Look, Touch, and Listen!

Equine Patient Assessment

ASHLEIGH OLDS-SÁNCHEZ, DVM

DABVP-EQUINE PRACTICEKEYSTONE PVMA CE CONFERENCE

AUGUST 2019

Patient Assessment: History

�Don’t underestimate the value and importance of the patient history!� Signalment (age, gender, breed)�Regional location?

�California – enteroliths�Southern states – more fungal infections, cicatrix�Regional variations of diseases like silicosis, coccidiodomycosis, pigeon fever, lyme, VS etc.

�Recent history of disease outbreaks EHV, strangles etc.

�What are they presenting for? Symptoms?�When did it start?

Patient Assessment: History

�When did they last eat? Fecal consistency and amounts?

� Travel history? (potential exposure to disease?)�Vaccination and deworming history?�Other horses or other animals affected? Do other horses travel?

�What do they eat (pasture, hay, grain, supplements etc)�Alfalfa hay – blister beetles?�Bermuda grass hay – ileal impactions?

�Medication history?�Antibiotic induced colitis�GI ulceration secondary to NSAIDS

Patient Assessment: Physical Exam

� Don’t underestimate the value of the physical exam!!!

� This skill is being lost in human medicine!!! Touch your patient! Look at your patient!

� Diagnostic tools do NOT replace a thorough history and hands-on physical examination

� Practice thorough PE on all patients so that you will be more likely to pick up on abnormalities on sick patients.

� Use eyes, ears, stethoscope, thermometer, hands, sense of smell

Patient Assessment: Physical Exam� Heart rate

� Respiratory rate

� Skin turgor

� Mucus membrane color, capillary refill time (CRT), presence or absence of “toxic rims”

� Temperature

� GI sounds

� Digital pulses

� Sclera – injection or icterus?

� Posture – lameness? Neurologic deficits? Wounds?

� General attitude and demeanor.

Physical exam: Heart Auscultation

1 2

3 4

5 6

Physical exam:Heart auscultation

� Normal: 30-44 bpm – Auscult both right and left

� Bradycardia (low HR) may be due to second degree AV block, high resting vagal tone –should resolve with exercise or may be true pathologic

� Tachycardia (high HR > 48 bpm):

- Pain? Shock? Fluid or blood loss?Dehydration? Endotoxemia? Excitement?

Heart auscultation: Murmurs� Be aware of murmurs and arrhythmias

� Physiologic murmurs are common – mild systolic murmurs

� Dehydration, viscous blood

� Should resolve when horse is rehydrated

�Mitral regurgitation common in horses and often non-pathologic (systolic, PMI left side over the mitral valve)

� Aortic regurgitation common in older horses (musical decrescendo diastolic filling murmur)

� Murmurs should be noted, graded, and ideally followed up with ECG and echocardiogram to document if benign or pathologic

Heart auscultation: Arrhythmias

�Most common benign arrhythmia in horses is second degree AV block (dropped beats)�Non-pathogenic should be regular other than missing beats

�High resting vagal tone

� Large heart size

� If any doubt – should resolve with exercise

�Run ECG – (iphone app?)�Will have regular p-waves, but some p-waves will not have a QRS complex if benign 2nd degree AV block

Heart auscultation: Arrhythmias

� Atrial fibrillation – irregularly irregular (jungle drums)

� Ventricular tachycardia – need ECG

� Arrhythmias may be associated with some toxins (oleander, monensin, etc), endotoxemia, envenomation, or electrolyte disturbances

� Calcium, magnesium, potassium – hypo or hyper

Heart auscultation: “Thumps”

� Synchronous diaphragmatic flutter (‘hiccups”)

� Abdomen and diaphragm contracting at same rate as heart (heart beat on abdomen)

� Due to dehydration and electrolyte imbalance – usually hypocalcemia

� Common in endurance horses

� Requires treatment with IV fluids

� Usually resolves with treatment

Heart abnormalities� If any concerns about murmurs or arrhythmias, or even just a very high persistent rate, strongly recommend at least ECG

� Iphone app fairly useful and reliable for field use � (See notes from AAEP Milne lecture by Dr. Reed 2018)

� Observe for other signs of heart failure:� Exercise intolerance, Jugular pulses, Weak pulses

� Ventral or distal limb edema, Pulmonary edema

� Ascites

� Echocardiogram by cardiologist ideal but not always feasible. At least consider recommendation if murmurs or arrhythmias don’t resolve with medical treatment of obvious condition (colic, dehydration, electrolyte disturbance, etc.)

7 8

9 10

11 12

Physical exam: Respiratory Rate

� Normal: 8-16 bpm

� Elevated rate: Pain? Shock? Cardiac or respiratory distress? Pneumonia? RAO? Viral or bacterial infection?

� Increased effort associated with abdominal pressing on expiration -> RAO (Heaves)

� Stridor, stertor?

� Lung sounds: Crackles? Wheezes? Tracheal rattle? Absence of lung sounds (pleural effusion, ventral consolidation)

Respiratory exam

Heave line

Check for tracheal rattle

Rebreathing exam

Assess Hydration:

� Skin turgor –interpret carefully especially in older patients (reduced elasticity)

Capillary refill time – should be less than 2s. Dry tacky MM,

slow refill time may be indicative of dehydration or reduced circulatory volume (shock? endotoxemia?)

Assess Hydration:

� Sunken eyes = severe dehydration

Indicators of dehydration:

- Pale or tacky mm- Delayed CRT- Tachycardia- Tachypnea

- Poor skin turgor- Sunken eyes- Slow jugular fill

- Reduced peripheralpulses

Endotoxemia/Septic shock:

� Horses are profoundly sensitive to endotoxemia

� Late stages of severe colic –compromised intestine translocation

� Anterior enteritis/proximal jejunitis� Laminitis� Metritis� Peritonitis� Pneumonia/pleuropneumonia� Grain overload� Colitis – (C. Dificile, Potomac Horse Fever, Colitis X, Salmonella)

Patient assessment: Temperature� Rectal temperature easy to obtain

� Always take PRIOR to administering medications, rectal examination

� Elevated temperature -> bacterial or viral infection? Excitement? Recent exercise or high ambient temperature?

� Will alter response to sedation –febrile horses � profound sedation, heavy breathing

� Normal: 98.5 F – 100.5 F adults

� Up to 101.5 F in foals.

13 14

15 16

17 18

Patient assessment: Temperature

� Be more aware of hypothermia in foals – often in conjunction with hypoglycemia, failure of passive transfer, sepsis etc.

� Recent trailer ride, exercise, excessive ambient heat, or excitement may falsely elevate temperature – allow horse to rest in cool shady area and retake temperature in 30 minutes

Patient Assessment: GI sounds

� Presence, or absence? Complete absence -> obstruction,displacement,dehydration?

� Hypermotility -> spasmodic colic, impending enteritis/colitis?

� Sand?

Patient Assessment: Digital Pulses

� Assess strength, symmetry

� Feel hooves and coronary bands for heat

� Impending laminitis?

� Consider ice baths, boots?

� Frog support?

� Endotoxemia – often distal extremities are ice cold, weak pulses

� Practice feeling “normals” so you can detect abnormal

Patient Assessment: Sclera

� Icterus/jaundice:

�Hepatic/liver disease

�Hemolysis

� Foals: Neonatal isoerythrolysis

� Injected sclera:

� Inflammation

� Sepsis – foals especially

�Difficult labor – hypoxemic syndrome “dummy foal”?

Assessment: Posture, Lameness, Wounds, General demeanor, Neurological Deficits

Acute neurologic deficits:

- Trauma- Stylohyoid fracture- EPM- Brain abscess- Meningitis- EEE, WEE, WNV- Rabies- EHV- Cervical instability or narrowing –“Wobblers”

- Lower cervical OA - Hyperammonemia

19 20

21 22

23 24

Initial Physical Exam:

� All of these factors should be evaluated in a brief exam (< 5 min)

� Lots of valuable information!!!

�May not provide a diagnosis, but helps assess patient needs and direct initial treatment, additional diagnostics indicated

� Suggests possible diagnoses

Considerations for Isolation:

� Fever

� Nasal discharge

� Neurologic symptoms

� (EHV -1/EHM? Rabies)

� Diarrhea

� High PCV, low TP, low WBC

� Gloves, separate thermometer, stethescope, footbaths, barrier protocol/gowns etc.

Thank you!

Questions?

25 26

27