PHYSICAL EXAMINATION RECORD

Preparation for the initial contact time with the client and patient should begin with a system of record keeping. Ambulatory records are usually more flexible than “in-house” hospital admission forms. Both field and clinic forms should include designated spaces for the client or agent’s address and phone number. An area for the complete signalment (name, sex, breed, color, age), including an estimated weight, should be provided. If the patient is unnamed, as with foals, it should be listed in the dam’s name with the year of birth (e.g., Curious’ 06). The sire’s name should not be used because more than one foal per year would be expected from a stallion’s crop. Whenever surrogate mares produce multiple foals from a single embryo transfer dam, a new system of naming and identification will have to be incorporated. Additional identification of the patient may include a lip tattoo, freeze brand, or microchip number and if available should be noted in the horse’s record. By 2009 the federal government will have in place a system that uses microchip technology to permanently identify and track the movement of all species of livestock, including Equidae. In the event of a disease outbreak, rapid identification and surveillance of affected or exposed individuals will be possible. The National Animal Identification System (NAIS) will allow all livestock owners, including hobbyists, to enroll and participate in this program.¹

EQUINE INSURANCE

If the animal is insured, this should be documented, preferably with the insurer’s telephone number. In addition, the type of insurance should be noted (e.g., mortality and/or surgical and medical). It is the client’s or his or her agent’s responsibility to notify the insurance company representative whenever an animal insured for full mortality contracts an illness or sustains an insult, life-threatening or not, that requires a veterinary examination. If the patient is insured, it is considered a professional courtesy for the veterinarian to also communicate directly with the insurance company, especially with a life-threatening illness. Also, permission from the insurance company is required whenever a general anesthetic, surgical procedure, or euthanasia is to be performed. Whenever euthanasia is requested, the insurance company may require a second opinion from an adjusting veterinarian. If a direct representative from the insurance company cannot be contacted immediately, the clinician must exercise professional judgment in assuming the responsibility for a humane or critical decision. The client or agent should be in agreement with the decision, and all communications and pertinent data should be documented in the medical record. If a necropsy is to be performed, it should preferably be in the presence of another veterinarian from a different practice. The American Association of Equine Practitioners (AAEP) provides an insurance pamphlet as a guide to veterinarians.² Table 2-1 is an abbreviated list of the types of equine insurance offered.³

Table 2-1 Equine Insurance

Type of Insurance*	Coverage	Role of Attending Veterinarian
Perils	Covers mortality claims for shipping accidents, fire, and natural disasters such as lightning	Inform clients of responsibility to inform insurance company
Mortality†	Covers mortality claims for all life-threatening conditions (e.g., colics)	Inform clients of responsibility to inform insurance company of any anesthetic, surgical needs, or euthanasia
Use	Covers a loss in intended use (e.g., racing, fertility)	Inform clients of responsibility to inform insurance company of any anesthetic, surgical needs, or euthanasia
Major medical or surgical	Covers payment of medical or surgical costs with set limits based on policy	Inform clients of responsibility to inform insurance company before procedures Supply estimate of cost to client Policy is in addition to mortality coverage

* The client is responsible for the costs of veterinary care and treatment unless a medical and surgical policy exists.

† Fetal mortality insurance covers unborn foals, usually until 24 hours after birth.

HISTORY

The medical history should be directed to the clinical problem. The “herd health” of the stable or farm is briefly depicted by the vaccination and parasite control program. The diet should be determined, including supplements, the grazing environment, stall or housing schedule, and the medical problems concerning other animals on the premises that may coincide with a group incidence of the client’s complaint.

When a veterinarian is dealing with neonates, the reproductive and foaling history of the mare is important in establishing an early diagnosis. Any compromise to the mare’s gestation (e.g., systemic disease, general anesthesia, or administration of certain medications), foaling, or lactation; placental abnormalities; and any problems that occurred during previous pregnancies should be questioned and considered to be important, pertinent historical data.

A description of the types of medication used before hospitalization may aid in determining if “masking” agents have inadvertently been used. Tranquilizers or sedatives are frequently used for vanning and shipping purposes, and in many instances a van driver or hauler is unaware of medications used or the patient’s medical condition. Analgesics such as flunixin meglumine, which are often inappropriately administered by owners or farm staff, may mask signs of pain or colic and alter interpretation of the severity of the horse’s condition on arrival. These drugs can cause confounding clinical signs of hypotension, bradycardia, lethargy, weakness, and ataxia. Failure of such an analgesic to abolish clinical signs may necessitate hospital or clinic admission for further evaluation or surgical consultation. Conversely, the failure of other previous medical treatments can aid in the initial selection of more appropriate therapeutic planning.

The patient’s individual problems should be determined according to such factors as clinical history of onset, feed and water consumption, fevers, and decrease in performance. In essence, the clinician must effectively “zero in” on the problems at hand.

PHYSICAL EXAMINATION

The extent of the physical examination will be subject to the environment where the examination is conducted (field vs. hospital), the equipment at hand, and the ancillary personnel available for restraint and procedural purposes. In a hospital setting the clinician should have immediate access to most of the equipment and diagnostic instrumentation listed in Box 2-1. The physical examination sheet should provide a systematic list of the organ systems being evaluated. Vital signs (temperature, pulse, and respiratory rate) should be documented in the “calm” animal, if possible. Abnormal findings are described in an appropriate space provided, usually below the body systems checklist. Using the same numeral for each body system throughout the examination process and in problem identification is useful for future caseload recall, especially if a computer is used and codes can be applied to clinical findings and diagnosis. At the completion of the physical examination, the major problems identified are listed, and appropriate laboratory tests can be requested. The final diagnosis is seldom determined at the time of the initial examination. The final diagnosis represents the final assessment and should be filled in at the appropriate time (e.g., hospital discharge).

A general evaluation of the equine patient should be made from afar. This is particularly important for neonates at the side of their dams. The initial observations of body condition, posture, weakness, lethargy, incoordination, lameness, and musculoskeletal asymmetry are more easily observed a slight distance away from the patient.

The integumentary system can usually be quickly evaluated as to the type, distribution, and number of lesions and site and layer of involvement—for example, 3 × 6 × 2 cm raised, nodular, nonpainful mass involving the cutis and subcutis. Such a lesion would be readily available for superficial evaluation. However, subtle lesions of petechia and ecchymosis cannot be visualized in the integument because the hair coat and pigment hide lesions that are obvious in other species, such as purpura of nonpigmented humans and pigs. In these instances the mucous membranes must be examined as an extension of the integumentary system. If obvious multiple lesions of the skin are present, documentation is usually expedited by drawing a picture of a horse and indicating the distribution in the drawing, including both sides of the horse (see Skin Disease Examination, Chapter 11). Gross generalized distortions (e.g., anasarca) may be viewed as lesions of possibly more than one body system (integumentary and circulatory).

For the internist, evaluation of the musculoskeletal system usually involves a rudimentary examination of the site and appearance of the disease processes. Primary lameness is more commonly evaluated by clinicians familiar with diagnostic nerve blocks, arthrocentesis methods (e.g., septic arthritis in foals), and radiographic findings. It should be noted, however, that acute (caused by fracture) or chronic lameness can coexist with primary neurologic disorders (e.g., equine protozoal myeloencephalitis). Therefore, when warranted, the patient should receive a cursory neurologic evaluation (see Chapter 8) in conjunction with the musculoskeletal examination. Conversely, all horses presented with systemic illness (pneumonia, colitis) should also be evaluated for the presence of laminitis, as this complication is often the limiting factor for the horse’s survival. Careful palpation of the lower limbs may indicate increased intensity of digital pulses or changes in the coronary band that may be related to the “sinker” syndrome (distal phalangeal displacement).⁴ If laminitis is present as a complicating factor, the clinician should be able to add to the clinical prognosis by using Obel grading (1 to 4).

Evaluation of the circulatory system starts with assessment of heart rate, rhythm, and any presence of murmurs. Mucous membrane color, capillary refill time, scleral injection, palpable changes in the temperature of the ears and extremities, jugular pulsation, and pitting subcutaneous edema are the most common obvious circulatory physical examination parameters. The heart should be auscultated bilaterally, and murmurs graded according to intensity (I to VI or I to V), character, the valvular site, and phase of the cardiac cycle. Arrhythmias usually involve a request for an electrocardiogram (ECG), except with the common findings such as type II heart blocks in clinically asymptomatic horses. Type II heart block in normal horses can usually be obliterated by exciting the horse with a threatening gesture. In addition to electrocardiography, transcutaneous ultrasound examination of the heart and pericardium and transrectal evaluation of the caudal aorta and iliacs for intraabdominal thrombotic lesions can be used.^5,6 If procedural assessments of blood pressure are needed, a manometer for central venous pressure or a sphygmomanometer with Doppler ultrasound is used on the base of the tail in adults and the tail or inside radius (forearm) in foals.⁷

The respiratory system is similar to the circulatory system in that the breathing rate and mucous membrane color are important assessments. Respiratory effort and the phase of increased work should be assessed (e.g., heaves). Auscultation should be of both the upper (larynx and trachea) and lower airways. Nasal airflow can be determined by wetting the hands and holding them gently over the nostrils so that both intensity and equality of air movement can be assessed. Smelling the breath for fetid or necrotic odors (ozena) is similarly important, and endoscopic evaluation of the upper airways should be an adjunct to abnormal clinical findings. A penlight can be used to visualize the internal nares (septal mucosa). Percussion of the sinuses should be performed for detection of dullness, suggesting sinusitis or the presence of fluid within the sinus cavity. In addition, the head should be carefully examined ventrally and caudally for the presence of lymphadenopathy.

The interpretation of lung sounds has been described elsewhere,⁸ and the clinician should make an effort to auscultate dorsal and ventral regions of the thorax bilaterally and document findings as to the location or absence of sounds and the phase of respirations involved.

Percussion is a reliable clinical tool and should be performed in cases of suspected abscess, tumor, or pleural effusion. A pleximeter and tablespoon are the only tools required, although some clinicians are adept at direct finger percussion of the chest. In foals, percussion can be performed by placing a stethoscope on one side of the chest and reaching over the back of the foal to manually percuss the opposite side. Fractured ribs may be recognized in the neonatal foal as palpable asymmetry or a bony crepitus (“clicks”), often with edema of the sternum or elbow coinciding with the fractured side.

Ultrasound has revolutionized the clinical evaluation of the thoracic cavity. Unfortunately, the familiarity of clinicians in thoracic interpretation is directly related to access and frequency of ultrasound use. However, subtle pneumonia, abscess, and pleural effusion represent rapid and definitive objective findings.⁵ Because radiographic changes often lag behind clinical disease, serial examinations via ultrasound may be a more accurate way of monitoring response to treatment. Ultrasound may, in fact, eliminate the need for chest radiographs in numerous cases, thereby increasing efficiency and decreasing client costs.

A systematic approach should always be used when examining the horse for gastrointestinal disease. Although the majority of emergencies and referrals are related to colic or acute intestinal disease, the clinician should resist the temptation to focus only on the abdomen, so that important clinical signs relating to other problems are not missed (e.g., gastric ulceration, botulism). If a clinical complaint involving the abdomen is present or in suspected cases of intestinal displacement, obstruction, or volvulus, the gastrointestinal system is initially examined by bilateral auscultation of intestinal sounds. In addition, the abdomen should be auscultated ventrally for sounds similar to “ocean waves” or sand pouring on itself, indicative of the presence of sand within the gastrointestinal tract.⁹ In cases in which the gastrointestinal tract is the site of the primary lesion, checking for gastric reflux and performing a rectal examination¹⁰ may become a necessity. Clinicians should strive to become adept at rectal palpation and regard the procedure as a premier diagnostic skill while respecting the risks involved for the patient and veterinarian.

The patient should be observed for the presence of normal prehension, eating, and drinking whenever dysphagia is present or neurologic dysfunction is suspected. The evaluation of the gastrointestinal system should also include a dental examination for the presence of malocclusion and dental abnormalities (e.g., missing or damaged teeth) that can affect prehension or mastication. Accurate notation of affected teeth should be made in the medical record using a universally accepted identification system, such as a numeric system in which the horse’s head is divided into four quadrants, with each tooth described by its own number (e.g., two central upper incisors on horse’s right and left would be 101 and 201, respectively). Clinicians should also become adept at dental age determinations, albeit with an awareness of its limitations and subjectivity.¹¹ Nasogastric intubation is useful in evaluating dysphagia and esophageal blockage (choke) and determining the presence or absence of gastric reflux. In addition, the volume and character (e.g., color, pH, presence of blood or toxic plant material) of reflux obtained can be rapidly evaluated and may aid in the diagnosis.

The use of long endoscopes (e.g., 2 to 3 m) is valuable in the visual assessment of the esophagus and stomach with lesions such as esophageal stricture and gastric ulceration. For a diagnostic endoscopic examination of the stomach, it is recommended that the patient be muzzled or held off feed for at least 10 hours to allow complete visualization of the stomach.¹²

Ultrasound evaluation of the abdomen in conjunction with aspiration and analysis of fluid visualized may quickly reveal peritonitis, uroperitoneum, hemorrhage, ascites, visceral rupture, or abdominal masses. In adults, palpable abdominal masses and enlarged lymph nodes usually can be scanned transrectally.

The urogenital system can be examined by manual palpation, rectal palpation, vaginoscopic (speculum examination) viewing, endoscopic viewing, and ultrasound. The caudal portion of the left kidney is easily palpated in most horses. Catheterized samples should be obtained (e.g., cultures, urinalysis) before any contaminating invasive procedures (e.g., rectal palpation) are performed and before fluid therapy is initiated. Sphincter tone may be subjectively or objectively (urethral pressure profile) assessed in horses with urinary incontinence or stranguria. Horses with incontinence often demonstrate “scalding” of the perineum and hind legs.

The eyes can be examined by a rapid visual assessment using a penlight. The cornea and cranial and caudal lens capsules can be evaluated by horizontally moving the penlight and noting the crossing light reflexes. Pupillary constriction to light and the “menace” response should be observed, although these reflexes may be significantly slower or absent in the neonate. An ophthalmoscopic retinal examination should be performed whenever the eyes represent the primary complaint, and fluorescein dye strips should be used for the detection of corneal ulcers. Blindfolding of one eye at a time may aid in the assessment of unilateral blindness and should be conducted in a safe area with “blunt” devices contrived as an obstacle course.

The neurologic system examination should involve a consistent procedure for all patients with nervous system disorders (see Nervous System Examination, Chapters 8 and 35). The patient’s attitude, posture, and head carriage should be assessed from afar. The cranial nerves should be evaluated, followed by examination of the spinal reflexes and tail tone. Sensory deficits should be noted at this time. Conscious proprioception and postural responses (e.g., placement, hemihopping, sway) can then be assessed before observing the patient in locomotion. Notes regarding symmetry, asymmetry, ambulation, paresis, muscle atrophy, and upper and lower motor neuron deficits should be documented to aid in determining the sites for any additional ancillary tests such as radiographs or cerebral spinal fluid collection. Blindfolding should be conducted in a safe area, especially for patients with vestibular disease. An area of incline is useful for evaluating the locomotor deficits, especially when the horse is led with the head elevated.

The lymphatic system is usually evaluated merely by recording any obvious lymphadenopathy. This can be regional or local (as in strangles) or generalized (cutaneous lymphosarcoma) and may be appreciated on rectal examination. Lymphangitis or the presence of edema should also be noted.

Once a patient has been admitted to the clinic or hospital, well-organized flow charts should be used for monitoring and assessing the patient.

MEDICAL RECORD

In 1968 Lawrence Weed¹³ published on the use of the problem-oriented medical record. This system of recordkeeping emphasizes the justifications for daily decision making during hospitalization. Problems are defined by the history, physical examination, and laboratory findings. Daily (and more frequently for intensive care unit patients) subjective findings (e.g., appetite, attitude) are documented, and objective data (e.g., heart rate, temperature) are recorded. This information (e.g., patient is febrile) is then assessed by the clinician, and a plan (e.g., resubmit laboratory tests, change antibiotic medications) is derived based on the assessment. The abbreviated form of this type of medical record is SOAP, and this method is applied to each problem identified. Although the system encourages medical judgment and accountability, it more directly serves as a teaching tool within institutions by which the student’s clinical thinking can be evaluated by the in-charge clinician. In private practices the method of record keeping is more flexible and tends to document vital information that primarily serves as an accounting of services and provides a medicolegal record. Unfortunately, many medical records function only as invoices and do not record medical information regarding the patient. This is more often true of ambulatory records but can be found in certain hospital practices. Whichever system is used, the responsibly prepared medical record should provide medical information, justification for charges, and a protection from liability. A thorough medical record further allows for the retrieval of retrospective information. The accumulation of data is beneficial to the communication of clinical caseload experiences to other clinicians for the benefit of their patients.