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Home , Palpation, Physical examination

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The

Alice Defarges, DVM, DACVIM Ontario Veterinary College

d A plantigrade or palmigrade 1 stance noted during the general observation portion of the physical examination can suggest a neuropathy, as in this German shepherd dog with .

A number of important steps must be examination. The examiner must use the included in physical examinations of cats of sight, hearing, smell, and touch FOR AN EXTENSIVE and dogs, although the order in which the throughout the examination. COLLECTION OF steps are completed can vary. Veterinari- SHORT, ILLUSTRATIVE ans should develop the habit of complet- General Observation VIDEOS, VISIT ing each step in the same order for every The physical examination begins when cliniciansbrief.com/ . More is missed by not looking the veterinarian enters the examination physical-examination than by not knowing. room. General observation includes assessment of body condition, posture, All examination findings must be gait, and behavior. The patient should recorded in the ; a simple ideally be off-leash or out of the carrier “physical exam was normal” notation is so that it can move freely and be less not enough. Including details about each anxious. body area ensures that any abnormalities will be addressed during follow-up. Mentation and behavior can be assessed first. A normal puppy or kitten may be excited and active; conversely, a puppy or FOR A DETAILED FORM TO HELP kitten with a portosystemic shunt may be GUIDE YOUR PHYSICAL flat and difficult to arouse. A blind patient EXAMINATION, VISIT that does not show any signs of blindness cliniciansbrief.com/physical- in its home environment may bump into examination-handout furniture in the examination room.

The physical examination consists of When observing the patient, the veterinar- general observation and hands‑on ian should listen for abnormal breath

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sounds or grunting. Body size and posture should Overweight pets may be overfed, have hypothyroid- also be observed. A plantigrade stance could suggest ism, or simply be inactive. Thin may be a neuropathy (Figure 1, previous page), and neck systemically ill (eg, chronic renal failure, protein- ventroflexion in a cat may suggest hypokalemia. A losing enteropathy) or underfed. If a patient is hunched posture could suggest cranial abdominal presented for weakness or lameness, observing the pain. A stiff gait may suggest polyarthritis. A patient animal move is essential. This may require having reluctant to move its neck or lift its head could have the patient walk on a surface with adequate traction neck pain related to a herniated disk or meningitis. and noting any lameness, signs of neurologic The owner may fail to point out abnormalities such deficits, or gait irregularities. as a head tilt. Gait can be assessed more in-depth by asking the Close observation of the patient allows the veteri- owner to walk the dog in front of the veterinarian. narian to evaluate muscle mass and body condition. This helps to localize the origin of the lameness (ie, which limb) and to evaluate or limb dragging. Observing gait in a cat can be challenging. TABLE 1 To avoid stress-induced changes, the clinician can NORMAL VITAL PARAMETERS evaluate the patient’s breathing pattern and rate before hands-on manipulation (Table 1). Listening to the can reveal cough, stridor, Variable Dogs Cats stertor, or snoring.

The patient can be weighed after the observation rate (bpm) Adults: 70–160 120–240 Giant breeds: 60–140 (mean, portion of the examination (Figure 2). Toy breeds: <180 187) Puppies: <220 Hands-On Examination The hands-on examination should cover every 12–40 20–40 (breaths/min) aspect of the animal from nose to toes to tail. It may be a challenge to perform a hands-on Temperature (°C) 38.5–39.5 38.5–39.5 examination in some cats. A general rule of thumb Capillary refill time <2 <2 is to hold the cat as little as possible (Figure 3). (seconds)

2 3

d Weighing d Hands-on examination of a cat is best performed by the patient. holding the cat as little as possible. This cat has been placed in a non–stainless steel basket with a towel.

74 cliniciansbrief.com September 2015 STEP-BY-STEP THE HANDS-ON EXAMINATION

STEP 1 HEAD AND NECK 1A 1D

1E

1B 1C 1F

Assess the shape and symmetry of on any patient in which the pupils WHAT YOU WILL NEED the skull (1A). Examine each eye are adequately dilated (which is separately, assessing eye position typically the case for cats in the h Stethoscope and movement, vision, , con- hospital). Pharmacologic dilation h Lubricating jelly junctiva, pupillary response to a of the pupils and a complete fundic h Thermometer penlight (1B), palpebral and menace examination can be performed if response (direct and consensual), indicated. h Disposable digital oral thermometer sheaths and lens position and clarity (using an indirect lens or ophthalmo- Next, examine the ears. The external h Latex glove scope). Check eye compression/ pinnae should move in response h Penlight retropulsion to rule out retrobulbar to sound and a light touch on the h Otoscope masses. Look for evidence of ocular underside. Grossly examine the ear h Watch discharge or blepharospasm. A fun- canals for discharge, then use an h Scale dic examination can be performed otoscope to examine the internal

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canal and tympanic membrane (1C, and/or ecchymoses, dryness (eg, and movement, and view the previous page). dehydration, excessive panting), underside for string or other foreign and excessive moistness (eg, bodies, masses, or laceration of the Examine the bridge of the external nausea). Push gently on the gums to frenulum. nose for shape, symmetry, color, blanch the capillaries, then observe and erosions. Examine the nares for capillary refill time 1( F, previous Palpate the mandibular lymph discharge and patency. page). A slow capillary refill time nodes, which are usually more crani- (>2 seconds) may indicate poor al, ventral, and closer to the jaw Open the mouth by grasping the peripheral perfusion. Check the than the mandibular salivary glands maxilla with 1 hand and the mandi- gums and hard and soft palate for (1G). While the neck is flexed and ble with the other (1D, previous color and integrity. Check the teeth extended, turn the head to each side page), and evaluate the oral cavity. and palpate them for pain or to check for pain. At the same time, Resistance to opening the mouth looseness. Evaluate dental occlu- monitor eye position for normal may indicate pain at the temporo- sion, and assess for tartar presence; nystagmus. Then palpate the trachea mandibular . Examine the if tartar is present, grade the degree. from the larynx to the thoracic inlet. mucous membranes for color (eg, The tonsils are not normally seen Squeeze the trachea slightly; a , icterus [1E, previous unless they are inflamed. Examine cough, if elicited, may indicate page], , hyperemia), petechiae the top side of the tongue for color tracheitis or a collapsing trachea.

Author Insight Examine the glands, which lie adjacent to the trachea and are Another technique for thyroid consists of gently turning palpable when enlarged. The thyroid the head toward 1 side while sliding a finger along the opposite is normally not palpable. Thyroid side of the trachea. Some cats fare better with this technique. enlargement can be detected by using the thumb and forefinger in a steady movement to trace the 1G tracheal margins from the larynx to the thoracic inlet (1H, 1I). The head should be extended while the examiner is performing this manipulation. In cats, an enlarged gland is palpated as it slips through the fingers. Thyroid gland enlarge- ment is uncommon in dogs.

Visualize the jugular veins by occlud- ing the thoracic inlet. A jugular may be observed without occlusion in cases of right‑sided heart (also consider cardiac 1H tamponade or heart base mass).

Gently manipulating the neck in dorsal, lateral, and ventral flexion can help detect pain and a reduced range of movement.

76 cliniciansbrief.com September 2015 STEP 2 2B INTEGUMENT Run both hands over the entire surface of the body to assess the condition of the skin and haircoat. Check for cutaneous and subcutaneous masses, alopecia, ectoparasites, pustules and papules, scale, erythema, , petechiae (2A), and ecchymoses (2B). Use a flea comb to screen for live fleas and flea dirt. Assess hydration status by tenting the skin in the interscapular area (2C). If the skin does not immediately spring back to 2C its original position, the patient may be dehydrated. Thoroughly palpate each mammary gland along the entire chain to check for masses.

2A

Author Insight Measure lesions with calipers STEP 3 THORACIC LIMBS or a ruler for review and trend Examine each thoracic limb from the digits to the scapula. Palpate the muscles, , and long bones to evaluate for purposes. A photograph of the joint effusion, swelling, pain, or heat. Examine the nails, nail area is also useful. If a caliper is beds, and footpads on each foot for color, symmetry, erosions, unavailable, compare the size of masses, foreign bodies, interdigital dermatitis, cysts, and the lesion with a common item masses. Place each foot in a knuckling position to assess conscious proprioception. Palpate the prescapular (also known (eg, tennis ball, golf ball). as the superficial cervical) lymph nodes to evaluate size and shape. The axillary lymph nodes are not normally palpable.

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STEP 4 4A Observe and palpate the thoracic cage to evaluate the integrity of the ribs. Palpate both sides simultaneously to assess symmetry. To palpate the spine, apply gentle downward pressure on the spinous processes and then along the transverse processes; progressively increase the degree of pressure being applied. Note the presence of spinal hyperesthesia or deformity.

Auscultate the thorax while simultaneously palpating the pulse to identify normal vs abnormal heart and pulmonary sounds and to assess heart rhythm and 4B rate.

Focus on cardiac separately from pulmonary auscultation. For cardiac auscultation, the animal should be standing, if possible, so that the heart is in its normal position. Carefully auscultate both sides of the chest and pay special attention to the valve areas (4A and 4B). Move the stethoscope gradually to all areas of the chest. Most heart murmurs in cats are heard parasternally. Simultane- ously evaluate the femoral arterial pulse rate (4C) 4C and the direct , which is obtained by chest wall palpation or auscultation. Fewer femoral than heartbeats constitutes a pulse deficit.

Inspiratory dyspnea is detected when the inspiratory phase is longer than the expiratory phase, indicating a problem proximal to the carina. Increased stridor or stertor can be heard with an upper respiratory problem. Expiratory dyspnea is noted by an expira- tory phase that is longer than the inspiratory phase. This indicates a problem in the lower airways. Significant pleural space disease (eg, , , masses, ) usually causes a Author Insight rapid, shallow breathing pattern, with shortened inspiratory and expiratory phases and the absence To discourage panting in dogs during this of sounds. portion of the examination, hold the dog’s mouth shut. In cats, purring may be Auscultate the lung fields in a systematic manner, stopped by holding a finger over 1 or both covering all areas of the chest. Adventitious lung of the cat’s nostrils, waving an alcohol- sounds are described as continuous (eg, ) or discontinuous (eg, ). Upper airway sounds soaked cotton ball near the cat’s nose, or can be referred to the lower airway. Always listen to turning on a water faucet near the animal. the trachea to differentiate this.

78 cliniciansbrief.com September 2015 can typically be grasped gently and palpated entirely. STEP 5 The spleen lies on the left side of the abdomen. Its tail can be felt lying on the ventral abdominal floor Author Insight in many normal dogs. Any tense could be referred from back pain. The back should Palpate the intestines throughout the abdominal be palpated in lateral recumbency to cavity. Initially, using 2 hands in large dogs and 1 hand in small dogs and cats, bring the fingers differentiate back and abdominal together dorsally and gently move them ventrally. discomfort.

Using a light but forceful touch, palpate the abdomen TABLE 2 by moving in a cranial-to-caudal and dorsal-to-ventral PALPABLE VS NONPALPABLE direction. Some animals, even when they are not ABDOMINAL ORGANS painful, tense the abdominal muscles in response to the procedure. Use the tips of the fingers to the size and shape of the organs or to detect any masses. Palpable Organs Nonpalpable Organs Note any abdominal distension, apparent pain, or (When Normal) masses. Intestines The liver is the most cranial organ and typically (if feces are present) Pancreas cannot be palpated when it is normal because it Bladder (if full) Stomach should not extend past the costal margin (Table 2). Caudal pole of the left Adrenal glands The kidneys are in the dorsocranial abdomen. Canine (in dogs) Spleen* kidneys are fixed in the retroperitoneal space. The Both kidneys (in cats) right kidney is more cranial than the left; therefore, Uterus (unless only the caudal end may be felt. Feline kidneys are or pyometra is present) more mobile than those of dogs. In cats, each kidney *In some dogs, the practitioner may feel the tail of the spleen. 5A 5C

5B 5D

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Feel the loops of bowel as they slip through the fingers 5A–5D( ). The colon can be palpated STEP 8 RECTUM dorsally in the abdomen. Feces in the colon may Take the rectal temperature with a lubricated thermometer be mistaken for masses. Fully distended urinary (with or without a thermometer sheath). The normal range of bladders are easily palpated in the caudal body temperature in calm, normal individuals in a cool environ- abdomen in most animals. ment is 100.2°F to 102.5°F (37.8°C to 39.1°C) in the dog and 100.5°F to 102.5°F (38°C to 39.1°C) in the cat.1 For animals that The inguinal lymph nodes (located between are large enough and will tolerate the procedure, gently insert the abdominal wall and the medial surface of a gloved and well‑lubricated finger into the rectum. Evaluate the thigh) are not normally palpable. rectal wall thickness, anal glands, pelvic , contours of the and sacrum, prostate gland (males), and vaginal tract (females). The normal prostate should be small, symmetric, and nonpainful on palpation. Facilitate palpation of the STEP 6 PELVIC prostate in large dogs by placing concurrent pressure in the caudal abdomen with the other hand. Anal glands are normally LIMBS AND TAIL located at the 4- and 8-o’clock positions. Palpation along the Palpate and examine each rear limb in a dorsal aspect of the rectum may allow detection of sublumbar manner similar to that used for the thoracic . Examine the feces for color and consistency. n limbs. Examine the tail for movement, masses, and hair loss. Apply gentle pressure to the base of the tail by pulling in a craniodorsal direction Author Insight to detect any lumbosacral pain. Palpate the In a stressed patient, rectal temperature can be popliteal lymph nodes behind the stifles to taken at the beginning of the examination to avoid evaluate size and shape. stress-induced hyperthermia. Sedation is typically needed and recommended before a in cats and small dogs. STEP 7 EXTERNAL UROGENITAL AND PERINEAL AREA Reference 1. Cote E. Clinical Veterinary Advisor Dogs and Cats. 2nd ed. St. Louis, MO: Saunders Examine the external vulva, prepuce, and Elsevier: 2011. scrotum for discharge, swelling, and redness. The testicles should be symmetric and com- Suggested Reading Ettinger SJ. The physical examination of the dog and cat. In: Ettinger SJ, Feldman EC, pletely descended. Exteriorize the penis to eds. Textbook of Veterinary Internal Medicine. 7th ed. St. Louis, MO: Saunders Elsevier; examine it. Assess the anus and perineal skin 2010:1-9. Mathews KA. Monitoring the ill, injured or surgical patient. In: Mathews KA, ed. Veterinary for swelling, masses, or fistulas. Stimulate the Emergency and Critical Care Manual. 2nd ed. Guelph, Ontario: Lifelearn; 2006:12. perineum with a hemostat using a gentle prod, Prošek R. Abnormal and heart murmurs. In: Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine. 7th ed. St. Louis. MO: Saunders Elsevier; which will result in contraction of the anal 2010:258. sphincter and flexion of the tail. This reflex tests the integrity of caudal of the tail, the pudendal , spinal cord segments 1-Cd5, and associated nerve roots. The author wishes to thank Laura Constantinescu and Benoit Cuq for contributions to this collection.

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