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Douglas Mader, MS, DVM, DABVP (Canine & Feline), DABVP (Reptile & Amphibian), DECZM (Herpetology), Marathon Veterinary Hospital, Marathon, Florida
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For every clinical problem missed for not knowing, 10 will be missed for not looking. Physical examination (PE) is the cornerstone of diagnostic medicine—everything the clinician does for a patient is based on its results. If something small is missed during the PE, it can complicate later diagnostic problem solving.
Related Article: Attending to In-Clinic Patient Behavior: Where, When, How
After graduation, my first job boasted 6-minute appointments. If a patient came in for what the client reported to be a bad ear, that was all I was to examine—just the ears. My boss considered it a waste of time and resources to look at the rest of the patient. In addition, he felt it was good business to churn through the appointments, 10 per hour, rather than examining the entire animal.
In actuality, it was bad medicine not to look at the entire animal—what if the ear problem was related to allergies, foreign bodies, or metabolic issues? From a business perspective, if only the ears are examined, one may miss the heart murmur, dental disease, cataracts, and other, possibly more pressing, medical problems.
Consistency must be a habit when it comes to PEs. By developing a consistent PE routine, the clinician is less likely to miss examining an area. The clinician should stick to a pattern when conducting the examination (eg, nose to tail, ears to feet). In cases in which the client brings a pet in for a specific complaint, the clinician–client relationship may benefit from focusing on the area of complaint before proceeding with a consistent, routine PE. The client may also benefit from an explanation that the presenting complaint may have roots elsewhere, emphasizing the necessity of the PE.
A PE can take on many forms and purposes (eg, annual, presurgical, health certificate, geriatric, insurance clearance, pre- or postpurchase examination). The clinician must decide how to approach these types of examinations and what services will be included or offered with them. For instance, for an annual examination on a young dog, the author is not likely to recommend an ECG unless the patient shows clinical signs (eg, heart murmur) or has a breed predilection to cardiac disease (eg, Cavalier King Charles). However, all senior pets (>8 years for small and medium breeds, >5 years for large and giant breeds) routinely get ECGs. Following are the steps this author considers essential to performing a thorough PE.
First, the technician should obtain temperature, pulse, and respiratory rates. Blood pressure should be taken at the start of the examination, before the patient has a chance to become anxious and affect results. This can be done by the technician before the veterinarian arrives.
The history may be the most important part of any PE. It may be taken by the veterinary technician during check-in and should include (but not be limited to): Presenting complaint, patient age, spay/neuter status, vaccine history, ecto- or endoparasite preventive medications, issues with administration of prior or current medications, behavioral issues, health status of other household pets, and medical history. Querying owners several times during history taking—and using different wording—may yield more information about a patient’s relevant history. Clients often leave things out or do not think things are important the first time around.
The technicians should then record the date of when the presenting problem began, whether the problem is progressive or stable, and anything else deemed relevant by the client.
Observe. Before handling the animal, evaluate its movement by watching it on the table or, if feasible, walking around the room. Vision can be evaluated by turning the lights down or off to watch the patient navigate in dim light, whereas hearing can be evaluated by calling to the patient or making a loud noise out of its line of sight.
Author Insight: For new pets, this author scans for a microchip at the beginning of the examination.
Examine eyes, ears, nose, and throat. Include capillary refill time, mucous membrane color, and dental score. Perform an otoscopic (with tympanic membrane evaluation) and ophthalmic examination (including evaluation of the fundus).
Conduct a cardiopulmonary examination. Include auscultation of the heart and lungs, assessment of pulse rate and quality, measurement of heart rate and characterization of heart rhythm, evaluation for murmurs, characterization of respiratory pattern, and notation of quality of lung sounds.
Palpate the abdomen. Palpate kidneys, liver, spleen, internal lymph nodes, and intestines. This can be difficult on large or obese patients. Note the patient’s response to palpation (eg, comfortable, apparent pain or discomfort [eg, splinting]).
Perform musculoskeletal examination. Look for gait abnormalities and deformities, palpate all joints, perform an orthopedic examination (eg, patellar luxations, drawer signs), and feel for crepitus and joint effusions. Record a body condition score. For overweight patients, note ideal weight in the chart.
Palpate all lymph nodes. Measure and note abnormal lymph nodes.
Check integuments. Evaluate the fur and skin; look for ectoparasites, lesions, masses, odor, texture, quality, color, and temperature. Perform skin tenting in several places to estimate hydration. Note hydration score in patient record.
Perform rectal examination, and palpate the anal glands.
Author Insight: There is considerable debate about whether a rectal examination should be performed at every examination. The author recommends rectal examinations for dogs, particularly for all intact males, all males with urinary issues, older male dogs, and any patient with issues relating to defecation. Cats should not receive a rectal examination unless there is radiographic or ultrasonograhic evidence of prostate enlargement.
Perform a basic neurologic examination. Include a cranial nerve evaluation and test proprioception and placing. For patients presenting with neurologic signs, conduct a comprehensive examination.
Author Insight: Dropping a cotton ball and watching the patient follow its movement is an excellent way to evaluate vision and tracking.
These are the basic steps for a PE; however, depending on the type of PE and the presenting complaint, additional diagnostics may be warranted and should be recommended to the client. Additional testing options should be discussed with the client, even if those tests are not generally part of an annual PE. For instance, the American Heartworm Society recommends biannual testing. Some tests, such as CBC, urinalysis, radiography, and ECG may also be warranted. Unnecessary or unwarranted testing should be avoided; for example, a yearly FeLV test for an inside-only apartment cat is likely unnecessary.
Although some clients may prefer to avoid a thorough PE on their pet out of fear of problems being found, it is important that the veterinary team helps clients understand that finding problems early helps safeguard pets and ensure they receive proper care.
The author wishes to thank Kristin Hall, DVM; Kirsten Ebb, CVT; and Mike Stachowski for help in preparation of this article.
DOUGLAS MADER, DVM, MS, DABVP (Canine & Feline Practice), DABVP (Reptile & Amphibian), DECZM (Herpetology), is the co-owner of Marathon Veterinary Hospital, a referral practice in the Florida Keys. He is also the consulting veterinarian for the Marathon Sea Turtle Hospital, Monroe County Sheriff’s Zoo, Key West Aquarium, Key West Butterfly Conservancy, and Theater of the Sea. Dr. Mader is an internationally acclaimed expert in Exotic Animal Medicine and travels over 50,000 miles every year teaching at veterinary conferences, veterinary schools, and specialty courses. Dr. Mader is also on the review and advisory boards for several scientific journals. He has published hundreds of articles in scientific and veterinary journals, national magazines, newspapers, and book chapters. He is the author and editor of Reptile Medicine and Surgery (Elsevier). Dr. Mader received his DVM from University of California, Davis.
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Clinician's Brief provides relevant diagnostic and treatment information for small animal practitioners. It has been ranked the #1 most essential publication by small animal veterinarians for 9 years.*
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