"Normal" was a middle-aged, long-haired cat due for his annual physical examination, a rabies vaccination, and worming. I didn't know Normal well. Except for routine wellness visits, he hadn't had any problems requiring my attention since becoming my patient several years back. Normal crouched nervously on the table, tucking himself into a fluffy cloud of fur. I exchanged pleasantries with his owner as I went through my usual drill, running my hands lightly over Normal's body. Ears, eyes, nose, teeth, throat, heart, lung, abdomen, skin, lymph nodes, musculoskeletal. My mental checklist. Animal after animal. Day after day. Week after week. Year after year. Even by conservative estimates, I examine an average of eight animals a day, five days a week, 50 weeks a year. That's 2,000 examinations yearly for almost 25 years. That's 50,000 physical examinations. I should have it down pat, huh?
I still remember the first time I walked into an exam room to face a pet attached to a person who expected me to figure out what was wrong with his dog. Veterinarians are not required to do internships or residencies like human physicians. Instead, our fourth year of vet school is spent in clinical rotations. Senior students see clients, make diagnoses, treat patients, perform surgery, and so on, under the supervision of experienced clinicians. Although I would do more interesting things that year, like anesthetize a kangaroo for cataract surgery, I knew my career was not going to focus on marsupial ophthalmology. My professors had drummed into my brain that a careful, detailed examination (combined with good history-taking) was the heart and soul of veterinary practice.
The examination routine
So what exactly does your veterinarian do when performing a physical examination? Over time, each doctor develops his or her own routine. At my office, an assistant takes a history and records weight, temperature, and heart rate.
Then it's my turn. While reviewing Normal's record, I observe his general demeanor. Does Normal seem depressed, disoriented? Is he alert, subdued, agitated? Behavior in my office does not necessarily correlate with behavior at home, but sometimes it is significant. My examination then proceeds, starting at the head. I try to always do things in the same order, so I don't overlook anything. First come ears. Any irritation, odor, or discharge? Eyes next. To you, it may just seem like a quick glance but I am actually evaluating numerous things. Any squinting, discharge, redness, abnormal pigmentation or cloudiness? Do the eyes bulge abnormally? Are the pupils even? Do they respond appropriately to light? Any evidence of cataracts? If indicated, I'll use an ophthalmoscope to look more closely and examine the inner structures of the eye. Nose, teeth, and throat follow, looking for discharge, tartar, loose teeth, abnormal growth - looking for anything... well... not normal.
In school we wrote detailed, legible notes about each of our findings, recording both normal and abnormal results. I occasionally still see a thorough, beautifully scribed record like that faxed from some other veterinarian.. but most of us get busy...and messy. Time is in short supply and calligraphy low on the priority list. Lots of practices use preprinted physical exam forms, stickers, or stamps where the doctor can check off each system. Ears? OK, check. Eyes? OK, check. Nose? OK, check. You get the idea. I personally just scrawl my own notation: EEN, HLA, SK, LN, MS all OK. On a really busy day this may degenerate into PE- NSF That means Physical Exam - No Significant Findings. Or PE-WNL. Physical Exam - Within Normal Limits. It's quick. It's probably legally adequate for a wellness exam, but it always makes me a little nervous. Hmm, I may wonder the next year, did I really listen to Normal's heart that day? If I have written HLA O, well then, yes, I know I definitely picked up my stethoscope and listened.
I proceeded with Normal's exam, listening to his heart and lungs. Normal rate? Normal rhythm? Any murmurs or unusual sounds? How about his tummy? Any tenderness or unusual masses palpable? Next comes the skin. Any sores, redness, flaking, bad odor, or itchiness? How about the coat? Is it shiny? Any bald spots, fleas, or flea dirt? I continue running my fingers over Normal's body. I'm not giving him a massage. I'm palpating lymph nodes - mandibular, prescapular, axillary, inguinal and popliteal lymph nodes, to be precise. Enlarged lymph nodes can be a sign of infection or cancer. Finally I do my musculoskeletal exam, noting any abnormal lumps or bumps and assessing body condition. Too fat? Too thin? Any evidence of muscle atrophy or bony abnormalities? If there is an orthopedic complaint, like limping or stiffness, I palpate the joints and check the range of motion. I end my exam at the end, with a quick peek under the tail.
Check and double check
Normal was as healthy as could be, although still hunkered down motionless on the table. While drawing up his rabies vaccine, I gave my standard spiel about potential side effects. "There's a form of cancer in cats that appears to be related to vaccination," I rattled off. "It's very uncommon, but nasty. Today Normal will get a rabies shot in his right hind leg, sort of low down on the outside. Check the vaccination site for any lump that persists for more than two to three weeks."
The owner looked concerned, a common reaction. "It's really a very safe vaccine," I reassured her, but she shook her head. "It's not that," she replied. "I'm just worried it may be hard to feel for any lumps, the way his stump is."
Stump? What stump?
I nodded my head, trying to look like I knew what she was talking about, glancing surreptitiously at his record for a clue. "Yeah," she continued, "The scar tissue from where he lost the leg feels pretty lumpy anyway." Wordlessly I slid my hand down Normal's right hind leg... which ended abruptly below the knee. My professors would be mortified. I had done a complete physical exam but somehow overlooked the fact that, underneath all that cowering fur, the cat only had three legs. Sure enough, on the front of his file on the "Description" line it read "Grey - three legs." "Refresh my memory," I said, quickly recovering my poise. "How did he lose the leg?" Turns out that when Normal was a kitten (long before I met him) he had been hit by a car. His lower leg had been too badly mangled to save. Since I had not been involved in the amputation, it didn't stick in my mind. Since he was long-haired, and crouched on the table, it wasn't immediately visible. That's it for excuses. I scrawled across the record EENT, HLA, SK, LN all OK...Musculoskeletal: three legs. Check.
We're only human. If you think your veterinarian has forgotten to check something you want checked at Normal's next visit, don't hesitate to remind him or her. On the other hand, if you're tempted to skip his annual visit, think again. Your veterinarian covers a lot of ground in that seemingly simple examination and may pick up problems about which Normal lacks the words to tell you.