2: Patient Evaluation and Organ System Examination

Section 2 Patient Evaluation and Organ System Examination



Richard B. Ford, Elisa M. Mazzaferro




Patient Evaluation,


Owner Assessment of Pet Health: The BEETTS Test,

Clinician Initial Assessment: The Problem List,

The Medical Record,


Medical Record Content,

The Organ System Examination,


The Alimentary Tract,

Cardiopulmonary Examination,

Integument (Skin, Hair Coat, and Toenails),

Ophthalmic (Ocular) Examination,

Otic (Ear) Examination,

Lymph Nodes and Thyroid Examination,

Musculoskeletal (Orthopedic) Examination,

Nervous System Examination,

Reproductive Tract Examination: Canine—Male,

Reproductive Tract Examination: Canine—Female,

Normal Breeding Behavior and Physiology,

Upper Respiratory Tract Examination,

Lower Respiratory Tract Examination,

Urinary Tract Examination,


Patient evaluation



Owner assessment of pet health: the beetts test


Most pet owners, particularly first-time owners, have limited understanding of animal health issues and therefore are not well prepared to recognize early signs of illness in a pet dog or cat. The most common medical disorders are not recognized by owners at all (e.g., accumulation of dental tartar and gingival erosion), or their treatment is delayed until the pet has advanced illness. Ironically, few veterinary practices take time to teach pet owners how to (proactively) assess a pet’s health. Educating owners on how to recognize early changes in health status not only encourages early awareness of potential health problems but also supports earlier intervention by the veterinarian.


A simple-to-remember, owner-prescribed examination is the BEETTS (pronounced “beets”) test. This acronym represents a means for willing owners to assess significant changes in a pet’s activity or physical appearance that will alert them to common minor problems and possibly more serious health problems, thereby avoiding the consequences of delayed diagnosis and treatment.



B for Behavior



Know Your Pet!


Owners should be aware that subtle changes in behavior may be the first sign of underlying illness. Several such behavior changes—such as reduced or no appetite and associated weight loss, increased demand for water, frequent need to urinate or defecate, unexplained aggression, reluctance to play, difficulty standing, or persistent licking of skin (particularly in one location)—might signal early and serious illness. Such changes often justify a physical examination and laboratory profile.



E for Eyes


Asymmetry of the eyes and eyelids (denoting pain or injury) is as important as discoloration of the eye (cataracts, intraocular hemorrhage) or the accumulation of mucus on or around the eyelids. Pets with hair covering the eyes are reasonably considered at risk of serious eye disease owing to delayed diagnosis. Frequent evaluation of both eyes for clarity and absence of irritation (redness) is essential.



E for Ears


Owners should be alert for signs that might indicate an ear disease (e.g., head tilt or scratching, pain on manipulating the ears, ear abrasions, discoloration, discharge, malodor). If the pinnae hang below the opening of the external ear canal, owners should be willing to lift and look. Owners must be advised to avoid inserting any instrument or medication into a pet’s ears unless specifically instructed how to do so.



T for Teeth (and Gingiva)


The relationship between halitosis and serious dental or gingival disease is important, and such disease can easily be missed if the teeth are not examined on a regular basis. Owners are not encouraged to open the mouth of a dog or cat. However, most dogs will allow owners to lift the lip and visually examine the teeth for evidence of damaged or discolored teeth. It is sufficient for the owner to occasionally assess the outside appearance (labial surface) of the teeth and gingiva once or twice annually. Examination of the teeth of cats is generally not recommend because of the risk associated with being bitten.



T for Toes (and Toenails)


Most owners are not aware of when or how to examine a pet’s toenails. Although a cat’s toenails are periodically shed and usually do not require clipping, the toenails of sedentary dogs living predominantly indoors deserve attention as often as every month. Because dogs may resist any attempt to handle or examine the feet, owners are instructed to listen to their dog walk across a noncarpeted surface. If the owner can hear toenails clicking against the floor as the pet walks, clipping is indicated. Occasionally an owner will express interest in clipping their own pet’s toenails. It is important to advise owners of the risks inherent in what may appear to be a simple procedure: pain, bleeding, aggressive resistance, and even biting. Owners willing to attempt nail trimming at home should be instructed on what equipment to purchase and how to safely perform the procedure.



S for Skin (and Hair Coat)


Variability in hair coat type, length, and density makes examining the skin one of the home examinations that pet owners least often accomplish. The skin is the largest organ of the body, and serious disorders may develop many weeks or months before they become evident. This is particularly true in long-haired dogs and cats. In addition to routine brushing, which benefits all dogs and cats, and the occasional bath, owners are instructed to thoroughly touch their pet’s skin and hair coat in a systematic manner. One technique owners find appealing begins with the owner standing behind the pet. Starting at the pet’s head with one hand around each ear, the owner uses his or her fingers to “crawl” from the head to the tail while gently massaging the pet and touching the entire surface of the skin over the thorax and abdomen. Then, gently grasping one leg at a time with one hand, the owner massages each limb from the point closest to the body to the toes.



Clinician initial assessment: the problem list


A correct diagnosis is based on the clinician’s ability to assess and define constituent problems affecting the patient. This sounds simple enough. However, unless the term “problem” is defined, actually doing a thorough diagnostic assessment of the patient is simply not possible. When pursuing a diagnosis, the astute clinician works from a clear definition of a problem:



1. The clinical history: Any abnormality described by the owner (whether or not the owner’s interpretation is correct) is a problem.


2. The physical examination: Any abnormality discovered during the physical examination is a problem (see Organ System Examination).


3. Any imaging (radiographic or ultrasound) or laboratory abnormalities are considered to be problems.


The problem list, once acquired, becomes the foundation on which a diagnosis is built. Problems that are obviously related are grouped and may either confirm the diagnosis or suggest which additional diagnostic studies need to be performed to elucidate the diagnosis.



Clinical History


The clinical history is a critical component of the patient’s problem list and frequently is the single most revealing part of the diagnostic assessment of a given patient. It requires unique skills and experience to elicit an unbiased, pertinent clinical history about a pet’s illness. Some owners are astute observers and can readily communicate important information, whereas others either may not be aware of certain abnormalities or may purposely withhold information. The clinical history is centered around, but not limited to, the chief complaint. The chief complaint is the reason the patient is being presented. What should be recorded is a sign (vomiting), not a diagnosis (enteritis). Note the duration or frequency of the sign. Determine whether the duration or frequency has increased, decreased, or remained unchanged since onset. It is important to determine whether or not the pet’s overall condition since the onset of illness has improved, worsened, or remained the same.


Ask neutral questions—ones that will not prejudice the owner’s answers—for example, “Tell me about your dog’s water consumption.” Questions requiring only a “yes” or “no” response tend to introduce bias—for example, “Is your dog current on its vaccinations?” If the answer is “yes,” further questions such as “Anything else?” “How do you mean?” or “Tell me about that” are helpful in inducing the owner to elaborate. Given the widespread use of preventive medications in pets (e.g., heartworm, flea, tick preventative), a complete list of drugs and medications is a critical part of the clinical history. If the same sequence of history taking and physical examination is followed each time, the procedure gradually requires less time, and important facts are less likely to be omitted.


The clinical history is not inherently distinct from the physical examination. It is not uncommon for the client to be completely unaware that a physical abnormality is present until it is pointed out. When examining the patient, any unusual or unexpected physical findings justify additional inquiry as to causal relationships with the pet’s environment, diet, exposure to other animals, and so forth. For example, discovering severe abrasions on the footpads of both rear feet should prompt additional inquiry into possible causes.



Note: Failing to obtain a thorough clinical history is the first step in a missed diagnosis!



Physical Examination


The physical examination is the means whereby the clinician evaluates the health status of the patient through a methodical, “hands-on” organ system evaluation. It is a critical step in problem definition and objective diagnostic assessment of the patient. The physical examination is predicated on the clinician’s ability to distinguish normal from abnormal.


The extent of examination carried out on the individual patient varies. The “well-patient” physical examination is characteristically employed when evaluating healthy animals presented for routine health care (i.e., there is no chief complaint). The basic elements involved in the physical examination include the following:



Vital Signs


Temperature, pulse, respiration, and weight are the most fundamental health parameters evaluated when examining the patient. Capillary refill time (CRT) is commonly recorded (normal: < 2 seconds) but is a relatively poor test of peripheral vascular perfusion. Blood pressure (see Section 4) is more sensitive but requires some operator experience to obtain reliable readings and multiple measurements in the individual patient to obtain a reasonable value. Although weight is not strictly a “vital” sign, all patients should be weighed at every visit.



Behavior and Mentation


Observing the patient’s behavior, activity, and alertness in the examination room can be particularly helpful in assessing patients with significant neurologic (brain) disease. Even animals that are nervous or scared in the hospital can be assessed and should manifest reasonable awareness of their surroundings. Dogs and cats that are particularly aggressive need to be handled with extreme care, yet evaluated for possible organic brain or neurologic disease.



Conformation and Body Condition Score


Several methods exist for documenting conformation and body condition in dogs and cats. One commonly applied scale entails use of a 5-point grading system. Making appropriate entries in the medical record allows the clinician to assess, over time, changes in conformation other that just weight. Parameters for the 5-point grading scale are listed in the following paragraphs.



Grade 1/5—Emaciated



• Ribs, backbone, and pelvic bones easily seen, even from a distance


• No body fat


• Obvious loss of muscle mass


See Figure 2-1.


image

Figure 2-1: Dog with a body condition score of 1 out of 5.



Grade 2/5—Underweight



• Ribs can be seen and easily felt


• Pelvic bones are prominent


• Obvious waist and abdominal tuck



Grade 3/5—Ideal Body Score



• Ribs can be felt


• Waist obvious when viewed from above


• Abdominal tuck evident



Grade 4/5—Overweight



• Ribs hard to feel, covered by fat


• Noticeable fat deposits over back and base of tail


• Waist and abdominal tuck barely discernible



Grade 5/5—Obese



• Ribs cannot be felt under heavy fat covering


• Massive fat deposits over back and base of tail


• No waist or abdominal tuck


See Figure 2-2.


image

Figure 2-2: Cat with a body condition score of 5 out of 5.



The 9-Point Body Condition Score


An alternative 9-point body condition score for cats and dogs has also been described. In this scoring format, a BCS of 4 to 5 represents the ideal weight and conformation. A BCS of less than 4 represents underfed, underweight dogs and cats, whereas a BCS of 6 to 7 and higher represents overfed, overweight animals.



The Laboratory Database


Clinical evaluation of the sick patient entails obtaining a laboratory profile to assess and characterize biochemical and hematologic abnormalities. Laboratory test abnormalities are a critical component of the diagnostic evaluation and are necessarily included, individually, on the patient’s problem list. In companion animal practice, performing a laboratory profile meets the standard of care accepted in veterinary medicine. Although the specific test methods used and analytes assayed will vary from practice to practice, the laboratory database for any ill dog or cat should include most or all of the tests listed in Table 2-1.


Table 2-1 Components of the Minimum Laboratory Database (MDB) for Dogs and Cats































  Canine Feline
Hematology Complete blood count (CBC) includes the following:

• Total RBC count


• Hematocrit or packed cell volume


• Hemoglobin


• Total WBC count


• Differential cell count


• Total solids


• Estimation of platelet numbers


• Reticulocyte count if patient’s hematocrit is low (e.g., <30%)

 Complete blood count (CBC) includes the following:

• Total RBC count


• Hematocrit or packed cell volume


• Hemoglobin


• Total WBC count


• Differential cell count


• Total solids


• Estimation of platelet numbers


• Aggregate reticulocyte count if patient’s hematocrit is low (e.g., <30%)

  Note: Some laboratories will also provide values for the RBC indices: MCV, MCH, and MCHC. Note: Some laboratories will also provide values for the RBC indices: MCV, MCH, and MCHC.
Biochemistry Individual analytes included on biochemistry panels will vary among laboratories. (See Section 5 for a comprehensive review of the various analytes that are likely to be included.) Individual analytes included on biochemistry panels will vary among laboratories. (See Section 5 for a comprehensive review of the various analytes that are likely to be included.)
Urinalysis Includes the following:

• Specific gravity, color, and


• appearance


• Biochemistry, usually includes protein, glucose, ketones, blood (hemoglobin), and urobilinogen


• Microscopic, includes a description of cell types and number as well as presence of crystals, casts, bacteria, fat

 Includes the following:

• Specific gravity, color, and


• appearance


• Biochemistry, usually includes protein, glucose, ketones, blood (hemoglobin), and urobilinogen


• Microscopic, includes a description of cell types and number as well as presence of crystals, casts, bacteria, fat

Parasites Fecal flotation for intestinal parasites
Heartworm antigen test		 Fecal flotation for intestinal parasites
Other   Feline leukemia virus (antigen) test and feline immunodeficiency virus (antibody) test

MCH, mean corpuscular (cell) hemoglobin; MCHC, mean corpuscular (cell) hemoglobin concentration; MCV, mean cell volume; RBC, red blood cell; WBC, white blood cell.


The availability of numerous supplemental laboratory tests (see Section 5) dictates careful assessment of the initial laboratory database described. The decision to perform additional or specialized laboratory tests is based on the clinician’s interpretation of initial test results and physical examination findings.



Imaging and Special Diagnostics


The results of any abnormal findings observed with conventional radiography, ultrasound examination, or echocardiography or as a result of performing special diagnostic procedures are defined and included individually on the patient’s problem list. Routine, special, and invasive diagnostic procedures are described in Section 4.



The medical record


Documenting health care delivery and administration of medical procedures is said to date as far back as ancient Egypt, when early physicians recognized a need to record (on papyrus) details of surgery and prescriptions. Since that time, those involved in healing or treatment have acknowledged the importance of documenting health care and communicating details of successful procedures or potions either by written methods or through an oral tradition.


The problem-oriented medical record (POMR) was introduced into human medicine in 1969. This format for recording clinical information consists of a problem list; a database (i.e., results of the history, physical examination, and laboratory findings); and then, written out separately for each problem, a plan (diagnostic, therapeutic, and educational); with a daily SOAP note (subjective, objective, assessment, and plan) entered into the medical record as a progress note. A “Master” problem list served as an index for the reader so that each problem could be followed through until it was resolved. This system widely influenced note keeping by recognizing four distinct phases of the clinical decision-making process: collecting data, formulating problems (not necessarily diagnoses), devising a management plan, then reviewing the situation and revising the plan if necessary.


In veterinary medicine, a modified version of the POMR is commonly taught in veterinary schools. Unfortunately, despite the availability of published guidelines, there are no generally adhered to standards for either making medical record entries or maintaining individual patient records in veterinary medicine. This fact becomes most apparent when veterinary medical records are subpoenaed and become the subject of legal scrutiny.


The primary purpose of the medical record is to benefit the patient by documenting the standard of care provided at the time of need and to support the continuity of health care by the same or another clinician in the future. The secondary purpose of the record is to provide a medicolegal record of the care provided should there be any reason to investigate the competence of the clinicians providing care. Hence the secondary purpose of the medical record is to demonstrate the competence of the clinicians. The medical record must be respected as a legitimate, legal document and must not jeopardize the primary and secondary purposes.


Thus, a health care record can operate in the interests of a number of people and has a potentially wide audience. It is a key element in individual care, acute and preventative care, supporting and authorizing clinical care, and decision support. It provides the basis for liability in case of negligence and is a source of health care statistics.



Medical record content


Legal standards outlining the content of veterinary medical records have not been established for veterinary medicine. However, the clinician and technical support staff should consider the following information as reasonable content to include in the patient’s medical record.



Inpatient Medical Record




1. Patient identification data, including patient’s name, date of birth, breed, gender, current owner’s address, and medical record identifier or number


2. Admission and discharge date (and time)


3. Existing diagnosis(es) and date


4. Medical history, to include the following:


image Chief complaint (reason for presentation)

image Details of present illness and current medications

image Relevant past, social, and family histories

image Summary of relevant past examinations

5. Statement on the conclusions or impressions drawn from the admission history and physical examination


6. Statement on the course of action planned for this episode of care and its periodic review, as appropriate


7. Diagnostic tests ordered or recommended and therapeutic orders


8. Evidence of informed consent, as appropriate


9. Clinical observations and progress notes, including the results of therapy and the patient’s response to treatment


10. Information on every medication ordered or prescribed and administered, to include dosage and any adverse drug reaction


11. Reports of all operative and other invasive procedures performed


12. Reports of any diagnostic and therapeutic procedures and test results


13. Final diagnosis(es)


14. Recommended: Conclusions at termination of hospitalization to include a discharge summary, condition at discharge, disposition of care, and provisions for follow-up care


15. If applicable, cause of death and necropsy results



Outpatient Medical Record




1. Patient identification data, including patient’s name, date of birth, breed, gender, current owner’s address, and medical record identifier or number


2. Admission and discharge date and time


3. Relevant history of the illness or injury and physical findings


4. Diagnostic and therapeutic orders


5. Clinical observations, including results of treatment


6. Evidence of informed consent, as appropriate


7. Report of procedures, tests, and results


8. Diagnostic impressions


9. Patient disposition and pertinent instructions given to owner for follow-up care


10. Immunization record



Note: In human medicine, a list of significant medical diagnoses and conditions, known operative and invasive procedures, known adverse and allergic drug reactions, and medications known to be prescribed for or used by the patient must be started not later than the third outpatient visit.



Emergency Patient Medical Record




1. Patient identification data, including patient’s name, date of birth, breed, gender, current owner’s address, and medical record identifier or number


2. Admission and discharge date and time


3. Emergency care provided to the patient by the owner or other veterinarian before arrival, if any


4. History of disease or injury


5. Physical findings


6. Results of diagnostic tests, if applicable


7. Diagnosis(es)


8. Record of treatment


9. Conclusions at the termination of treatment are documented, to include the following:


image Final disposition

image Condition at discharge

image Instructions for follow-up care

10. Notation when owner refused medical care


11. Patient transfer information provided to other facilities (e.g., an after-hours emergency practice), when applicable, to include the following:


image Reason for transfer

image Stability of patient

image Acceptance by the receiving organization and location (address)

image Responsibility during transfer

image Documentation that relevant patient information accompanied the patient


The organ system examination


The sections that follow address indications, options, and techniques for performing examinations on the individual patient. The organ system examinations outlined here are merely intended to serve as a guide for evaluating the ill patient. The challenge for the clinician is not limited to the examination technique but entails determining which organ systems should become the subject of a more comprehensive examination.



The alimentary tract



The Dental Examination


Before examining specific areas of the alimentary system, carefully observe the general physical status of the animal, particularly noting any evidence of emaciation, abdominal enlargement or asymmetry, the position of the animal at rest, and body carriage while moving (e.g., tucked up abdomen, stiffness).


In most animals a routine examination of the mouth can be done without anesthesia or tranquilization. Gently retract the lips and examine the teeth and gingiva. When examining the teeth and gingiva of a cat or a puppy, using a cotton-tipped applicator to lift the lips and even open the mouth is particularly effective.



Normal Dentition: Canine




Formula for deciduous teeth: 2 (Di3/3 Dc1/1 Dm3/3) = 28 (total)


Formula for permanent teeth: 2 (I3/3 C1/1 P4/4 M2/3) = 42 (total)


Canine eruption dates are shown in Table 2-2.


Table 2-2 Eruption Dates of Deciduous and Permanent Teeth—Canine






















































  Age at Eruption
Teeth Deciduous (Weeks of Age) Permanent (Months of Age)
Incisor 1 4-5 4-5
Incisor 2 4-5 4-5
Incisor 3 5-6 4-5
Canine 3-4 5-6
Premolar 1 — 4-5
Premolar 2 — 5-6
Premolar 3 — 5-6
Premolar 4 — 5-6
Molar 1 4-6 4-5
Molar 2 4-6 5-6
Molar 3 6-8 6-7

In dogs, deciduous teeth should be in place by 7 to 8 weeks. Permanent teeth begin to replace the deciduous teeth by about 4 months of age. All permanent teeth should be in place at about 7 months. In some breeds, all the permanent teeth may not be erupted until about 1 year of age.



Normal Dentition: Feline




Formula for deciduous teeth: 2 (Di3/3 Dc1/1 Dm3/2) = 26 (total)


Formula for permanent teeth: 2 (I3/3 C1/1 PM3/2 M1/1) = 30 (total)


Feline eruption dates are shown in Table 2-3.


Table 2-3 Eruption Dates of Deciduous and Permanent Teeth—Feline






















































  Age at Eruption
Teeth Deciduous (Weeks of Age) Permanent (Months of Age)
Incisor 1 2-3 3½-4
Incisor 2 2-4 3½-4
Incisor 3 3-4 4-4½
Canine — 5
Premolar 1 — —
Premolar 2 — 4½-5*
Premolar 3 — 5-6
Premolar 4 — 5-6
Molar 1 — 4-5
Molar 2 4-5* —
Molar 3 4-6 —

* Upper only.

Related posts:

  1. 3: Clinical Signs
  2. 5: Laboratory Diagnosis and Test Protocols
  3. 1: Emergency Care
  4. 6: Charts and Tables

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Sep 17, 2016 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on 2: Patient Evaluation and Organ System Examination

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