That prompted some of you to ask (in so many words), "Well, what’s in that almighty physical exam?"
And so, today, I offer you an abbreviated answer––or, at least, my version, since there are as many different approaches to the physical exam as there are veterinary clinicians performing them.
I’ve organized mine into "ten easy steps," but if you ask an internal medicine specialist, surgeon, or neurologist you’ll find they’re hard-pressed to simplify their fiendishly detailed physical examination methods into so few paces. With this disclaimer in mind, and with my late Sophie Sue as my subject, here goes…
Most physical exams start with a technician taking down notes on weight and vitals––temperature, pulse rate, respiratory rate, etc.––but we’ll also include immediate impressions along the lines of "bright, alert and responsive" (abbreviated as BAR) or "depressed," "quiet," "recumbent" and/or "unresponsive." This is also when we note the animal's "body condition score," to denote the pet's degree of heaviness or thinness, as the case may be.
#2 The head
I know it sounds a tad strange to start a physical with something as broad as "the head," but this is a nod to how many vets pick one area (the front, in this case) and move towards the back, systematically incorporating each additional zone. Being geographically organized helps ensure we don’t forget steps in our physicals.
On the head we look at ears, eyes, nose, mouth and teeth. We check for discharge, normal appearance of structures, details on dentition and periodontics, character of the mucous membranes to assess hydration, etc.
Some vets pull out all the tools for these exams (otiscopes and ophthalmoscopes), others only do so when the pet’s history and/or initial evaluation points to their necessity (and when their behavior makes this possible).
#3 Skin and coat
Taking in the condition of the coat and skin may seem like it wouldn't take much time, but some pets have such dense hair that getting to the level of the skin in key areas can be like wading through a forest of fur. Finding fleas, ticks, and lumps is extra-tough on these pets, especially if they have a large surface area. Most vets will also check for hydration here by "tenting" the skin at the shoulders.
#4 The chest
This is when we pull out our stethoscopes and apply them to your pet’s chest. But that’s not all we’re doing. We try to alter your pet’s breathing pattern with our hands on the nose and mouth and feel the pulses as they relate to the beats of the heart. Twenty to thirty seconds of this is a bare minimum but some vets will listen for several minutes. Be patient with us when you see us do this…and try to hold your tongue in the process. We’re usually trying to ignore you when you do forget to keep your mouth in check during the chest exam, as we might be counting the pulse or just listening intently.
Unfortunately, some pets can make this difficult, either by growling loudly enough to blow out your eardrums, by nervously shaking up a storm, or by purring uncontrollably.
This is sometimes done as part of steps #1 and #4 where we check mucous membranes for their refill time and when we feel pulses during our chest exam to make sure they synchronize well with the heartbeat.
The orthopedic portion of the exam includes a variety of steps: Assessing the symmetry (or lack thereof) of the musculature, observing how the pet moves/ambulates and physically manipulating limbs and their joints.
Most vets will also address the spine individually, feeling down every intervertebral junction to identify painful spots.
#7 The abdomen
Palpating the abdomen is not easy in some cases. Some pets hold their abdomens tightly, refusing to allow you a good feel. When that’s the case, I’ll usually come back to it for a second pass. What we’re feeling for is the size and texture of the organs and the possible presence of abnormal masses. Sometimes we can’t feel much though, even if a pet does let us, and usually that’s because they’re overweight or obese.
#8 Lymph nodes
We’ll usually go out of our way to feel all the peripheral lymph nodes that are typically palpable: in the neck, in front of the shoulders, and behind the knees. We’ll also check those spots where enlarged lymph nodes will make themselves known (but are otherwise not palpable).
The neuro exam is always the hardest for me. I’ll typically evaluate the cranial nerves as part of the head exam and address some basic reflexes, but beyond that I really don’t do much––unless it’s a case where serious neurologic disease is present. Even then, all I do is check a few more reflexes, as all my serious neuro cases go straight on to the neurologist.
#10 The invisible intangibles
These are the issues you may not notice us addressing specifically by the way we are looking at and touching your pet, but which we are picking up as we perform the exam. Issues such as your pet's scent, and little things that might set off our intuitive alarms; that almighty sixth sense we all cultivate with experience.
How long should this take? Some vets are fast and thorough, others are slow and sloppy. The vast majority of us fall somewhere in between. Either way, speed (or lack thereof) does not make for a good exam. It’s more about thoroughly covering all the bases, picking up on historical and physical cues, and knowing where to pause to make sure we heard, saw or smelled that right.
I’d say the best physical examinations are always the one's performed by internal medicine specialists. Other docs call them "fleas" for their thoroughness in this regard. I just think they’re a little crazy on this score––but in a good way. But maybe that’s just me…I just can’t imagine spending a full forty minutes of my undivided attention on one physical examination.
I hope this run-down helps you to interpret what your vet is doing, and encourages more willingness to ask questions and involve yourself in the process. Doing so will doubtless improve the quality of the physical examination your pet receives. It will also cue your vet in to your expectations for your pet’s level of care. And it doesn’t cost you one dime more to do so.
Dr. Patty Khuly