ASPECTS OF CASE TAKING

 Signalment - Identification of animal like species, breed, age sex

 Anamnesis - Collection case history, past and present including vaccination,

deworming etc.
 General Clinical inspection of the animal.

 General Clinical examination of the animal.

 Collection of various materials for investigations of the animal(Sampling).

 Application of diagnostic aids as required.

SIGNALMENT

 It means identification of the animal like species, breed, colour, sex and
age, basic biometrics like weight, height and body mass index etc.
 Apart from this ear tags, tattoo, branding marks and microchips can be

included which is vital in vetero-legal cases and also forinsurance purpose.

ANAMNESIS/ HISTORY TAKING
  A minimal interview consisting of the chief complaint and primary history of
present illness.
 Chief complaint
 History of present illness
 Past history
 The past history which is not relevant at that point may be omitted when

circumstances say so. In certain cases all body systems is not necessary when
there is focus on particular system.
CHIEF COMPLAINT

Major health issues at the time of presentation like nasal bleeding, seizures,


syncope, haemetemesis, hypersalivation, vomiting etc.,.

Sample questions
 Has the appetite changed?
 Has the animal vomited?
 Any change in appearance/Posture?
PAST HISTORY
 Includes major illnesses, any previous surgery/operations, any current ongoing
illness eg. diabetes, tuberculosis, demodicosis etc
 In case of animals in groups history should be oriented in such a way that when

they were vaccinated, transported, dewormed, change in diet, whether any disease
outbreak, death etc.,
Sample questions
 Has the animal been suffering from any disease before?
 Has it been vaccinated/dewormed?
 Has it had any surgeries before?
 AN INTRODUCTION TO GENERAL IMPRESSION/INSPECTION

GENERAL IMPRESSION is formed by looking and listening to an animal from

a slight distance. This is used for collecting information about the animal inaddition to
history and form a decision to proceed on problem oriented approach.
LEVEL OF CONCIOUSNESS

 Healthy animal shows intrest in the environment whereas sick animal may
  Sopor - sleepy
 Stupor - may be aroused with stimulus
 Coma - can't be aroused
APPEARANCE / BODY SHAPE

Appearance is the conformation or stature of the body

So when an animal is brought to you look for its appearance
Eg.You see a pot belly in case of intestinal parasitism in puppies
You see a bow leg in rickets in young dogs

APPEARANCE OF ABDOMEN

Visual inspection of the abdomen

 The contour or silhouette of the abdomen should be viewed from the rear and
each lateral region and from an oblique angle.Examination of contour will assist
in determining the cause of abdominal distension. Abdominal distention may be
unilateral, bilaterally symmetrical or asymmetrical or more prominent in the
dorsal half or ventral half. Recognition of the area of maximum distension
suggests diagnostic possibilities.
 Normal - Oval and slightly pear shaped.

 Free gas bloat - Slight bulging on the left flank.

 Frothy bloat- Unilateral ventral distension on left side.

 Over loading of the rumen - Distension of left flank region and less on the

right.
 Vagus indigestion - Round appearance of the left part of abdomen and

distension on right lower region of abdomen. “L” shaped rumen on

rectal palpation.
 Hydrops - Due to accumulation of fluid the weight drags down the abdomen so

that the lower part is round and prominent.

 Physiological hydrops - normal pregnancy more than one fetus.

 Pathological hydrops - hydrops amnion, hydrops allantois, and fetal

emphysema
 Ascites - Bilateral distension of lower abdomen – CHF, peritonitis and

ruptured bladder.
 Paralytic ileus with secondary ruminal tympany - Bilateral and ventral

distension of the abdomen.

  Pneumo peritoneum - Bilateral distension of dorsal half of abdomen.
 Right torsion of abomasums - Unilateral right side distension.

 Dilatation of the abomasums/torsion - Unilateral right side distension in the

right flank and right paralumbar fossa may be severely distended.

BEHAVIOUR

 Looking in for the behaviour of an animal when presented to you gives a clue to
the underlying disease condition.
 Mostly when the animals are presented to you the animals are calm and co-

operative, but they also turn to be nervous, restless, anxious and tense
 Pathological variationas eg.

 Restlessness to violence in case of colic in horses & lead poisoning in

cows
 Comatose in milk fever in cows
 Frenzy in rabies in dogs
 Does not respond to owner's call & running into objects with
staggering gait in case of Organophosporus poisoning in dogs
 Posture

POSTURE

 Check for limping, in-coordination or unsteadiness and abnormal limb

placement in animals brought for check up.
 Standing& Recumbent(Sternal or Lateral)

 Standing:Changes in posture associated with diseases takes a variety of forms

including curvature of the vertebral column. Eg. Kyphosis, lordosis, scoliosis,

rotation of the head, abnormal position of the limbs.
 Horses shift its weight from limb to limb in laminitis

 Pain arching of back, praying position in pancreatitis in dogs are associated with

abdominal pain
 Obvious abduction of the elbows seen when there is pain in chest or

dyspnoea( difficulty in breathing)

 Erection and rigid ears, Stiff limb and rigid tail seen in tetanus

 Star gazing posture seen in early pregnancy toxaemia (sheep).

 Vestibular disease, listeriosis, coenurosis, ketosis (goat) there will be deviation

of neck to one side.

 Crossing of the legs, straddling, head pushing, learning into the stanchion:
Ketosis (nervous form, OPC poisoning in dogs.
 Opisthotonus and lateral recumbency seen in hypomagnesemic tetany in calves.

 “Dog sitting” posture with kicking at the belly seen in colic in horses.

EXAMPLES OF GAIT ABNORMALITY

 Stiff gait : Tetanus, rheumatism, osteomalacia, fluorosis, calcinosis.

  Stumbling gait : later stages of grass tetany in the cow in such a way as
practically to result in a somersault.
 Circling gait: Vestibular disease, Cystic stage of taenia multiceps (Gid),

Listeriosis, Pregnancy toxaemia, Ketosis in cattle, Otitis media / interna,

 Staggering gait : Acidosis, ketosis, hypomagnesemia.

 Goose stepping gait : excessive range, force, exaggerated flexion – Pantothenic

acid deficiency (Pigs).

 Stilted gait: walking on the tip of the toe.

 Wobbling gait : there is slight in co-ordination of gait with knuckling over of

the fetlock and swaying particularly of the hindquarters.

 Swaying of the hind quarters: hind limb paralysis in dogs

ABNORMAL SOUNDS

Hear for sounds in the examination room at a distance. Few examples

 Brachycepahlic - respiratory sounds are heard loud which are characteristic for
the breed
 Pathological resipartory and intestinal sounds are heard from a distance

 Snapping sounds during walking are heard when there are joint disorders
 TEMPERATURE AND ODEMA OF SKIN

Temperature
The temperature of skin is felt extremities like limbs, pinna or lips. The normal
animal have warm extremities whereas when animal is in shock where the
peripheral circulation fails the extremities feel cold. If there is any inflammation
there warmth will be more.
Odema
The odema of the ski occurs because of gravity and tissue pressure. In dogs it
occurs in the ventral aspect. The area when pitted remain pitted for some time.
When there is inflammatory odema skin is warm and painful.
RECORDING OF RESPIRATION

The respiratory movements bring about ventilation of the lungs. The movements
are regulated by respiratory centers which receive impulses from peripheral and
central chemoreceptors and from mechanoreceptors in the lungs and thoracic wall.
  Frequency of respiration increases with incraese in temperature thus playing
arole in thermoregulation
 The respiratory movements are influenced by both environment and behaviour.

How will you check the respiration as and when the animal is brought to you?
movement of ribs, sternum and abdomen (standing animal)
 movement of the nasal alae

What can we look for?

 Depth
 Type
 Rhythm
 Frequency

CHANGES IN RESPIRATION

 Physiological increase eg. young animals, excitement, environment & decrease

obesity
 Pathological increase in fever, pulmonary diseases, severe cardiac diseases,
 partial obstruction of respiratory passages, pleurisy, peritonitis, anemia &
decrease in animals with space occupying lesions of brain, in stenosis of upper
respiratory tract, uremia.
DEPTH OF RESPIRATION

 Respiratory muscles help in normal respiration.

 Respiratory movements depend on both physiological and pathological status of

animal.
 In case when there is deeper breaths it may be giving a clue in diagnosis that

there is increase demand for ventilation.

 If the respiratory movements are forced or difficult then we call it

as dyspnea . (Click to watch the video of dyspnea in cat)

 If the difficulty is found after an exercise then it is called as dypnea of

excertion.
 When there dyspnea there are auxillary muscles giving hands to regular

respiratory muscles, they are the scalenus and the sternocephalicus muscles
 They work along with the muscles of nasal alae
 In case of respiratory movements we can observe the movements of nasal alae,
where in brachycephalic breeds like pug the movement is restricted
 In brachycephalic breeds the nasal passage are narrower that they produce a loud

sound with dyspnea called nasal stridor

 In some dogs dyspnoes leads to opuffing up of cheecks and in cats there is open

mouth breathing
TYPE OF RESPIRATION

 When respiratory muscles and the diaphragm are involved in respiratory

movements it is called costoabdominal respiration which noticed in both dog and
cat
 Pendulous respiration occurs in diaphargmatic rupture occurs here bulging of

the abdomen is absent due to loss of diaphargams function and also the there is
decrease in abdominal circumference
 Pseudopendulous occurs in severe dyspnea here it is a forced inspiration as

little air is drawn and flattening of diapragm is absent.

 At the end of expiration when abdominal pressure is exerted on diaphragm it is

abdominal type of respiration.

 Inspiration is active and expiration is passive.
  Inspiratory dyspnea occurs when there is n arrowing in the respiratory
passages cranial to the thoracic inlet showing costal type ofrespiration (Watch
video)
 Expiratory dyspnea occur when there is l oss of elasticity of the lungs as well

as loss of flexibility of the thorax which is assisted by abdominal pressure which

inturn displaces the diaphragm resulting in slow incomplete expiration
TECHNIQUE OF RECORDING RESPIRATION

 Count the inspiration for a minute without touching the animal.

 Inspiration – Check the thoracic lateral movements and abdominal bulging.
 Allow time for the animal to adjust with the new environment.
 Expiration – Check the falling of ribs and decrease in abdominal bulging.
 Also look for the ventral exertion by lowering yourself to observe.
VISIBLE MUSOUS MEMBRANE

Visible mucous membrane will be useful in giving the health status of animals
How do you do that?
 The sites for examining the mucous membranes in different species of animals


conjunctival, nasal, buccal, vaginal, cloacal, urethral, rectal, and tissues

surrounding the orifices.
 Hold the hand with one hand over the head and other under the jaw

 Slightly press the upper eyelid with the thumb of the top hand and then turn

down the lower eyelid with thumb of the hand holding the lower jaw( cattle) in
dog just turn down the lower eyelid.
 For examining the oral mucous membrane the hand over the head is moved

further down so that the thumb and index finger is used to lift the upper lip
 In cats, the tongue is best indicator as the gingival mucous membrane is always

pale due to the fibrous lamina propria.

What all you can observe?
Colour - icteric in jaundice, pale in anemia, petichiae in coagulation


abnormalities, cyanosis in card iac insufficiency

Capillary refill time
 Press a finger on a non pigmented area of the upper gingival mucosa for a
second, now release the finger to notice the disappearance of the whiteness. The
time taking for this change is recorded as CRT
Moisture
 Moist in healthy animals and dry/sticky in dehydrated animalsnjury, growth,
dental calculous etc.
Lesions
 Look for any injury, lesions haemorrhage etc.
EYE

 Conjunctive is examined by depressing slightly and then everting slightly the

lower eyelid with fingers.
 Eyelids

 Examine both the eyelids for any changes like dryness or wet eye, nay
secretions etc.
 Eyeball

 Look for the movement of the eyeball. Look in for nystagmus

 Pupil – by passing a beam of light.

 Miosis – constriction of the pupils(OPC poisoning in dogs

 Mydriasis – dilatation of the pupil.
 Squint – abnormal deviation of the visual axis.
 Cornea – look for any injury, opacity etc.
 LYMPHNODES

 The lymph nodes are structural and functional units of the lymphatic system.
Lymph nodule or group of lymph nodules vary from individual to individual.
 They are well placed so that they are no influenced by external factors

 Lymphnode is made up of thin capsule (collagenous connective tissue has a

sinus inside along with septa and trabeculae formed by the connective tissue)
 They perform the phagocytosis function by filtration of microorganisms

 They are responsible for cell-mediated immunity.

Various lymphnodes and their drain

1. Mandibular
2. Prescapular
3. Axillary
4. Red dots -drain to deeper area
5. Superficial inguinal
6. Popliteal
7. Parotid
 Apart from mandibular and parotid there is elongated retropahryngeal
lymphnodes between the atlas and the larynx.
What do you look for?
 Size - Lymph node can be palpated, if there is increase to more than one and a
half times than the normal size ( imagined based on animal size) is suspicious and
if greater the swelling then it is pathological.
  Shape - Normally ellipsoidal and maintain the shape unless the lymphnodes are
affected by metastasis.
 Consistency - Normally rubber like whereas turn hard when there some

pathology.
 Pain & Adherence - No pain normally and are freely movable where as when

there any inflammation or tumour involvement the nodes can't be moved.

BODILY CONDITION

State of Nutrition
 It can range from normal to obese based on the presence of subcutaneous fat.
 For image reference you can visit this site for body scores
HAIR COAT

General apprearnxce of hair coat like dryness, dullness, pigmenation changes,

hairloss- localized or generalized is looked for.
 TEMPERATURE AND ODEMA OF SKIN

Temperature
The temperature of skin is felt extremities like limbs, pinna or lips. The normal
animal have warm extremities whereas when animal is in shock where the
peripheral circulation fails the extremities feel cold. If there is any inflammation
there warmth will be more.
Odema
The odema of the ski occurs because of gravity and tissue pressure. In dogs it
occurs in the ventral aspect. The area when pitted remain pitted for some time.
When there is inflammatory odema skin is warm and painful.