section epub:type=”chapter” id=”c0003″ role=”doc-chapter”> Vicki Thayer Cats are masters at hiding illness and delivering obscure and sometimes confusing messages through their behavior. Preparing a complete medical history and performing a feline-centric physical examination are two essential tools for resolving patient issues and informing clients of the best means to keep their feline companions healthy. Working to establish relationship-centered care helps the veterinary health care team deliver the consistent message that cats benefit from routine examinations and wellness health care to increase the length and quality of their life. Medical history; physical examination; communication; adherence; compliance Cats are masters at hiding illness. (Dr. Jim Richards) Above all, by working together as a unit, the veterinary health care team can deliver a consistent message: that cats benefit from routine examinations and wellness health care, along with early disease intervention, thus increasing the length and quality of the feline companion’s life. Emphasizing this message should be the goal of the veterinarian during all interactions with the client and patient. All clients expect the veterinarian to care about cats and to care about their cat in particular. By using the cat’s name and referring to its sex correctly and by eliciting and acknowledging the client’s comments, the veterinarian builds on the bond with the client and cat and provides a strong foundation for meeting the client’s expectations. Use of respectful and appropriate handling techniques further enhances the veterinarian’s message while minimizing the stress and anxiety many cats exhibit during veterinary visits. A friendly introduction, handshake, and extending greetings to the cat as well as the owner can be invaluable in establishing rapport. A model for demonstrating concern for the patient and enhancing the clinical interview using distinctive, describable behaviors is well established in human medicine. A similar concept in the veterinary field is called relationship-centered care.1 Studies suggest that organizing these communication skills into a pattern of behaviors or habits is integral to the process and outcomes of medical care. The “Four Habits” model quickly establishes rapport and builds trust, facilitates the effective exchange of information, demonstrates caring and concern, and increases the likelihood of compliance and positive health outcomes for the patient (Box 3.1, Fig. 3.1).2 The goal is to achieve a joint effort between the veterinarian and client to provide optimal care for the cat.3 Further detail regarding improving compliance will be covered later in this chapter. With today’s electronic media, the veterinarian can obtain relevant information for building an initial history before the kitten or cat visits the hospital. For example, many owners use e-mail and social networks to communicate their observations and concerns. Sending a history questionnaire to the client, either electronically or by regular mail, is an effective way to gather information for a new or extended patient medical evaluation before the scheduled visit. Furthermore, this questionnaire can be used when an owner cannot be present for the history taking and physical examination (e.g., when patients are dropped off or accompanied by another family member). Having correct contact information and a method or time for follow-up ensures accurate communication at the beginning of the client–veterinarian relationship. The veterinary team can also establish an initial history when the appointment is scheduled or during client and patient check-in. Specific questionnaires can also be developed for different medical issues, such as behavior or mobility problems and cognitive dysfunction.4–6 Histories must be consistent and comprehensive. Open-ended questions requiring a definitive response rather than a simple yes or no result in the best answers. The following are examples of open-ended questions: “What was the last day you noticed a normal appetite?”; “How is your cat eating?’; “When did you last notice a normal volume and consistency of stool?”; “What other changes have you noticed?” The client’s initial responses can lead to more specific questions or prompts to continue (e.g., “Please describe what you have seen”; “What else?”; “Go on”) to help define a specific problem (Table 3.1). Studies indicate that using fewer lifestyle/social closed-ended questions and more open-ended inquiries provides more medically-related education and communication of emotional rapport, which elicits more medically-informed responses and engagement by clients.3 Questions should also be asked in a positive, rather than accusatory manner, for example, “What kind of treats or table scraps does your cat get?” will often get a different answer than “How many treats a day does your cat get?” By repeating key information provided by the client, veterinarians demonstrate that they are paying attention and care about the client’s perspective. With the improvements in record keeping through electronic medical records on computers or tablets, it is important to achieve balance between attending to the needs of the patient and the client versus recording medical information in the patient record. Maintaining eye contact with the client, listening to their comments, and not having the client feel the computer or note-taking is a barrier to their answers being understood and accepted is a valuable skill. Furthermore, demonstrating the various behaviors and sounds cats make with certain conditions (especially with the use of sample videos), such as when coughing, regurgitating, or vomiting, can help owners better describe their cat’s signs. Clients should also then be asked about the frequency of regurgitation as well as vomiting as many recognize these as separate entities. If clients cannot give clear histories when questioned, recommending the client keep a calendar or diary reporting when the clinical sign occurs along with how many times a day and a description of what is produced (e.g., fluid, mucous, digested versus undigested food, hair, bile) is a good option. By videotaping signs or behaviors and sharing the video with the veterinarian via email or text message, or on social media, the client can communicate a complicated or an infrequently noted problem. This is also a useful way for the veterinarian to monitor the ongoing status of a case, especially when the cat becomes highly stressed during veterinary visits and is therefore difficult to examine. The author has prior experience with this method where a patient had a slowly improving right tibial nerve and hock injury requiring a series of re-evaluations for the condition and the need for rebandaging. Hospital visits were problematic, and video monitoring allowed for effective and less stressful follow-up. Table 3.1 Adapting the communication style depending on the client’s age group and individual preferences may be constructive. For example, some elderly clients require extra time and a more sympathetic ear for their concerns. Other clients prefer the veterinarian to get started quickly doing their work and spend less time on informal conversation. On the other hand, some younger clients prefer to communicate using newer technologies and social media. A more focused set of interview questions and additional attention to treatment compliance may be necessary to ensure understanding for different types of individuals. For example, reminders for follow-up examinations, vaccinations, testing, dosing, and medication refills can be accomplished using email or especially text reminders that are frequent communication methods for the millennial generation. Sharing patient updates by text is also a great way to communicate with clients and alleviate concerns. For all clients, it is preferable to ask about their preferred communication method: text, email, or phone call. Signalment collection is part of the initial informational stage and includes age, breed, sex, and reproductive status. There are different wellness and disease concerns for kittens (up to 6 months of age), junior (7 months to 2 years), adult (3 to 6 years), mature (7 to 10 years), senior (11 to 14 years), and geriatric cats (15 years and older) (see Chapter 8: Preventive Health Care for Cats).7 Often, other factors such as diet, behavior, and medication history are more significant considering the patient’s age group. Including questions about where the cat was acquired (e.g., cattery, shelter, rescue group, found as a stray) or whether the cat previously lived or recently traveled in another geographic location helps define essential elements of the history. Cats adopted from shelters are more likely to have been exposed to infectious disease agents (e.g., feline herpesvirus). Veterinarians practicing in the United States Pacific Northwest region are less likely to diagnose feline heartworm disease in a cat raised locally than in one that was recently relocated from the Gulf State region and is not on a heartworm preventive.8 Inquiries about a cat’s breed should include information about the general health of its lineage, including parents, siblings, and any offspring. In this scenario, the veterinarian may be determining if there is a genetic cause for a certain condition. Knowing if this clinical presentation has been recorded in the breed or found in any close relatives indicates if further genetic testing or counseling might be necessary. An increasing number of kittens and cats adopted from shelters, as well as strays and owned cats, have been microchipped. Each new patient should be scanned, preferably with a universal microchip scanner, to confirm the presence of a microchip and document the radio-frequency identification (RFID) in the patient record. According to research, rescanning during annual examinations ensures that the microchip remains functional and has not migrated. Also, encouraging clients to register the microchip number and keep their personal information current with their microchip registry helps reunite the client and cat in case of separation.9 Established in 2009, the American Animal Hospital Association operates an online microchip look-up tool which is available for association of a microchip number with one of several participating microchip company registries to help access a client’s contact information.10 Clients should be made aware that some companies do not participate in this online search tool and those companies’ registries would have to be determined and then contacted individually. While being a worthwhile identification method, clients should be made aware of these challenges and the lack of uniformity in the microchip industry. If no microchip is present, further discussion of the benefits of microchipping or another form of visual identification is warranted. A new kitten or new patient visit is a great opportunity to discuss behavior. An unaddressed behavior problem can lead to a diminished cat–human bond and increase the cat’s risk of being relinquished to a shelter or euthanized. An initial set of behavior-based questions can help clients and veterinarians explore this issue. Some undesirable behaviors (e.g., urinating outside the litter box) may be the result of an undiagnosed medical condition. Further, a discussion of general litterbox habits is appropriate.11 Reviewing behavior during the kitten visits also helps the client understand the interactions required during the early socialization period from 2 to 7–9 weeks of age. Proper bonding and socialization early in the kitten’s life leads to fewer behavioral problems later in life (Fig. 3.2).4 A complete vaccination history documenting the types and dates of vaccinations, especially those given prior to and when the client first acquired the kitten or cat, is a critical step in building a complete patient medical history. It is important to note and highlight any past adverse reactions to vaccinations and follow up with a discussion of the potential disease risks and benefits associated with an immunization program. Age, health status, and whether the cat is kept indoors or has regular outdoor access are primary risk determinants. Even cats that are kept inside should not be considered strictly indoor creatures because outdoor pathogens and parasites can be brought indoors, and cats may periodically escape outside. Because of this possibility, vaccination against rabies remains an essential recommendation for cats in communities where it is required by statute/law or where the virus is endemic.12 Clients should be asked whether preventive drugs for heartworm, fleas, and other external and internal parasites are used; if they are, the veterinarian should note the product, dosage, and application interval in the medical record. A cat’s retroviral status (feline leukemia virus and feline immunodeficiency virus) is also an essential part of a complete history. Retrovirus testing is performed at different times in a cat’s life, and the dates and results should be documented in the medical record. Depending on the responses and history obtained thus far, the key retrovirus risk factors (e.g., male sex, age, outdoor access) can be explored with the client to determine the need for initial testing or retesting.13 Nutrition, especially diet type and source (including treats), and daily caloric intake are other important components of a cat’s medical history. A nutritional assessment is considered the fifth vital sign.14 Because a dietary change can either create or resolve an acute or chronic medical condition, updating the patient’s nutritional history is a recommended practice. Further, because some clients do not know the brand, flavor, type, and amount of food consumed by their pet, persistent questioning and follow-up may be required. Having clients complete a previsit questionnaire15 or bring in photos of all the canned food, dry food bags, supplements, and treats being offered aids in acquiring this important information. This issue becomes especially important when there is a significant change in the cat’s weight and body condition score (BCS) (Fig. 3.3). A change in weight may also affect the prescribed dosage of a medication. For example, because prednisolone does not appear to distribute to adipose tissue, the dosage for obese cats is based on ideal or lean body weight instead of current body weight.16 In addition, incorporating muscle condition scoring along with a BCS allows early detection of muscle wasting and monitoring the status of a chronic disease. (Fig. 3.4) Questions regarding water sources, water intake, and the amount and type of urine and feces produced by the patient can follow. Using a fecal scoring system can also aid in evaluating the consistency of stool. Changes in fecal consistency can signal the presence of diarrhea or constipation. (Fig. 3.5) Using veterinary software to track the nutritional history and maintain contact information is beneficial in the event of a pet food recall. The significance of the 2007 melamine contamination of pet food demonstrates the value of dietary information management.17 Given the increasing importance of environmental enrichment to cats’ physical and emotional health, a description of a cat’s environment should be included in each patient’s history. Discussing the cat’s environment is more than just a question of “indoor, outdoor, or a mix of both.” Questions regarding time spent on leash walks, in “catios”, free roaming, or in other outdoor activities adds detail and understanding to the discussion. Access to toys, other cats, and other animal species are also important factors. Encouraging clients to include cat trees, elevated perches, and other vertical accessible spaces for climbing and exercise is an effective way to meet the cat’s essential environmental needs.18 Additional history is required when the client seeks veterinary care for an existing complaint. Knowledge of current and past medications, as well as prior laboratory test results, may help clarify a medical problem or spur additional issue-oriented questions (e.g., “How did the cat respond to treatment?”; “Did anyone have difficulty giving the medication?”; “Were there any side effects, and if so, what were they?”). Specific questions should be asked about the name, dose, and frequency of administration of prescribed medications because clients sometimes make changes without consulting the veterinarian. Moreover, clients may not report the use of nonprescription medications or supplements unless questioned directly. Requesting a client to bring in all medications, supplements, and treats that pass the cat’s lips will aid in determining compliance (more appropriately termed adherence), with treatment or any incompatibilities between medication or food and liquids ingested.19 In addition, it is important to note any oral, topical, or injectable prophylactics administered at home. Three common general presenting clinical signs are anorexia, lethargy, and a change in normal behavior (e.g., hiding). Clients regularly report one or more of these general signs when asked to describe their cat’s problems. It is important to elicit the client’s observations during the history, not their conclusions. Questions focusing on specific observations by the client before the onset of the problem and during the initial phase help the conversation move from generalizations to a specific description. Responses also help the veterinarian establish a timeline for additional intervening signs. The following are examples of questions that might prompt such responses: “Was the onset acute or gradual?”; “Were the signs steady or intermittent?”; “Has the problem occurred previously, and if so, what was the response?” Evaluating the client’s answers helps the veterinarian determine the diagnosis, develop a list of possible causes, and decide on subsequent diagnostic planning. However, diagnosis can be fluid; new or different medical problems may emerge after the initial diagnosis. If so, the veterinarian may need to ask the client additional questions, further observe the patient, and re-evaluate the original diagnosis. An effective medical history summarizes the known health situation and the needs and potential problems of the patient (Table 3.2). The next step, a comprehensive physical examination, helps assemble the pieces of the puzzle. Table 3.2
Deciphering the Cat: The Medical History and Physical Examination
Abstract
Key Words
INTRODUCTION
ESTABLISHING RELATIONSHIP-CENTERED CARE
THE MEDICAL HISTORY
Initial Information Phase
Routine History
Prior and Existing Complaints
Signalment
Age, breed, sex, and reproductive status
Locality
Disease prevalence in current and prior geographic locations
Acquisition
Private home, shelter, stray, pet store, or breeder
Environment
Primarily indoor, outdoor, or both; other household pets; city, urban, or rural; possible toxin exposure; layout of home and yard
Vaccinations
History and any adverse reactions
Parasite Control
History and treatment, current and prior
Diet
Canned food, dry food, or both; brand and quantity; raw food; hunting prey; treats and supplements
Microchip
RFID number, registry information, periodic rescanning
Retroviral Testing
Dates, results, and risk evaluation
Prior Medical History
Illnesses, medications, adverse reactions, laboratory tests and results
Existing Complaints
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