Manipulação, Contenção e Exame Físico de Cães e Gatos

http://www.vetmed.wsu.edu/resources/restraint/index.aspx#Handling

By CR Dhein

These instructions are available as public information. This information is not meant to be a substitute for veterinary care. Always follow the instructions provided by your veterinarian. Washington State University assumes no liability for injury to you or your pet incurred by following these descriptions or procedures. 

This information is copywrited to Washington State University. You may link to this site but please do not copy this information to other web sites.

Handling

Before handling the animal get his/her attention. Call the pet by name and encourage him/her to come to you. If the pet doesn't come, slowly approach from the front. Never surprise the animal by approaching from behind. Extend your hand, palm down. You may want to curl your fingers into a fist to prevent nipping or biting of your digits. Let the animal sniff your hand, then slowly move your hand to touch the side of the face then stroke the top of the head.

If the owner is holding the pet, don’t take the pet from their arms. Instead have the owner place the animal on the exam table. Animals may be protective of their owners and may bite if they feel you are threatening their owner.

It is acceptable to examine a large dog on the floor in either a sitting, standing or recumbent position (The dog….not the veterinarian). I know of a feline specialist who examines all her patients sitting on the floor with the cat in her lap.

To pick up a dog to place it on the table, put one arm in front of the of the animals chest and the other either behind the rear legs, at the level of the stifles or under the abdomen and lift in a "scooping" motion. If the animal has a history that indicates abdominal disease, avoid lifting it under the abdomen as it may cause pain.

	A large dog may require 2 people to lift. One person lifts behind the front legs and the other under the abdomen.
	Decide BEFORE picking up the animal if it will be placed in sternal or or lateral recumbancy and if lateral, if the legs will be directed toward or away from the holders.

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Getting an animal out of a cage

Many animals are so happy to get out of a cage that they will leap without looking. To remove those eager pets, as you open the cage door insert your other hand into the cage to keep the animal from leaping to the floor. Place one arm in front of the of the animals chest and the other either behind the rear legs or under the abdomen to lift them out of the cage. To remove a cat, you can hold the scruff of the neck instead of placing a hand in front of the chest but hold the cat's weight by lifting the rear, not by lifting by the scruff.

Animals who are frightened and don't want to come out of a cage can be difficult to handle. There are several options for handling these animals:

Throw a towel over the head of cats and small dogs, then grasp the scruff of the neck through the towel, lifting the rear end with a hand or arm behind the rear legs to "scoop" them out of the cage.

	A pair of heavy work gloves can be used to handle the animal.
	This home-made box is sort of a "squeeze chute" for small animals. The plastic door on the front pulls up and out. The open box is used to confine the animal against the inside of the cage, then the door can be inserted behind them. If need be, inhalation anesthetic agents can be vented into the cage to sedate the animal before removal from the box.

This net bag can be opened and used to catch a small animal in a cage, then closed, trapping the animal in the net. The animal can be handled through the netting to give injections or place catheters.

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Carrying a cat or small dog

The pet you are carrying to another part of the hospital may appear very content being carried like a human infant but as soon as the cat gets excited when a dog barks, you will loose your grip and the animal will leap from your arms. The animal should be carried gently with minimal restraint but you should carry the animal in a position that allows you to increase the amount of restraint instantaneously.

	I prefer this method in which the animal's rear quarters are cradled in the handler's arm and the front legs are loosely griped with the same hand. The other hand is free to pet and stroke the cat's head but can also quickly grab the zygomatic arches to control the head if the animal attempts to escape.
	Cat's will try to hide when frightened. You can carry a cat with one hand under the hind quarters and the other holding the scruff of the neck, letting the cat hide it's head.

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Restraint

More is NOT better. Work with the animal in the position that the animal finds most comfortable yet provides you adequate exposure to do what you need to do. The LEAST amount of restraint that is needed should be applied. Often the only restraint needed is to have some one stand behind the animal to make sure they do not back up off the exam table. Excessive restraint becomes a test of wills and you will find animals to be stubborn and not give up. The more you attempt to restrain them, the harder they resist and the less pleasant and more dangerous the experience becomes for all. It is also is very upsetting to the client.

"Talk to the animals" Many dogs and cats can be comforted by being talked to in a quiet, soothing voice. What you say is not important...the tone of voice is.

The client should not be the one to restrain their animal. A large number of lawsuits filed against veterinarians are by the owners who have been injured by their own animals. A technician will likely do a better job. The owner can talk to and comfort the animal and can be within sight of the pet although occasionally it is better to examine the animal away from the owner.

If the animal is known to have bitten or attempts to bite, I believe early application of a muzzle actually reduces the need for additional restraint. The need to apply muzzle should be explained to the owner in advance. Once the muzzle is in place the animals often "give up" and stop struggling. The examiner can work in a safer environment with the animal muzzled, they will give less indication of fear to the animal. Several types of muzzles can be used. The end of the muzzle can be closed (basket-style) (A,B) or open (C, D) . They can be made of leather (D), plastic (A, B) or cloth (C). The plastic and cloth muzzles are easiest to clean between patients. Leather muzzles are difficult to clean between use and the leather gets stiff from saliva. The closed ended muzzles allow the animal to open their mouth to pant. The open ended muzzles allow the animal to extrude their tongue to drink. Usually the muzzle is not left in place for long periods of time so the need to drink is not crucial. Always apply closed end- basket style muzzles to brachycephalic breeds which may experience problems breathing if their mouth is held closed. All the muzzles have a strap that buckles behind the ears, on the top of the head.

A		basket style closed end, plastic
B		basket style closed end, plastic
C		open ended, cloth
D		open ended, leather

	cloth open-ended muzzle
	plastic basket-style

The small muzzles used for cats cover the end of the face and the eyes. Fractious cats are much easier to handle when they cannot see the handler. I prefer those made of cloth (C) rather than the more rigid leather muzzles when being used as a hood.

There are two ways to apply a muzzle. If the animal is aggressive it may be easier to get the muzzle on by approaching from the rear and quickly applying the muzzle over the nose and mouth. If the animal is fearful, I prefer to apply the muzzle from the front so they can see me approaching. The basket style muzzles are easier to apply if the animals mouth is open (trying to bite) because this style is wider.

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If a muzzle is not available a length of roll gauze can be used to create a muzzle. The gauze should NOT be stretchy (don't use "Cling" gauze). As the gauze is not very strong it should be doubled to increase strength.

	The length must be adequate to wrap around the muzzle at least twice, then tie behind the ears.
	A large loop is made in the center of the length of gauze. The loop should be about 3 times the diameter of the dog's muzzle.
	The loop is placed around the muzzle and pulled tight at dorsum of the nose. A single knot is placed.
	The ends of the gauze are then tied under the jaw with a single knot.
	The long ends of the gauze are brought behind the ears and tied in either a square knot or a easy release bow. I prefer to tie a square knot and have a scissors handy in case the muzzle needs to be quickly removed.

If the animal has a short face this style of muzzle easily slips off. To reduce slippage, after tying the square knot behind the ears, bring the long ends of the gauze forward and loop the ends under the loop of gauze which is around the muzzle, then pull the ends back over the forehead and under the gauze a behind the ears, then tie another square knot.

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Use of a cat restraint bag

	Restraint bags can be used to restrain cats and small dogs. The bags are made of canvas or nylon, with a hook or other type of fastener at the neck opening and one or more zippers (or strips of Velcro) to allow selective exposure of a body part. Instead of a restraint bag, a heavy towel can be used to wrap the cats body, leaving the head exposed but use of a towel is not nearly as effective as a bag.
	The open bag is draped over the cats back and the neck closure is fastened. The neck fastener should be tight enough that the cat cannot insert a front foot through the neck opening.
	The cat is either flipped into dorsal recumbancy or held off the table so the longest zipper can be zipped. As you close the zipper, take care not to catch the cat's fur in the zipper.

Zippers are strategically placed around the bag to allow selective exposure of a body part. The image on the right shows exposure of the medial aspect of the hind limb for venipuncture or catheter placement in the medial saphenous vein.

An alternative method is to lay the bag on the table with the zipper open. Lay the cat in sternal recumbancy on the bag and pull the sides of the bag up toward the cat's back until you can zip the zipper. This hasn't worked well for me as the cat usually tries to stand.

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Positional restraint

To restrain an animal in lateral recumbancy the holder places their elbow over the neck and holds the elbow of the leg closest to the table. The other arm is draped over the abdomen of the animal with the hand holding the rear leg which is closest to the table. The limbs should be held at a point close to the body, if you hold the limbs too far distal, the animal has more leverage to roll themselves back into sternal recumbancy.

The holder should only apply light pressure at all restraint points. If the animal struggles, the holder applies greater pressure and may learn their body over the thorax of the animal for additional control. As soon as the animal stops struggling, reduce the amount of pressure applied. Most animals quickly "learn" to lie still if you "reward" them with minimal restraint.

	Cats can be restrained in lateral recumbancy using the "stretch" method, holding the scruff of the neck and the hind legs. It is more difficult for the cat to get a hind limb loose from the grasp of the holder if the legs are held between different fingers of the same hand rather than both legs grasped together.
	This photo shows restraint for a medial saphenous venipuncture. I prefer to bring the cat's body to the edge of the table (marked by the red X) so I can hold the limb off the table. More mellow cats don't need to be held by the scruff and can be held in lateral recumbancy as described above for the dog.

This dog is being restrained for a venipuncture of the lateral saphenous vein. The holder is encircling the rear leg just proximal to the tarsus to cause the lateral saphenous vein to engorge with blood.

Restraint in sternal recumbancy

For examination, many animals will lie still in sternal recumbancy with minimal restraint. Sometimes all that is required is for the holder to pet the animals head or lightly tap a finger on the top of the animal's head to distract the animal's attention from the exam.

The animal is restrained in sternal recumbancy for placement of a cephalic catheter. Notice that the holder is standing on the side of the dog opposite the leg that is being catheterized. The dog is restrained close to the body of the holder. The muzzle is held away from the face of the holder and the person placing the catheter. She is reaching over the dog to hold off the vein and can apply downward pressure over the dog's back, if needed to keep the dog in sternal recumbancy. If the animal is not struggling, it is not necessary to apply pressure over the animal's back. The dog's leg is being held at the elbow to prevent her from pulling back her leg.

	The thumb is placed on the medial side of the limb and then "rolled" to the dorsum of the leg, close to the elbow in order to roll the cephalic vein in a more dorsal location.
	The thumb is being used to occlude venous blood returning from the leg, causing the vein to distend with blood. In some cases the vein will be clearly visible, in other cases you may palpate the distended vein.
	The holder also prevents the dog from pulling the limb away from the venipuncturist.

Restraint for jugular venipuncture

A jugular catheter can be placed with the patient in sternal recumbancy, with the neck extended upwards and the front legs held over the front of the table, or with the animal in lateral recumbancy. Notice that the holder is keeping the dog's head directed away from herself and away from the venipuncturist.The venipuncturist is using one hand to press at the thoracic inlet to engorge and vein with blood and the other to manipulate the syringe and needle.

The cat is held positioned similar to the dog but the cat's head is held with the fingers on the zygomatic arches. The zygomatic arches are "natural cat handles" which provide secure restraint of the head without risk of compromising breathing.

Large dogs can be restrained in a sitting position on the floor by standing behind them, so the dogs body is braced against the holders legs. The dogs head is extended upwards.

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History Taking

Greet the client and pet by name at the beginning of the office visit. Continue to talk to the animal and call it by name during the examination. Try to make the examination enjoyable for the pet or at least as least stressful as possible. Owners are impressed if you know the breed of their pet. It is better error on the side of calling a mixed breed a purebred than to refer to a Bichon Frise as a "cute, little cock-a-poo" which immediately makes you loose some credibility even before you can demonstrate your medical skills. See the VM 568 index for web sites with breed photos.

Try to make the client at ease as well. Give them you undivided attention during the examination. Try not to take phone calls or have interruptions during the exam.

There are many different ways to take a history and perform a physical examination. Consistency is important to make sure the history and examination are complete. You can perform a thorough history and physical exam in ~10-15 minutes.

I prefer to take the history prior to the examination. I encourage the client to let the pet roam the exam room during the history history (assuming the exam room is safe and secure from escape). While obtaining the history, observe the animal.

The history is usually taken in a specified format and on a specific form.

Make sure you understand the client's relationship to animal, i.e., owner, trainer, friend of owner. It is important to know who is for daily care and therefore observation of feeding habits, behavior, defecation, urination, etc.

Know the purpose of visit. You need to establish client goals, for example have they already seen another veterinarian and are they seeking a second opinion.

Medical History - general comments

• Avoid leading questions (example: "You haven't observed any change in appetite, have you?" This question format may lead the client to answer in a manor in which they think you expect, in this case the answer is most likely to be, "no". )
• Record observations, not interpretations. Have the client explain what they observed rather than accepting their interpretation that the pet is regurgitating, when in fact it may be vomiting.
• Signalment (age, sex, breed, name)
• Chief complaint - Usually want to address this with owner early so they are aware that you know the reason for the visit.

Past history

• Vaccination history - Type and dates.
• Major medical, surgical problems
• Family history of the pet. Have any related animals displayed similar signs or problems?
• Home environment-indoor/outdoor, confinement, other pets? Health of other pets?
• Travel history-some diseases are endemic to certain areas of U.S.
• Diet- Type, frequency, any recent changes in diet?

History of present illness

• Has the pet received any medications? Have they altered the clinical signs?
• Duration of clinical signs?

Body system review

Try to develop general questions associated with each system. This will enable you to quickly identify problem areas. If the answer to the general screening question is yes, then more specific questions can be asked about that organ system. If the answer to the screening question is "no" then the organ system need not be investigated with further questioning. Assure the clients that it is OK if they cannot answer some of the questions you ask. For example, they may not observe elimination in an outdoor dog or cat. If they feel comfortable that you will not "judge them as a bad pet owner" if they cannot answer all the questions, they are more likely to provide accurate information.

• Integument - "any history of skin problems; i.e., fleas, allergies, hair loss ...?"
• Eyes and ears - "any previous infections, hearing difficulties, sore eyes, head shaking...?"d.Musculoskeletal - "any problems walking or climbing stairs?...?"
• Cardiovascular - "any coughing or weakness with exercise...?"
• Respiratory - "ever see runny eyes, runny nose, cough, sneeze...?"
• GI - "how's his/her appetite; any vomiting/diarrhea; foul breath...?"
• Urogenital - "is he/she neutered/spayed; any discharges; how is his/her H20 intake - increased/decreased; how is his/her urination - same as always; intact female?..."
• Nervous - "any history of seizures; tremors; weakness; collapse?..."

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Physical Examination

Tools - Stethoscope, penlight, pleximeter, hemostat, otoscope, ophthalmoscope, glove.

A thorough exam requires concentration and consistency in performance. Try to always use the same order of examination so as not to forget a component of the exam.

Inspection from a distance:

• Observe gait as animal enters room
• Demeanor: shy, assertive, etc.
• Mental status
• Conformation and symmetry
• Nutritional status
• Neurological deficits
• Visual deficits present
• Head tilt
• Weakness

Close inspection

• Socialize first
• Proceed slowly, using least restraint necessary

Can use a systems approach, or start at head and work toward tail. May need to address obvious problem first; i.e., that which owner came in for, to put client at ease

General appearance

• Body and coat condition
• Demeanor

Oral cavity

	The outer surface of the teeth and gingiva are examined by lifting the lips.
	The inner surface of the teeth, palette, tongue and throat are examined by opening the mouth. Light pressure on the roof of the mouth with the dog's lip between teeth and your thumb will reduce the chance of being bitten.

A cat's mouth is opened by holding the head by the zygomatic arches and pulling down on the lower jaw, keeping your finger on the midline, over the incisors, rather off center near the canine teeth. You can use the middle finger of the hand on the lower jaw to push up in the inter-mandibular space which will elevate the tongue allowing a view of the underside of the tongue...a site which string foreign bodies may be located.

• Hold head gently but firmly
• Eyes, air movement through nostrils, face, philtrum.
• Check labial surface of teeth, mm, CRT, condition of gums and teeth. Open mouth - examine occlusal and lingual surfaces of teeth, gums, tongue, hard and soft palate; pressure on base of tongue to check tonsils of dog (cat tonsils not normally visible)
• Check breath (not everyone can detect these smells)
  
  foul
  uremic (NH3)
  sweet (acetone)
• Check underside of tongue for string FB, especially in vomiting animals

Eyes

• Check vision (menace) and pupillary light reflexes
• Check for exophthalmos; enophthalmos
• Check upper, lower, third eyelids for symmetry, ectropion, entropion, mucus membrane color, discharge
• Corneas should be clean, glistening

Ears

• Check for inflammation, exudate-shine penlight down vertical ear canal
• Smell for yeast (fruity) or bacterial odors
• Check pinnae for alopecia, scaling, self-trauma
• Thorough otoscopic exam if abnormalities noted
• Remember cats have normal preauricular alopecia

Lymph nodes

• Mandibular, prescapular and popliteal lymph nodes normally palpable in large dogs, prescapular and popliteal nodes are often not palpable in smaller patients
• Don't confuse mandibular lymph nodes and mandibular salivary glands

Respiratory system

• Check respiratory rate, evidence of dyspnea, abdominal breathing
• Palpate larynx and trachea. Gentle palpation should not elicit a cough. Palpate ribs to check for pain or fractures. Can assess obesity at this time. In normally conditioned animal you should feel, but not see ribs.
• Auscult thorax
• Cat thorax should be compressible with gentle pressure between thumb and fingers
• Purring cat - should get it to stop (various ways)

Cardiovascular system

• Check for jugular distension,
• PMI of heart
• femoral pulses
• Ascertain HR and rhythm

Urogenital system

• Check mammary glands for nodules, cysts, pain
• Check for mastitis in lactating bitch/queen - milk expressed from each nipple
• check vulva for discharge or swelling
• Check prepuce, penis, testes
• Rectal examination to evaluate prostate

Check anus and perineum for neoplasia or anal sac disease

Musculoskeletal system

• Gait abnormalities, lameness - assessed on general appearance
• Muscle swellings/atrophy
• Check joints/bones for swelling, pain or crepitus if indicated

Integument

• Much of the integument examination is performed during other parts of the physical examination

Nervous system

• A complete neurological examination is not routinely performed, however may be indicated from history or other physical examination findings.

Abdominal Palpation - Use application of light finger pressure to the body surface to determine consistency of parts underneath. Trace structures, don't grab them.

Terms to describe organs/masses

• Is it firm or compressible?
• Does it feel fluctuant (fluid filled)?
• Is the organ/mass movable or fixed relative to adjacent structures?
• Is the surface smooth or irregular?

Trace location, shape, site of organs or masses

Be gentle. You may want to postpone palpation until midway through exam when animal is more relaxed.

You can manipulate the animal to better delineate certain structures; e.g., elevate forequarters to better feel liver, spleen, anterior intestinal structures. You can push upward on the caudal abdomen to move the prostate into the pelvic canal to palpate per rectum.

Techniques

• Cats and smaller dogs - one hand
• Larger dogs - both hands
• Gently push hands dorsally and then draw hands ventrally, letting viscera slip between fingers.

Organs - Cannot usually feel liver, stomach, right kidney. Left kidney may be palpable. Ability to palpate bladder is dependent upon degree of distension.

Auscultation

• Primarily used for evaluation of the cardiovascular and respiratory systems. Can also auscult gastro-intestinal system.
• Bell for low-pitched sounds-heart
• Diaphragm for high-pitched sounds-airways
• Ensure stethoscope is comfortable and fits snugly. Have quiet surroundings and minimal distractions. Concentrate and hold stethoscope head firmly against the animals coat to reduce extraneous noise production.

Auscultation of respiratory system

• Includes thorax, sinuses, larynx, trachea. Sounds can radiate from upper airway to lower, so need to differentiate from pulmonary disease.
• Normal sounds

Bronchial (tubular) - blowing, like air through straw. Created by air moving through larger airways (sinuses, larynx, trachea, major bronchi)

Loudest over larynx, trachea, decrease in intensity as move away from hilus of lung

Can be heard farther peripherally (where you expect to hear only vesicular sounds), when lung contains less air than normal; e.g., with consolidation

• Vesicular sounds - thought to originate in part from separation and distention of alveoli by in-rushing air.

Increased vesicular sounds occur with intensified respirations (physiologic), increased respiratory excursions (e.g., from fever), emphysema (are harsh), developing bronchitis.

Decreased sounds secondary to decreased expansion of a lung, pleuritis, consolidation, neoplasia, pneumothorax

• Abnormal sounds = adventitial sounds

Rales - most prominent on inspiration but can be heard in both phases. Produced by exudate within air passages. May vary in intensity, temporarily relieved by coughing.

Moist - fluid of low viscosity. Can be coarse, medium or fine

Dry - vibration of sticky, tenacious mucus within large bronchi; in chronic respiratory conditions. May be hissing, squeaking or whistling

Pleural friction rubs - between parietal and visceral pleura. Develop following chronic pleuritis when pleura is thick and dry. Not altered by coughing and best heard at periphery of lung fields.

Cardiac auscultation - Detect presence of murmurs, other abnormal heart sounds, arrhythmias

• 1st heart sound - AV valve closure - louder, longer, lower pitched- "lub"
• 2nd heart sound - semilunar valve closure - softer, shorter - "dub"
• Interval between 1st and 2nd (systole) is shorter than between 2nd and 1st (diastole)
• point of maximal intensity (PMI) of valves should ausculted on left (pulmonic, aortic, LAV) and right (RAV). Auscult thoracic inlet.
• Murmurs - characterize as to location, intensity, systole/diastole. Use bell and diaphragm as murmurs will differ in pitch.
• Muffled heart sounds - associated with hydrothorax, pneumonia, masses, hernia, effusions, cardiac paresis, obesity.
• Note the strength of the femoral pulse in both legs. Auscult the heart and simultaneously palpate the pulse to detect pulse deficit (heart beat not associated with a pulse).

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