100 Top Consultations in Small Animal General Practice PDF

100 Top Consultations in Small Animal General Practice 100 Top Consultations in Small Animal General Practice Peter Hill BVSc, PhD, DVD, DipACVD, DipECVD, MRCVS, MACVSc Senior Lecturer in Veterinary Dermatology and Immunology, The University of Adelaide, South Australia, Australia Sheena Warman BSc, BVMS, DSAM, DipECVIM-CA, PGCert(HE), MRCVS Clinical Fellow in Small Animal Medicine, University of Bristol, Bristol, UK Geoﬀ Shawcross BVSc, Cert SAO, MRCVS General Practitioner (retired), Liss, Hampshire, UK A John Wiley & Sons, Ltd., Publication This edition first published 2011 © 2011 Blackwell Publishing Ltd Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley–Blackwell. 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If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data 100 top consultations in small animal general practice / edited by Peter B. Hill, Sheena Warman, Geoff Shawcross. p. ; cm. One hundred top consultations in small animal general practice Includes bibliographical references and index. ISBN 978-1-4051-6949-3 (pbk. : alk. paper) 1. Pet medicine. I. Hill, Peter B. (Peter Barrie) II. Warman, Sheena. III. Shawcross, Geoff. IV. Title: One hundred top consultations in small animal general practice. [DNLM: 1. Dog Diseases. 2. Cat Diseases. 3. Professional-Patient Relations. 4. Veterinary Medicine–methods. SF 991] SF981.A55 2011 636.089–dc22 2010040961 A catalogue record for this book is available from the British Library. This book is published in the following electronic formats: ePDF [ISBN 9781444393347]; ePub [ISBN 9781444393354] Set in 9/11 pt Calibri by Toppan Best-set Premedia Limited Printed in Singapore 1 2011 Contents Miscellaneous Speciﬁc conditions Differential diagnosis Appendices List of contributors ix Acknowledgements x Chapter 12 The FeLV-positive cat 47 About this book xi Andrea Harvey Introduction Diagnostic and therapeutic 1 Chapter 13 The FIV-positive cat 51 approaches in small animal Andrea Harvey general practice Peter Hill Chapter 14 The cat with FIP 54 Andrea Harvey Section 1 Health checks and vaccinations Section 3 Skin problems Chapter 1 The new puppy or kitten 13 Geoﬀ Shawcross Chapter 15 The itchy dog 59 Peter Hill Chapter 2 The annual health check 18 Geoﬀ Shawcross Chapter 16 The itchy cat 62 Peter Hill Chapter 3 Advising on spaying and 20 castration Chapter 17 Diagnosing and treating skin 66 Geoﬀ Shawcross diseases caused by ectoparasites Peter Hill Section 2 General signs and illnesses Chapter 18 The dog with demodicosis 74 Peter Hill Chapter 4 Inappetence and anorexia 25 Sheena Warman Chapter 19 The dog with pyoderma or 78 Malassezia dermatitis Chapter 5 Weight loss 27 Peter Hill Sheena Warman Chapter 20 The atopic dog 82 Chapter 6 Polydipsia and polyuria 29 Peter Hill Sheena Warman Chapter 21 The dog with a hot spot 86 Chapter 7 Pyrexia 32 Peter Hill Sheena Warman Chapter 22 The dog with acral lick 88 Chapter 8 Anaemia 35 dermatitis (lick granuloma) Sheena Warman Peter Hill Chapter 9 Jaundice 39 Chapter 23 Anal sac problems 91 Sheena Warman Peter Hill Chapter 10 Collapse 42 Chapter 24 Ear infections 94 Sheena Warman Peter Hill Chapter 11 Abdominal distension 45 Chapter 25 Pododermatitis 99 Sheena Warman Peter Hill v Chapter 26 The dog or cat with a 104 Chapter 42 Liver disease 151 cutaneous lump or swelling Sheena Warman Peter Hill Chapter 43 The dog or cat with pancreatitis 155 Chapter 27 The dog with urticaria 107 Sheena Warman or angioedema Peter Hill Chapter 44 The dog with gastric 158 dilatation and volvulus Chapter 28 The cat-bite abscess 109 Geoﬀ Shawcross Peter Hill Chapter 45 Obstipation and megacolon 162 Chapter 29 Lipomas 111 Geoﬀ Shawcross Peter Hill Chapter 30 The dog with a histiocytoma 113 Section 5 Musculoskeletal problems Peter Hill Chapter 31 Mast cell tumours 115 Chapter 46 Orthopaedic problems in young 169 Peter Hill and growing dogs Martin Owen Chapter 32 Sebaceous adenomas and 118 follicular cysts Chapter 47 Forelimb lameness 177 Peter Hill Martin Owen Chapter 33 The dog that is losing hair 120 Chapter 48 Hindlimb lameness 180 Peter Hill Martin Owen Chapter 34 Dermatophytosis 123 Chapter 49 Cranial cruciate ligament 183 Peter Hill insufﬁciency Martin Owen Chapter 35 Skin problems in non 126 dog/cat species Chapter 50 Advising on osteoarthritis 187 Sharon Redrobe and Peter Hill Martin Owen Chapter 51 Initial fracture diagnosis and 190 management Section 4 Gastrointestinal problems Martin Owen Chapter 52 Spinal pain and disk herniation 194 Chapter 36 Dental disease 133 Martin Owen Norman Johnstone Chapter 37 Retching and gagging 138 Section 6 Cardio-respiratory problems Geoﬀ Shawcross Chapter 38 Vomiting 140 Chapter 53 Coughing 201 Sheena Warman Paul Smith Chapter 39 Diarrhoea 143 Chapter 54 The dog with kennel cough 205 Sheena Warman Paul Smith Chapter 40 The dog with haemorrhagic 146 Chapter 55 Sneezing and nasal discharge 207 gastroenteritis Andrea Harvey Sheena Warman Chapter 56 The puppy or kitten with a 210 Chapter 41 Colitis 148 heart murmur Sheena Warman Paul Smith vi Contents Chapter 57 The dog with heart failure 214 Chapter 71 Pregnancy and whelping 263 Paul Smith Geoﬀ Shawcross Chapter 58 The dyspnoeic cat 218 Chapter 72 Oestrus control, misalliance 266 Paul Smith and false pregnancies Geoﬀ Shawcross Section 7 Eye problems Section 10 Endocrine problems Chapter 59 Eyelid problems 223 Jim Carter and Peter Hill Chapter 73 The dog with hypothyroidism 271 Sheena Warman Chapter 60 Conjunctivitis 227 Jim Carter Chapter 74 The dog with 274 hyperadrenocorticism Chapter 61 Corneal ulcers 230 Sheena Warman Jim Carter Chapter 75 Diabetes mellitus 278 Chapter 62 Cataracts 234 Sheena Warman Jim Carter Chapter 76 The cat with hyperthyroidism 282 Chapter 63 Blindness 237 Andrea Harvey Jim Carter Section 8 Urinary tract problems Section 11 Emergencies and trauma Chapter 77 The road trafﬁc accident 287 Chapter 64 The dog with signs of cystitis 241 or haematuria Geoﬀ Shawcross Sheena Warman Chapter 78 The pharyngeal foreign body 291 Chapter 65 The cat with signs of cystitis 245 Geoﬀ Shawcross or haematuria Sheena Warman Chapter 79 Problems associated with 294 grass seeds Chapter 66 The blocked cat 247 Geoﬀ Shawcross Sheena Warman Chapter 80 Burns 297 Chapter 67 The dog with urinary 250 Peter Hill incontinence Peter Holt Section 12 Cancer Chapter 68 Chronic renal failure 252 Sheena Warman Chapter 81 The dog or cat with cancer 303 Chapter 69 The dog with prostatic disease 256 Mark Goodfellow Peter Holt Chapter 82 The dog with a mammary 307 tumour Section 9 Reproductive tract problems Mark Goodfellow Chapter 83 The dog with multicentric 310 Chapter 70 The bitch with pyometra 261 lymphoma Geoﬀ Shawcross Mark Goodfellow Contents vii Chapter 95 The sick Guinea pig 363 Section 13 Neurological problems Sharon Redrobe Chapter 96 The sick bird 368 Chapter 84 The dog having seizures 315 Sharon Redrobe Sheena Warman Chapter 97 The sick tortoise 374 Chapter 85 Hindlimb ataxia and weakness 319 Sharon Redrobe Martin Owen Chapter 86 Vestibular disease 322 Section 17 Miscellaneous Sheena Warman Chapter 98 The post-surgery check-up 385 Section 14 Behavioural problems Geoﬀ Shawcross Chapter 99 Illnesses in animals that have 388 Chapter 87 The aggressive dog 327 travelled abroad Jon Bowen Sue Shaw Chapter 88 The frightened dog 330 Chapter 100 Elective euthanasia 392 Jon Bowen Geoﬀ Shawcross Chapter 89 Separation problems in the dog 333 Jon Bowen Section 18 Appendices Chapter 90 House-soiling and elimination 335 problems Appendix 1 Rational use of antibiotics 397 Jon Bowen Sheena Warman Appendix 2 Rational use of glucocorticoids 402 Section 15 Poisonings Peter Hill Appendix 3 General principles of 404 Chapter 91 Dealing with suspected 341 non-steroidal anti-inﬂammatory poisoning drug (NSAID) use for the Geoﬀ Shawcross treatment of musculoskeletal pain Chapter 92 Anticoagulant rodenticide 347 Martin Owen toxicity Sheena Warman Appendix 4 Weight loss and obesity 406 control Sheena Warman Section 16 Problems in non dog/cat species Appendix 5 Interpretation of haematology 409 and biochemistry proﬁles Chapter 93 The sick rabbit 353 Peter Hill and Sheena Warman Sharon Redrobe Abbreviations 415 Chapter 94 The sick hamster 359 Sharon Redrobe Index 417 viii Contents List of contributors Editors Peter Holt, BVMS, PhD, DipECVS, CBiol, FSBiol, FHEA, FRCVS Peter Hill Emeritus Professor of Veterinary Surgery, Division of BVSc, PhD, DVD, DipACVD, DipECVD, MRCVS, MACVSc Companion Animal Studies, Department of Clinical Senior Lecturer in Veterinary Dermatology and Veterinary Science, University of Bristol, Langford House, Immunology, The University of Adelaide, School of Langford, Bristol BS40 5DU, UK Animal and Veterinary Sciences, Roseworthy Campus, Roseworthy, SA 5371, Australia Norman Johnston, BVM&S, FAVD, DiplAVDC, DiplEVDC, MRCVS Sheena Warman RCVS American and European Recognised Specialist in BSc, BVMS, DSAM, DipECVIM-CA, PGCert(HE), MRCVS Veterinary Dentistry, DentalVets, 31 Station Hill, North Clinical Fellow in Small Animal Medicine, Division of Berwick, Lothian EH39 4AS, UK Companion Animal Studies, Department of Clinical Veterinary Science, University of Bristol, Langford House, Martin Owen, BVSc, BSc, PhD, DSAS (Orth), DipECVS, Langford, Bristol BS40 5DU, UK MRCVS ECVS Recognised Specialist in Small Animal Surgery, Geoﬀ Shawcross RCVS Recognised Specialist in Small Animal Surgery BVSc, Cert SAO, MRCVS (Orthopaedics), Dick White Referrals, Six Mile Bottom General Practitioner (retired), Shrublands, St Patrick’s Veterinary Specialist Centre, Station Farm, London Road, Lane, Rake, Liss, Hampshire GU33 7HQ, UK Six Mile Bottom, Suﬀolk CB8 0UH, UK Additional authors Sharon Redrobe, BSc(Hons), BVetMed, CertLAS, DZooMed, MRCVS Jon Bowen, BVetMed, MRCVS, DipAS(CABC) RCVS Recognised Specialist in Zoo and Wildlife Medicine, Behavioural Medicine Referral Service, Queen Mother Clinical Associate Professor in Zoo, Wild and Exotic Hospital for Small Animals, Royal Veterinary College, Animal Medicine, Director of Life Sciences, Twycross Zoo, Hawkshead Lane, Potters Bar, North Mymms, Hatfield, School of Veterinary Medicine and Science, University of Herts AL9 7TA, UK Nottingham, College Road, Sutton Bonington, Leicestershire LE12 5RD, UK Jim Carter, BVetMed, DVOphthal, MRCVS RCVS Recognised Specialist in Veterinary Ophthalmology, Sue Shaw, BVSc (Hons), MSc, Dip ACVIM, Dip ECVIM, South Devon Referrals, The Old Cider Works, Old Cider FACVSc, MRCVS Works Lane, Abbotskerswell, Devon TQ12 5GH, UK Senior Lecturer in Dermatology and Applied Immunology, Division of Companion Animal Studies, Mark Goodfellow, MA, VetMB, CertVR, DSAM, Department of Clinical Veterinary Science, University of DipECVIM-CA, MRCVS Bristol, Langford House, Langford, Bristol BS40 5DU, UK European Recognised Specialist in Veterinary Internal Medicine, Molecular Oncology Laboratories, Weatherall Paul Smith, BVetMed, DVC, MRCVS Institute of Molecular Medicine, John Radcliﬀe Hospital, RCVS Recognised Specialist in Veterinary Cardiology, East University of Oxford, Oxford, UK Anglia Cardiology Ltd, The Bakers Cottage, Church Street, Buntingford, Hertfordshire SG9 9AS, UK Andrea Harvey, BVSc, DSAM(Feline), DipECVIM-CA, MRCVS RCVS Recognised Specialist in Feline Medicine, Feline Advisory Bureau, Taeselbury, High Street, Tisbury, Wiltshire SP3 6LD, UK ix Acknowledgements Peter Hill would like to thank Sarah, his wife, for her had the pleasure to work during his career for their constant support during the writing of this book. unstinting support and advice, without which his contribution to this book would not have been possible. Sheen Warman would like to thank her husband Adrian for his patience and support whilst this book has been written. She would also like to thank colleagues and Dedication students, past and present, who have provided inspiration This book is dedicated to all the animals we have treated and helpful suggestions. over the course of our careers. Without them, we would have known nothing. Geoﬀ Shawcross would like to take this opportunity to thank all the professional colleagues with whom he has x About this book This multidisciplinary text begins with a comprehensive better?’, ‘ The low-cost option’ and ‘When should I refer?’, guide to the consultation process in small animal practice. which can be quickly identified by their colour (red, Within this section, clinicians will find highly practical, orange and purple, respectively). This type of information invaluable tips about history taking, physical examination is rarely taught at veterinary school and practitioners and diagnostic approaches. usually have to learn it the hard way, by trial and error. The book then covers 100 of the most common sce- There are then five appendices covering the use of anti- narios that a small animal practitioner will have to deal biotics, glucocorticoids and non-steroidal anti-inflamma- with in the consulting room. These chapters are of three tory drugs, as well as information on obesity control and main types: the interpretation of laboratory tests. Never before has such practical information been put 1) Presenting-sign-based chapters – These chapters, together in a single text. When grouped together, these coloured blue, cover an important symptom, listing chapters provide a comprehensive guide to the vast the common diﬀerential diagnoses, outlining the majority of consultations undertaken in small animal diagnostic approach for its investigation and general practice. It ’s like having an experienced or special- indicating how the case should be treated. These ist clinician standing by your side in the consulting room. chapters inform clinicians about what to tell clients This book will be invaluable to: before a diagnosis has been made. 2) Diagnosis-based chapters – These chapters, Undergraduate veterinary students coloured purple, cover important diseases and Newly graduated veterinarians describe how clinicians should diagnose and treat Experienced veterinarians who are looking for an them. These chapters inform clinicians about what up-to-date refresher on small animal practice to tell clients after a diagnosis has been made. Veterinarians who are returning to the profession 3) Miscellaneous chapters – These chapters, coloured after a leave of absence red, cover various topics that are rarely found in Veterinarians who are converting from large animal veterinary texts, such as annual health checks, to small animal practice, or for whom small animal neutering, oestrus control and euthanasia. consulting constitutes only a small part of their duties. Within the first two types of chapter, there are three unique ‘boxed’ sections covering ‘What if it doesn’t get xi Introduction: Diagnostic and therapeutic approaches in small animal general practice Peter Hill In order to treat diseases of small animals, clinicians must is an important aspect of the veterinarian’s ‘bedside adopt a systematic approach that leads to a diagnosis and manner ’ and is essential if the appropriate information is specific treatment. This process typically involves the fol- to be gathered. Too much listening can lead to incomplete lowing steps: or confusing histories; too much questioning can come across as an interrogation. Mastering this important skill 1. Obtaining a history. requires practice and students should observe a number 2. Performing a physical examination. of experienced practitioners to determine the optimal 3. Making a diagnosis or generating a list of diﬀerential balance. diagnoses. When asking questions, it is important that clinicians 4. If necessary, performing tests to rule in or out do not speak to clients using technical terminology that is diﬀerential diagnoses. not widely understood. Veterinarians must become ‘bilin- 5. Determining a prognosis. gual’, using plain language for clients, and veterinary ter- 6. Prescribing treatment. minology for professional colleagues and medical records. In general practice, this whole process has to be orches- As an example, ‘Is he pruritic on his ventral abdomen?’ trated around a consultation that typically lasts around should become ‘Is his tummy itchy?’ Clinicians should also ten to fifteen minutes. In order to achieve this, clinicians have to develop and hone their skills so that they can deliver competent medicine without compromising patient care, as well as appearing unhurried in front of the client. The basic structure of a typical consultation is Preparation Create a professional and safe environment illustrated in Figure 0.1. Prior to seeing a case, the clinician should know the Initiating the consultation signalment of the animal (age, breed and sex) and be Establish initial rapport with the client and animal Identify the reason for the consultation aware of its vaccination and worming history. This infor- mation should be in the animal’s medical records, but if it Gathering information is a new client, it can be obtained by the reception staﬀ. Provide Exploration of the client’s presenting complaint using a Continually balance of open and closed questions Other information that should be in the animal’s records structure to Determine the clinical history build a the Determine the client’s expectations and wishes relationship includes dietary, foreign travel and previous medical Acquire any relevant background information consultation with the history. client Physical examination Non verbal History taking Maintain flow behaviour Bedside manner Taking a history is a process in which a veterinarian listens Explanation and planning Involve the Tell the client what is wrong with their pet to, and questions the owner of a pet, in order to deter- Provide the appropriate amount/type of information client Assist with understanding mine what abnormalities or signs have been observed. Achieve a shared understanding and plan by Involve the animal incorporating the client’s wishes Typically, the owner is first asked what the problem is, and then allowed to describe the problem in more detail. The clinician can supplement the information obtained by Closing the consultation Summarise asking specific questions. Outline forward planning To be good at history-taking, clinicians must learn to get the right balance between listening and questioning. This Figure 0.1 An overview of the consultation process, modiﬁed from a system known as the Calgary– Cambridge Model Framework. This approach is commonly taught in medical and veterinary schools. 100 Top Consultations in Small Animal General Practice, First Edition In general veterinary practice, some of the By Peter Hill, Sheena Warman and Geoﬀ Shawcross ‘information gathering’ may take place during, or © 2011 Blackwell Publishing Ltd after, the physical examination 1 be aware of regional variation in the use of terminology observed, an approach to investigating the problem can (such as use of the term ‘jags’ to signify injections in be found later in this book. Further questions that provide Scotland) and the various terms that can be used by specific information about various organ systems include: owners to describe symptoms. Any vomiting or diarrhoea? In addition to keeping the questions simple, clinicians Any coughing, sneezing, or changes in breathing? must be logical and objective when questioning clients. Any problems with urination? They need to extract information from the client that Any sign of lameness? might not otherwise be forthcoming. Clients may not Any problems with sexual activity or heat cycles? mention important facts because they are not aware of Any fits, seizures, ‘funny turns’ or strange their relevance. They may also be embarrassed at disclos- behaviour? ing information about previous home remedies or condi- Any skin or coat problems? tions involving neglect. If the clinician is not entirely convinced by a particular response, it is often helpful to Whether or not a clinician needs to ask all these questions repeat the question in a slightly diﬀerent way to deter- will depend on how specific or vague the initial informa- mine if the answers are consistent. Useful information can tion is, and the index of suspicion for a multi-systemic also be obtained by listening to other people in the exami- disorder versus an organ-specific disorder. nation room such as the client ’s partner or children. During recheck examinations, it is not necessary to When obtaining a history, clinicians should first ascer- obtain the same type of history as in the initial consulta- tain what the owner ’s complaint is and how long it has tion. The clinician should focus on the following aspects: been present. An immediate assessment should be made Is the treatment working, i.e. is the animal better, at this stage to determine if the animal looks well enough worse or unchanged? to continue with history taking. Seriously ill animals (e.g. Are there any new problems? road accidents, haemorrhage, collapse) may need urgent Have there been any problems or adverse eﬀects hospital treatment and should be admitted for physical associated with the treatment? assessment and stabilisation. The length of time devoted to obtaining histories will depend on the nature and severity of the presenting Physical examination problem. In some cases, the owner may provide very spe- The aim of the physical examination is to evaluate an cific information that clearly refers to a single organ abnormality that an owner has noticed, or to determine system and progression to a physical examination can if there are any detectable abnormalities that may account occur after one or two answers. For example, ‘I’ve found for a problem revealed in the history. When performing a a lump on my dog ’s leg ’ or ‘My dog was running around physical examination, a clinician can use the senses of and suddenly started limping.’ In such cases, further ques- vision (direct observation), hearing (listening or ausculta- tioning is likely to arise during and after the examination, tion), touch (palpation) and smell. An ability to perform a in order to find out if there are any related symptoms. In physical examination requires knowledge of normal topo- other cases, the owner may report a specific problem that graphical and organ anatomy. warrants further questioning to clarify its nature. For A physical examination can be partial or complete. A example, if the owner says ‘My dog has diarrhoea’, the partial examination is when only a particular part of the clinician should ask for further details about the nature of body or one organ system is examined. Normally, this the stools, such as consistency, frequency, smell, colour, would be an area that the owner has identified as being presence of blood or mucus and whether there are any abnormal, such as a limb or the skin. A complete examina- associated signs of straining or diﬃculty defecating. tion involves examining the whole animal. However, an If animals are presented with non-specific problems, examination is rarely truly ‘complete’ because there appear very unwell or clearly have a serious condition, it would rarely be suﬃcient time to evaluate all the organ is necessary to obtain a more complete medical history. systems in detail. In reality, a routine ‘complete’ physical Four questions are particularly valuable in characterising examination normally refers to examination of the head, an animal’s general health: chest, abdomen, lymph nodes, genitalia, legs and skin, and measuring the animal’s temperature, pulse and res- Any changes in appetite? piratory rate (see Table 0.1). Any changes in thirst? The order in which a complete physical examination is Any changes in weight? performed is at the discretion of the clinician. Some clini- Any changes in behaviour or activity level? cians like to record the temperature, pulse and respiratory If none of these parameters has altered, it can be assumed rates first, followed by a systematic examination of the that the animal feels well in itself. If changes have been organ systems. Other clinicians (the author included) 2 100 Top Consultations in Small Animal General Practice Table 0.1 The components of a routine ‘complete’ physical examination. Normal findings Abnormalities General appearance Bright Lethargic Alert Depressed Responsive Collapsed General symmetry Hyperactive Body weight and condition Normal for breed Too fat or thin Eyes Bright Discharge Clear Redness Moist Opacities Normal pupil size Abnormal mucous membrane colour Anisocoria Nose Moist Discharge Cobblestone appearance Lesions Mouth Clean teeth Tartar Healthy gums Periodontal disease Pink mucous membranes Abnormal mucous membrane colour CRT < 2 seconds CRT > 2 seconds Normal tongue and palate Inflammation Normal pharynx Ulceration Foreign bodies Swollen tonsils Ears Clean Inflammation Discharge Odour Lymph nodes: Normal size Enlarged submandibular, (prescapular may not be palpable Painful prescapular and popliteal in normal animals) Larynx and trachea Normal shape on palpation Cough induced by gentle palpation Cough not induced by gentle palpation Thorax Normal heart sounds Murmurs (assess by auscultation) Normal heart rate (correlate with Tachycardia pulse rate) Bradycardia Normal heart rhythm Abnormal rhythm Breathing pattern normal Laboured breathing Normal respiratory rate Increased respiratory rate Normal breath sounds Increased lung sounds or audible crackles/wheezes Abdomen Normal size Distended or pendulous abdomen (assess by palpation) Liver not palpable Hepatomegaly Stomach not palpable Stomach enlarged with food or gas Spleen not palpable Splenomegaly Intestines feel like squelchy tubes Can palpate intestinal gas, thickening, Normal kidneys (easier to palpate foreign bodies, constipation, pain in cats) Enlarged or painful kidneys Normal bladder Bladder distended or painful No abnormal masses Abnormal mass palpable (Continued ) Introduction: Diagnostic and therapeutic approaches 3 Table 0.1 (Continued ) Normal findings Abnormalities Perineum/genitalia Normal anus Masses or lesions Normal vulva Swelling Normal/absent testicles Discharge (pus or blood) Normal penis/prepuce Limbs Normal musculature Lameness/abnormal gait Normal joints Swollen or painful joints Limited range of movement Atrophy Skin Shiny coat Skin lesions Healthy skin Parasites Normal elasticity Skin tenting (dehydration) Rectal temperature Normal Elevated Decreased CRT = capillary refill time. prefer to conduct the examination from the front of the tory systems assessed in detail, but examination of the animal to the rear. The advantage of starting at the front skin or limbs would not be necessary. Despite this, there end first is that the clinician can interact with the animal are many situations where a complete examination should and put it at ease as the examination begins. Putting a be considered essential, including: thermometer into the rectum initially might not be the best way to make friends! Whichever way it is done, a When a diagnosis is not obvious based on history skilled clinician should develop a routine that becomes and partial physical examination second nature, allowing a complete examination to be When an animal hasn’t responded to treatment as performed in less than five minutes. expected There has been a traditional view amongst educators in When an animal presents with vague clinical signs veterinary schools that a complete physical examination such as lethargy, inappetence or weight loss is mandatory in every case. The reality is that this is When an animal presents with serious symptoms neither practicable (due to time constraints) nor neces- such as anaemia, jaundice, severe depression or sary in order to deliver good quality medicine. Clinicians collapse need to use their clinical skills and experience to deter- When an animal appears very unwell mine what level of physical examination is required, based When an animal is pyrexic and there isn’t an on the nature and severity of the illness that is presented. immediately obvious cause A partial examination can be appropriate for many prob- When an animal has symptoms that may indicate a lems seen in general practice such as lameness, skin prob- systemic cause lems, ocular problems, dental disease, minor external When a neoplastic disease is suspected or confirmed trauma or mild medical disorders. For example, a dog When puppies and kittens are checked prior to presenting with fleas does not need to have its abdomen vaccinations or limbs palpated; a dog with a mild case of diarrhoea When an animal is having an annual health check. does not need a full dermatological or thoracic examina- tion; a cat with ear mites does not need to have its tem- A complete examination may be initiated immediately perature, pulse and respiration recorded. after the history has been obtained, or it may follow on In other situations, a detailed assessment of multiple from a partial examination. If an owner has pointed out a parts of the animal would be indicated, without necessar- particular area of concern, it is most appropriate to ily performing a full examination. For example, prior to examine that part first. For example, if an animal is pre- general anaesthesia, an animal should have its tempera- sented with a cutaneous mass or is limping on one leg, ture, hydration status and cardiac, respiratory and circula- the owner will expect those areas to be examined first. 4 100 Top Consultations in Small Animal General Practice The clinician can then decide if a complete examination is sarcoptic mange, kennel cough and certain forms of warranted. If it is deemed necessary, the clinician can say lameness. It is essential when using this approach ‘We’ll just check him all over to make sure there’s nothing that the animal is re-evaluated if the clinical signs wrong anywhere else.’ Some clinicians suggest that a com- do not respond to treatment as expected. By plete examination should take place first, followed by a definition, this approach implies that other more focussed examination, but it may seem strange to a diﬀerential diagnoses could be causing the signs and client when a veterinarian starts to examine the teeth of these need to be investigated if the initial outcome a dog that presents for lameness. is not satisfactory. In addition to the partial and routine complete exami- 3. In some cases it is only possible to generate a list of nations described above, there are additional examina- diﬀerential diagnoses. This is the case in animals tion techniques that may be necessary in particular presenting with general signs of illness such as circumstances. These include ophthalmoscopic examina- polydipsia, weight loss or jaundice, but also with tion, otoscopic examination, detailed examination of the many organ-specific signs that either do not allow a skin, in-depth orthopaedic palpation and assessment (e.g. precise diagnosis to be made, or have not resolved flexing and extending every joint), thoracic percussion, following treatment based on pattern recognition or neurological examination and behavioural assessment. probability diagnosis. In order to diﬀerentiate Clinicians only need to employ these techniques when between multiple possible causes of a condition, there is a specific clinical requirement. clinicians need to use a problem-oriented approach. In this approach, the predominant problem is determined from the initial history and physical Making a diagnosis or generating examination (e.g. pruritus, vomiting, diarrhoea, a list of differential diagnoses coughing, lameness, haematuria) allowing a list of prioritised diﬀerential diagnoses to be generated. If Based on the history and physical examination, a clinician there is more than one problem, multiple will arrive at one of four possible outcomes. diﬀerential lists can be generated. A diagnostic plan 1. It may be possible to make a definitive diagnosis is then formulated which involves tests and and recommend specific treatment. This ability is investigations to rule in or out the conditions on the derived from clinical knowledge and experience and list(s). The tests may all be carried out at one time, is known as pattern recognition. This approach is or they may be staggered so that the most common based on the fact that many diseases produce a or potentially serious conditions are investigated characteristic pattern of historical and clinical first (a sequence known as a diagnostic algorithm). features that the clinician can recognise. Many In general practice, the tests are often staggered, common conditions in small animal practice can be but the final decision will be determined by the diagnosed in this way (e.g. abscesses, flea allergy, severity of the presenting problem, the likelihood of dental disorders, some lameness, superficial ocular the various diﬀerentials, and the wishes and problems, traumatic injuries). Pattern recognition is financial circumstances of the client. A fundamental a very cost-eﬀective approach which can save the principle of the problem-oriented approach is that owners money and time, avoid unnecessary tests, only tests which relate to conditions on the and allow the animal to get the most appropriate diﬀerential list should be performed. Clinicians treatment quickly. However, it takes time for new should not perform a standard set of tests (a graduates to gain the necessary experience to be ‘workup’) in the hope that a diagnosis will emerge fully confident with this approach. from the laboratory. Failure to observe this principle 2. It may be possible to make a tentative diagnosis and will result in unnecessary tests being performed on provide empirical treatment. This approach is a frequent basis. The only exception to this rule is similar to pattern recognition but diﬀers in that the the performance of haematological and biochemical history and physical examination do not allow a tests, which are often more economical when run definitive diagnosis to be made. With this approach, as a panel. However, clinicians should not use this the clinician is basing the diagnosis on probability. as an excuse to avoid the initial thought processes Probability diagnosis requires the clinician to choose that lead to a diﬀerential list. the most likely possibility for a set of clinical signs, The problem-oriented approach can be used by based on the premise that ‘common things occur students and new graduates for all cases before commonly ’. As with pattern recognition, this they have the necessary experience to utilise approach is used widely in small animal practice, pattern recognition and probability diagnosis. and is appropriate for conditions such as gastritis, However, it can lead to long diﬀerential lists and Introduction: Diagnostic and therapeutic approaches 5 excessive use of tests that might not be required. Tests are rarely 100% sensitive: This means that an Experienced clinicians can also use this approach for animal could have a disease and the test would not complicated cases and those that are not detect it responding to treatment as expected. Tests are rarely 100% specific: This means that the 4. In some cases, clinicians may not be able to think of test may say the animal has the disease when in fact any diﬀerential diagnoses for the condition they are it doesn’t faced with. This can happen with recent graduates Many tests have a grey zone: This means that there who lack experience, but it can also occur with can be overlap between what is considered normal experienced practitioners when uncommon or rare and abnormal entities are presented. When this happens, Some tests require interpretation: This means that clinicians should first seek a second opinion from the clinician has to employ clinical skills to someone else within the practice. If the condition determine if a test result is abnormal or not still remains an enigma, the most appropriate Some tests require specialised skills to perform: This option is to recommend referral to a specialist. would include procedures such as ultrasonography Specialists can apply any of the three diagnostic and endoscopy approaches outlined above to conditions that may Some tests require skilful sample collection: This be rarely seen in general practice. In some cases, applies to samples such as skin biopsies, CSF pattern recognition may be possible, saving the collection or bone marrow aspirates. If good quality owner and animal a prolonged series of samples are not submitted, it will be impossible to investigations. Unless enforced by the client, it is obtain meaningful results. not appropriate to perform an extensive set of tests To overcome these problems, the use of diagnostic tests when the clinician does not know what they are must always be focussed and not indiscriminate. They looking for. must be based on a previously generated list of diﬀeren- Throughout this book, the appropriate use of these tial diagnoses, and ‘standard workups’ should be avoided. various diagnostic approaches is highlighted. Each test must answer the specific question – will this test help me decide if the animal has this disease? Finally, the Performing diagnostic tests results of diagnostic tests must always be interpreted in the context of clinico-pathological correlation. This means Diagnostic tests are an essential component of the inves- that the results can only be interpreted in conjunction tigation of many cases in small animal practice. As with the clinical findings, whether they are blood tests described above, they are an integral part of the problem- results or biopsy reports. As it is only the clinician that has oriented approach. However, there has been a trend in access to all the clinical and laboratory data, it is the clini- veterinary medicine for tests to be over-used when not cian who has to perform the clinico-pathological correla- needed (e.g. running blood tests on young, healthy tion and make the final diagnosis. If the case appears too animals prior to anaesthesia for routine procedures), complex for all these principles to be adhered to, referral under-used when they are needed (e.g. not performing to a specialist should be recommended. cytology on ear infections and cutaneous masses), or used to replace a sound clinical approach (e.g. performing skin Determining a prognosis biopsies on a chronically itchy dog). The prognosis is a critical factor in veterinary medicine. In It is crucial that clinicians do not transfer the responsi- humans, appropriate treatment is given regardless of the bility for making a diagnosis onto laboratories and pathol- prognosis. However, in animals the cost of treatment, and ogists. The clinician has the benefit of a full history and a general desire to not see animals suﬀer, influences the the findings from a thorough physical examination, and decision as to how, and when, to treat. The prognosis may these go a long way towards establishing a diagnosis. have a large bearing on this decision. Some owners desire Sending small pieces of the animal away for analysis can treatment for their animal even if the outlook is bleak. be a very valuable adjunct to this clinical process, but it Other owners may favour euthanasia for their pet if long- must never replace it. Some of the pitfalls in diagnostic term management is required, even if a successful testing that clinicians must be aware of are: outcome is likely. The meaning of a normal range: Normal ranges are The prognosis is usually categorised as good, fair, established to include 95% of the healthy guarded, poor or grave. A good prognosis indicates that population. This means that 5% of the population the animal has a good chance of making a full recovery, would be outside the normal range, and could be or having its condition successfully managed. A fair prog- misdiagnosed as having a disease nosis indicates that the animal has a reasonable chance 6 100 Top Consultations in Small Animal General Practice of making a full recovery, or having its condition success- belief that it is beneficial to start a course of treatment by fully managed. A guarded prognosis means that it is always giving an injection of a drug or vitamin solution. uncertain whether or not the animal will make a recovery. There is often no rationale to this approach and it has A poor prognosis means that the animal has little chance more to do with a clinician’s perceived need to be seen to of making a full recovery, and a grave prognosis means be doing something technical in front of the client in order that the animal is likely to die in the near future. to justify their fee. The prognosis is essentially determined by the diagno- Clinicians should always balance the potency or aggres- sis, but will be influenced by other factors such as the siveness of a treatment regime against the severity of the owner ’s commitment (both practical and financial) to disease. This follows the principle of ‘First, do no harm’. the treatment regimes. The earlier a diagnosis is made, An animal should never be placed in a situation where the the earlier the owner can be informed about the progno- eﬀects of the treatment are worse than the original sis. The majority of animals entering veterinary practices disease. For example, this can happen when long-term suﬀer from minor illnesses that have a good prognosis. In glucocorticoids are used inappropriately to treat pruritus, seriously ill animals, the prognosis should be determined resulting in iatrogenic Cushing ’s syndrome. In addition to as rapidly as possible so that the owner can make a deci- potential adverse eﬀects, clinicians need to ensure that sion about their pet. Some serious illnesses carry a good owners are aware of the cost of medications, and any prognosis, but when the prognosis is poor or grave, eutha- associated monitoring, especially if they are required in nasia should always be considered as a potential option. the long term. In most countries, the prescribing of drugs to animals is governed by law. In Europe, the process is regulated by Prescribing treatment asking veterinarians to follow a prescribing cascade. This Treatment of small animal patients can be specific or states that drugs should be chosen in the following order: symptomatic. Specific treatments target the actual cause of the illness and can cure or control it (e.g. antibiotics for The first choice of drug should be a veterinary product that is licensed to treat a specific condition an infection, insulin for diabetes mellitus). Symptomatic in a specific species treatments target the clinical signs associated with the illness. They cannot cure the underlying condition, but If a specific product in this category is not available, clinicians should choose a veterinary product that is they can control it whilst the body heals itself or responds licensed in the species to treat a similar condition to a specific treatment. Symptomatic treatments can also (e.g. the treatment of Cheyletiella mite infestation be used to provide long-term control of incurable condi- with selamectin) tions such as atopic dermatitis or arthritis. However, symptomatic treatments should not be given in the If no such product exists, a product licensed for use in other veterinary species to treat similar conditions absence of a tentative or specific diagnosis. For example, should be considered (e.g. the use of ivermectin to anti-emetics would be appropriate if a tentative diagnosis treat refractory canine demodicosis) of gastritis had been made, but they should not be used indiscriminately to treat every animal that presents with If there are no appropriate licensed veterinary products to treat the condition, clinicians can then vomiting. At best they will delay implementation of more consider using either human drugs (e.g. the use of specific therapy and at worst, they may actually harm the azathioprine to treat immune-mediated diseases) or patient. importing a veterinary drug from another country When treatment is prescribed, clinicians should ask under license (e.g. the use of milbemycin to treat themselves ‘Why am I giving this specific medication and refractory canine demodicosis). what do I hope to achieve?’ The systematic review, appraisal and use of clinical research findings to ensure The treatment of animals with generic human drugs, the delivery of optimum care for a particular condition is where equivalent licensed veterinary products exist, is known as ‘evidence-based medicine.’ At the moment, illegal. It is also illegal to progress down the prescribing evidence-based veterinary medicine is still in its infancy, cascade in order to save costs. and many drugs are prescribed on the basis of clinical and When prescribing treatment, clinicians should also con- anecdotal experience. The ultimate aim is that the eﬃcacy sider the complexity of the treatment regime, and how it of all drugs and treatment regimes will have been deter- will fit in with the owner ’s lifestyle. Lack of owner compli- mined on the basis of blinded, randomised, controlled ance is common, both in human and veterinary medicine. trials that definitively prove their benefit. At the opposite The easier the treatment is to administer, the more likely end of the spectrum to evidence-based medicine are that it will be done properly. In general, drugs that can be some old prescribing practices that appear to have sur- given once daily are more likely to be administered cor- vived into the modern era. One such practice is the false rectly than drugs requiring three times daily dosing. Introduction: Diagnostic and therapeutic approaches 7 Compliance is also more likely if time is taken (by the should be discussed with the owner and second veteri- veterinary surgeon or nurse) to ensure that the owner is nary surgeon in advance. able to medicate their pet in an eﬃcient manner. Hospitalised patients Re-check examinations If an animal needs to be admitted into the veterinary clinic, it needs to be carefully monitored by the nursing Re-check examinations are not required if the owner can staﬀ and thoroughly examined on at least a daily basis so adequately assess the outcome of a treatment course. that the eﬀects of any treatments can be assessed. One This is likely to be the case when the condition has an way of monitoring such patients is to use the ‘SOAP’ obvious clinical sign, such as vomiting or diarrhoea. system (Subjective Objective Assessment Plan). The sub- However, a re-check will be necessary if the response to jective parameters include such things as whether the dog treatment can only be assessed by a trained clinician. This looks brighter, has started to eat, or has stopped vomiting. would be the case if further physical examination were The objective parameters include things such as the tem- required, such as abdominal palpation or auscultation of perature, pulse rate, respiratory rate or volume of water the chest. Re-checks should not be arranged just to see drunk. Based on the subjective and objective parameters, how the animal is ‘doing ’. There must be a specific purpose the clinician can make an assessment. This might be for the re-check and the clinician needs to decide in something like ‘ The dog is brighter, the vomiting has advance why the animal needs to come back, what mile- stopped and the temperature is back to normal. Much stones it should have reached, and what decisions will be improved from yesterday ’. After the assessment, the clini- made, based on how it has responded. If the animal is on cian can make a plan. For example, in the above case the long-term treatment, periodic re-checks may be neces- plan might be to ‘introduce small amounts of food, sary for monitoring, fine-tuning and to comply with local monitor for vomiting and keep in until tomorrow’. The rules or legislation requiring animals to be under the vet- hospitalised animal is ‘SOAPed’ each day until the plan is erinarian’s care before prescribing drugs. to send it home. During a re-check, the diagnostic approaches outlined above can all be used, but usually in a truncated form. The history can be brief and the physical examination can The role of specialists focus on the abnormality being treated. However, if the Within the first year of entering general practice, new animal is not responding as expected, it may be necessary graduates will have built up a wide portfolio of experience to re-evaluate the whole diagnostic approach to ensure that covers many of the common conditions seen in small that nothing has been missed. For example, if the animal animals. By that stage, they should feel confident and has been treated on the basis of a pattern or probability competent in their abilities to handle routine cases. diagnosis, it may be necessary to consider a wider prob- However, the explosion of knowledge in veterinary medi- lem-oriented approach which brings in some other dif- cine has resulted in large numbers of rare diseases being ferential diagnoses. Additional testing may then be described and the emergence of ever more advanced warranted. In the absence of a definitive diagnosis, it is forms of diagnostic testing. It is no longer possible for not appropriate to just keep changing treatments to see general practitioners to be informed about all the if another drug would work better. advances in all disciplines, and to develop the technical In some cases, it is necessary for a diﬀerent clinician to expertise to conduct all the procedures. In addition, man- see an animal for a re-check. Although this is not ideal in agement of complex cases can require specialist experi- terms of continuity, it is sometimes unavoidable for practi- ence and monitoring. It is no longer acceptable for a cal or logistical reasons. In such cases, it is essential that clinician to attempt to diagnose and manage a complex the first clinician provides medical records that clearly condition of which they have no previous experience, indicate to the second clinician what the owner is expect- without having received further training in that discipline ing. An example might be ‘If no response to nonsteroidal or having suggested referral to the owner. Veterinarians anti-inflammatory drugs (NSAIDs), advise radiography.’ should, therefore, consider referral to a specialist as a This ensures that the owner receives consistent advice. normal extension of their everyday practice, as it is in the Accurate medical records, stating clearly what was medical field. It is certainly not a sign of failure. observed during the first consultation, and consistent use In general, referral should be recommended at the of terminology, are also important so that clients realise outset if an unfamiliar disease is encountered. It is far the two clinicians are talking about the same thing. better for the animal and owner to see the specialist Clinicians should not deliberately book cases in to see immediately than as a last resort after multiple consulta- a diﬀerent veterinarian in order to avoid seeing a diﬃcult tions and a whole series of tests. In some cases, an initial or frustrating case. If a second opinion is required, it specialist opinion can also save the owner money, because 8 100 Top Consultations in Small Animal General Practice it may be possible to avoid unnecessary tests. When it is of qualified specialists. At the end of this training period, not initially obvious that the case is going to be diﬃcult the clinician should obtain a Diploma or become Board to diagnose, the ‘three-consultation rule’ can be used as Certified in their speciality. Some veterinary clinicians a general guide to determine if referral should be oﬀered. oﬀer referral services without having received such train- This states that when an animal is seen for the same ing or qualifications. In some countries, lesser qualifica- complaint, a clinician should have made a definitive diag- tions (e.g. the certificate system in the UK) might be put nosis within three consultations. If at the end of the third forward as providing eligibility to provide a referral consultation, the clinician is no nearer to establishing a service. These qualifications were never intended to definitive diagnosis than they were at the outset, the assess a candidate’s ability to practice referral medicine owner should be oﬀered a referral. Referral should also and in no way compare to the level of knowledge and be oﬀered when a condition that requires specialist man- clinical training that is required to obtain a Diploma. agement is diagnosed. Examples of when cases should be Therefore, when oﬀering a referral, clients should be referred are highlighted throughout this book. made fully aware of the options available so that they can Clinicians should be selective in their choice of a spe- make an informed choice. They may decide to consider cialist. To develop specialist expertise in a specific disci- factors such as travel distance in preference to level of pline requires many years of advanced training, typically expertise, but that must remain their choice, and should acquired during a residency under the close supervision not be imposed on them without prior discussion. Introduction: Diagnostic and therapeutic approaches 9 Section 1 Health checks and vaccinations 1 The new puppy or kitten Geoﬀ Shawcross A new puppy or kitten will be presented either by an exist- to be returned, and are often prepared to invest the nec- ing client who has acquired another pet, or by a new client essary care and finances to resolve the problems. If the who has never been to the practice before. The purpose animal is to be returned, treatment (especially surgical of this consultation is to evaluate the clinical well-being procedures) should not be instigated unless there are sig- of the pet, advise on diet and discuss preventative medi- nificant welfare issues. cine. However, during this time, the client will also be forming their opinion of the expertise, compassion and The ﬁrst consultation eﬃciency of the whole practice team. The pet may be presented as soon as it has been acquired, but it is often better to see the animal after it has had the Pre-purchase advice chance to settle in its new home for a few days and the Clients may occasionally ask veterinarians for advice owner has had the opportunity to observe its behaviour about choosing particular breeds. However, what appears and demeanour. The owners can then describe any issues to be a simple question can have a very complicated of concern and may describe signs that warrant further answer. Choosing a breed of dog or cat is a very personal evaluation during the clinical examination. In most cases, matter, so the final decision can rest only with the pur- puppies and kittens will be presented when they are 8–10 chaser. Potential owners should be advised to do some weeks of age, at which time they require their first research into the breeds they are considering, and ensure vaccinations. that they have the time, facilities and financial resources It is always helpful if reception or nursing staﬀ can to own the breed that they choose. Factors that need to obtain the signalment (breed, age and sex) before the be considered are the size of the animal, the amount of clinician sees the animal. It is permissible for them not exercise it will need and its likely temperament. In particu- to know that the dog is a Nova Scotia Duck-Tolling lar, veterinarians need to be aware of the many breed Retriever and not a mongrel but, unfortunately, not the predispositions to disease so that they can answer specific veterinary surgeon! questions when asked. For example, potential owners Many owners are worried that their newly acquired pet may want to know if the breed they would like to buy is will be exposed to infections at the practice and this prone to joint disease, skin problems or cancer. concern should be appreciated. Practice policy may If there is the opportunity to advise the client before include keeping kittens and puppies contained within a they actually purchase their new pet, it should be sug- pet carrier, or even waiting outside the building in the car, gested that finalising the purchase should be dependent pending their appointment. At all times, the examination on a satisfactory report from a veterinary surgeon. If the room, equipment and clinician should appear to be scru- clinician subsequently finds a problem that could be det- pulously clean. Owners of pedigree pets should be asked rimental, or have long-term financial implications, the about the future use of the animal, whether it is for animal then can be returned. The clinician should appreci- breeding, working or simply a family pet. Owners who ate, however, that the majority of clients ‘bond’ very wish to show their animals should be advised to seek the quickly with their new pet and cancelling the purchase, opinion of a recognised judge of the breed, if conforma- even after an unsatisfactory veterinary surgeon’s report, tion is an absolute priority. The clinician’s opinion should is rarely an option. Indeed, many owners will feel that be confined to veterinary matters. they have ‘rescued’ their new pet if they felt that the The clinician should check through any paperwork that breeder/supplier would not look after it properly were it the client has been given by the breeder/supplier. Often, they will have been given copies of the results of breed- related health schemes of the parents (e.g. hip scores, elbow scores, eye schemes) and this will introduce a dis- cussion about diseases that will not be apparent at the time of the examination but may develop as that animal 100 Top Consultations in Small Animal General Practice, First Edition By Peter Hill, Sheena Warman and Geoﬀ Shawcross gets older (such as hip dysplasia, elbow dysplasia, cata- © 2011 Blackwell Publishing Ltd racts, retinopathies, heart disease). In addition, the client 13 Section 1 is likely to have been given a diet sheet, together with occlusion varies with the breed standards, although advice about worming and vaccinations. This information in most breeds maxillary prognathism (overbite) is a should be checked, to make sure it is broadly consistent fault. Although malocclusions are a serious show with practice policy. Any diﬀerences in advice should be fault, they are rarely of clinical significance for the explained to the client. pet animal The eyes should be clear and bright, with no ocular The clinical examination discharges or epiphora. The eyelids should not show signs of entropion, which if present can lead to Time taken to ensure the consultation is pleasurable for severe corneal damage. A degree of ectropion is a the pet will pay dividends later. Forceful restraint and characteristic of certain breeds and would have to painful manipulations may make the animal fearful at be deemed normal in such individuals. The nictitans future visits. should be in the correct position and there should The physical examination should be thorough and be no deformity of its free edge. The globes and follow the general principles outlined in the Introduction. pupils should be of equal size, and there should be Particular attention should be focussed on signs of infec- no signs of a strabismus or nystagmus. The tious and congenital disease. The limitations of the exami- identification of lens defects and retinopathies in nation should be explained to the owner and the results very young animals requires considerable expertise, of all parameters that have been checked (whether and it is often diﬃcult to obtain the necessary normal or not) must be recorded. restraint required for a thorough ophthalmoscopic examination. Rather than carry out a poor General ﬁndings ophthalmoscopic examination, it may be preferable to outline the conditions that may exist (within the Puppies and kittens should be alert, bold and breed) and advise referral to a specialist at the inquisitive, but it should be appreciated that some appropriate age individuals are naturally reserved in a strange environment. Young animals that are genuinely ill The ear canals should be clean and odour-free. Infestation with ear mites (Otodectes cynotis) is are invariably lethargic, disinterested in their quite common and requires prompt treatment. The surroundings and reluctant to eat pinnae of most prick-eared dogs will not be erect Coughing (dogs) and sneezing (cats) initially should until they are several months of age be considered as signs of an infectious disease The nose should be free of discharges. The external Diarrhoea is common and often associated with a nares are often small in brachycephalic breeds (both change in diet but if the animal has diarrhoea when dogs and cats) and although this may accepted as purchased, this concern should be addressed as it part of the breed standard, extreme stenosis may could have an infectious cause. Diarrhoea in young result in respiratory problems as the animal cats can be frustrating to treat matures. Neurological signs such as intention tremors, ataxia or dysmetria may or may not progress, but rarely improve Chest and abdomen Breeds that have extreme characteristics (e.g. Auscultation of the lungs should not reveal any dwarfism, hairlessness, excessive skin folds) have abnormal sounds their own ‘in-built ’ problems and these should be The heart should be carefully evaluated on both mentioned, so that the owner knows what to look sides of the chest, over the entire cardiac area, out for/expect as the animal matures. However, it listening for heart murmurs that would suggest a would be unwise to make disparaging remarks about congenital heart defect (see Chapter 56). Some the characteristics of a particular breed to the murmurs associated with congenital heart disease owner, because often it is the eccentricity that has can be very focal. If there is any doubt about the attracted the owner to the breed in the first place. origin or significance of a murmur, the opinion of a specialist should be sought The head The rib cage should be palpated for symmetry The mucous membranes should be normal. Abdominal palpation need not be exhaustive, Abnormalities, such as cyanosis or pallor, are serious especially if it is being resented, as it is rarely and will be associated with other clinical signs productive. In the absence of other gastro-intestinal The mouth should be checked for cleft palates and signs, thickening of the intestines would suggest a normal primary dentition. Acceptable dental significant worm burden 14 100 Top Consultations in Small Animal General Practice Umbilical hernias are very common and some may Dogs are typically vaccinated against distemper, parvo- Section 1 warrant surgical correction. This, however, is rarely virus, infectious canine hepatitis (adenovirus-1) and lepto- urgent and can usually be deferred until the spirosis. In some countries, rabies vaccination is also vaccination course is complete. In bitches, it can required. Protection can also be given against canine often be corrected at the same time as neutering. kennel cough organisms by vaccinating for canine para- Inguinal hernias are much less common and can be influenza and Bordetella bronchiseptica. The necessity for diﬃcult to detect. They carry a higher risk of these latter vaccines should be based on a risk–benefit complications later in life and should be repaired analysis. The clinical signs that can be seen with these when the animal is reasonably mature diseases is summarised in Table 1.1. Cryptorchidism is common but the testicles of very Cats are typically vaccinated against feline viral rhino- small animals can be diﬃcult to palpate. It is a tracheitis (herpes virus, FHV), feline calicivirus (FCV), and serious defect in animals that are to be shown or feline panleukopenia (feline parvovirus). In some coun- used for breeding and the clinician must be tries, rabies vaccination is also required. Protection confident before declaring both testicles are present. against feline leukaemia virus (FeLV) should also be If there is any doubt, the clinician should defer advised in cats that are at risk of contracting this infection making a decision. (especially outdoor cats or in multi-cat households). Vaccination against feline immunodeficiency virus is Skeletal system Limbs of chondrodystrophic or giant breeds can be Table 1.1 Clinical signs of the infectious diseases that dogs are normally vaccinated against. diﬃcult to evaluate but should always appear symmetrical when viewed from the front and rear. Disease Signs and symptoms Growth plate disorders are uncommon but can lead to limb deformity that develops at an alarming rate. Distemper Oculo-nasal discharge, If such a deformity is suspected, expert advice conjunctivitis, coughing, dyspnoea, should be sought at an early stage. vomiting, diarrhoea, lethargy, anorexia, fever followed by Skin neurological signs (seizures, The coat should be clean and should not smell vestibular diseas

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