Possible Kidney Damage - I Really Need Reassurance!!

[hamhoos]

What I think I need right now are stories about your cats and lilies/kidney failure.

Last Thursday was my birthday. I received a bouquet from a friend which they placed on my kitchen counter. When I went to go look at it, I realized it was lilies and immediately went to throw it out. One of my cats I know came into contact with it. I took her to the emergency vet immediately and she's totally fine now. No damage done at all. She's home after one day at the vet.

My other two cats never came into direct contact with the bouquet. The kitchen door was closed the whole time until I went in there. When I went to toss it, I noticed the bouquet did leak water on the floor. I wiped it up ASAP. But of course I was paranoid that one of my other cats might have got it on their paws and licked themselves, so I called pet poison hotline, and they agreed, and I took them to the regular vet. I also gave them a shower immediately after. Both the hotline and my vet assured me that the risk is very low. They both did recommend a blood panel so they sent it off on Friday and said if there's anything urgent in the results they would call me on Saturday. They never called me on Saturday so I assumed everything was ok. They're closed Sunday and so I took them in for a followup blood test Monday morning (today).

We get in and the vet tells me that for one of the cats, the SDMA (2 above) and UREA (2.5) levels were outside of the normal range. For one cat, IDEXX SDMA was 15 when the normal values are 0 -14 ug/dL. The other cat is 16 IDEXX SDMA and 16 for the UREA (BUN) test which normal values range between 5.7 - 13.2 mmol/L.

The vet says this is concerning and was unexpected as they're less than two years old. She said it is in line with poisoning and ordered another set of tests. She said she would call me tonight or latest tomorrow morning. She said their urine is perfectly concentrated and has normal specific gravity though. And they have no other symptoms.

At this point I'm freaking out. If there was any indication they were in distress on Friday I would have taken them to the emergency vet ASAP and try to treat it. I'm just terrified that if their values were already high on Friday then they're be even higher now that it's been 3 freaking days.

What's your experience with this? Should I try to remain calm until I know for certain? If she doesn't call me tonight I'm tempted to rush them to the emergency vet. I would never forgive myself if anything happens to them.

 

[1 bruce 1]

I have little experience with this, but am I understanding correctly that the normal limits for IDEXX SDMA are 0-14, and one cat is 15 and one is 16? And the normal range for BUN is 13.2 at the highest and one is at 16?
I would remain calm but stay vigilant, as I am sure you will, to any behavior change. I guess I always thought a cat coming into contact with something toxic would show a reaction like throwing up, foaming at the mouth, not eating, etc.?
I think it's really odd that the cat that came into contact with the flower is fine but the two that did not are having higher than normal readings!

I'm unaware of information pertaining to IDEXX SDMA but I do know certain diets in dogs can lead to higher BUN readings. Our dogs have tested for higher readings (3-5 points higher than the highest of the normal range) and tested perfectly normal after a few weeks. Has their BUN been tested before, and if so was it high on the scale of being WNL (so there's a comparison?)

I understand your fear but if the cats are acting normally and are being playful, eating, doing things they normally do, etc., I would try not to stress out, but keep a good open communication with your vet, just in case!
Hopefully someone with more experience will add!

 

[hamhoos]

I have little experience with this, but am I understanding correctly that the normal limits for IDEXX SDMA are 0-14, and one cat is 15 and one is 16? And the normal range for BUN is 13.2 at the highest and one is at 16?
I would remain calm but stay vigilant, as I am sure you will, to any behavior change. I guess I always thought a cat coming into contact with something toxic would show a reaction like throwing up, foaming at the mouth, not eating, etc.?
I think it's really odd that the cat that came into contact with the flower is fine but the two that did not are having higher than normal readings!

I'm unaware of information pertaining to IDEXX SDMA but I do know certain diets in dogs can lead to higher BUN readings. Our dogs have tested for higher readings (3-5 points higher than the highest of the normal range) and tested perfectly normal after a few weeks. Has their BUN been tested before, and if so was it high on the scale of being WNL (so there's a comparison?)

I understand your fear but if the cats are acting normally and are being playful, eating, doing things they normally do, etc., I would try not to stress out, but keep a good open communication with your vet, just in case!
Hopefully someone with more experience will add!

Sorry if I was unclear, I am a bit frazzled lol. You're correct about the values. I'm positive that my two cats didn't come into direct contact with the lily plant. Only POSSIBLY the bouquet water, which would have been at most a few droplets. They are eating, drinking, playing normally. They literally have no symptoms of poisoning besides from these elevated test results. My vet even said that the SDMA test is fairly new and very sensitive. She said that two years ago, if I brought them in, she would have sent them home without a thought.

My male cat Kovu (with the high BUN and SDMA) is spayed but has never had his blood tested before. Tofu (who had a slightly high SDMA only) had a blood test when she was spayed at 8 months, and the vet told me the readings were normal so I don't have the actual test results.

Thank you so much for sharing about your dog. I was also thinking that the diet might account for Kovu's higher levels since he eats dry food every other day and Tofu is on a full wet diet. I asked my vet if it's possible that the values just fluctuated and happened to be higher that day, and she said it is possible but usually with SDMA that shouldn't change very much as it's a very early indicator of kidney disease. Overall, she said the high levels were concerning, but since their urine output is good, physical exam is good, general activity and mood are good, she told me to try not to worry as well. I'm just scared that the longer I wait the worse they could get

 

[1 bruce 1]

Sorry if I was unclear, I am a bit frazzled lol. You're correct about the values. I'm positive that my two cats didn't come into direct contact with the lily plant. Only POSSIBLY the bouquet water, which would have been at most a few droplets. They are eating, drinking, playing normally. They literally have no symptoms of poisoning besides from these elevated test results. My vet even said that the SDMA test is fairly new and very sensitive. She said that two years ago, if I brought them in, she would have sent them home without a thought.

My male cat Kovu (with the high BUN and SDMA) is spayed but has never had his blood tested before. Tofu (who had a slightly high SDMA only) had a blood test when she was spayed at 8 months, and the vet told me the readings were normal so I don't have the actual test results.

Thank you so much for sharing about your dog. I was also thinking that the diet might account for Kovu's higher levels since he eats dry food every other day and Tofu is on a full wet diet. I asked my vet if it's possible that the values just fluctuated and happened to be higher that day, and she said it is possible but usually with SDMA that shouldn't change very much as it's a very early indicator of kidney disease. Overall, she said the high levels were concerning, but since their urine output is good, physical exam is good, general activity and mood are good, she told me to try not to worry as well. I'm just scared that the longer I wait the worse they could get

Does Kovu like wet food too? It might be a good thing to feed a bit more of to maybe help the kidneys work.
How Helpful Is the New Kidney Test in Dogs and Cats? | petMD

^This article makes an interesting note that the only research and testing done on SDMA is sponsored (at least partially) by IDEXX. This is NOT an attempt to slam the test, nor any vet that uses it (I know I want a vet that stays up on the latest tests and procedures to detect problems early!) Again, I don't think this test sounds like a bad idea at all, but I usually keep it in the back of my mind that sometimes new stuff isn't tried and true? I hope someone else who has experience with this test will join in with their two cents...

But yes, I do get your concern and I would keep on top of it! I'm glad they have good activity, mood, and appetite, etc. I would find that encouraging.

 

[Margret]

I have experience with kidney failure in an elderly cat, and that was nearly 30 years ago when they didn't give the owners actual test results. With possible kidney damage from poisoning my guess is that the readings would decrease back toward normal over time, not increase. Kidneys can heal, at least somewhat, and even if there's permanent kidney damage there is no reason that I know of to expect it to progress.

If the lilies themselves were undamaged (no bite marks) it's not at all surprising that the cat who came into contact with the lilies is fine. The only cats who've been affected actually ingested something; this is what I would expect.

I'm glad your vet is taking this seriously, but her comment that a year ago, without the SDMA test to back it up, she would have sent the cats home without a second thought means that the BUN numbers aren't high enough to be worrisome! That's important.

Blood tests in healthy young cats do not normally include any tests for kidney function; I had to specifically ask for that for Jasmine because I wanted a baseline against which to compare any future tests. This means that, no, it's unlikely that either cat has been tested previously.

My conclusions:

1. So far you've done everything right.
2. You have a good vet, who is well up on the current literature and tests and is diligent about giving your cats the best care possible. Congratulations.
3. Any damage that's been done appears to be minor.
4. It's way too soon to tell whether any permanent damage has been done, and it will probably be months before anyone can tell.
5. Even if there is permanent damage it's almost certain that you'll be able to manage it without too much difficulty.
6. Stress makes everything worse, both for you and for your cats. The more you worry about this the more stressed your cats will be. Therefore, worry is counterproductive. Please note: "worry" and "concern" are not synonyms. I'm not saying that you're wrong to be concerned - your concern is what led you to do everything right, and is the reason you'll be taking them back to the vet for further blood work when she tells you to. Worry, however, is counterproductive. It can only make things worse. For yourself, you should probably be getting some extra B vitamins, to help your body deal with this extra stress. And to help you ditch the worry, I recommend a YouTube search on "relaxing music," "meditation music," or "happiness music." If you find something that says "binaural beats" you have to listen to it with headphones for it to have the full value. I've also found this to be quite helpful:

Margret

 

[hamhoos]

I have experience with kidney failure in an elderly cat, and that was nearly 30 years ago when they didn't give the owners actual test results. With possible kidney damage from poisoning my guess is that the readings would decrease back toward normal over time, not increase. Kidneys can heal, at least somewhat, and even if there's permanent kidney damage there is no reason that I know of to expect it to progress.

If the lilies themselves were undamaged (no bite marks) it's not at all surprising that the cat who came into contact with the lilies is fine. The only cats who've been affected actually ingested something; this is what I would expect.

I'm glad your vet is taking this seriously, but her comment that a year ago, without the SDMA test to back it up, she would have sent the cats home without a second thought means that the BUN numbers aren't high enough to be worrisome! That's important.

Blood tests in healthy young cats do not normally include any tests for kidney function; I had to specifically ask for that for Jasmine because I wanted a baseline against which to compare any future tests. This means that, no, it's unlikely that either cat has been tested previously.

My conclusions:

1. So far you've done everything right.
2. You have a good vet, who is well up on the current literature and tests and is diligent about giving your cats the best care possible. Congratulations.
3. Any damage that's been done appears to be minor.
4. It's way too soon to tell whether any permanent damage has been done, and it will probably be months before anyone can tell.
5. Even if there is permanent damage it's almost certain that you'll be able to manage it without too much difficulty.
6. Stress makes everything worse, both for you and for your cats. The more you worry about this the more stressed your cats will be. Therefore, worry is counterproductive. Please note: "worry" and "concern" are not synonyms. I'm not saying that you're wrong to be concerned - your concern is what led you to do everything right, and is the reason you'll be taking them back to the vet for further blood work when she tells you to. Worry, however, is counterproductive. It can only make things worse. For yourself, you should probably be getting some extra B vitamins, to help your body deal with this extra stress. And to help you ditch the worry, I recommend a YouTube search on "relaxing music," "meditation music," or "happiness music." If you find something that says "binaural beats" you have to listen to it with headphones for it to have the full value. I've also found this to be quite helpful:

Margret

Thanks Margaret. I really appreciate your insight, reading your comment really did help me calm down. I just spent the last hour playing with the cats, they seem totally happy and healthy. I'm hoping for the best, and I will give an update when I know more.

 

[1 bruce 1]

Thanks Margaret. I really appreciate your insight, reading your comment really did help me calm down. I just spent the last hour playing with the cats, they seem totally happy and healthy. I'm hoping for the best, and I will give an update when I know more.

Please do! I'm glad they're playing and acting silly!

And for Margret, that was a lovely audio/video. Thank you for the share!

 

[Margret]

And for Margret, that was a lovely audio/video. Thank you for the share!

You're welcome. I bought this on audio tape when it first came out, and was gratified and astonished to find it on YouTube. My old tape disappeared long ago, but now I have it again since I was able to download from YouTube. When I want to meditate I just run this on automatic repeat. Ah. So relaxing!

1 bruce 1 is correct; increasing fluid intake can help the kidneys, and the easiest way to do that for cats is feeding them wet food, maybe even adding a bit of water to it.

Margret

 

[1 bruce 1]

You're welcome. I bought this on audio tape when it first came out, and was gratified and astonished to find it on YouTube. My old tape disappeared long ago, but now I have it again since I was able to download from YouTube. When I want to meditate I just run this on automatic repeat. Ah. So relaxing!

1 bruce 1 is correct; increasing fluid intake can help the kidneys, and the easiest way to do that for cats is feeding them wet food, maybe even adding a bit of water to it.

Margret

We add water to grinds and our IBD/asthmatic gets water added as well as fish oil. Our cats seem to like water (if they don't drink it, they sit by the fountain and become fascinated by it), but I don't think we can offer too much water.

A few years ago we bought a CD inspired by Native Americans and flutes, and the entire thing was accompanied by wolves. What a relaxing listen!! <3

 

[Margret]

Maybe we need a new thread in the lounge to discuss music? Unfortunately, I don't have time to start it up tonight.

I have several lovely CDs featuring R. Carlos Nakai, a Native American Flautist; he's a marvelous player. None with wolves, though.

Margret

 

[hamhoos]

I have 3 cats, Tofu eats all wet food and Kovu and Mila only started dry food once a day within the last month. They used to all eat wet for the last two years but it became unsustainable for me to feed them good quality wet food every meal They're very picky and stopped eating a lot of their wet food rotation, so I had to improvise. They pretty much only like Nutro max chicken supreme.

 

[1 bruce 1]

I have 3 cats, Tofu eats all wet food and Kovu and Mila only started dry food once a day within the last month. They used to all eat wet for the last two years but it became unsustainable for me to feed them good quality wet food every meal They're very picky and stopped eating a lot of their wet food rotation, so I had to improvise. They pretty much only like Nutro max chicken supreme.

Silly kittens! They can be quite picky, but I think it's for a good reason!

I feed my cats raw, but I get feeding cats and that they develop a preference.
One of my boys refuses certain foods and a few others decided they didn't like the bison I was offering as a supplemental ten-buck-a-pound treat. Brats, LOL!
I wonder if they would turn onto "lesser quality" food? It sounds ridiculously stupid, but when our raw fed cats had a URI (upper respiratory infection) run through them, they ALL got it and a poor sense of smell = raw food was snubbed, but cheap, stinky canned food wasn't.
Our raw fed cats are former kibble lovers and when they were all sick, they were given cheap canned food (fancy feast and friskies) a few times a day. We also left dry food (Natural Balance; it's the only dry food our IBD boy can handle) out 24 hours a day.
The cats ate this food. It stank, but sometimes stinky food works!
If you're not nuts about feeding this brand, they may be OK eating a rotation, or a combo. (When the cats started getting better from their URI, we mixed FF or Friskies in with cooked meat, then raw meat, etc.)
I understand wet food can be cost prohibitive, totally get that.
Our IBD cat eats a mid-grade wet food in rotation with a higher quality wet food and a cooked diet. We only do this because he dislikes anything non-poultry based (our cooked diet of beef and veg and elk and veg went to our dogs, ugh, BRAT lol) and high quality canned food seems to be less, uh, "smelly" than mid-grade. He's eating a combo of cheap Fancy Feast, not as cheap Wellness, and easy to make cooked chicken, steamed vegetable puree, and pumpkin mix we make at home with a few supplements.

Who ever said cats were low maintenance and "easy"? I worry about the cats more than the dogs. The dogs eat anything! =D

 

[Margret]

Even low quality wet food will help get extra moisture into them, and right now that's what they really need. Worry about the quality of their diet once the emergency is past.

Margret

 

[hamhoos]

Silly kittens! They can be quite picky, but I think it's for a good reason!

I feed my cats raw, but I get feeding cats and that they develop a preference.
One of my boys refuses certain foods and a few others decided they didn't like the bison I was offering as a supplemental ten-buck-a-pound treat. Brats, LOL!
I wonder if they would turn onto "lesser quality" food? It sounds ridiculously stupid, but when our raw fed cats had a URI (upper respiratory infection) run through them, they ALL got it and a poor sense of smell = raw food was snubbed, but cheap, stinky canned food wasn't.
Our raw fed cats are former kibble lovers and when they were all sick, they were given cheap canned food (fancy feast and friskies) a few times a day. We also left dry food (Natural Balance; it's the only dry food our IBD boy can handle) out 24 hours a day.
The cats ate this food. It stank, but sometimes stinky food works!
If you're not nuts about feeding this brand, they may be OK eating a rotation, or a combo. (When the cats started getting better from their URI, we mixed FF or Friskies in with cooked meat, then raw meat, etc.)
I understand wet food can be cost prohibitive, totally get that.
Our IBD cat eats a mid-grade wet food in rotation with a higher quality wet food and a cooked diet. We only do this because he dislikes anything non-poultry based (our cooked diet of beef and veg and elk and veg went to our dogs, ugh, BRAT lol) and high quality canned food seems to be less, uh, "smelly" than mid-grade. He's eating a combo of cheap Fancy Feast, not as cheap Wellness, and easy to make cooked chicken, steamed vegetable puree, and pumpkin mix we make at home with a few supplements.

Who ever said cats were low maintenance and "easy"? I worry about the cats more than the dogs. The dogs eat anything! =D

I totally get it. I did a lot of research on food before I got them and tried to get them on raw - but they just wouldn't take. I've tried 80% of the wet foods out here (and I'm in Canada so I can't get some of the stuff that people recommend in the states) before I turned to dry food. I kept costs down before by giving them fancy feast pates which they loved for a long time, then out of the blue within the last 6 months they rejected it and will starve rather than each it. Sigh.

Until we are out of this scare I am strictly giving them their nutro max chicken and primal freeze dried raw turkey. Those are the only things they'll eat besides the orijen. They're so picky it's infuriating!! I bought so many expensive brands before and they just turn their nose up at it. I turned to the orijen dry food as a last resort lol, 2/3 will eat it so I leave it out when I'm at work.

 

[hamhoos]

Vet called me this morning.
Cat#1 who had high BUN and SDM is now in the normal range for SDM. The vet said she isn't concerned about him anymore, he's pretty much out of the woods.

Cat#2 who had slightly elevated SDM is now at a 20 (!!!!) when she was at a 15 before (0-14 normal range). All other indicators of kidney stress came back normal. She is eating and playing and drinking. We will go back in a few days (Thursday) for another round of tests. The vet and I are so confused because we were sure she wasn't anywhere near the bouquet at all. I vacuumed and wiped the floors twice already. I'm not sure what's happening, but she said since all the other indicators are normal hospitalization isn't necessary. I'm really scared though and I feel like I failed my kitty and should have taken them all to the ER even though I was confident two of them were fine. Really hating myself.

 

[1 bruce 1]

Vet called me this morning.
Cat#1 who had high BUN and SDM is now in the normal range for SDM. The vet said she isn't concerned about him anymore, he's pretty much out of the woods.

Cat#2 who had slightly elevated SDM is now at a 20 (!!!!) when she was at a 15 before (0-14 normal range). All other indicators of kidney stress came back normal. She is eating and playing and drinking. We will go back in a few days (Thursday) for another round of tests. The vet and I are so confused because we were sure she wasn't anywhere near the bouquet at all. I vacuumed and wiped the floors twice already. I'm not sure what's happening, but she said since all the other indicators are normal hospitalization isn't necessary. I'm really scared though and I feel like I failed my kitty and should have taken them all to the ER even though I was confident two of them were fine. Really hating myself.

First off, I'm glad the one kitty is doing much better!!!!!
Could this be a genetic link? Like I said before, I have no experience with SDM and all that stuff.
The indicators of kidney stress (= normal)...what does that mean exactly? I'm not up to speed on this kidney stuff!
Don't hate yourself and don't feel you've failed anything or anyone. If hospitalization isn't necessary, I'd watch it but try not to stress!
If she wasn't near the bouquet at all and you've vacuumed and mopped twice already, I would think this is a fluke, is genetics, etc. I'm assuming there are no recent surgeries?

 

[1 bruce 1]

This is really a shot in the dark and kind of "out there", but I'll share because why not...
After a serious illness in which I thought our dog wouldn't live (I mentioned earlier), this dogs kidney and liver values went all wonky, everywhere, the liver enzymes were all over the place and his kidney levels were fluctuating like mad.
I am no vet and even if I were diagnostics over the internet is stuff of the insane, but in this dogs case we always have wondered if the liver and kidneys weren't working hard to get rid of whatever caused him to become ill in the first place.
Cats are harder, in that the most stoic or pain tolerant dog looks like a complete baby-wimp next to the worlds wimpiest cat. Our critically ill cats in the past show no signs until they're, unfortunately, past the point of treatment. Our toughest dogs (with the exception of a few) are tough enough but show subtle signs of not feeling well. (One of our past beloved dogs was famous for injuring himself to the point of blood, open wounds, skin hanging off exposing muscle, etc., and showing no signs....but would scream out in melodramatic agony if we bumped a tail or stepped on a toe, etc. Crazy!!!!!!)

I have limited experience (thankfully for me and me alone) with kidney problems. I do know that the kidneys do a lot of work in ridding our pets body of "old crap" and work hard, and are pretty sensitive organs (compared to, say, the liver that's tough as heck and keeps on chugging even when it's pretty well shot), and I've always wondered if monitoring kidney values isn't a good thing (in that we can keep track and compare) or a bad thing (in that, if the levels go up, we flip out and start going paranoid about everything our pet comes into contact with.)

I'd keep an open communication with your vet. You seem extremely willing to spare no expense with these guys and I'd continue this communication and possible testing for awhile just to be safe, but like Margret said, it's WAY too early to know if there's any "real" damage or not. This could be a complete fluke, but you're very smart to keep checking these levels and continuing to make adjustments if and when necessary!

 

[hamhoos]

This is really a shot in the dark and kind of "out there", but I'll share because why not...
After a serious illness in which I thought our dog wouldn't live (I mentioned earlier), this dogs kidney and liver values went all wonky, everywhere, the liver enzymes were all over the place and his kidney levels were fluctuating like mad.
I am no vet and even if I were diagnostics over the internet is stuff of the insane, but in this dogs case we always have wondered if the liver and kidneys weren't working hard to get rid of whatever caused him to become ill in the first place.
Cats are harder, in that the most stoic or pain tolerant dog looks like a complete baby-wimp next to the worlds wimpiest cat. Our critically ill cats in the past show no signs until they're, unfortunately, past the point of treatment. Our toughest dogs (with the exception of a few) are tough enough but show subtle signs of not feeling well. (One of our past beloved dogs was famous for injuring himself to the point of blood, open wounds, skin hanging off exposing muscle, etc., and showing no signs....but would scream out in melodramatic agony if we bumped a tail or stepped on a toe, etc. Crazy!!!!!!)

I have limited experience (thankfully for me and me alone) with kidney problems. I do know that the kidneys do a lot of work in ridding our pets body of "old crap" and work hard, and are pretty sensitive organs (compared to, say, the liver that's tough as heck and keeps on chugging even when it's pretty well shot), and I've always wondered if monitoring kidney values isn't a good thing (in that we can keep track and compare) or a bad thing (in that, if the levels go up, we flip out and start going paranoid about everything our pet comes into contact with.)

I'd keep an open communication with your vet. You seem extremely willing to spare no expense with these guys and I'd continue this communication and possible testing for awhile just to be safe, but like Margret said, it's WAY too early to know if there's any "real" damage or not. This could be a complete fluke, but you're very smart to keep checking these levels and continuing to make adjustments if and when necessary!

I'm honestly hoping it's a fluke. It just seems so odd. She was no where near the flowers. I wonder if maybe this is completely unrelated to the flowers? Who knows. The vet said all the other indicators of kidney stress were within the normal realm,the SDM is just the one thing that is making us nervous. They are clinically fine, her urine was concentrated according to the vet and and my cats are acting totally normal. But you're right about cats being stoic too, which is why I'm trying to err on the safe with repeated testing to make sure they're happy and healthy. I am in a position where I can pay for their medical care (have insurance) so I just want to be sure.

I honestly am not very confident in all this testing either - it really is just causing unnecessary stress. My vet said if they didn't have this test then she wouldn't have been particularly worried. It's just extremely strange that it would jump so high without any other kidney health measurements being out of range.

 

[hamhoos]

First off, I'm glad the one kitty is doing much better!!!!!
Could this be a genetic link? Like I said before, I have no experience with SDM and all that stuff.
The indicators of kidney stress (= normal)...what does that mean exactly? I'm not up to speed on this kidney stuff!
Don't hate yourself and don't feel you've failed anything or anyone. If hospitalization isn't necessary, I'd watch it but try not to stress!
If she wasn't near the bouquet at all and you've vacuumed and mopped twice already, I would think this is a fluke, is genetics, etc. I'm assuming there are no recent surgeries?

Exactly, hoping it's a fluke. She's had no recent surgeries. Other than this she's never had any issues whatsoever. I've had her for two years and she's been to yearly checkups and they all were fine. But the bloodwork is a first since they don't cover that in checkups.