Performing the Small Animal Physical Examination
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About the Author xiii
Preface xiv
Acknowledgments xv
Part One Performing the Feline Physical Examination 1
1 Setting the Stage: Feline-Friendly Practice 3
1.1 Challenges Faced in Feline Practice 3
1.2 The Emergence of Feline-Friendly Practice 4
1.3 Key Principles of Feline-Friendly Practice 4
1.4 The Role of Sound 8
1.5 The Role of Tactile Stimulation 8
1.6 The Role of Scent 8
1.7 The Role of Advance Preparation 9
1.8 Examination Room Etiquette: Accessing the Cat 10
1.9 Recognizing Body Language 12
1.10 Feline-Friendly Handling 16
1.11 Other Feline Handling Tools 20
2 Assessing the Big Picture: the Body, the Coat, and the Skin of the Cat 24
2.1 Forms of Identification 24
2.2 Body Condition Scoring 25
2.3 Assessing Hydration 29
2.4 Inspecting the Coat: First Impressions 30
2.5 Identifying Coat Colors and Coat Patterns 32
2.6 Assessing Coat Quality 34
2.7 Inspecting the Skin 40
3 Examining the Head of the Cat 52
3.1 Skull Shape and Facial Symmetry 52
3.2 The Eyes and Accessory Visual Structures 52
3.2.1 A Systematic Approach to the Eye Examination 52
3.2.2 Evaluating the Adnexa of the Eye 53
3.2.3 Evaluating the Globe 58
3.2.4 Evaluating the Sclera 60
3.2.5 Evaluating the Cornea 61
3.2.6 Evaluating the Iris 61
3.2.7 Evaluating the Pupils 62
3.2.8 Assessing Ocular Reflexes 62
3.2.9 Assessing the Anterior Chamber 64
3.2.10 Assessing the Lens 65
3.2.11 Introduction to Fundoscopy 66
3.2.12 Fundoscopy and Direct Ophthalmoscopy 67
3.2.13 Fundoscopy and Indirect Ophthalmoscopy 67
3.3 The Ears 68
3.4 The Nose 72
3.5 The Extra-Oral Examination 73
3.6 The Intra-Oral Examination 75
3.6.1 Assessing Mucous Membrane Color 75
3.6.2 Assessing Capillary Refill Time 76
3.6.3 Examining the Mucosa 76
3.6.4 Examining the Gingiva 78
3.6.5 Assessing the Dentition 78
3.6.6 Assessing the Occlusion 79
3.6.7 Assessing for Calculus 81
3.6.8 Opening the Mouth 81
3.6.9 Examining the Tongue 82
3.6.10 Assessing for Periodontal Disease 82
3.6.11 Feline-Specific Dentistry 84
4 Examining the Endocrine and Lymphatic Systems of the Cat 90
4.1 Evaluating the Thyroid Gland 90
4.1.1 The Pathophysiology of Hyperthyroidism 90
4.1.2 The Etiology of Hyperthyroidism 91
4.1.3 The Art of Palpating an Enlarged Thyroid Gland 91
4.2 Assessing the Lymphatic System 93
4.2.1 Examining the Submandibular Lymph Nodes 93
4.2.2 Examining the Superficial Cervical or Pre-Scapular Lymph Nodes 93
4.2.3 Examining the Popliteal Lymph Nodes 94
4.2.4 Feeling for Lymph Nodes That Should Not Be Present 94
5 Examining the Cardiovascular and Respiratory Systems of the Cat 98
5.1 The Cardiac Patient 98
5.2 Assessing the Cardiovascular System Prior to Auscultation 99
5.2.1 Attitude 99
5.2.2 Respiratory Rate 99
5.2.3 Respiratory Effort 99
5.2.4 Respiratory Route 99
5.2.5 Mucous Membrane Color 99
5.2.6 Capillary Refill Time (CRT) 99
5.2.7 Jugular Pulse 99
5.2.8 Palpating the Ventral Neck 100
5.2.9 Palpating the Limbs for Warmth and Assessing the Extremities for Color 100
5.2.10 Assessing Femoral Pulses 100
5.3 Cardiothoracic Auscultation 101
5.3.1 Recalling the Cardiac Cycle 101
5.3.2 Normal Heart Sounds 101
5.3.3 Abnormal Heart Sounds: Murmurs 101
5.3.4 Other Heart Sounds 102
5.3.5 Ausculting the Heart 102
5.3.6 Understanding How the Stethoscope Is Built to Facilitate Auscultation 105
5.4 The Respiratory Patient 105
5.4.1 The Upper Airway Patient 105
5.4.2 The Lower Airway Patient 105
5.4.3 The Patient with Thoracic Cavity Disease 107
5.5 Assessing the Respiratory System Prior to Auscultation 110
5.5.1 The Nose 112
5.5.2 The Larynx and the Trachea 113
5.5.3 Thoracic Compliance 113
5.5.4 Thoracic Percussion 113
5.6 Understanding Normal Airway Sounds 114
5.7 Ausculting the Airway 114
5.8 Understanding Adventitious Airway Sounds 115
5.9 Using Airway Sounds to Corroborate Percussive Findings 116
5.10 Purring as an Obstruction to Auscultation 116
6 Examining the Abdominal Cavity of the Cat 120
6.1 Overview of the Digestive Tract as It Pertains to Presenting Complaints 120
6.2 The Esophagus 122
6.3 Visual Inspection of the Abdomen 122
6.4 Superficial Palpation of the Abdomen 122
6.5 Deep Palpation of the Abdomen 124
6.5.1 The Liver 126
6.5.2 The Stomach 127
6.5.3 The Spleen 127
6.5.4 The Pancreas 127
6.5.5 The Small Intestine 128
6.5.6 Mesenteric Lymph Nodes 129
6.5.7 The Large Intestine 129
6.5.8 The Rectal Examination 130
6.6 The Upper Urinary Tract 132
6.7 The Lower Urinary Tract 134
6.8 The Male Reproductive Tract 135
6.9 The Female Reproductive Tract 137
6.10 Being Presented with a Female of Unknown Sexual Status 138
6.11 Neonates 138
7 Examining the Musculoskeletal System of the Cat 145
7.1 Muscle Condition Score (MCS) 145
7.2 The Skeleton as a Whole 146
7.2.1 Key Components of the Axial Skeleton to Appreciate on Physical Examination 148
7.2.2 Key Components of the Appendicular Skeleton to Appreciate on Physical Examination 150
7.2.3 Additional Components of the Skeleton to Appreciate on Physical Examination 153
7.3 The Appendicular Skeleton: The Forelimb 153
7.4 The Appendicular Skeleton: The Hind Limb 160
8 Evaluating the Nervous System of the Cat 174
8.1 Assessing Behavior and Mental Status 174
8.2 Assessing Posture 176
8.3 Assessing Coordination and Gait 177
8.4 Assessing Postural Reactions 178
8.5 Assessing for Other Abnormal Movements 180
8.6 Evaluating the Spinal Reflexes 181
8.7 Assessing the Cranial Nerves 183
8.7.1 Reviewing the Ocular Reflexes Associated with the Cranial Nerves 183
8.7.2 Reviewing the Cranial Nerves Associated with Ocular Movement 185
8.7.3 Reviewing the Cranial Nerves Associated with Tactile Sensation 185
8.7.4 Reviewing the Cranial Nerves Associated with Muscle Movement Other Than Ocular 186
8.7.5 Reviewing the Cranial Nerves Associated with Digestion 186
8.7.6 Reviewing the Cranial Nerves Associated with Maintaining Posture 186
8.8 Assessing Nociception 186
Part Two Performing the Canine Physical Examination 191
9 Setting the Stage: Canine-Friendly Practice and Low-Stress Handling 193
9.1 Challenges Faced in Canine Practice 193
9.2 The Concept of Low-Stress Handling 194
9.3 White Coat Syndrome 196
9.4 The Role of Scent 198
9.5 The Role of Advance Preparation 199
9.6 Examination Room Etiquette: Setting the Tone for Initial Veterinary Interactions with the Dog 199
9.7 Recognizing Body Language 199
9.8 Creative Approaches to Challenging Interactions with Canine Patients 205
9.9 Other Canine Handling Tools 206
10 Assessing the Big Picture: the Body, the Coat, and the Skin of the Dog 213
10.1 Forms of Identification 213
10.2 Body Condition Scoring 214
10.3 Assessing Hydration 221
10.4 Breed Designation 222
10.5 Inspecting the Coat: First Impressions 223
10.6 Identifying Coat Colors and Coat Patterns 225
10.7 Assessing Coat Quality 233
10.8 Inspecting the Skin 237
10.9 Primary Skin Lesions 240
10.10 Secondary Skin Lesions 245
10.11 Miscellaneous Skin Lesions 246
10.12 Hyperkeratosis 249
10.13 Skin Folds 250
10.14 Nails and Paw Pads 251
10.15 Skin Incisions 252
10.16 Mammary Glands 255
11 Examining the Head of the Dog 261
11.1 Skull Shape: Function Versus Cosmesis 261
11.2 Facial symmetry 265
11.3 The Eyes and Accessory Visual Structures 265
11.3.1 A Systematic Approach to the Eye Examination 265
11.3.2 Evaluating the Adnexa of the Eye 265
11.3.3 Evaluating the Globe 274
11.3.4 Evaluating the Sclera 275
11.3.5 Evaluating the Cornea 277
11.3.6 Evaluating the Iris 278
11.3.7 Evaluating the Pupils 280
11.3.8 Assessing Ocular Reflexes 281
11.3.9 Assessing the Anterior Chamber 281
11.3.10 Assessing the Lens 282
11.3.11 Introduction to Fundoscopy 282
11.3.12 Fundoscopy and Direct Ophthalmoscopy 283
11.3.13 Fundoscopy and Indirect Ophthalmoscopy 283
11.4 The Ears 284
11.5 The Nose 289
11.6 The Extra-Oral Examination 291
11.7 The Intra-Oral Examination 295
11.7.1 Assessing Mucous Membrane Color 295
11.7.2 Assessing Capillary Refill Time 296
11.7.3 Examining the Mucosa 296
11.7.4 Examining the Gingiva 296
11.7.5 Assessing the Dentition 297
11.7.6 Assessing the Occlusion 301
11.7.7 Assessing for Calculus 302
11.7.8 Miscellaneous Acquired Tooth-Related Defects 303
11.7.9 Opening the Mouth 304
11.7.10 Examining the Tongue 305
11.7.11 Assessing for Periodontal Disease 306
12 Examining the Endocrine and Lymphatic Systems of the Dog 312
12.1 Thyroid Gland Neoplasia in the Dog 312
12.2 The Typical Presentation of Thyroid Gland Neoplasia in the Dog 313
12.3 The Pathophysiology of Hypothyroidism 313
12.4 The Typical Presentation of a Hypothyroid Dog 314
12.5 The Atypical Presentation of a Hypothyroid Dog 315
12.6 Assessing the Lymphatic System 315
12.7 Examining the Submandibular Lymph Nodes 316
12.8 Examining the Superficial Cervical or Pre-Scapular Lymph Nodes 316
12.9 Examining the Popliteal Lymph Nodes 316
12.10 Feeling for Lymph Nodes That Should Not Be Present 317
13 Examining the Cardiovascular and Respiratory Systems of the Dog 320
13.1 Congenital Heart Disease in the Dog 320
13.2 Acquired Heart Disease in the Dog 321
13.3 Assessing the Cardiovascular System Prior to Auscultation 322
13.3.1 Attitude 322
13.3.2 Respiratory Rate 323
13.3.3 Respiratory Effort 323
13.3.4 Respiratory Route 323
13.3.5 Mucous Membrane Color 323
13.3.6 Capillary Refill Time (CRT) 323
13.3.7 Jugular Pulse 324
13.3.8 Assessing Femoral Pulses 324
13.4 Cardiothoracic Auscultation 325
13.4.1 Normal Heart Sounds 325
13.4.2 Abnormal Heart Sounds 326
13.4.3 Other Heart Sounds 326
13.4.4 Ausculting the Heart 326
13.4.5 Understanding How the Stethoscope Is Built to Facilitate Auscultation 326
13.4.6 Understanding the Limitations of Cardiothoracic Auscultation 326
13.5 The Respiratory Patient 330
13.5.1 The Upper Airway Patient 330
13.5.2 The Patient with Laryngeal Disease 332
13.5.3 The Lower Airway Patient 332
13.5.4 The Patient with Thoracic Cavity Disease 333
13.6 Assessing the Respiratory System Prior to Auscultation 334
13.6.1 The Nose 334
13.6.2 The Larynx and the Trachea 334
13.6.3 Thoracic Compliance 335
13.6.4 Thoracic Percussion 335
13.7 Understanding Normal Airway Sounds 335
13.8 Ausculting the Airway 335
13.9 Understanding Adventitious Airway Sounds 336
13.10 Panting as an Obstruction to Auscultation 337
14 Examining the Abdominal Cavity of the Dog 342
14.1 Overview of the Digestive Tract 342
14.2 The Esophagus 342
14.3 Visual Inspection of the Abdomen 343
14.4 Auscultion and Superficial Palpation of the Abdomen 344
14.4.1 Auscultation of the Abdomen 344
14.4.2 Superficial Palpation of the Abdomen 344
14.5 Deep Palpation of the Abdomen 346
14.5.1 The Liver 348
14.5.2 The Stomach 348
14.5.3 The Spleen 350
14.5.4 The Pancreas 351
14.5.5 The Small Intestine 352
14.5.6 The Mesenteric Lymph Nodes 354
14.5.7 The Large Intestine 354
14.5.8 The Anal Sacs 354
14.5.9 The Rectal Examination 355
14.6 The Upper Urinary Tract 357
14.7 The Lower Urinary Tract 358
14.8 The Male Reproductive Tract 361
14.9 The Female Reproductive Tract 364
14.10 Being Presented with a Female of Unknown Sexual Status 367
14.11 Neonates 368
15 Examining the Musculoskeletal System of the Dog 380
15.1 Muscle Condition Score (MCS) 380
15.2 The Skeleton as a Whole 382
15.2.1 Key Components of the Axial Skeleton to Appreciate on Physical Examination 382
15.2.2 Key Components of the Appendicular Skeleton to Appreciate on Physical Examination 383
15.2.3 Additional Components of the Skeleton to Appreciate on Physical Examination 386
15.3 The Appendicular Skeleton: The Forelimb 386
15.4 The Appendicular Skeleton: The Hind Limb 392
16 Evaluating the Nervous System of the Dog 412
16.1 Assessing Behavior and Mental Status 412
16.2 Assessing Posture 413
16.3 Assessing Coordination and Gait 415
16.4 Assessing Postural Reactions 415
16.5 Assessing for Other Abnormal Movements 418
16.6 Evaluating the Spinal Reflexes 419
16.7 Assessing the Cranial Nerves 421
16.7.1 Reviewing the Ocular Reflexes Associated with the Cranial Nerves 421
16.7.2 Reviewing the Cranial Nerves Associated with Ocular Movement 422
16.7.3 Reviewing the Cranial Nerves Associated with Tactile Sensation 422
16.7.4 Reviewing the Cranial Nerves Associated with Muscle Movement Other than Ocular 423
16.7.5 Reviewing the Cranial Nerves Associated with Digestion 423
16.7.6 Reviewing the Cranial Nerves Associated with Maintaining Posture 423
16.8 Assessing Nociception 423
Index 432
1
Setting the Stage: Feline-Friendly Practice
1.1 Challenges Faced in Feline Practice
Every 5 years, the American Veterinary Medical Association conducts a national survey to track trends in pet ownership. In 2012, the number of owned cats exceeded the number of owned dogs in the United States by over four million [1]. Yet despite their growing popularity and the increased perception that cats are members of the family, cats remain underserved when it comes to veterinary care [1-4].
By their own admission, cat-owners are less likely than dog-owners to pursue annual wellness examinations. According to the Bayer Veterinary Care Usage Study, a four-phase analysis of companion animal practice, only 37% of cat-owners over a 12-month period visited a veterinary clinic for routine examination [2]. Indoor-only [2, 5] and aged populations [6] were at increased risk of escaping veterinary medical attention. The former were perceived as being less likely to succumb to illness [2], and the overall value of the veterinary wellness visit was lost on cat-owners, 83% of whom believed their cat to be in "excellent health" [2]. Were it not for vaccinations, many cat-owners would not pursue routine veterinary care at all [6].
The Bayer Veterinary Care Usage Study concluded that cat-owners' reluctance to seek veterinary medical care is multifactorial [2]. One major driving force is lack of owner education [2, 6]. Many cats are unplanned acquisitions: "I didn't necessarily find the cat, the cat found me" [2]. As a result, cat-owners may receive limited, if any, initial guidance as to when to pursue veterinary care [2]. By contrast, dog-owners tend to plan the introduction of a new pet into the household and are more likely to seek out instructions on proper care from breeders and shelters.
Many cat-owners are unaware that routine wellness care is essential [7]. Further compounding the issue is that cats effectively mask subtle signs of illness. Cat-owners often find it difficult to determine when their cat is sick [3, 8]. When cat-owners do recognize illness, over one-third of them look to the Internet for veterinary medical advice rather than pursue veterinary medical attention [5, 6].
Of those cat-owners who do perceive value in preventive medicine, the toll that veterinary visits take on the cat and cat-owner alike represents a significant barrier to follow-up care [2]. Cat-owners view the veterinary visit as an ordeal, the stress of which begins well before the client and cat ever set foot in the clinic [2, 6].
Owners must first capture the cat, which is easier said than done. The cat may hightail it at the sight of a cat carrier or aggressively resist being confined to it. As a result, cat-owners look forward to this aspect of the veterinary visit the least [6], yet of those surveyed, only 18% had been instructed by the veterinary team on how to decrease transportation-associated stress [2].
Once confined to the cat carrier, the cat may vocalize for the duration of the journey to and from the clinic. Upon arrival to the clinic, cats become visibly stressed in the waiting room, especially when their space is encroached upon by other patients. When they finally reach the examination room, their tolerance may be sufficiently limited [6].
To summarize their veterinary experience, the Bayer Veterinary Care Usage Study asked 1938 cat-owners to create a collage representing their veterinary experience. The majority of cat-owners used pictures from horror films [2]. Fifty-eight percent of cat-owners described their cats as hating veterinary visits [9].
This perception of the veterinary experience adversely impacts the profession's ability to attract and retain cat-owners and to provide consistent, high-quality medical care. The veterinary visit is undoubtedly a source of feline stress, the net result of which may be provoked aggression. When cats are fractious, the veterinary team is unable to examine them thoroughly. Feline stress may artificially create abnormal physical examination findings such as tachycardia and tachypnea. The intensity of the stress response may also induce abnormalities in routine screening and other diagnostic tests. Stress hyperglycemia is common, and can be challenging to differentiate from diabetes mellitus without additional testing. If stress is not recognized as the culprit for these abnormalities, the veterinary team may use the test results to support a diagnosis that is inaccurate. This places the patient at increased risk of being subjected to irrelevant or inappropriate treatment plans [10, 11].
Of equal concern is that cats' behavior in the home appears to be altered for some period of time after the veterinary visit. Cats may become standoffish after visiting the clinic, and this may last for several days [6]. In addition, the residual effect of the veterinary visit may transiently impact inter-cat dynamics in multi-cat households. The hospital-goer is not always welcomed back into the fold with open arms, and inter-cat aggression may ensue.
As a result of the many challenges that cat-owners face when committing to a veterinary visit, most prefer to avoid the clinic altogether [6]. This, combined with feline resistance, represents two significant obstacles to cats receiving veterinary care.
1.2 The Emergence of Feline-Friendly Practice
As a result of feline and owner resistance, cats are a largely untapped resource for the veterinary profession: between 2001 and 2011, annual feline visits decreased by 14% [2].Hence cats represent a rich opportunity area to increase veterinary revenue. Practice management tools may help to capture this underrepresented population through the use of social media and by relying upon business metrics more effectively to identify patients with lapsed appointments [9]. However, without addressing cat-specific issues surrounding the veterinary visit, marketing campaigns focused strictly on data may not be as effective.
The concept of feline-friendly practice emerged from the realization that the burden is on the veterinary profession to adapt to cats, not the other way around. Cats are not small dogs. Cats have different behavioral, physiological, medical, and psychological needs. Furthermore, owners hold different expectations when it comes to their care [6]. The American Association of Feline Practitioners developed the Cat Friendly Practice program to cater to this distinct population of companion animals [12]. Although practitioners are not required to participate, those who do are provided with the tools necessary to adopt a feline-centered practice philosophy [12]. It is hoped that participating institutions will elevate their approach to feline care in order to attract, medically manage, and retain cat-owning clientele.
1.3 Key Principles of Feline-Friendly Practice
Feline-friendly practice philosophy centers on an understanding of normal cat behavior and communication. Cats are often misunderstood, especially when it comes to our perception of how cats respond to conflict [13, 14]. Cats are by nature solitary: prior to domestication, they lived and hunted alone [13, 14]. Hence they avoid altercations with other cats rather than engage in conflict whenever possible [13-15]. This explains why the provision of escape routes and hideaways is so important when dealing with inter-cat aggression in the home [16]. Cats need to feel that they can get away. They need both to be able to hide a visual source that is distressing to them and to be themselves hidden from view (Figure 1.1). Cat trees with hideaways that have a separate entrance and exit are preferred so that cats do not become trapped by an aggressor.
Figure 1.1 Cat tree demonstrating a hideaway with a separate entrance and exit.
Cat trees and shelves are also used to create a buffer between cats in shared living quarters. This vertical space serves a dual function: an elevated escape route or a way to increase distance between cats [16]. Cats are able to seat themselves where they feel comfortable based upon their preexisting social hierarchy (Figure 1.2).
Figure 1.2 Cat tree demonstrating how vertical space allows cats to share living space. Source: Courtesy of Bianca J. Hartrum.
One can take these same principles and adapt them to feline-friendly practice by creating a clinic setting in which cats are minimally exposed to other cats and other species [17]. The ideal feline-friendly practice has a designated cat-only waiting room (Figure 1.3).
Figure 1.3 Separate waiting area designated for cats.
Preferably, shelving is provided to keep carriers off of the ground to build a sense of security through the simulation of vertical space [18].
When at all possible, the practice should structure its appointment schedule to minimize wait times. When unforeseen circumstances extend the wait, feline patients should be directed into cat-only examination rooms as soon as possible.
If the examination rooms have windows facing the interior of the corridor, blinds may be installed to reduce visual stimuli (Figure 1.4).
Figure 1.4 Blinds installed in cat-designated examination rooms may...
