Introduction

Keeping the physical exam procedure as consistent as possible ensures that the entire animal has been examined in a systematic manner. It is important to investigate all body systems when presented with clinical signs as premature diagnosis is a slippery slope that can lead to wrong treatment plans.
Below are the categories of body system with Gigi the cat, featuring Buster the dog.

By Ketherine Li BVSc III
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Methods

The method I chose is via anatomical order.
By starting by the head and ending with the tail, I can be sure that I have covered all anatomical aspects.
Below are the physical exam procedures organised by body systems.

Species Specific Considerations

Dogs and cats have distinct physiology and anatomic make ups which must be reflected in how we perform their physical exams. Techniques that work for the dog may not be appropriate for the cat and vice versa.
Below are species specific aspects of the physical exam separated by body system.

General assessment

Clinical presentation and thorough history taking is essential in order to direct our physical exam.
Body condition score, weight and coat condition can give valuable information about the animal’s overall well-being. Palpate the fat covering over the ribs and look for abdominal tuck for body condition score. The coat should have sheen, be well groomed especially in cats.
Comparison to previous physical exams can pick up subtle changes that may not be noticed by the owner.
A thorough history should always be taken as small nuggets of information can profoundly change your list of differential diagnoses.

Dogs

• Walk the dog around the waiting room to assess lameness or neurological signs (ex: Vestibular disease).
• A general assessment of gait and demeanour in the waiting room can be done before stressful handling.
• Additionally respiratory effort, rate and any audible noise can be observed from afar, with minimal masking/interference by the sympathetic nervous system triggered by veterinary procedures.
• Blood pressure can be done in the waiting room for similar reasons [1].
• Most breeds have specific ideal weight ranges.

Cats

Leaving the cat in the carrier while taking history allows the cat to settle in a strange environment. Stand behind or beside the cat, never in front. With cats, minimal restraints and contact is usually better tolerated.

Head

Musculature

Palpate/visualise the muscles of the head for muscle atrophy or masses. There should be symmetry.

Ears

• Check pinna for any nodules/scabs.
• A healthy ear should have smooth epithelium, no inflammation and minimal to no discharge.
• Olfaction can be useful in determining if there is otitis externa.
• Gently pull the pinna upwards to straighten the horizontal ear canal and insert otoscope. The tympanic membrane should be opalescent, intact, and without erythema.

Be sure that the ear piece is appropriately sized for the animal.

Eyes

• Check for any discharge, crusting or alopecia around the eye.
  • There should not be spasming or paralysis of the eyelid.
• The cornea should be clear and smooth. Check for any ulceration. Further testing such as fluorescein dye may be needed.
• Assess lens opacity/density.
• Examine the iris for colour change which may be an early indicator of uveitis.
• Gently depress the globe and lift the eyelid to visualise nictitating membrane for inflammation or jaundice.
• Check pupil size - it should be appropriate for the light level and bilaterally symmetrical. A pupillary light response can be undertaken at this time.
• The sclera should be white with minimal vascularisation. Jaundice can be picked up here.
• Check the anterior chamber for cellular deposits. This is best done by looking side on.

Geriatric Patients

Intra-ocular pressure measurement should be done on senior pets and breeds predisposed to glaucoma (pugs, Persians) [2].

Nose

• Check the nasal planum for ulceration or depigmentation.
• Classify any nasal discharge as unilateral/bilateral and determine type of exudate.
• Check airflow is patent through both nostrils by assessing condensation on a microscope slide. The nostrils should move gently with respiration.

Cats

• As cats are dedicated to cleanliness, any nasal discharge must be significant as it has overcome the grooming threshold.

Dogs

• Excessive licking should prompt investigation for increased nasal discharge.
  

Mouth

• Check that the lips are symmetrical.
• Elevate the upper lip to assess mucous membranes. They should be pink and moist. Capillary refill time should be under 2 seconds when moderate pressure is applied.
• Look for peridontal disease or gingivitis. Calculus build up, tooth fractures, abnormal wear of teeth, retained teeth or absence of teeth should be assessed at this time [2].
• Early signs of icterus can be seen in the soft palate.
  

Cats

• The mouth can be easily opened by grasping the top of the maxilla and pointing the nose skywards. The jaw should fall open passively and can be opened further by placing pressure at the intermandibular junction.
• Check underneath the tongue for any masses, lesions or string foreign bodies that can be wrapped around the base.
  

Dogs

• Gently open the mouth using one hand to grasp at the diastema of the upper muzzle while the other hand depresses the lower jaw.
  
• It is best to leave this for last as some dogs will resent having their mouths opened.

Neck

Jugular veins

• Wet the area of the jugular veins and check if prominent distension or pulsation. If so, this is an indication of right sided heart failure and further testing should be done.
• Sometimes jugular vein distension can be difficult to visualise. If suspecting heart failure, gently place pressure on the abdomen caudal to the liver for 10-30 seconds. The jugular vein should not distend in a normal animal.

Thyroid

• Palpate adjacent to the trachea right down to the thoracic inlet while the head is elevated, feeling for a thyroid flick. Be sure to feel more laterally as well to detect an enlarged thyroid if present.
  This is not normally felt in a young, healthy cat.

Larynx

• Palpating a larynx should elicit a swallow. This is a non invasive way to assess the gag reflex.

Trachea

• Gentle yet firm pressure on the trachea should illicit a single cough. Protracted coughing may indicate pathology causing increased tracheal sensitivity.

Mandibular Lymph Nodes

• Sift through the soft tissue behind the ramus of the mandible for a small, firm, bean shaped lymph node.
• Do not confuse with the salivary gland caudally which are larger lobulated and softer.

Pre-scapular lymph nodes

• Feel in the region of the remnant clavicle. The lymph nodes should be small, firm and discrete.

Auscultation

Note: it is better to do auscultation while the animal is standing.

Heart

• Determine if there are any murmurs or gallops. Use the species specific directions next to this card.
• Determine if there are dropped pulses or pulse deficits by palpating both femoral veins simultaneously, then also in conjunction with auscultating the heart. They should occur at the same time. Assess for pulse amplitude and symmetry.
• Normal heart sounds, ‘lub-dub’, should be crisp and clear.
• Palpate the cardiac apex beat at 6th intercostal space for intensity and any thrills [5].
• Be sure to take into consideration stress/post exercise physiological alterations.

Cats

• Normal heart rate for a cat is 120-200 beats per minutes.
• Auscultate for murmurs in the sternal and para-sternal areas while standing as the sternum can magnify any sounds.
• Gallop sounds are usually S4
• Determining femoral pulse is especially important in the cat due to the increased incidence of aortic thromboembolism. Check for concurrent signs such as cyanotic paw pads, sudden onset hindlimb paralysis, and heart enlargement.
• Take care as diagnosis of cardiac disease in cats is difficult as few clinical signs are present and auscultation is present in 30% of cats with heart disease [2].

Dogs

• Normal heart rate for a dog is size/age specific. Small breed = 100-160 beats per minute. Large breed = 70-90 beats per minute. Puppies can have respiratory rates as high as 220 [5].
• Ensure the dog is standing and place the stethoscope over the points of maximum intensity for the:
  -pulmonary valve (low left 3rd intercostal space under the elbow)
  -aortic valve (higher left 4th intercostal space)
  -mitral valve (low left 5th intercostal space slightly dorsal to costochondral junction) and
  -tricuspid valve (right 3rd intercostal space at the level of the costochondral junction) [4, 5].
• The muzzle may be held closed if the animal is panting.

Lungs

• Further assessment to the respiratory movements should be taken with as little handling as possible to minimise stress.
• Determine if there is any wheeze, stidor or stertor. If so determine on what phase of respiration it is most prominent.
• Assess if there is increased respiratory effort.
• Auscultate the lung fields and listen for increased/decreased noises or crackles. Place stethoscope cranially and caudally, ventrally and dorsally on both sides.
• Percussion with 2 fingers against the chest wall may reveal hyper-resonance indicating pneumothorax. Hypo-resonance may indicate increased soft tissue or consolidation of the area.
• Be sure to listen over the trachea/larynx as well to prevent misdiagnosis due to referred sounds from the upper airway.
• If hearing gut sounds in the thorax, this indicates diaphragmatic hernia and further tests should be done.

Cats

• Normal respiratory rate for a cat is 20-32 breaths per minute.
• Thoracic cavity in cats is compressible. Resistance may indicate a space occupying mass [3].

Dogs

• Normal respiratory rate for a dog is 10-30 breaths per minute.
• Dogs may pant if stressed, warm environmental temperature, or had just exercised. Panting if none of the above is present may indicate pathology. It is best to get the owner to do a sleeping respiratory rate to get true results.

Gut sounds

• Increased sounds may indicate increase in gut transit times and movement.
• Decrease may indicate obstruction or ileus.

Abdominal Palpation

Kidneys

• It is usually not be possible to feel both kidneys in a healthy animal.
• Firmly press palms together on both sides of the abdomen until there is only abdominal wall between the fingers. Move pressure upwards and ‘pluck’ the kidney from the dorsal wall.
• Shape, firmness and smoothness can be assessed. Any deviation from the expected can indicate kidney disease.

Dogs

• Normally only the tip of the left kidney can be palpated. The right kidney sits within the rib cage, but may be felt if enlarged.

Cats

• The right kidney should be 4-5 cm long, smooth and firm on palpation. It can be located along the caudal border of the ribs at the midline.
• Feel for any irregularity in shape/size. Fluid structures may be present in polycystic kidney disease.

If the animal remains tense despite steady gentle pressure or vocalises, this indicates abdominal pain and further investigation is warranted (may just be stress however).

Intestines

• Bring the fingers together in the caudal abdomen, feeling the loops of intestines slide through. Any thickening/masses, intussusception, or foreign bodies may be palpated.
• The colon can be felt in the dorsal caudal abdomen as a tubular structure 1-2 cm in diameter. Placing pressure here can be painful if the animal is constipated.

Liver/Spleen

• Determine if there is any enlargement of the liver or if any masses are present. The liver should not be felt unless enlarged.
• Palpate the abdominal floor for splenic enlargement.

Dogs

• The tip of the spleen may be felt in a normal dog.

Bladder

• The bladder can be palpated in the caudal abdominal floor as a fluid filled structure that is likened to a balloon. It can be trapped between the fingers and thumb for manual expression or cystocentesis. If the animal has just voided it will be too small to palpate.

Urogenital Tract/ Rectum / Tail

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Urogenital Tract

• Check the vulva/prepuce for any discharge or bleeding.
• The vaginal vestibule/prepuce can be assessed for trauma and conformation.
• In the entire male animal, the scrotum should be gently palpated to ensure both testes are present. If indicated, the prostate can be examined.

Dogs

• Serous discharge from an entire female dog may be normal during oestrus.
• Haemorrhagic discharge from entire female dogs is normal during dioestrus.

Cats

• Vaginal discharge not usually seen in entire female cats due to grooming habits.

Rectum

• The anal sphincter should be constricted and pucker on pressure in the perineal region.
• Check the anal glands for symmetry, size or pain [2].
• Temperature can be taken during this time. Be sure to insert the probe an adequate distance and place against the rectal wall for a true reading.
• A rectal exam may be required if the animal is straining to defecate but is not indicated for a routine exam.

Dogs

Normal temperature index = 37.5-39.3 degrees Celcius

Cats

Normal temperature index = 38.0-39.3 degrees Celcius

Tail

• Palpate the tail for any nodules, scabs or lesions.

Integument

Fleas

• Use a flea comb to assess flea dirt or flea presence on the animal. Best place to assess this is at the tail base.
• Feel the entire integument for scabs, masses or lesions.
• Brush the fur forwards to examine the skin for erythema, nodules or excessive dandruff.
• Expose the nail bed to assess for fungal growth.

Cats

• Check the ventral chin for feline acne.
  
• Check the pre-auricular area for any alopecia which may indicate allergy.
• Check for any nodules on the head and neck are common areas for miliary dermatitis manifestations.

Musculoskeletal System and Additional Lymph Nodes

Musculoskeletal System

• Palpate each limb individually and assess full range of motion. There should be no pain upon a normal range of flexion and extension of all limb joints.
• Palpate the muscles for atrophy, masses or pain. Palpate the joints for thickening/heat/swelling.
• Muscle tone should be examined at the same time as joint mobility [2].
• Examine the digits and skin of footpads or erythema or cracking.
  

Dogs

• Comfortable range of motion can be determined by gently moving the head.
  Dorsal range - Lift head with support to look at the ceiling.
  Ventral range - Tuck head to touch pectorals.
• Move head laterally on both right and left sides until almost parallel with the thorax to assess lateral motion.
• Limb assessment and weight bearing should be done standing. Paw proprioception for neurological soundness can be conducted quickly at this time.
• Watch facial expression as some dogs will be stoic and not vocalise pain.

Cats

• Assess the limbs in lateral recumbency.

Additional Lymph Nodes/Glands

• All peripheral lymph nodes should be assessed for size and symmetry [2].
• Inguinal and axillary lymph nodes should not be palpated in a normal animal. Assess for any enlargement.
• The popliteal lymph nodes sit between the belly of the gastrognemius muscle. Do not confuse for the ventral fat pad. The popliteal lymph nodes are more discrete and firmer.
• Examine the mammary glands and determine if any masses. Lift gently underneath each axilla.

References

1. Barrs, VRD 2006, ‘Respiratory Patters - A Diagnostic Aid to Feline Respiratory Disease’, Australian College of Veterinary Scientists at Science Week, Combined Small Animal Medicine Chapter and Feline Medicine Chapter Meeting.

2. Beijerink, N 2015, ‘Anatomy and Physiology of the Normal Heart’, lecture notes distributed in the Unit of Study VETS 3244 Small Animal Therapeutics and Medicine, University of Sydney, Camperdown on 7 August.

3. Mader, Douglas 2013, Physical Examination: The Cornerstone of Veterinary Medicine, Marathon Veterinary Hospital, Marathon, viewed 24 August 2015, http://www.cliniciansbrief.com/article/physical-examination-cornerstone-veterinary-medicine#b51kaaotv00ix2h

4. Naylor, JM, Carr, AP & Walker, RE 2009, Canine Cardiology: A multimedia Guide to Cardiac Auscultation, Vet Visions, viewed 1 September 2015, http://www.vetvisions.com/p411.htm

5. ‘Standards of care: Regular health check standards for dogs and cats’ 2013, The Australian Veterinary Association,viewed 23 August 2015, http://www.ava.com.au/sites/default/files/AVA_website/ASAVA/ASAVA_StandardsofCare_Web.pdf