1 Major body system examination

Clinical Tips

• The initial physical examination should focus on the major body systems, namely the cardiovascular, respiratory and central nervous systems, as severe abnormalities in these systems have the potential to be rapidly fatal. This approach is somewhat different from the head-to-tail physical examination commonly performed that is only appropriate for non-emergency patients.

• Pain assessment is also a high priority in the initial evaluation.

A considerable amount of invaluable information can be obtained from the physical examination of the emergency patient. The initial priority is to identify any potentially life-threatening problems so that immediate intervention can be provided. As such the initial physical examination (primary survey) should focus on the major body systems, namely the cardiovascular, respiratory and central nervous systems, as severe abnormalities in these systems have the potential to be rapidly fatal. Abdominal palpation and measurement of body temperature are also important. Once measures have been taken to stabilize abnormalities in the major body systems a more comprehensive physical examination (secondary survey) can be performed. This approach is somewhat different from the head-to-tail physical examination commonly performed that is only appropriate for non-emergency patients.

Cardiovascular System

The most important questions to be answered when examining the cardiovascular system are, does the patient have signs of compromised systemic perfusion, and is there any evidence of primary cardiac disease? The following should be examined during evaluation of the cardiovascular system:

• Heart rate, sounds and rhythm

• Pulse quality and rate (are there pulse deficits?)

• Mucous membrane colour and capillary refill time

• (Mentation)

• (Temperature of the extremities).

All of the information obtained from this evaluation should be used to guide subsequent therapy. For example, a patient with severe hypovolaemia will require aggressive fluid administration (see Ch. 4). However a more conservative approach may need to be taken if a non-physiological heart murmur is detected during initial evaluation. The most common cause of hypoperfusion in the emergency patient is hypovolaemia (see Ch. 2). Cardiovascular abnormalities may also be seen for example with heart failure (see Ch. 31), anaemia (see Ch. 19) and systemic inflammatory response syndrome (SIRS) or sepsis.

Respiratory System

Animals with respiratory embarrassment are amongst the most unstable emergency patients and in some cases even a brief major body system examination will not be tolerated. Oxygen supplementation and potentially other empirical intervention (e.g. sedation of a dog with severe upper respiratory tract dyspnoea, see Ch. 32) may have to be performed prior to examination of these patients. This is especially true for cats (see Ch. 23). The following should be examined during evaluation of the respiratory system:

• Respiratory rate

• Respiratory effort

• Respiratory pattern and noise.

Respiratory rate in a normal adult dog or cat is usually 15–30 breaths per minute although a certain degree of normal variation occurs due to factors such as anxiety and excitement.

Clinical Tip

• Panting in dogs is often an innocuous finding. However, occasionally it is the earliest sign of compensation in a dog with respiratory compromise and must not therefore be automatically ignored.

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Respiratory effort

Dyspnoeic animals may show postural adaptation as described in Box 1.1. Some dyspnoeic animals demonstrate increased abdominal effort (increased contraction of abdominal muscles) that assists with expiration only. Paradoxical abdominal breathing, whereby the thoracic and abdominal walls move in opposite directions, is generally associated with severe respiratory distress (during normal inspiration the thoracic wall moves out and the abdominal wall also moves out passively).

BOX 1.1 Postural adaptation to dyspnoea

• Open-mouth breathing

• Neck extension

• Repeated changing of position

• Abduction of elbows (dogs)

• Sternal recumbency (cats)

Respiratory pattern and noise

Respiratory distress can occur as a result of an abnormality affecting any one or more of the following areas:

• Upper respiratory tract (URT) (e.g. laryngeal neoplasia)

• Lower respiratory tract (e.g. feline bronchial disease)

• Lung parenchyma (e.g. pulmonary contusions, pulmonary oedema)

• Pleural space (e.g. pleural effusion, pneumothorax)

• Thoracic wall and diaphragm (e.g. traumatic diaphragmatic rupture).

Being able to identify the area affected is extremely important with respect to patient management. Depending on the case in question, a combination of observation and listening may allow reliable localization of the affected area. This is described further in Box 1.2. Lung sounds are typically louder cranioventrally and may not be audible in a normal cat at rest.

BOX 1.2 Interpretation of respiratory pattern and noise findings

• Inspiratory stridor/stertor; prolonged inspiration: dynamic extrathoracic upper respiratory tract (URT) obstruction (e.g. laryngeal paralysis)

• Inspiratory and expiratory stridor: fixed URT obstruction (e.g. mass lesion) (or diffuse tracheal disease)

• Expiratory stridor: intrathoracic tracheal abnormality

• Prolonged expiration with increased abdominal effort: lower airway disease

• Muffled lung sounds ventrally: pleural effusion (lung sounds may be louder than normal dorsally)

• Muffled lung sounds dorsally: pneumothorax (lung sounds may be louder than normal ventrally)

• Louder than normal lung sounds (harshness, wheezes, crackles): small airway or parenchymal disease

Central Nervous System

Initial examination of the central nervous system (CNS) focuses on mentation and ability to stand and ambulate. If the animal is ambulatory, then gait is assessed. Mentation may be affected by cardiovascular and respiratory abnormalities and if such abnormalities are present, it is important to decide whether the animal’s mentation is appropriate. Inappropriately altered mentation should raise the index of suspicion for a primary CNS disorder. In some cases mentation cannot be reliably evaluated until other abnormalities have been resolved or improved (e.g. fluid therapy to correct systemic hypoperfusion, warming to treat hypothermia).

Similarly, animals may be recumbent as a result of primary CNS disorders but also due to cardiovascular and respiratory compromise. Gait abnormalities in ambulatory animals are most likely to be related to the nervous systems (central or peripheral) and multiple limb involvement often suggests a more serious disease.