The Integrative Physical Examination
Steps to a complete integrative physical exam, along with tips on communicating with mainstream veterinarians and specialists.
The first step in excellent patient care starts with a thorough history and physical examination. This article presents a step-by-step walk-through of a thorough integrative physical exam, with tips on how to coordinate conventional and holistic examinations, and how to communicate effectively to both conventional practitioners and veterinary specialists.
Veterinarians who can integrate conventional and complementary medicine may be better prepared to identify and understand the relationship between patient symptoms and their underlying pathology. When working closely with specialists and conventional referring practitioners, the integrative practitioner must also be able to effectively communicate holistic findings in conventional scientific terminology.
START WITH OBSERVATION
The first part of the integrative physical examination entails observation. Before touching the patient, the practitioner observes how he moves, breathes, and interacts with his environment, including any people in the exam room. We watch for clues about Traditional Chinese Veterinary Medicine (TCVM) constitution, signs of lameness, appropriate mentation, overall musculature, quality of hair coat, and patient symmetry. For example, a simple observation of head carriage can clue the practitioner in about a chiropractic malalignment of the atlas.
Clients are always impressed with the insightful questions asked about their pets before the integrative practitioner even sets her hands on a patient. For example, you might ask, “Is your dog an avid ball chaser?” as you note the suggestive head carriage of an occipital malalignment – potentially caused by the dog crashing into stationary objects to obtain the ball.
A THOROUGH EVALUATION
The physical examination continues with a thorough evaluation of the eyes, ears, nose and mouth, including the cranial nerves.
Those trained in TCVM may pay extra close attention to the patient’s tongue, which can provide many clues to underlying medical conditions and overall health status.
- A tongue with a white coat could indicate the presence of phlegm or inflammation in the body. Explaining that this finding is often indicative of inflammation will make more sense to a conventional colleague than a description of “TCM Phlegm”.
- A purple or lavender tongue may indicate blood stagnation or deficiency, and may prompt the submission of a complete blood count.
- A tongue with a curled red tip will clue the TCVM practitioner into careful auscultation of the heart, as variation of color or tone in the tip of the tongue can indicate a possible cardiac condition in Chinese Medicine.
Conjunctival hyperemia may indicate allergic conjunctivitis or glaucoma, but the eyes can also provide subtle clues about the patient’s “Shen” or emotional well-being.
The aforementioned condition may be due to TCVM Liver Heat Rising, informing the integrative practitioner to pay more attention to the musculoskeletal examination and the liver enzymes in the patient’s blood work. Liver Heat Rising is a challenging TCM pattern to communicate to conventional practitioners, but requesting baseline laboratory tests and bile acids is the “gold standard” in conventional medicine that all veterinarians understand.
When moving into this region, the integrative practitioner palpates for pain, range of motion and cervical hypo- or hypermobility, and continues with the hyoid apparatus, thyroid, and jugular fill. The author has palpated early evidence of a ventral cervical mass before clinical manifestation by noting the hypomobility of the hyoid apparatus. Although this was not a typical finding, the internist on call was told that the hyoid apparatus did not appear to palpate or move normally; it seemed there was some tissue restriction in the cervical region. This type of palpation may not be usual, but applying it to basic anatomy allows colleagues to understand and appreciate the palpation skills of the integrative practitioner. The patient may later be diagnosed with a cervical abscess on CT scan.
Continuous adjustments of the same listing should clue the astute practitioner into searching for a primary cause of these secondary compensatory listings. For example, a dog that repeatedly requires adjustment of the left ilium may indicate pain in a structure within the right forelimb as weight is shifted from right to left. A patient that presents with sudden pain when gentle cervical traction is applied could alert the practitioner to a developing intervertebral disc lesion.
Lymph nodes, integumentary system, musculature, body condition
As the TCVM practitioner continues with the examination, these areas are evaluated next.
- A dry, flaky or oily hair coat means blood deficiency and/or stagnation to the TCVM practitioner – a finding that is easily conveyed to a conventional practitioner as a subtle and early sign of faulty peripheral circulation.
- Conventional muscle condition scoring should be a quick and essential part of every physical examination. Muscle condition scoring is based on a scale of 3 (3/3 indicates perfect musculature, 0/3 indicates muscle wasting or sarcopenia). The best locations at which to evaluate muscle condition scoring are over bony prominences of the scapula, head, spine and pelvis. These areas include the temporalis, epaxials, and hind end muscles (gluteals, quadriceps and hamstrings).
In some cases, the patient can be assigned two different muscle condition scores. For example, a patient recovering from a cruciate injury might be assigned a 3/3 overall, but 2/3 locally over the hamstring and quadriceps muscles on the right. Discovery of muscle wasting or sarcopenia should always garner the attention of the clinician and prompt a more thorough workup and referral to a rehabilitation practitioner.
- Since obesity is a growing problem, body condition score (BCS) is another essential part of the physical examination that is often ignored. The 9-point scoring system is preferred, with 5 out of 9 being the ideal score. For accurate and consistent recordkeeping, it is handy and convenient to keep a reference chart in every exam room.
- After auscultation of the cardiopulmonary system, and palpation of the abdomen, the TCVM practitioner will palpate and assess the patient’s pulses for these various TCVM characteristics:
- A “wiry” or “guitar string-like” pulse on the patient with hyperemic conjunctiva may further prompt the practitioner to consider TCVM Liver, and the need to request a bile acids test.
- A “slippery” or “cooked spaghetti-like” pulse could indicate early (or advanced) signs of inflammation or phlegm within the body. A subtle “slippery” pulse is common in patients that suffer from seasonal allergies in the early spring. Prophylactically treating the inflammation/phlegm at this time could avoid or lessen severity of symptoms later in the season when the allergen is at its peak.
- A “surging” or “forceful” pulse in a West Highland terrier with a cough would place kennel cough higher on the differential diagnosis list than a more chronic condition such as pulmonary hypertension.
- Pulse diagnosis is also very positional. A TCVM practitioner will address the finding of a pulse weakening in the right proximal pulse position of a Cavalier King Charles spaniel, as it can indicate early cardiac dysfunction. The optimal and most successful holistic intervention occurs before the full pathologic manifestation of the disease.
ORTHOPEDICS AND NEUROLOGY
The practitioner with advanced training in rehabilitation will perform full orthopedic and neurologic examinations on every patient. Accurate knowledge of anatomy and careful palpation of the shoulder tendons, their insertion and origin, can help identify a supraspinatous or biceps tendinopathy in an athletic dog, while careful digit palpation can identify a thickening or crepitus of the metacarpal phalangeal joints that may be contributing to a geriatric patient’s discomfort. Most importantly, demonstrating how to gently work out compensatory myofascial trigger points to a devoted owner in order to provide pain relief for their companion will further enhance the human-animal bond between them.
The complete and thorough physical examination always ends with a recorded temperature to be included in the traditional TPR, as well as a rectal examination. The chief complaint of arthritis in a geriatric patient quickly becomes secondary when a fever is noted or a recto-anal mass is detected.
Integrating the results of both a conventional and holistic multi-modal physical examination defines an excellent veterinary diagnostician. Using the integrative physical examination in combination with conventional treatment plans and holistic principles can be interpreted as the “science and art” of integrative medicine. Using this approach, it is clear that there is no one “fit for all” treatment for Bony Bi or hip dysplasia or Damp Heat in the Lower Jiao or chronic urolithiasis. Effective communication and collaboration between conventional veterinarians, specialists and integrative practitioners results in optimal care for all patients. These concepts embrace best practice veterinary medicine.
Learn how to assign muscle condition scores by palpating your own facial muscling while smiling.
3/3 MCS – corresponds to the “apples” of the cheeks while smiling
2/3 MCS – corresponds to the chin
1/3 MCS – corresponds to the brow between the eyes
0/3 MCS – corresponds to the bony bridge of the nose