PHYSICAL EXAMINATION OF DOGS AND CATS
*Below is a FANTASTIC guideline, modified from the RAVS notes – notes pertaining to Nicaragua are added*
The physical examination is the most important practical skill for a clinician to develop. It can also be one of the most challenging. A good physical examination can detect minor abnormalities before they become serious problems as well as identify major organ dysfunction without extensive and expensive medical tests.
Careful pre-operative assessment is necessary for selection of appropriate anesthetic protocols. Many surgical and anesthetic complications are a result of pre-existing clinical conditions, most of which are associated with abnormalities that could have been identified by a skilled examiner and thorough exam. A good physical exam can point to many conditions and cause a change in anesthetic or surgical technique, monitoring, and support.
Learning to trust your physical exam skills can be challenging as technologic advances and the increasing availability of diagnostic equipment can lead to a reliance on these tools. It is important to remember that you may not always have the ‘bells and whistles’, whether due to availability or client resources.
While a thorough examination is completed at intake before an animal is vaccinated or admitted for surgery, every interaction you have with an animal should be used as an opportunity to assess its physical condition as parameters may change. With experience, this can be done quickly and easily.
Be consistent and thorough
Examine the animal from head to tail, or systematically, and be sure to check everything in between. Develop a consistent method and use it every time. Avoid the temptation to immediately focus on the most obvious complaint. The dog presenting for limping might also have a life-threatening head injury. Perform a complete exam regardless of the presenting complaint.
Write it down
Record ALL results (both positive and negative) of your examination. Normal findings can be abbreviated NSF (no significant findings) or WNL (within normal limits), but should be indicated for each part examined, however it is preferable to specify exactly what parameters you have evaluated and deemed normal. Just as important as recoding all information, it’s equally important to note any systems or areas you DO NOT examine, and what the reason may be (aggression, time limit, etc.) Your colleagues will be using this information to evaluate and track the patient’s condition. It is crucial that exam results are thorough and legible. Remember to sign the exam record so that the next person working with the animal can ask follow-up questions if necessary.
Don’t forget to back up and examine the animal from a distance. Note how the animal walks, sits, breathes, etc.
It can be extremely difficult to safely restrain and adequately examine an animal at the same time. Be sure to have an assistant restrain it for a thorough exam. Remember, however, that sometimes the best restraint is light or moderate restraint, which decreases the amount of stress on the animal. If at any time you feel the animal may be aggressive, ask the owner to put a muzzle on it (we provide them in wellness), grab a more experienced student/veterinarian, or simply say the animal is too aggressive to be examined.
Remember to socialize yourself with the animal before abruptly starting the examination. Taking a few moments to develop a relationship with the animal will save time and stress later.
Learn from your experience
The more animals you examine, the more skilled you will become. Make a commitment to yourself to learn something new from every animal you examine. If you have NAY questions as to whether a finding is abnormal or how to interpret an exam finding, consult a supervising veterinarian.
PHYSICAL EXAM ALERTS
When examining potential surgery patients, keep in mind that you are not only determining their general condition, but evaluating them for anesthetic and surgical risk factors as well. ANY physical exam finding that might impact anesthesia or surgery MUST be evaluated by a designated veterinarian or lead technician BEFORE the animal is admitted for surgery so that any potential risks can be discussed with the client before the animal is admitted. We always reserve the right to decline surgery on any animal is we believe that there may be risk factors that cannot be adequately evaluated in the field.
The physical exam record includes an area for ‘surgical or anesthetic risk factors’, which may include age (pediatric or geriatric), physical condition, reproductive status (in heat, pregnant), or specific clinical findings. These are recorded to help you in evaluating whether surgery is appropriate for the patient and to provide additional information to anesthetists or others who may work with the animal later.
Abbreviations: some commonly used medical abbreviations to describe physical exam findings include:
TPR: temperature, pulse and respiratory rate
BAR: bright, alert and responsive (responsive animal who is aware of their surroundings – not acting sick)
QAR: quiet, alert and responsive (still aware, but not as happy/active)
GA: general appearance
EENT: eyes, ears, nose, throat (and mouth)
ABD: abdomen (gastrotintestinal / genitourinary)
PLN: peripheral lymph nodes
BCS: Body Condition Score (1-5 or 1-9)
OS: left eye
OD: right eye
OU: both eyes
AS: left ear
AD: left ear
AU: both ears
v/d: vomiting / diarrhea
c/s: coughing / sneezing
Helpful hint: The abbreviation “S” for left and “D” for right date back to the days when left handed people were considered Sinister while right handed people were admired for their Dexterity. The “U” can be thought of as standing for Universal.
PHYSICAL EXAM PROCESS
1) Signalment / History
2) General Appearance / Initial Observations
3) Vital Signs
4) Physical Exam (Systems Approach or Head to Toe)
5) Surgical / Anesthetic Risk Assessment
- Complete description of the animal
- Species, breed, age, sex, reproductive status, other distinguishing characteristic
- Always double-check client reported information (sex, age, etc.) – especially with the language barrier!
- Keep this information in mind as you examine the animal and make clinical judgments
- Includes origin, environment, diet, medical history, breeding history, vaccination status and current medication – remember, not all of these will be applicable in Nicaragua...
Important note on patient histories
Many of the animals that we treat in the field will be presented by caretakers who do not have extensive information on the animal’s background or even daily observations. The animals may live outdoors or roam free much of the time, preventing the caretaker from making close observations. In order to obtain a useful history, it is important to phrase questions in such a way as to obtain the most accurate information possible. Asking, “Has the animal had diarrhea?” may prompt the client to answer “No”, as they have not observed the animal to have diarrhea. Instead, asking “Have you seen the animal’s stool recently?” will allow you to determine whether the client can provide an accurate description, or whether you may need to look to other physical signs for the information
GENERAL APPEARANCE / INITIAL OBSERVATIONS (GA)
- General appearance – observe animal from a distance and up close before any handling
- Symmetry – note any asymmetry; note any difference in size or shape of extremities
- Body condition / State of nutrition
- Assign appropriate Body Condition Score (BCS), indicating the range of scale used (ex: 4/9, 2/5)
- In general, the animal is too thin if its ribs are easily seen, normal if they are readily felt without a layer of fat lying over them and obese if it is difficult to feel them at all – most dogs, cats, and horses on Ometépe will be in the 2-4 range; cattle tend to be in better condition
- Mentation / Level of consciousness – attentiveness / reaction to environment
- Alert and responsive – Depressed – Uncontrolled hyper-excitability – Stupor – Coma
- Eg: Normal healthy animal’s mentation is often bright, alert and responsive or “BAR”. A healthy puppy may be described as “active and playful”, while a sick puppy may be “moderately depressed and inactive”
- Posture and gait – watch the animal walk if possible
- Look for limping, incoordination or unsteadiness or abnormal limb placement
- Hydration status
- Often expressed as percentage of body weight (0-15%), which can be fairly subjective.
- For our purposes hydration is reported as either ‘adequate’, ‘marginal’, or ‘inadequate’
- Loss of the elasticity of the skin (skin turgor) is first sign of dehydration. Check the skin of the upper eyelid and the neck for tending
- Signs of dehydration are more difficult to see in some animals. Skin may “tent” more in emaciated animals and certain breeds. Obese animals may not have skin tenting even when dehydrated.
VITAL SIGNS – Evaluated in relation to presenting complaint, history and current health status
*** Normals are included in this packet, and will be provided in the wellness clinic area ***
- Body weight
- Weigh all animals by stepping on scale with animal, then subtracting your own weight
- INDICATE KG OR LBS WHEN RECORDING WEIGHTS – preferably record in kgs
- Most drugs are dosed in mg/kg
- Temperature: via rectal thermometer
- Examine rectal area for signs of diarrhea, parasites or other abnormality
- Most animals will resist having their temperature taken. Complete the rest of the exam before obtaining a temperature to avoid agitating the animal and making examination more difficult.
- Do not struggle with an aggressive animal to obtain a temperature. If having difficulty taking an animal’s temperature, consult a veterinarian.
- Heart / Pulse rate
- Evaluate pulse at femoral artery
- Evaluate pulse rate, strength and quality (eg: strong, weak, thready, bounding)
- Compare both sides and heart rate: pulse rate < heart rate = pulse deficit ® consult!!
- Respiratory rate and character
- RR determined visually or by auscultation. Count either inspirations or expirations.
- Perfusion Indicators
- Mucous membrane color (MM) – provides indication of blood flow to peripheral tissues
- Any abnormal mucous membrane color should be further assessed
- Capillary refill time (CRT) – reflects perfusion of peripheral tissue
- Press on an area of mucous membrane. The gums will “blanch” white as they are pressed and become pink again when pressure is released.
- Normal: <2 seconds
- Prolonged CRT (>2 seconds) may indicated compromised circulation due to cold, shock, cardiovascular disease, anemia or other causes and must be further evaluated before admitting for surgery
SYSTEMS OR HEAD TO TOE EXAM
Head and Neck (EENT/Mouth)
- Compare both sides of face and head for symmetry
- Assess eyes for size, position, discharge – lids, conjunctiva, sclera, pupil, cornea, lens
- Note discharge, inflammation, redness, uneven/abnormal pupil size, corneal clouding, squinting
- Evaluate nose and nares for symmetry, conformation, and evidence of discharge
- Classify discharge: serous, purulent, hemorrhagic, mucoid, or mucopurulent
- Examine oral cavity – lips, mucous membranes, teeth, hard and soft palate, tongue, pharynx, tonsils
- Evaluate carriage and position of ears, thickness/malleability of pinnae and cleanliness of ear canals
- Palpate the submandibular lymph nodes
- Palpate salivary glands (normally palpable), larynx and thyroid gland (not normally palpable)
- Palpate the trachea – note coughing, swelling (tracheal squeeze should elicit a normal cough 1-2x)
Trunk and Limbs (INTEG/MS/PLN)
- Inspect body for symmetry, masses, tenderness, etc.
- Palpate each limb and joint: Note abnormalities in angulations, deformities, swelling, bleeding, body protrusions, obvious fractures or joint luxations, range of motion, atrophy, knuckling, creptius, etc.
- Assess all limbs in weight-bearing and non-weight-bearing positions
- Note the condition of the feet, nails or hooves
- Evaluate muscle mass and tone
- Examine skin and haircoat for alopecia, masses, parasites, dryness, excessive oil, matting, etc.
- Include identification of ectoparasites (fleas, ticks, lice)
- Palpate pelvic region for conformation and symmetry
- Palpate vertebral column to assess for deviation and pain
- Palpate peripheral lymph nodes (PLN): submandibular, prescapular, axillary, inguinal and popliteal
- Normal lymph nodes should be firm, and freely movable. Enlarged or asymmetric lymph nodes may indicate a local or systemic infection, allergy or neoplastic disease
- Normally palpable: submandibular, prescapular, popliteal, inguinal (prescapular and inguinal can be difficult to locate in small or overweight animals). Not normally palpable: axillary
- Observe and palpate the thorax for conformation, symmetry, masses, etc.
- Cardiac auscultation (CV)
- Palpate the area between the 4th and 6th intercostal spaces on both sides of the thorax for the point of maximum intensity (PMI) of the heartbeat and any cardiac thrills
- Evaluate heart rate (HR) and rhythm (count beats for 15 seconds and multiply by 4)
- Normal heart sounds:
- ‘Lub-Dub’ = Should be a short time gap between heart sounds
- S1 = loud, long, low pitch (closure of AV valves); S2 = closure of semilunar valves
- Abnormal heart sounds:
- Arrhythmia = eg: sinus arrhythmia, atrial fibrillation, heart block, premature ventricular contractions, gallop rhythm (three of four sounds instead of two)
- Sinus arrhythmia = slight increase in heart rate during inspiration and decrease with expiration. Normal finding. More common in the dog than cat
- Prolonged series of audible vibrations during normally silent part of cardiac cycle
- Often heard as a soft, swooshing sound
- Murmurs described on basis of location, timing, duration, character, and grade
- Muffled heart sounds may be a result of fluid in the chest – if having difficulty hearing the heartbeat do not assume it is just you – it never hurts to get a second opinion
- Auscult the heart in multiple locations on both the right and left sides of the chest. A heart murmur or other abnormality may go undetected unless each valve is ausculted independently.
- Locations to auscult specific heart valves (Remember, PAM-T):
- Left 4th-6th (PMI) intercostal space just above the sternal border = mitral valve
- Left 2nd-4th intercostal space above sternal border = pulmonic valve
- Left 3rd-5th intercostal space at mid thorax = aortic valve
- Right 3rd-5th intercostal space at mid thorax = tricuspid valve
- While we likely can’t fix anatomical heart abnormalities in Nicaraguan animals, those abnormalities may influence them under anesthesia and in surgery
- Respiratory auscultation (RESP)
- Listen for noisy breathing at mouth and nares without stethoscope, then auscult at least four different areas of the chest, including right and left ventral and right and left dorsal lung fields.
- Respiratory Rate (RR) – assess visually or auscult and count breaths per minute
- Depth / Effort – watch degree of chest movement (normal, shallow, deep)
- Character - note sounds and any difficulty on inspiration and/or expiration
- Normal respiratory sounds: vesicular / bronchial (soft, brezy/rustling sounds)
- Abnormal lung sounds:
- ‘Wheezes’ (continuous high pitched hissing heard more often on expiration) – occur with small airway diseases such as asthma
- ‘Rales/rackles’ (course to fine – discontinuous, nonmusical, brief sounds heard more commonly on inspiration) – may be heard when fluid in the lungs
- ‘Rhonchi’ (musical sounds – low or high pitched)
- ‘Dull’ lung sounds may indicate pneumonia, or consolidation
- Absence of breath sounds may indicate pleural space disease (pleural effusion) or space-occupying lesions
- Changes may be associated with location of respiratory system disease
- Loud breathing = large airway disease (nasal passages, trachea, larynx/pharynx)
- Inspiratory noise or difficulty = extra thoracic airway disease (esp. the larynx)
- Expiratory noise of difficulty = intrathoracic tracheal disease
- Rapid/shallow breathing = pleural space disease (fluid or air)
- Difficulty breathing on both inspiration and expiration = lung disease
- Signs of respiratory distress (dyspnea) will change as disease progress
- First signs usually change in respiratory rate.
- Next a change in respiratory rhythm and character (depth).
- Posturing is a very late sign of respiratory disease: may be standing or sitting with back arched, neck extended, and elbows out and will be reluctant to lie down.
- Other signs include exaggerated chest or abdominal movements on inspiration, open-mouth breathing and flared nostrils. In extreme cases the animal may become cyanotic.
- Inspect for distention, deformity, displacement, symmetry, and bruising
- Auscultate abdomen to detect intestinal hypermotility or hypomotility
- Abdominal palpation
- Using 1 or 2 hands, begin at the spine and move ventrally, allowing the abdominal viscera to slip through the fingers. Repeat throughout abdomen, noting organ size and location and the presence of, fluid, gas, fetuses, masses or feces. Note any pain or guarding of the abdomen.
- General identifications:
- Cranial abdomen – stomach, caudal border of liver, spleen, area of pancreas, small intestine loops
- Mid-abdomen – spleen, kidneys, small intestine
- Caudal abdomen – urinary bladder, prostate, uterus, colon, small intestine
- Notes on Specific Species:
- Dogs: caudal pole of left kidney
- Cats: spleen is very small, both kidneys
External Genitalia and Perineum
- Always verify sex and reproductive status – don’t assume client has provided accurate info
- Inspect perianal area for hair mats, hernias, feces, masses and evidence of discharge
- In dogs – palpate for impacted or abscessed anal sacs
- Inspect prepuce and penis – noting any discharge, inflammation, tumors (TVT)
- Expose penis and look for masses (TVT) and evidence of trauma, note any color abnormalities
- If intact – inspect both testicles for symmetry, size, location (both descended) and conformation
- Palpate and visually assess mammary glands for tumors, cysts, swelling, heat, or discharge
- Inspect vulva for size, inflammation, discharge (blood, pus), polyps, tumors (TVT), or structural defects
Note – External Parasites: Evidence of parasitism should be recorded during the physical exam in association with the relevant body system, as well as in the provided area below the systems chart.
No abnormalities seen – skin immediately returns to normal position after tenting, CRT normal, eyes normal, mucous membranes pink and moist
Slight delay (2-4 seconds) in return of the skin to normal position, slight increase in CRT (2 sec), eyes slightly sunken in sockets, mucous membranes slightly dry or tacky
Obvious delay (5-10 seconds) in skin returning to normal position, increased CRT (2-2.5 seconds), eyes sunken in sockets, mucous membranes dry, slightly tacky
Skin remains tented (10-30 seconds), CRT increased dramatically (3+ seconds), eyes very sunken, dry mucous membranes, animal is depressed, may see signs of shock (cool extremities, rapid/weak pulse, tachycardia)
State of shock, death is probable
Assessing Mucous Membrane Color:
Adequate perfusion/oxygenation of peripheral tissues
Pale or White
Anemia, poor perfusion, vasoconstriction
Blood loss, shock, decreased peripheral blood flow
Increased perfusion, vasodilation
Early shock, sepsis, fever, systemic inflammatory response syndrome
Hepatic or biliary disorder and/or hemolysis
Acetaminophen toxicity in cats, intravascular hemolysis
Platelet disorder, DIC, coagulation factor deficiencies
Evaluating Heart Murmurs
Location: Usually the valve area over which the murmur is loudest = Aortic / Mitral / Tricuspid / Pulmonic
May also be described in relation to chest structure (eg: sternal border)
Timing: The part of the cardiac cycle during which the murmur is heard = Systole / Diastole / Continuous
Duration: Duration within cardiac cycle murmur is heard = Early systole / Holosystolic / Diastole
Character: The quality of the murmur
- Plateau or regurgitant type (same sound for the duration of the murmur)
- Descrescendo, crescendo, crescendo-decrescendo or ejection type (intensity changes throughout duration of murmur)
- Macinery (heart throughout systole and diastole)
- Decrescendo or blowing
Grade: Loudness. Subjective assessment, does not necessarily indicate degree of cardiac dysfunction
1/6 – Can only be heard in quiet room after several minutes of listening
2/6 – Can be heart immediately, but is very soft
3/6 – Low to moderately intense
4/6 – Loud, but without a palpable thrill
5/6 – Loud, with a palpable thrill
6/6 – Can be heard with the stethoscope slightly off the thoracic wall