How to get the most from the feline physical examination – Lessons learned from cats (Proceedings)

Cats are masters at hiding illness, so that clinicians must become expert at uncovering illness with a thorough medical history and feline-specific physical examination. Obtaining a medical history is easier than ever in today's electronic world. Clinicians can take advantage of multimedia tools to collect information, ranging from an email containing a basic signalment to videos of a particular behavior. The value of designing questionnaires that are tailored to specific needs, such as a wellness exam for a geriatric cat or an examination of a sick cat, is well established. These questionnaires can be supplied to the client to fill out in advance of an appointment, thereby saving time and improving collection of detailed data. These questionnaires are especially valuable when the owner cannot be present for the appointment (e.g., "drop-offs").

Medical history taking is an art and a learned skill. The process of taking a history should be consistent and comprehensive, but adaptable. The best responses from owners come from open-ended questions, rather than questions that elicit a simple "yes" or "no" (e.g., "How has Fluffy been doing since the last visit?"). The clinician should repeat key information relayed by the client to ensure accuracy and demonstrate attention to detail and a caring attitude. It can be very helpful to collect videos of common medically related behaviors (such as a coughing cat or a female in estrus) to show owners when they are unsure how to describe their cat's behavior. In turn, most owners can readily make short videos of behaviors that occur at home and either post the video to an internet site or email it to the clinician for viewing.

Communication styles vary by age group, and are influenced by other factors. Some elderly owners will require more time and a sympathetic listening style to relay their concerns. An abbreviated and more focused set of interview questions may be more effective in eliciting necessary information. For many cat owners, it is helpful to encourage them to write down questions in advance. Younger cat owners readily utilize social media and will be more comfortable using familiar communication methods, such as email and internet tools. At the end of the history and physical examination, the owner should be encouraged to ask more questions with an open and inviting query, such as "What questions do you have for me?" If the patient has complicated problems, it may be more productive to invite the owner to ask questions periodically during the interview and examination, rather than at the end.

A basic part of the medical history is the signalment (i.e., age, breed, gender, reproductive status). Categorizing feline patients by life stage helps the clinician focus on specific wellness, behavior and disease concerns. The AAFP-AAHA Feline Life Stage Guidelines recommend the following categories and detail the concerns associated with each:1

     • Kitten: up to 6 months of age

     • Junior: 7 months to 2 years

     • Adult/Prime: 3 to 6 years

     • Mature: 7 to 10 years

     • Senior: 11 to 14 years

     • Geriatric: 15 years and older

Other essential pieces of the history include how and where the cat was acquired (e.g., found as stray, purchased from breeder or pet store), whether the cat has lived in another geographic location (influences disease prevalence), and the cat's current lifestyle and environment (e.g., outdoor access, interactions with other cats). A complete vaccination history documents the types and dates of vaccinations, and ideally would be acquired via the cat's previous medical records. It is also important to document any current or past medications, and to inquire about the current dose and frequency of medications at each visit as owners have been known to make changes to treatment protocols without veterinary consultation or through misunderstanding. A dietary history would ideally include brands, flavors, type (e.g., dry diet, canned diet, soft-moist diet), and exact amounts fed. Getting this information may take persistence and follow up. Don't forget to ask about any nutritional supplements the owner is administering. It is also important to inquire about the location of food and water resources in the home. Having the owner draw a basic floor plan of the home and note the location of food, water, litter boxes, sleeping areas, etc. can be extremely helpful. It can also be very helpful, particularly when attempting to solve house soiling problems, to have the owner take photographs of key locations (e.g., food, water, litter boxes) so that the exact arrangements can be understood. For example, an owner may volunteer the information that the cat's litter box is in the basement, but not add that it is placed near a noisy appliance such as a washing machine or dryer.

When a cat is presented for a specific medical complaint, additional information must be obtained, especially if the problem is chronic or has been previously treated. Medical records from other veterinary clinics may have to be sought, particularly if they may contain valuable information about previous laboratory test results or medications. The most common presenting clinical signs for any ill cat are anorexia (partial or complete), lethargy, and a change in behavior (e.g., hiding). Specific questions will be required to move from these generic and uninformative complaints to more detailed information. It is important to remember while building a problem list and a tentative diagnosis list that the situation is fluid and may be adjusted as more information is acquired. For investigation of illness, the minimum database for most cats includes a complete blood cell count (CBC), serum chemistries and electrolytes, urinalysis, and FeLV/FIV testing. For senior and geriatric cats, a total T4 and blood pressure measurement are added. Most referral laboratories will accept small volumes of blood collected from cats in Microtainer™ blood collection tubes, especially for a CBC.

The medical history is taken before the physical examination as it allows the cat time to adjust to the exam room and provides information that can focus the examination. While a thorough PE is essential, not all feline patients are amenable, and knowing what areas to target in a less than cooperative patient can save time and reduce stress. Stress can affect several laboratory parameters, causing changes such as hyperglycemia, decreased potassium, lymphocytosis and neutrophilia, and "white coat" hypertension. Ideally, the cat should be allowed to venture out of the carrier on its own, while the attention of the clinician and owner are focused on the medical history. Ignoring the cat may increase the chance that it will exit the carrier. The cat should be examined wherever it is most comfortable rather than insisting all patients are examined on a table. For example, some cats are best examined on the floor, on a chair, in the clinician's lap, or even in the bottom half of the cat carrier after the top has been removed. The temperament of the cat is important, however, as some cats will become more fearful if allowed to roam the exam room or hide under chairs. Clinicians must become adept at recognizing facial and body postures associated with fear in cats. Cat treats may entice and distract some anxious cats. Spraying surfaces and towels with Feliway® or using Feliway® diffusers in the exam room can help reduce stress. Excellent information on feline handling techniques has recently been published and should be reviewed.2

Effective physical examinations follow a consistent pattern, while allowing for flexibility when required to meet a patient's needs. Weigh every patient at every opportunity, even if it must be performed with the cat in a carrier or a towel. Table-top scales designed for small veterinary patients or human babies are ideal for cats. During the examination, move calmly and slowly, use a quiet voice, and maintain physical contact with the cat. There is no way to avoid the fact that a good feline physical examination requires time and patience, and restraint is best described by the adage "less is more." The author prefers to work with the cat facing away, and to start the examination at the head and work backwards. Facing the cat away helps minimize eye contact that many cats find threatening. However, for some cats, it is more effective to change the order of the examination, performing the least stressful parts first, and examining body areas the cat doesn't like touched last. Foregoing temperature measurement during wellness examinations for healthy cats is acceptable and can remove a source of stress. Unfortunately, infrared ear thermometers may not be accurate in cats.3

The following tips associated with certain body systems or structures can improve the yield of the feline physical examination.

     • Head and neck

          Jaundice is often most apparent on the hard palate

          Apply gentle pressure with a thumb in the intermandibular space to elevate the tongue for better inspection of the oral cavity for lesions or linear foreign bodies

          Perform a retinal exam on every cat – signs of certain diseases may be found there and regular practice will improve your ability to visualize the retina

               • Retinal detachment and hemorrhage are associated with hypertension and may appear before other systemic signs

          o Nystagmus is "normal" in cats with Siamese heritage

     • Thorax

          o Use both the bell and diaphragm of the stethoscope to auscultate the heart

          o For kittens and small cats, use a pediatric stethoscope

          o Chest percussion can be useful to detect increased air or the presence of fluid or masses

          o Most heart murmurs in the cat are best heard over the sternum

          o ECG is not very useful for diagnosis of heart disease in cats unless an arrhythmia is present; cardiac ultrasound is required for definitive diagnosis

          o Hypertension is common in older cats with chronic renal disease and may cause a heart murmur

     • Abdomen

          o The liver, stomach and pancreas are not typically palpable in their normal state

          o Discomfort on palpation of the cranial abdomen is most often associated with pancreatitis, and sometimes with liver or proximal small intestinal disease

          o Cats can have significant liver disease without elevation of liver enzymes, but

               • Any elevation of ALP (SAP) in the cat is significant

               • If the ALP is proportionately more elevated than the ALT and GGT is normal to mildly increased, the tentative diagnosis is hepatic lipidosis

               • If the ALT is proportionately more elevated than the ALP and GGT, the tentative diagnosis is inflammatory disease

               • AST is not liver-specific in cats

               • Any amount of bilirubinuria is significant in the cat

               • Serum bilirubin >3 mg/dL is mostly likely associated with hepatic disease; serum bilirubin <3 mg/dL is more likely associated with non-hepatic disease

     • Respiratory System

          o With the small feline tidal volume, pulmonary pathology must be advanced before changes are heard on auscultation

          o Respiratory rate and character are very important; if in doubt, have the owner measure *sleeping* respiratory rate at home

          o Heartworm is primarily a respiratory disease in cats that mimics asthma

          o Coughing is not a sign of heart disease in cats and is not due to hairballs!

     • Musculoskeletal System

          o The majority of senior and geriatric cats have some degree of osteoarthritis so always check joints for pain, range of motion, swelling, etc.; the most common sites in cats are the elbow, hip, shoulder and stifle

          o Osteoarthritis in the lumbosacral area may produce neurologic signs

          o Cats can suffer from hip dysplasia and patellar luxation

          o Creatine kinase (CK or CPK) is most commonly increased due to anorexia or the simple act of venipuncture

     • Gastrointestinal System

          o Inflammatory bowel disease is very common in cats and may present with classical signs of vomiting and/or diarrhea, or subtle signs such as only weight loss

          o Many cats with heartworm disease vomit

          o Intermittent vomiting followed by a period of anorexia is a common presenting history for cats with pancreatitis and/or small intestinal inflammatory disease

          o Always ask about vomiting, as some owners consider it normal for a cat to vomit periodically and may not mention it

          o Owners should be taught never to "dry pill" cats with any medication; due to the risk of esophageal damage from many medications, pills or capsules should always be given with a liquid or food/treat chaser

          o Cats can have significant periodontal or other oral disease without the owner noticing obvious signs of discomfort; subtle signs may include favoring one side of the mouth when chewing, dropping food when eating, resenting touching of the head

          o Constipation may be due to chronic dehydration (e.g., chronic renal disease) or musculoskeletal pain and stiffness (e.g., hip or lumbosacral osteoarthritis)

     • Genitourinary System

          o The testicles may not remain in the scrotum permanently until a kitten is 6-7 months old

          o The presence of penile spines indicates a source of testosterone (such as a retained testicle); the spines disappear within 6 weeks of castration

          o Urinary incontinence is rare is cats and most often associated with FIP, FeLV or FIV

          o The majority of cats under 10 years of age with lower urinary tract signs do NOT have bacterial cystitis, so don't use antibiotics without a positive urine culture

          o Urine should be collected via "agitated" cystocentesis whenever possible

          o Urine specific gravity less than 1.035 is abnormal in the cat

          o Urine should be examined within 60 minutes of collection and should not be refrigerated

     • Skin

          o Matting of the hair coat may be associated with obesity or may indicate the cat is too painful to groom itself

          o Alopecia over a joint may indicate pain from arthritis, and alopecia on the ventral abdomen may indicate bladder pain

          o Mammary masses in cats are neoplastic until proven otherwise; the exception is mammary hyperplasia in young cycling queens

     • Body Condition

          o In addition to body weight (use the same scale every time), use a body condition scoring system for every cat at every visit (e.g., a 5-point or 9-point scale, or the Waltham Feline Body Mass Index4)

          o Express weight gain or weight loss as a percentage as it is more meaningful to owners (i.e., "Your cat has gained 20% more weight since the last visit")

          o For most cats, the weight at about 1 year of age is their normal adult body weight

          o A small decrease in body weight is often the first sign of illness, especially in kittens, and senior or geriatric cats

          o Older cats often lose muscle mass (especially of the legs and lumbar area) but maintain abdominal and inguinal fat; weight loss in this age group can be associated with a wide range of medical problems and should always be investigated5-6

          o Skin tent testing for hydration status is not reliable in the very young or very old

     • Behavior

          o Many diseases are associated with behavior changes

          o Hypertension may be associated with vocalizing at night

          o Hyperthyroidism may be associated with restlessness or irritability

          o Cognitive dysfunction may be associated with wandering, disorientation, vocalizing, and house soiling

          o Pain is typically under recognized in cats as it is more difficult to diagnose7

               • Postural changes, especially while sleeping or sitting, may indicate pain due to abdominal discomfort or osteoarthritis

               • Anorexia, lethargy, irritable or aggressive behavior, hiding, decreased ambulation or activity, house soiling may all be signs of pain in cats

No matter how many new tests and diagnostic machines become available, the foundation of feline medicine will always be a detailed history and careful physical examination. Concentrating on this "old school" approach will be more effective than relying primarily on laboratory data to build a problem list and guide initial diagnostic and therapeutic plans. The clinician's eyes, ears and hands are the most valuable tools we have. Taking the time to hone history taking and physical examination skills will reap rewards in patient care.

References

1. Vogt AH, Rodan I, Brown M, et al. AAFP-AAHA: Feline life stage guidelines. J Feline Med Surg 2010;12:43-54.

2. Rodan I, Folger B. Respectful handling of cats to prevent fear and pain: American Association of Feline Practitioners, 2010. (http://catvets.com/uploads/PDF/Nov2009HandlingCats.pdf)

3. Kunkle G, Nicklin C, Sullivan-Tamboe D. Comparison of body temperature in cats using a veterinary infrared thermometer and a digital rectal thermometer. J Am Anim Hosp Assoc 2004;40:42-46.

4. Hawthorne A, Butterwick R. The feline body mass index - a simple measure of body fat content in cats. Waltham Focus 2000;10:32-33.

5. Pittari J, Rodan I, Beekman G, et al. American Association of Feline Practitioners. Senior Care Guidelines. J Feline Med Surg 2009;11:763-778.

6. Caney S. Weight loss in the elderly cat. Appetite is fine and everything looks normal. J Feline Med Surg 2009;11:738-746.

7. Hellyer P, Rodan I, Brunt J, et al. AAHA/AAFP pain management guidelines for dogs and cats. J Feline Med Surg 2007;9:466-480.