, than from not knowing.

AlexH May 3rd, 2009 10:10:37 AM

What about x-rays?  Should veterinarians do routine chest x-rays on animals to make sure nothing is abnormal?  On a yearly basis?  Before anesthesia (sometimes, everytime)?  What about abdominal x-rays?

Jim May 3rd, 2009 10:14:01 AM

Barbara - agreed... hence my initial recommendation that any vet suggesting bloodwork should have a better understanding of how to interpret the results.

Regardless of your vets abilities (or lack thereof) having that panel in your file can be a lifesaver down the road.  Also, it can provide information to informed clients (like most of us here!) that a second opinion may be in order.

Dr. Dubin, you are correct - however, how many people actually notice their dog/cat's "increased thirst" as a symptom of something more serious?  Particularly when these symptoms are timed with a weather change, they are very easily dismissed.  Pets who are large water consumers to begin with, or who have access to self-watering jugs and fountains are also harder to judge.

It's also imperative to take into consideration diabetes, thyroid and other endocrine disorders that are truly becoming epidemic in number.  I see sooooo many pets on a daily basis that are suffering the symptoms of these disorders and their owners are extremely dismissive when I suggest bloodwork.  Their response?  "I was just at the vet, I'm sure if there was a problem he would have said something."

On the other hand, the anger and downright fury they feel towards their veterinarian if they have their animals tested and do in fact find what I've suspected (I've had several diabetes cases and countless thyroid cases) could have easily been avoided had their vet simply a) taken the time to really get an idea of the pet's total health picture and b) suggested a workup on the basis of ruling out any problems and providing a baseline level for future use.

This follows right into the failure of vets to urge their diabetic clients to test levels at home with a self-test kit.  In my opinion, not enough emphasis is put on bloodwork and what can be determined by a skilled practitioner.  Say what you will, Dr. Dubin, but we have not had a single "surprise" health-wise from any of our animals since adopting this yearly protocol eight years ago.  Given our special needs household, and our constant surprises before this, we consider this investment more than worth it.  And as for the episode of House, well... don't believe everything you see on the Tee-Vee.  ;O)

Kim May 3rd, 2009 10:18:19 AM

I would also be interested to hear opinions on routine x-rays... it's been my experience that they're very difficult to read unless something is noticeably out of whack.  However, as said before, having that baseline to compare back to may be beneficial.  Should I be booking 12 appointments?  ;O)

Kim May 3rd, 2009 10:24:00 AM

I have to say that I don't do routine X-rays on my patients. I do them when I have an indication. This is true in human medicine where routine X-rays are relegated to looking at very specific areas when certain risk factors are present ( as with mammography, where it's only routine after a certain age or when you have a familial predisposition). 

Orthopedic issues, cardiac issues, respiratory issues, abnormal abdominal findings on palpation, abnormal liver findings on chemistry, etc. tend to factor in more than age, species or any other concerns. (Though breed or familial predisposition may give rise to "survey" X-rays to scan for certain conditions such as hip dysplasia, cardiac enlargement, small tracheas and other problems.)

Dr. Patty Khuly May 3rd, 2009 11:45:00 AM

The former clinic that did the majority of spays on my dogs , suggested chest x-rays pre-spay, I complied. Pocket as well as my others have those films. The second/present clinic suggest ECG pre-anesthesia, I complied with that also & wondered the benefit/risks between the two.

Also, numerous x-rays were performed, hopefully to rule out: bladder stones, disk disease, general picture as problems arised. Amazingly, Dottie had an a 2 view x-ray , after an ulcerated mammary gland, and my goodness, things that you would have expected to be awry were not! But she lived about 18 more months-post appearance.

Barbara A. Albright/NH May 3rd, 2009 12:09:54 PM

The lab that our practice uses for 90% of routine labwork (Antech) has an option where we can directly email lab results directly to the owner/client. We have all email addresses on file and email results, updates, case management info to clients on a routine basis. Yes, while it is true that the client may not be able to interpret the results, it is good information for them to have on file if they needed to seek emergency care after hours. 

Note: I have a hard time comprehending how a lab tech can say... "I compare it to my health care: the only time I would have blood drawn was if I were feeling really sick--the last time I had a blood workup, it was 10 years ago when I had mono." That isn't health care, it's health neglect in my opinion...

Teri and the cats of Furrydance May 3rd, 2009 01:38:59 PM

sarah: I'd like to address your comment too. I agree in full. And even venture to say that some of the valuable testing & confirmation may be the easiest and cheapest to perform "in-house", in other words, profitable to the clinic and not so far out of line for the client.

You mentioned blood smear--- a box of slides, stain, & microscope, reticulocyte count, hemoglobin via copper sulfate (I volunteered once for a Red Cross blood donor clinic) specific gravity on urine, one of my faves! And to not suggest any confirmation tests for gross abnormalities is simply unethical.

I clearly remember confirming Dottie's coagulation (PT/PTT), upon complaint of finding blood in the house (floor, bed, on her-intermittently). No coagulation or platelet issue, which was a relief.

Pocket's Story from New Hampshire

Barbara A. Albright/NH May 3rd, 2009 03:00:45 PM

But if I may be so bold to add, who knows, maybe all those things were done on Pocket for benefit of the students huddled in the corner staring at me, and watching me clean her up of black-green diarrhea and nostrils filled with goop, without nary a thought of wearing gloves. There, I feel better.

Couldn't even clean up the filth off my dog.

Barb A./NH May 3rd, 2009 04:03:11 PM

Jim

Take your companion's X-rays and run to a radiologist for a correct reading and interpretation!

Asproolee's Story

Fotini May 3rd, 2009 05:00:57 PM

sarah the lab tech and Sarah are two different people! i (the lab tech, who will always allow lab tests on myself and my pets because i'd rather be safe and outta money than find one of us preventably and seriously ill) am now sarahMT ok? ;)

sarahMT May 3rd, 2009 05:16:45 PM

Oops, so sorry sarah...I did not even notice that the other Sarah was spelled with a capital T...

My apologies.

Teri and the cats of Furrydance

Teri and the cats of Furrydance May 3rd, 2009 05:24:03 PM

I have to say, I thought the days of pushing vaccine visits were way, way in the past.  Where I have worked, we've emphasized for years the value of exam visits and comprehensive health care.  Partnering with our clients in the care of their dogs and cats has been the primary factor in guaranteeing a high compliance ratio...and yes, this includes routine lab work-ups for our young patients as well as older. 

One of the biggest setbacks I see in general practice, is the failure of medical staff to demonstrate the full value of what is recommended for preventative health care.  There are so many lost opportunities to catch problems earlier than when clinical signs are apparent.  If the client elects not to have routine labs and other work-ups done, so be it.  At least they have made a decision after have been educated on the basics. The client deserves this-and your veterinary business thrives on this.  Good and thorough medicine is good business-and just plain common sense.

Obviously, one region's routine work-up may differ from another's, and age is a great factor in determining what might be medically appropriate for any pet.  Also, interpretation certainly goes beyond just looking at the basics.  I'd hope one would have a decent and detailed history on hand and factor that in.  Afterall, once you look at your results, the next question ought to be 'why?', and then move on from there to your further diagnostics and recommenrdations (in regard to the comment about the dehydrated dog).  There must be skill applied to even the most mundane and routine aspects of practice.  

I couldn't possibly feel good about making the assumption and judgement that something as sensible as routine work-up should not be offered to my clients.  What am I here for, otherwise?

Renee May 3rd, 2009 07:54:22 PM

Renee: Bravo! My biggest concern in my state of NH, were the many years I spent educating other pet-owners to the benefit and meaning of taking "baseline" lab tests & then monitor changes through middle-advanced age.

That became such a "mockery" to me personally, that I just am in the horrible position of not offering a word. I used to stress how important it was to shell out the minimal dollars each year, not only for the pet's benefit, but to show good faith to the clinic , in other words....indeed they should be making money too. And that good faith should payoff in a time of need for ethical & compassionate care, along with the expected honesty.

Hard to make that my regular mantra, post-Pocket

Barb A./NH May 3rd, 2009 08:17:56 PM

Kim: Re: "increased thirst"...how can that be overlooked, when one has to replenish the water bowl more often? Or the pet sits at the bowl drinking & drinking post meal?

Barb A./NH May 3rd, 2009 08:40:07 PM

Barbara - you would be amazed...

I've had people contact me looking for nutritional advice to put weight on their cat because he's been losing weight for oh, say, eight or nine MONTHS.  Ummmm... hello, vet visit?! 

Or people who have literally had their dogs turn yellow before they went in for liver failure - and yes, in the final stages of renal failure when they say "come to think of it, he HAS been peeing an awful lot..."

To you or I (and again, the vast majority of readers here) the idea of missing such a symptom is... well, your reaction says it all.  But as I mentioned, when the increase comes in time with a season change, a move, a lifestyle change, a food change, etc - or if the owner is using a self waterer, it can be overlooked or dismissed.  Homes with multiple pets are also more difficult to monitor.  When you water a half dozen cats out of a couple of fountains/bowls, an increase in water consumption in one of them could be missed, particularly if the water dishes are in out of the way areas.

Renee - very well said.  :O)

Kim May 3rd, 2009 10:15:38 PM

I forgot to mention, that the Ohio State Greyhound Health and Wellness Program, is available to any greyhound owner - and any vet - at no charge - to discuss health issues, so there shouldn't be any reluctance by a vet or ownerto get in touch with them in reference to bloodwork results, or other questions of health/treatment.  Go to the website (addy below) and click on 'Resources for Owners and Veterinarians' - there are FAQs right there that might answers questions, as well. 

http://www.vet.ohio-state.edu/2376.htm

KateH May 4th, 2009 11:51:48 AM

Of course, this program, while free, is always in need of donations to continue its work, so if anyone who needs it (or might need it in the future) has any spare change, or wants to do any fundraising events, and donate to them, that who be a mitzvah for all.

KateH May 4th, 2009 12:24:34 PM

Years ago I wasn't much of a believer in regular bloodwork for my cats. I felt the vet was out to make money. But when the second cat developed IBD I starting reading more and more about feline health and am now a believer.  Although I think that some people that don't run labs do have a good understanding of the implications, from the interactions I have with people as a moderator of a feline health list I think that most people don't understand the labs at all (why they are important, what they show).  We encourage people to request copies of all their pets labs, look for trends, and ask questions or research any item that is outside the normal value. 

I discovered that my then 5 year old cat had elevated creatinine that likely shows early kidney disease.  I asked the vet to switch from the standard young cat chemistry panel, to the full blown older cat one that includes electrolytes so we can trend changes over time.  A year and a half later he is still stable, but I am glad to have the information.

Another friend discovered through a normal screening that her cat's liver values were extremely high. The cat had no symptoms of liver problems.  About a year previously the owner had switched to a mostly seafood diet due to extreme food allergies. Her vet felt the cat would be safe for about 2 years before it would impact, and the plan was to try a different protein after about a year or so. Turns out that the cat, although being fed "quality" seafood cat foods from a variety of sources, had mercury poisoning.  The owner was very happy to discover this before it had any serious impact on her cat's health.

Other examples are more mild. My cat going to the ER on Christmas, I had a complete spreadsheet of all his labs. High albumin is normal for him so wasn't an item that caught the attention of the vets. 

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دلع السباق السريع العاب دلع لعبة سباق سيارات الأتاري العاب دلع اللانش السريع العاب دلع السيارة المجنونة العاب دلع المتاهة الصعبة العاب دلع دراجات نارية على الرمال العاب دلع سباق الخيول العاب دلع سباق ثلاث لفات العاب دلع سباق الجليد العاب دلع السباق الصغير العاب دلع سباق سيارات العاب دلع تسابق الميني كار العاب دلع اركن السيارة العاب دلع سباق الخيل العاب دلع سباق سيارات مانيوال العاب دلع كرة النجوم العاب دلع العاب كونتر سترايك العاب دلع لعبة مذكرات الحج العاب دلع تريكس العاب دلع كوتشينة21 العاب دلع سوليتير مطورة العاب دلع تحدي ترتيب الضيوف العاب دلع فري سل لعبة الذكاء العاب دلع سوليتير صعب العاب دلع من سيربح المليون 2009 العاب دلع لعبة بوش و هو مفهي العاب دلع كرة التوازن العاب دلع الاشياء المتشابهة العاب دلع المكعبات لماه جونج الصينيه العاب دلع لعبة حرب السفن العاب دلع لعبة البطاقات السياسية العاب دلع عدد النجوم العاب دلع لعبه الماستر مايند العاب دلع اصناف الطعام العاب دلع لعبه تذكير الاصوات العاب دلع لعبة الأختلافات بين الصورتين العاب دلع مهارات الدراجة العاب دلع تركيب الوجوة العاب دلع لعبة استعادة الذاكرة العاب دلع لعبة تعليم الأنجليزيه العاب دلع لعبة المحترفين بينج بونج العاب دلع لعبه الفيل في نادري الجولف العاب دلع قتال الكرات العاب دلع لعبة التنس بالفضاء العاب دلع لعبة البينج بونج الجديدة العاب دلع كوره الحائط العاب دلع جولف الكريسماس العاب دلع لغز الضفادع العاب دلع لعبة الطيران الشراعي العاب دلع لعبة تعليم التجديف العاب دلع لعبة التزلج في الجليد العاب دلع لعبة البطه الغواصه العاب دلع لعبة الكورة بالفول السوداني العاب دلع لعبة بلياردو 2009 العاب دلع تزلج على الماء العاب دلع دافع عن نفسك بالعصا العاب دلع لعبه بنج بونج المطورة العاب دلع الاعب زيدان العاب دلع الوصول الى الهدف العاب دلع لعبة البولنيج الرائعة العاب دلع لعبة قفزات القرد العاب دلع لعبة البينج بونج القدم العاب دلع لعبة التزلج على الجليد العاب دلع لعبة الكرة بالهوى العاب دلع لعبة البلياردو السريع العاب دلع لعبة هوكي الفضائية العاب دلع مسابقة الفرسان السريعة العاب دلع لعبة السكيتنج الجميلة العاب دلع التنس العاب دلع اصنع رجلا اليا العاب دلع الحروف و المدينة العاب دلع كورة قدم الطاولة العاب دلع لعبة الترامبولين جمبازي رائع العاب دلع لعبه البنج بونج مثلث العاب دلع العاب رياضية جميلة العاب دلع مهارات كرة القدم العاب دلع لعبة بلياردو القنابل العاب دلع البلياردو الجنونية والالوان العاب دلع البلياردو الرائعة العاب دلع منوعات البلياردو العاب دلع لعبة الكرة الطائرة العاب دلع تحدى دراجة السيرك العاب دلع كرة السلة العاب دلع رمية حرة كرة السلة العاب دلع لعبة الطاولة العاب دلع لعبة تمرير الكرة العاب دلع لعبه المطرقة العاب دلع لعبة كرة المضرب العاب دلع لعبة التزلج على الاسطح العاب دلع لعبة موتو سيكل اكس العاب دلع لعبة الرمي الحر لكرة السلة العاب دلع لعبة الشطرنج للأعبين العاب دلع تجميع النجوم العاب دلع لعبه السكواش العاب دلع لعبة راكب الامواج العاب دلع لعبة جولف فلاش العاب دلع لعبه التزلج على الماء العاب دلع لعبة القوس و السهم العاب دلع لعبة البولينج العاب دلع لعبة ميني كرة قدم العاب دلع لعبة هوكي بالجليد العاب دلع لعبة الادرينالين العاب دلع لعبة الصيد بالكرة العاب دلع فقاعة فى مهمة صعبة العاب دلع لعبه استنساخ العاب دلع لون توم و جيري العاب دلع لعبة المتاهة المميته العاب دلع توم و جيري في مطاردات العاب دلع تجميع منظر طبيعي العاب دلع الحشرة الحائرة العاب دلع الدائرة المختلفة العاب دلع كابتن مناحي العاب دلع لعبة الاشباح في متاهه العاب دلع توك توك فى الباركينج العاب دلع جمع الصور العاب دلع لعبة سونيك 2009 العاب دلع المربعات الملونة العاب دلع لعبة ترتيب الارقام العاب دلع لعبة الضفادع وتحريكها العاب دلع لعبة بازل صعب العاب دلع لعبه الفقاقيع والأ ارقام العاب دلع حارس مدينة الحيوانات العاب دلع لعبة للأذكياء فقط العاب دلع كره الفضاء العاب دلع الطائر والعظم العاب دلع لعبة الثعبان السريع العاب دلع لعبه سوكوبان بترتيب المستودع العاب دلع لعبة القفز العاب دلع متاهى حقيقية العاب دلع لعبة غرفة النوم العاب دلع تغيير الكروت العاب دلع الهندسة المعمارية بالبناء العاب دلع ترتيب البازل 24 رقم العاب دلع صندوق فضائي العاب دلع لعبة المتاهه المسليه العاب دلع طائرة نفاثة العاب دلع التيتريس العاب دلع ابحث عن الرجال الصغار العاب دلع لعبة الاشباح بالقبور العاب دلع لعبة الفضاء الجائع العاب دلع لعبة بازل الصخرة العاب دلع لعبة بازل السيارة العاب دلع لعبة بازل الشاطئ العاب دلع ساموراى الجبار العاب دلع غارات على البلدة العاب دلع الفارس و التنين العاب دلع هيرو فى مهمة إنقاذ العاب دلع حرب جوية العاب دلع حرب بحرية العاب دلع قتال النينجا العاب دلع قبلة التنين العاب دلع قتال في الفضاء العاب دلع القتال المفتوح العاب دلع التنين الاحمر العاب دلع النينجا الصغير العاب دلع بنج بونج نينجا العاب دلع مهمة للكوماندوز العاب دلع أحجار الأرض العاب دلع حارس المعبد العاب دلع الهجوم الشامل العاب دلع مشاجرة العاب دلع كاراتيه العاب دلع بوش ضد كيري العاب دلع قبضة التنين 2 العاب دلع الضربة القاضية العاب دلع غارب المحارب العاب دلع ملاكمة بلا رحمة العاب دلع سوكوبان ترتيب المخزن العاب دلع الطائرات الحربية العاب دلع طرزان الغابة العاب دلع لعبة الفلاح والشرطة العاب دلع لعبة المغامرة بالايميل العاب دلع لعبة العنكبوت العاب دلع العنكبوت سبايدر مان العاب دلع لعبة غامر في السيرك العاب دلع المغامرة مع هليكوبتر العاب دلع اجمع الكرات العاب دلع مغامرة الولد و البالون العاب دلع الديك الرومي العاب دلع بابا نويل على الجليد العاب دلع المطاط النطاط العاب دلع لعبة الفك المفترس العاب دلع لعبه انقذ القطط العاب دلع مدفع بشري العاب دلع لعبة الحرب با الفقاعات العاب دلع المغامرة بالكرة العاب دلع لعبة الهروب من الكلاب العاب دلع لعبة القفز في الشارع العاب دلع البيض الملون و الارنب العاب دلع الهيلكوبتر الحوادث بالجو العاب دلع ازحف مع عباس بن فرناس العاب دلع قوة ألفا العاب دلع لعبة طبق طائر العاب دلع لعبة حشرات فضاء العاب دلع لعبة البطة و المظلة العاب دلع الفأر والجبن العاب دلع لعبة التنافس بالكرة العاب دلع الكلب الطائر العاب دلع لعبة الارجوحة للبطريق العاب دلع لعبة الغوريلا و ماريو العاب دلع لعبة سوبر ماريو و المشروم العاب دلع لعبة نيون العاب دلع الطائرة المجنونة العاب دلع انقذ الاطفال من الحريق العاب دلع لعبة باكمان و الجدار العاب دلع لعبة مطاردة توم و جيري العاب دلع المغامرة في القصر المسكون العاب دلع لعبة كريات الدم البيضاء العاب دلع لعبة الصواريخ صواريخ العاب دلع سوبر ماريو ينقذ الأميرة العاب دلع لعبة سوبر ماريو الصياد العاب دلع القفز من اعلى الجبل العاب دلع لعبة مغامرة في المقبرة العاب دلع المطاردة العنيفة العاب دلع لعبة كارتون الفضاء العاب دلع لعبه مدينة الاشباح العاب دلع لعبة اكتشاف القمصان البيضاء العاب دلع لعبة حرب الكواكب العاب دلع المغامرة العاب دلع توصيل طلبات العاب دلع سونيك الجميلة العاب دلع لعبة انتي الفيروس البشري العاب دلع الصواريخ في الفضاء العاب دلع لعبة الهروب من الغابة العاب دلع الرجل الأخضر العاب دلع لعبه محارب الساموراي العاب دلع غزاة المفكرة العاب دلع سرعة رد فعلك العاب دلع إم حديجان العاب دلع لعبة اسحق المسوخ العاب دلع العالم السفلي العاب دلع لعبة النينحا الرشيق العاب دلع مغامرة القط العاب دلع لعبة المنطاد العاب دلع غواصة اللؤلؤ العاب دلع كرات الثلج العاب دلع لعبة الكرة النطاطة العاب دلع الفطائر الصعبة العاب دلع كوكب المفجوع العاب دلع لعبة مغامرة الامير العاب دلع لعبة الرجل الصاروخ العاب دلع لعبة الراعي الصغير العاب دلع لعبة الجندي الصغير قصتي تتوة بهالعناوين العاب دلع الفارس منصور العاب دلع قاتل باكمان العاب دلع بقرة ذكية العاب دلع عبور الضفدع العاب دلع القنابل الحرية العاب دلع لعبة عالم القرود العاب دلع المهمة السرية العاب دلع لعبة الاسطى عماشة العاب دلع ضفدع جوعان العاب دلع لعبة عصابة الالعاب العاب دلع لعبة صخور الفضاء العاب دلع لعبة انقاذ الهليكوبتر العاب دلع اللعب في النار العاب دلع أطعم التنين العاب دلع مهمة فى جبال الالب العاب دلع لعنه الفراعنه العاب دلع لعبة رجل الاطفاء العاب دلع لعبة الذبابة المسطولة العاب دلع لعبة لاتتوقف من الجري العاب دلع لعبة مغامرة النملة العاب دلع الحصار في القلعة العاب دلع لعبة سلم الدجاج العاب دلع الحرب في الكابوريا العاب دلع لعبة قاهر الارهاب العاب دلع لعبة فارس القرية العاب دلع الكرة المجنونة العاب دلع لعبة 60 ثانية العاب دلع لعبة التوصيل السريع العاب دلع التوازن الرهيب العاب دلع لعبة ابن الكلب العاب دلع لعبة ملك الطعمية العاب دلع التحدي في حمام السباحة العاب دلع حلاق سريع العاب دلع ابحث عن الذهب العاب دلع توصيل طماط العاب دلع الجواهر المتشابهة العاب دلع لعبة اتارى العاب دلع لعبة تكسير الكمبيوتر العاب دلع بطريق الطائر العاب دلع المغامرة مع القطط العاب دلع منطقة عمل العاب دلع الباص المجنون العاب دلع حرب الذكاء العاب دلع الذكاء والارقام العاب دلع الكرة والاشكال العاب دلع المغامرة فقاعة العاب دلع العقارات العاب دلع شوربة الحروف العاب دلع البوبى السريع العاب دلع صيد السمك العاب دلع لعبة مهارة القبطان العاب دلع التشبيك في المربعات العاب دلع لعبة الكرة الموجهة العاب دلع لعبة المربعات العاب دلع المغامرة في الجليد العاب دلع البكسل في ورطة العاب دلع تلبيس ماريو العاب دلع مكنسة خالتي مزنة العاب دلع الحديقة العاب دلع اللعب بالبيض العاب دلع لعبة سباق التصادم العاب دلع اشعة اكس العاب دلع لعبة الكرة المجنونة العاب دلع لعبة الطريق المكهرب العاب دلع لعبة خروج السيارة العاب دلع لعبة غزاة الفضاء العاب دلع لعبة نافع المدافع العاب دلع الدولاب المهبول العاب دلع الضفدع في الطريق العاب دلع لعبة كرة التحطيم العاب دلع إحذر المربعات العاب دلع التيتانيك العاب دلع جسر سلاحف العاب دلع نفق خطير العاب دلع مكعبات متشابهة العاب دلع جمع الارقام بسرعة العاب دلع المهمة في الانقاذ العاب دلع بوش يسقط من الاعلى العاب دلع الشطرنج العاب دلع لعبة من وسط المدينة العاب دلع الترتيب في المواسير العاب دلع الفأر صياد الجبن العاب دلع تمارين بوش الرياضية العاب دلع لعبة جسور صعبة العاب دلع مهارة في ركن السيارة العاب دلع لعبة ثعبان نوكيا العاب دلع حياة السمكة العاب دلع لعبة رجال الثلج العاب دلع بطريق و صناديق العاب دلع خطة الخروج العاب دلع اضرب في الكرة العاب دلع باك مان الرائعة العاب دلع الخروج من الممر العاب دلع كابوم قنابل العاب دلع شيكرز لعبة الأذكياء العاب دلع ثعبان في الحديقة العاب دلع ارسم طريقتك العاب دلع الكلاكيس لعبة التركيز العاب دلع السداسية هكساجون العاب دلع غميضة استغماية حلوة العاب دلع كاسحة الالغام العاب دلع تكوين الاشكال الهندسية العاب دلع الكلب و الغنم العاب دلع سوبرمان العاب دلع سودوكو ترتيب الارقام العاب دلع لعبة الماوس المتخفي العاب دلع لعبة اكس او x o العاب دلع ترتيب الارقام العاب دلع قيام جلوس العاب دلع رجل العنكبوت العاب دلع المربعات العاب دلع الكرة و المغناطيسية العاب دلع لعبة اطفئها العاب دلع كونكت فور 4 العاب دلع البالون المجنون العاب دلع لاتسقطي العاب دلع خليج السلاحف العاب دلع اسلحة الدمار العاب دلع الكرة الموسيقية العاب دلع السحلول الكسول العاب دلع بيت الرعب العاب دلع اصفع القرد العاب دلع نهايات غير سعيدة العاب دلع ورقات سبعة العاب دلع نيازك العاب دلع سباحة الشرغوف العاب دلع سودوكو الارقام العاب دلع لعبة ذكاء العاب دلع اضغط ادفع اسحب العاب دلع ولايات امريكا العاب دلع هانجارو تكوين الكلمات العاب دلع مانو مانو العاب دلع سوبر ماريو الاطفال العاب دلع لعبة تلوين الحمار الوحشي العاب دلع السيد قشطة و القنابل العاب دلع متعة الكرة و البلوكات العاب دلع مقبرة الفراعنة العاب دلع منشة الذباب الصينية العاب دلع حارس الغابة العاب دلع اختيار التوازن العاب دلع حرب كنتاكي العاب دلع ابوعطية في محطة بنزين العاب دلع الثعبان و الارنب العاب دلع الحلقة و السلك العاب دلع حروف طائرة العاب دلع بوش في مهنتة الجديدة العاب دلع صياد التفاح العاب دلع الآلى المدمر العاب دلع تلوين عدنان ولينا العاب دلع تحميل لعبة الشوربة الحروف العاب دلع مبيد النمل العاب دلع فارس القرية العاب دلع لغز الدائرة و المربع العاب دلع لعبة سونيك الجديدة العاب دلع همبرجر العاب دلع الآيس كريم العاب دلع لعبة قاتل الرادار العاب دلع الكرة والفواكه العاب دلع مغامرة القصر العاب دلع تويتي صديق البيئة العاب دلع غارفيلد المشاكس العاب دلع كافح التدخين العاب دلع الرزمة المتفجرة العاب دلع صراع البقاء العاب دلع الحديقة الموسيقية العاب دلع الهدف الصعب العاب دلع لعبة درجات خطيرة العاب دلع tom and jerry توم وجيري العاب دلع جنون البقر العاب دلع الاذرع الحديدية العاب دلع فتيات القوة العاب دلع قتال الشوارع 2 العاب دلع الضفدع و الشارع العاب دلع صيد البط العاب دلع توم وجيري العاب دلع اضرب بوش بالحذاء العاب دلع لعبة تصادم السيارات 2009 العاب دلع العاب سيارات الهمر 2009 العاب دلع لعبة سكوبي دوبي دوو الجديدة العاب دلع عادل امام و لعبة الكورة و الكرة العاب دلع SONIC PUZZLE GAMES العاب دلع لعبة سونك الرائع العاب دلع العاب سونك x العاب دلع لعبة الكابتن ماجد العاب دلع لعبة دورى ابطال اوروبا العاب دلع لعبة يورو 2009 The Campions 2 Euro 08 العاب دلع يوميات مدمن نت على الماسنجر العاب دلع لعبة تركيب السيارات الاودى العاب دلع 3D Rally Racing العاب دلع لعبة الاختلاف بين الصورتين العاب دلع سباق القتال النارى العاب دلع نوافذ نظيفة العاب دلع لعبة مقاتل الشوارع العاب دلع العاب بات مان الجديدة العاب دلع لعبة طرزان الجديدة العاب دلع لعبة المحقق كونان العاب دلع لعبة عصابة البنك العاب دلع لعبة قراصنة الكاريبى في البحار العاب دلع سباق ملاهى الروليت العاب دلع لعبة تيمون و بومبا العاب دلع مدرسة الامبراطور الجديدة العاب دلع لعبة ستروبري شورت كيك العاب دلع اللص 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