Comprehensive  Ways To Delightful Healthy Pets
THE LOST ART OF THE PHYSICAL EXAM
I have seen too many exceptions to always expect the rule.
ONE OF THE MOST POWERFUL LESSONS I HAVE LEARNED FROM animals is to pay attention to details. During a fifteen-minute physical exam, I am able to assess many things. These initial minutes allow me to become familiar with the totality of the animal.
Taking the time to look and touch, I have found conditions that were not readily discernible. I have also often surprised myself and the owner by coming to a different diagnosis than the one we had all expected.
Before I even begin the hands-on exam, I have already formed an impression about the overall condition of the pet based on energy, interest, ambulation or gait, weight, hygiene, and eye contact. Dogs and cats are some of the few species that truly look into your eyes. Neck and back posture, tail action, respiratory rate, and muscle tone also tell me much about the animal before I begin to physically examine them. I might be thinking “oh my, what a lot of energy,” or “great condition,” or “oh dear, how sad,” or “an obvious problem,” or “this is a tangle that needs unraveling,” or “none of this makes any sense.”
What do I know at a glance? Here’s what goes on in my brain (enter at your own risk):
Coat. A coat should have some luster to it, and some shedding is okay. Any shaved areas should show regrowth—unless it was recently shaved—or it may be an endocrine or nutritional issue. Dull, thin, poor hair coat could be caused by a recent bad haircut or playing in a dust bowl or secondary to an underlying systemic condition (endocrine, nutrition, organ function, mange/immune). Visible dandruff? Why is it there? Generally it means poor circulation to the skin. I may have to follow up with blood work or other diagnostics.
Unique to greyhound breeds are the painful corns that are thickened, keratinized areas of the pads that can cause severe lameness. Often the corn is discovered in a limping dog after many X-rays and other diagnostics have come up with nothing. Corn pain improves when walking on softer surfaces, or if the foot is in a bootie.
When examining greyhounds, check the feet first! Corns are subtle, hidden in the keratin of the pad. They are circular, flat, much firmer, and may protrude slightly. Corns are easier to see if the pad is wet.
Curing them can involve anything from periodically soaking and curetting them away, having the pet wear a boot for several weeks, or even just sticking a small cutout of duct tape over the lesion. When you remove it some of the tissue comes off. This is repeated every few days until it is gone. Check with your vet for the most effective treatment for your pet.
Gait. The way the legs move provides valuable information about the whole animal. Dogs and cats come equipped with three legs and a spare. Even mild irritations can make them choose to avoid a leg, and over time cause muscle atrophy and secondary back pain.
Watching how an animal walks gives clues as to what, where, and how bad the pain is, anywhere in the body.
Animals that walk hunched up and as if they are on eggshells could have limb pain or arthritis. Or this kind of tentative walk could mean a sick or injured core, or serious disk or neck injury. They could also have meningitis, or a central nervous system disease such as syringomyelia. Even a kidney or liver infection, or a painful spleen from a tumor or injury could be present. The animal may be walking slowly because they don’t know where they’re going. Typically with a cognitive (brain) issue or blindness, they will high-step, or look like they are goose-stepping.
Eye Contact. Interest in surroundings, hydration status, fear, aggression, pain, anxiety, friendliness, hunger, and blindness are all visible in the eyes.
I teach all my interns to look at the retina. The retina is a thin screen at the back of the eyeball that detects light impulses and sends them to the brain. Cats and dogs have a beautiful, reflective, iridescent area called the tapetum lucidum, which can be seen with an ophthalmic lens. It can be gold, blue, green, or variations thereof. It sits behind the photoreceptors of the retina and magnifies the available light. This is how pets can see so well in the dark. If the retina becomes detached, the tapetum lucidum is no longer visible.
I learned the eye component of the physical exam from my veterinary ophthalmologist friend Elaine. When we were in vet school, her enthusiasm about looking at retinas was contagious. We each bought the fancy, expensive lens so that we could look at retinas. In order to see the retina, the pupil needs to be dilated. Medical dilation is not necessary for felines, however, because most cats will naturally dilate their pupils out of fear of vets. Fear-dilation can work as well as dilating eyedrops, and doesn’t last as long. A quick look at the retina, even when normal, can divulge secrets that other parts of a physical exam won’t. Retinal clues have helped me to diagnose Lyme disease, brain tumors, and congenital problems.
NO-JUMP MISTY AND THE BLIND LEADING THE TEST
Misty was a cat with arthritis in her hips. She was sixteen years old, very active, and had always been a jumper. She could jump onto her owner’s shoulders in one leap. One day, she suddenly stopped jumping, but everything else seemed fine. A quick visit to the vet and some radiographs confirmed that her hip arthritis had worsened in the last three years. The owners wanted to pursue acupuncture rather than anti-inflammatory meds that could affect her kidneys. I did my typical physical exam on her. She was in pretty good shape but needed some diet adjustment. Her heart rate was a bit fast and she was so scared, her eyes were fully dilated. Cats don’t generally do gait exams well. They resist walking, and if they do walk, it always looks crouched. She was no exception. I moved on. She did seem stiff in her hips on palpation. But it didn’t make sense to me that she had stopped jumping so suddenly. So I took out my ophthalmic lens.
Misty’s retinas looked like parachutes billowing in a slow wind. Misty was blind. High blood pressure had blown the retinas off the back of her eyes. The good news for Misty was that her blindness wasn’t permanent. Within two weeks, a combination of acupuncture (even one treatment can transiently lower blood pressure), medication, and supplements, Misty was able to leap to her owner’s shoulder. Her hips had never been the problem.
THE BODY SCAN BY HAND
AFTER MY FIRST IMPRESSION is made, I move on to the manual exam. Nothing is more illuminating than getting my hands on an animal. I can sense much of what is going wrong. While I am impressed by the fine detail in digital radiology and the accuracy of genetic testing, I have to get my hands on the animal before I feel truly confident about any diagnosis. The physical exam is the lens through which I read every diagnostic test.
Technology should not replace the power of our hands. Instruments are, of course, an extension of our hands. They allow us to go places and do things we couldn’t do otherwise. I have worked with many tools including MRIs, endoscopy, surgery, and others. But I never underestimate the value of a good old-fashioned physical exam.
When you have an extra minute, do a hands-on body scan of your furry friend.
I don’t expect you to be an expert on physically examining your pet. But a good place to start for most pet owners is the simple hand scan. Your hands give you information about the health of your pet through his or her skin. Heat, cold, discharge, swelling, and/or sensitivity are important signs.
Move your hands over your pet’s body from nose to tail, down each leg, under the belly, and around the tail. A body scan will make you an authority on what is normal for your particular pet. If your pet is amenable, let that scan include a quick trip around the teeth and a gander inside the mouth. Take a good sniff of the mouth and ears. Become familiar with your pet’s normal odor. Changes in an animal’s odors can be the first sign of trouble.
A body scan will also tell you if your animal is overweight. You should be able to feel his or her ribs without too much pressure. When you are aware of what is normal for your pet, you can better assess weight loss and gain.
If your pet turns his head to look at you every time you move your hand over a part of his body, that is where a painful area could be. This is called guarding. Animals, like people, can be ticklish. Over time you’ll get to know the difference between feeling a ticklish area and a painful, guarded area. Don’t forget to examine less visible places, such as under the collar or between the legs.
A cat was brought to me because she couldn’t walk well. She was in a perpetual crouch and was barely moving at home. Her family hadn’t noticed that the fur was so matted between her legs that it restricted her stride. It was basically a little fur straitjacket. We shaved the cat’s matted hair and watched her leap around the examining room.
The salutation is the first part of my physical exam. I rub and scratch around the neck. This is calming for most animals. Other comforting moves include circles around the ears, between the eyes and down the nose, or around the neck, and rubbing on the forehead. The exam will be better tolerated if the animal is relaxed.
A dance of getting to know each other takes place during the physical exam. If an animal seems resistant during this initial phase, I do not drag them over to me. Instead. I will offer something appealing, such as a terrific meat treat. Often they take the treat and retreat to a corner of the room or under a chair. But usually they will come right back when I call them because of the possibility of another treat. They will now be more comfortable because it is our “second date.” This time I won’t let them go until the exam is over.
Odor is an important part of the exam. If there are any unusual odors from the ears, mouth, or anywhere else, I take note. Infections or pH problems have a distinct smell.
Many mouths have normal black pigmentation. To check the mucous membrane color, I pull up the lips to find an unpigmented pink spot. The coloring there can be various shades of pink, I press on the gum or cheek, turning it white. I count the seconds to measure how quickly the pinkish color returns. All this tells me about circulatory health.
I look at the tongue for color, size, and coating. These qualities of the tongue are an integral part of Chinese diagnoses.
The eyes should be moist and clear and the left and right pupil size should be uniform. I note any discharge and its color. The part of the eyeball above the iris should be mainly white with just a few pink vessels in it. If this upper part looks very vascular (not white but pink or red), the eye is irritated. Causes can range from allergies to infections to corneal ulcers to just “I’m hot and excited because I’ve been straining on a leash.” If the leash is the suspected reason, I’ll recheck at the end of the exam. It is normal if the lower part of the lid, when pulled down, looks vascular. I also check the eyelid margins for any growths, and nostrils for discharge.
Next I palpate the whole body for lumps or bumps. I check for lymph nodes under the jaw, on the front of the shoulder, in the armpits, behind the knees, and in the inguinal area.
After this, I palpate the abdomen, feeling for any lumps or bumps. For a cat, I will lift up the front legs to make the kidneys more accessible. Nothing I do when I palpate the abdomen should be painful. I will back off if I feel the pet tightening abdominal muscles or “guarding” any part of the abdomen. An area might need further investigation, and I will probably repeat that palpation later in the exam.
I look under the tail, checking the anus to make sure the anal glands don’t look swollen or have any masses or discharge. In girls, I’ll check the vulva and surrounding area to see if there is discharge or saliva staining red. In boys, I’ll extrude the penis and look at the sheath to make sure everything is normal.
I conduct a range-of-motion exam for all joints on all legs, checking for flexibility, strength, heat, and arthritis.
I check the spine for motility and comfort. Enticing with a treat, I make the head move in all directions. While I’m doing this, my hand is on the animal’s neck so I can feel any spasms or tension. I rub the sides of the spine with a light pressure of my fingers—not to elicit pain, but to feel the subtlety of muscle tension, heat, or cold over an area. I don’t need to make them scream to find a problem area.
We must be respectfully cautious of technology. This includes tools. When I get out the tools, everything changes for a skittish or recalcitrant animal. One good way to ruin the friendly relationship I’ve built is to take out a tool. I have to be surreptitious about it. Once they see me about to use even a harmless stethoscope, the animal often acts as if I am an alien. (I guess they don’t remember our first two dates.) I may place the treat on the tool and let them come over and sniff it. From then on, I must act with efficiency and speed. I use an ophthalmic lens and a light to look in the eyes and see the retina, searching for anything abnormal. I inspect the ear canal all the way to the tympanic membrane, looking for any ectoparasites, infections, discharge, or growths.
Finnegan, a twelve-year-old overweight Labrador with severe joint and spinal arthritis, was afraid to use stairs. He had had several bad falls because his rear legs were weak. He avoided stairs and wouldn’t use his painful rear legs. His weight was shifted forward off his rear legs when he walked—about 75% of his weight was on the front legs and 25% on the rears when it should be about 60% front and 40% rear. His atrophied muscles made the rear legs even more unstable. His owner brought him to me for therapy. First we had to alleviate the pain and inflammation. Acupuncture, weight loss, and a new diet worked wonders. The underwater treadmill helped him regain his muscle strength. Finally, we had to convince him to use the stairs again. This proved difficult until we hit upon the idea of putting treats on every step. It worked like a charm.
Finally, I take out my old friend, the one piece of equipment that goes with me everywhere, the stethoscope. As I place it on the chest, I feel the inside of the thigh where the femoral pulse is palpable. I assess the pulse with each beat of the heart, looking for three things: force, depth, and width. This is part of a Chinese diagnosis. I am also looking for pulse deficits. I listen to the heart for murmurs or odd beats. I auscultate the lungs and along the trachea to discern any respiratory noises. If I’m concerned about the GI tract, I put the scope on the four quadrants of the abdomen, listening for borborygmus (one of my favorite words), meaning the rumbly tummy noise heard in the digestive tract.
If there is an orthopedic problem, I’ll take the animal into a bigger space for a comprehensive assessment of their gait.
People like to say that “numbers don’t lie.” But numbers can be skewed for many reasons. Without a framework, the tests and numbers can be misleading. The physical exam is a reliable framework for my integrative practice.
LAMENESS IN YOUR DOG is more obvious than lameness in a cat.
Most lameness is easiest for owners to see when an animal is walking. An animal can often hide lamenesses better when running.
A client came to me in a panic. The family had moved, and he had taken his Weimaraner, Nala, to the local vet, who had found extremely high blood pressure (over 200 mm Hg systolic). I had already been treating Nala after knee surgery and the owner still drove to me for post-op therapy sessions. We discussed the blood pressure results. I remembered when I had first seen her three months before: She had been so terrified that she had to be carried into the exam room. She was shaking uncontrollably. I asked if that was her normal behavior or was exhibited only at the vet. The owner told me that Nala shook when she went into any building other than the houses she knew. She was a rescued pet and no one knew her history. Over the course of therapy, she had become so relaxed with us that she would run into my clinic. Her physical exams had been great and she was doing well. It didn’t make sense to me that she would suddenly develop high blood pressure. I suspected that she had been terrified at the new vet, just as she had been when she had first met me. The owner confirmed that she had been seized by a full-on terror with the new vet. We recommended having her blood pressure taken at home. It turned out to be normal.
Use common sense and double-check a result if it seems unlikely. Paying more attention to the numbers than the patient can be dangerous. Giving Nala the recommended blood pressure medication could have been harmful to her.
This means a front leg is most likely the issue. “Head down on sound” means that an animal’s head will be down while stepping on the leg that is the “sound” leg. In other words, it is not the painful leg. The head will be lifted to decrease pressure as they put their weight on the painful leg.
The leg that is lame is kept off the ground longer, letting the other legs do the walking.
Walking on the knuckles is a sign of slowed reflexes through the spinal cord, usually from disc disease. Occasionally it can be caused by significant weakness in a leg, joint inflammation, or a neurologic disease.
Check for soft tissue injury if arthritic animals are suddenly lame on a rear leg. Long-standing arthritis does not typically cause sudden-onset lameness.
A limping dog may just be trying to get attention. Not true. Lameness, in most cases, is caused by a physiological problem.