There are many parameters to evaluate in assessing patients during the physical exam.¬† Adults and foals differ in some respects of the physical exam, which will be covered in the following information.¬† As an attendant it is very important that this be a thorough exam as the technicians and doctors will rely on you to keep them updated on any changes in the patient‚Äôs status.¬† Remember that these patients have problems that are significant enough to warrant watching them around the clock.¬† This means that at any time the situation could change and your most important responsibility is to be alert and pick up on these changes as soon as they can be identified.¬† Often times these patients will look like nothing is happening, but indeed their bodies are trying to cope and deal with their injuries or illness.¬† Our best hope at assisting these patients back to health is in decisive and early detection of the problems they are having along with quick adjustments in treatments and therapies when the conditions change.¬† We are a team and these patients‚Äô lives may depend heavily on this team‚Äôs ability to work well together.
The exam starts before you touch the animal: where is the horse in the stall?¬† Is he in the back corner and unresponsive or is she in the front of the stall alert and observing the activity in the barn?¬† Does he have shavings on him that may indicate that he‚Äôs been down rolling or simply lying comfortably in sternal? Is he spending to much time lying down in the stall? Are their paw marks in the stall?¬† Are the shavings pushed to the sides as if the horse has been circling?¬† Is he eating his hay and grain and if so is he doing this aggressively or just passively nibbling?¬† Is she drinking water?¬† How is the horse standing? Is she standing square with all four feet under the body equally or is one foot pointed in front of the other?¬† Is the horse bearing full weight on all legs?¬† If not be sure to indicate in the history which leg seems to be the problem.¬† Is the horse rocking back onto its back legs when he moves or specifically when he turns?¬† What is the horse‚Äôs facial expression?¬†¬† Is he depressed, alert, frightened, relaxed?¬† Is the horse grinding its teeth?¬† Does¬† he hold his head normally, and are the ears erect and moving normally?¬† Does he have any ocular discharges?¬† Is the animal holding both eyes open normally?¬† Does the animal have any nasal discharge or do you hear any coughing?¬† If there is an abnormal discharge?¬† If so note the color and consistency of the secretions.¬† Does the animals muzzle deviate in an abnormal way and is it warm or cold?¬† Is the animal urinating a normal amount and what is the consistency of the manure.
Observation skills are quite important and it requires a lot of practice to mentally ask yourself these questions.¬† These are all important things to note, making all abnormalities clearly noted in the patients chart.¬† Once you have the patient haltered and tied you will start the hands on physical part of the exam.
Normal mucous membranes are pale pink to pink in color and moist to the touch.¬† If an animal has very dry gums this could be an indication of dehydration.¬† Press your finger against the surface of the mucous membranes in the horses‚Äô mouth for 2-3 seconds.¬† The gums will blanch (turn white) as the blood supply is compressed.¬† When you remove your finger, observe in seconds how long it takes the membranes to return to normal color. Normal capillary refill time is about¬† two seconds.
If it takes longer for the gums to return to normal color this may indicate poor perfusion or circulation. This would also be evident if the muzzle is cold.¬† Note any membranes that are red to purple or brick red, this may indicate toxemia or toxins in the blood.¬† Very pale gums indicate blood loss.¬† Yellowish membranes can indicate the horse has not been eating or may have liver disease.¬† The animal may have a ‚Äútoxic line‚Äù, a dark pink or purple line that is above the root line of the incisors. Any significant odor coming from the animal‚Äôs mouth would also be noted at this time.
If a patient has any dramatic changes in gum color in a short period of time this could indicate the patient is going into shock and would warrant immediate examination by the veterinarian.
Using a digital thermometer standing at the animals hindquarters alongside the horse left hind leg, elevate the base of the horses tail, gently insert the thermometer through the anal sphincter, it may help to apply KY jelly or other lubricant to the thermometer.¬† Some animals are very sensitive about having their temperatures taken.¬† I have found that once you get the thermometer inserted, if they are trying to clamp their tail you can use your other hand to scratch on the sides of the tail head or under where the tail joins the body (a spot they can‚Äôt reach and more often than not enjoy it being gently scratched). Be sure you hold onto the thermometer as they can pull the thermometer into the rectum . The temperature on critical animals should be taken several times during a day because body temperature can change in response to ambient or outside temperatures. The normal temperature an adult horse should be between 99.0¬∞-101.5¬∞.
The procedure of listening to sounds within the body to assess the functioning of an organ or to detect the presence of disease.¬† The sounds are heard through a stethoscope.
This is evaluated by palpating the mandibular artery on the horse lower jaw and we will demonstrate this technique to you. Most commonly we use the stethoscope to obtain the patient‚Äôs heart rate. Position the stethoscope on the left side of the horse lower chest, behind the elbow. Horses have two distinct audible sounds. That is to say that we will normally here a lub-dub sound.¬† It is important to remember not to count both sounds when taking a heart rate. Normal heart rate for resting adults would be 28-40 beats per minute. This will vary if the patient is in pain or excited. It is important to listen to the sounds for more than one minute. Sometimes patients may be apprehensive or scared and it takes a few¬† minutes to relax and for their heart rates to return to its normal rate. It is also important to note any arrhythmia (abnormal rhythm) in the chart and mention it to the doctors. Sometimes a horse presents with a jugular pulse (the jugular vein appears to be pulsing 3/4 up the horses neck) this can also indicate cardiac abnormalities.
This can be evaluated or measured by observing the horses flank, chest wall or observing the nostrils move when they breathe. This may best be evaluated from outside the stall because sometimes the horses interest in a person interferes with evaluating their respiratory rate.¬† They want to smell the handler and it can be misinterpreted as breathing faster than normal. As noted above with heart rate, respiratory patterns change during the day in response to environmental factors.¬† A normal adult respiratory rate would be 12-24 breaths per minute. This, is obtained by counting the breaths for 15 seconds and multiplying by four.
It is important to note if the patient has flared nostrils. This can be an indicator of pain, acidosis (low blood pH), or increased¬† accumulation of gastric secretions (reflux) in the stomach. (It is also important to evaluate the respiratory pattern.¬† Ask yourself is it relaxed, rapid, shallow and thoracic,¬† or is the abdomen elevated with each breath.¬† On auscultation you should listen to the ‚Äúupper‚Äù or dorsal lung fields and the ‚Äúlower‚Äù or ventral lung field behind the heart. Listen for abnormal sounds such as a crackling or wheezing sound. Also note any noises in the trachea or the windpipe. This is done, by simply laying the stethoscope on the ventral aspect of the horse neck.
This is very important part of the physical exam when dealing with our equine patients. It is important to note the color, consistency (formed fecal balls, semi-formed,¬† or diarrhea), and odor associated with the animals manure. During auscultation of the G.I. system, it is important to listen and note the motility on both sides of the horses abdomen including the upper (closer to the upper flank), and lower (lower flank area). This would be noted as normal or +, decreased or absent -, or hyper motile ^.¬† It is also important to place the stethoscope on the ventral or lower abdomen, and¬† listen for sounds like the ocean, which can indicate the presence of sand in the horses intestines. If a patient appears bloated (enlarged abdomen) place your stethoscope on the upper quadrant on both sides of the abdomen taking your index finger of your other hand and flicking the skin in a circular pattern 4 inches around the stethoscope. If you hear a ‚Äúping‚Äù this indicates the presence of excess gas. This is more commonly observed on the horses right side.
Auscultation of The Gastrointestinal System:
Listening for peristalsis which is the muscular movement of the intestines which propels the intestinal contents through the GI system.¬† Borborygmi is a medical term for movement of gas along the intestinal tract-this is the sound of a grumbling stomach when someone is hungry!¬† Correct interpretation of the auscultation takes time and a basic understanding of intestinal motility or movement.¬† The most important issue to understand here is that there are four primary quadrants of the abdomen and which distinct sounds we will hear in these areas.
Evaluating the Legs:
It is important to note any swelling above or below bandages, and any lameness as noted earlier. Note any excessive swelling of the limbs differentiating between pitting edema (press your finger into swollen area and your finger imprint remains).¬† This is non painful swelling and the limbs are cool to the touch; also referred to as ‚Äústocking up‚Äù¬† and is fluid accumulation usually in the rear legs as a result of being stalled for long periods of time.¬† Cellulitis is a non-pitting, warm and painful swelling. Palpation of the lower limbs over the medial and lateral digital arteries is also important. This is done by sliding your hand over the back of the horse‚Äôs fetlock palpating for the arteries and applying gentle pressure. Results are recorded as normal (no pulse), mild, to increased, to the extreme or bounding digital pulses. There are several disease factors that place a patient at risk for laminitis, which is inflammation of the tissue that holds the coffin bone to the hoof wall. This happens more commonly in the front feet but the hind feet can also be affected. Post-op colic patients, grain overloads, diarrhea, mares with retained placentas or endotoxic patients are those most commonly affected. Since this is considered an emergency situation early diagnosis is important! The first thing a horse does when their feet begin to hurt is they start gently shifting weight from one front hoof to the other continuously¬† If this gets missed they will progress and these horses then adopt a typical stance. They rock back on hind limbs and stand with the front legs extended in front of them.¬† When asked to move they¬† have a shortened stride and are reluctant to move or turn in the stall. They may also spend more time lying down. They are reluctant to have their feet picked up.
Evaluating Catheters and Jugular Veins:
This will be further addressed on the segment on catheters and catheterization, a visual exam of the IV catheter would include; noting if it is still sutured,¬† is there blood in the extension set or adapter plug, any visual signs of irritation or swelling at the insertion site, any discharge. Gentle palpation of the jugular vein is also very important. A thickening or hardening of the vein, pain or heat could indicate infection (phlebitis) or thrombosis (blockage by clotting) of the jugular vein.
Evaluation of Incisions:
This is a manual and visual exam as well if the incision is not bandaged. Look for edema(swelling)¬† and note excessive amounts. If the sutures or staples are intact, is there any discharge, redness or heat?¬† If discharge is present note the color and describe exact location along the incision.
The physical exam in young foals from birth to weanling is also an important task that you must master. These animals require close observation frequently as their condition can deteriorate rapidly.¬† ¬†Do not assume that a significant change in a heart rate or respiratory rate is a mistake.¬† Rather re-check and pay very close attention.¬† The same parameters for the adult physical exam apply but the parameters differ.¬† These will be presented later in the program.
Depending on the age of the foal, the umbilicus should be dry and small, with no heat or discharge. It is a good idea to watch the foal urinate to make sure no urine is coming from the umbilicus (patent urachus). It is also important to palpate the foals leg joints for swelling, heat or pain and observe for lameness (signs of septic joints).¬† Evaluate the clarity of the foals eyes.¬† Often when they are septic (infected) even before joint involvement occurs they will have a green tint or color to their eyes (due to fibrin accumulation).¬† Foals, when stressed, are also susceptible to gastric or stomach ulcers so be alert to efforts to roll up on the back.
Monitor for any teeth grinding or excessive salivation.¬† Also, note the foals gum color.¬† Are there any petechial hemorrhages (small areas of hemorrhage along the gum line)?¬† How often is the foal nursing?¬† Is the mares udder nursed out?¬† Does she have milk?¬† When the foal nurses does it cough or have any milk coming from the¬† nostrils?¬† The normal temperature of a neonatal foal is 100.5-1020 F, the is pulse 80-110 bpm, and the respiratory rate is 32-52 bpm; these will become elevated when handled so it is a important to note that the foal was struggling when these measurements were taken.¬† It is better or error on the side of caution when you observe an abnormality and alert the technicians or veterinarian of a potential problem.