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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
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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.)
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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.
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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
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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?
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