Clinical Anatomy Notes

Cathy Fuller BVSc PhD MRCVS c.j.fuller@bris.ac.uk You have two x 1 hour sessions during Term 1 and another two x 1 hour sessions during Term 2 to practise Clinical Anatomy when tutors are available to guide you. Remember this is part of the DSE exercise and therefore you are encouraged to have a go, think and learn for yourselves because this is the way in which the material you learn will become part of your experience and not just another set of notes filed away. The objectives suggested for Term 1 are linked to the topics you are learning in Anatomy lectures and practicals and likewise there will be another set of objectives for Term 2. Before you start: Health and Safety issues: For the health of the animal, please ensure that you are wearing a clean white coat or the boiler suits you use for Animal Management. Never wear the blue coats from the dissecting room in the barn. Make sure you have clean hands and boots. For your safety, do not examine animals alone. Approach the animals with care. They can be frightened and may kick or bite if alarmed. Make sure you read the Barn Rules. Remember the live animals are individuals and therefore need to be, and should be, treated with great respect. In order not to alarm the animal, approach quietly and talk to it in gentle tones. Make friends with the animal, stroke it gently whilst talking to it. Help the animals to calm down as this will make them more ready to accept being palpated. See Chris (the animal care technician) before working with the animals, outside of scheduled practical sessions. Aim: The aim of these sessions is to enable you to relate your theoretical knowledge to the live animals and to begin practising the techniques required for clinical examinations. Clinical Examination of the Domestic Species To be a great physician you must understand the whole storyEvery patient represents a story (Dr Robert Centor, Professor of Medicine, University of Alabama, Birmingham, USA) How do we find out that story? Communications skills in order to allow us to glean a detailed history from the owner Physical examination Diagnostic tests Integration of information acquired from above During Clinical Anatomy sessions you will be beginning to practise the skills required for the physical examination, thinking about some of the diagnostic tests and learning to integrate information you gather. All the things we advise you to practise will fit into the physical examination or become part of your diagnostic procedure. Below is an outline of the approach to the clinical examination and an indication of some commonly used diagnostic tests think how your knowledge of anatomy helps you to perform these tasks. You will not be examined on how to perform a clinical examination in Anatomy I or Anatomy II, but you will be examined on your application of anatomy and obviously you should understand how and why the anatomy we teach you is applicable to the clinical case! Remember how essential it is to know what is normal so you can recognise the abnormal.

Physical examination:
There are different ways to do this, and with experience you will develop your own preferred way, but it is important to develop a routine. Think about what can be learned from each stage (some ideas are provided). The bullet points below in bold will form the focus of Term 1s learning objectives (see below). Observation Palpation General: o Body condition o Bony landmarks o Abnormal bony lumps o Lymph nodes o Abnormal soft tissue masses o Site pain Examination o Eyes and Mouth Mucous membranes Capillary refill time o Nostrils o Ears o Perineum and genitalia o Limbs o Respiration rate o Pulse o Temperature Auscultation Thorax o Cardiac and respiratory sounds Abdomen o Gut sounds

Abdominal palpation in small animals

Diagnostic tests
Imaging
Examples: Radiography Ultrasonography MRI CT

Fluid and tissue sampling

Examples: Blood sampling Thoracocentesis (defn: centesis = puncture into a body cavity, usually to remove fluid) Abdominocentesis Liver biopsy

Objectives for Clinical Anatomy in Term 1:

Learning objectives for the first two sessions, this term, are indicated below by bullet points at the stage where they might fit into an examination or diagnosis. At the end of these sessions you should be able to:

Gain confidence in handling and examining the live animals.

Physical examination:
Palpation:

Locate and palpate surface anatomical structures including bony landmarks of the spine and appendicular skeleton.

Examine the entire mounted skeletons and determine the bony landmarks which may be palpated in the live animals. Practise palpation! See the posters on bony landmarks and palpable structures which are available to help you. Remember to notice any species differences between dog, horse and ruminant.

Determine which lymph nodes may be palpable in the healthy animal and understand which structures these lymph nodes drain.

Lymphadenopathy is a change in size (enlargement) or consistency of a lymph node. This may be a reactive response to infection or immunological challenge or may arise due to infiltration by neoplastic cells. In some instances, lymphadenopathy may be the only sign of disease in a patient. Understanding which areas the different nodes drain should help in determining which structures are involved in the disease process. Some lymph nodes can be palpated in the normal state, others can only be palpated when pathologically enlarged. The following lymph nodes may be palpated in the normal animal. Make sure you know their positions if they are small palpation can be difficult but this is a sign of health rather than disease! Think about which structures they are draining The nodes most easily palpable in the dog and cat are the mandibular, prescapular (superficial cervical), axillary, superficial inguinal and popliteal. In the horse it is often difficult to palpate normal lymph nodes in the horse. Those most likely to be normally palpable are around the head: mandibular, parotid and retropharyngeal. In ruminants mandibular, retropharyngeal, prescapular, superficial inguinal (mammary) should be palpable.

Practise palpating these lymph nodes in the dogs, ponies and goats. See the poster Palpation of lymph nodes in comparative species

Examination:

Describe and find the different sites for taking the pulse in different species.

There are a number of different sites from which the pulse may be taken. Know where the most appropriate places are to take the pulse in different species. Practise taking the pulse in the dogs, ponies and goats. Note the strength and rate. Dog and Cat: Femoral pulse femoral artery palpated on the medial aspect of the thigh. NB. May be imperceptible in obese cats. Median pulse median artery palpated distal to the metacarpal pad of the paw. Horse: Submandibular pulse The site where the facial artery passes under the lower jaw. The artery can be felt as a tubular structure below and slightly inside the lower edge of the mandible. Apply light pressure and count for at least 20 secs if possible. Other less common sites to take the pulse in the horse include: Median pulse This site may be useful if the horse is headshy. The median artery is felt high up and on the medial aspect of the foreleg. (NB. It can be difficult to palpate the pulse in this region as the artery is quite deep). Digital pulse The digital artery is palpated on the palmar/plantar surface of the fetlock. Facial pulse The transverse facial artery is felt midway between the base of the ear and eye. Cattle: Median caudal artery of the tail palpated in the proximal part of the tail Goats Femoral pulse as dog What information does the pulse give us?

See the poster Pulse points in comparative species

Auscultation:

Use bony landmarks to determine the extent of thoracic cavity in order to auscultate cardiac and respiratory sounds.

Take a stethoscope and practise auscultation of cardiac and respiratory sounds in the different species (it is easiest to start with the dog). Cardiac sounds: Use bony landmarks to determine where to auscultate the heart sounds in different species. What causes the characteristic heart sound?

What causes a heart murmur?

Which valves can you auscultate on the left vs right hemithorax and what are their landmarks?

Which anatomical landmarks would you use to perform intracardiac injection (for euthanasia of small animals cat, dog, rabbit, guinea pig, hamster etc.)

Respiratory sounds: Ensure you are able to determine the respiratory rate by watching the ribcage rise and fall, or by watching the nostrils. Note the character and frequency. Use bony landmarks to determine the extent of thoracic cavity in order to be able to auscultate the respiratory sounds. How do you work out the three different lung fields for auscultation?

What is the difference between vesicular and bronchial sounds?

Where are you likely to hear each type of sound?

Most importantly, get used to what is normal! See the poster Sites for auscultation of the heart and lungs and the DVD The Art of Equine Auscultation. Listen to The Littman Stethescope CD.

Diagnostic tests
Practice reading the radiographs. Remember the notes from your lecture you will be expected to approach these in the correct way.

There is a selection of radiographs in the small filing cabinet. Practice your approach to reading these, as explained in the lecture, and try to pick out the anatomical structures visible.

Describe the different sites for intravenous injections and for taking blood samples in different species.

Intravenous injections are commonly administered via the cephalic vein (dogs & cats) or the jugular vein (horse, cattle and sheep). The lateral saphenous vein may also be used in dogs and cats if necessary. The subcutaneous abdominal milk vein may be used in lactating cattle. In rabbits the marginal ear vein is the most readily accessed. Venous blood samples may be obtained from the jugular vein in most species. The cephalic vein is also commonly used in dogs. The lateral saphenous vein may also be used in dogs and cats. In cattle blood samples are commonly taken from the median caudal tail vein. See the poster Intravenous injection and blood sampling sites

Use bony landmarks to determine where to perform thoracocentesis and intracardiac injections.

When you perform thoracocentesis which structures do you need to avoid?

See the poster Thoracocentesis