The reporting of clinical signs in laboratory animals: FELASA Working Group Report
Abstract
Clinical observation and examination
Daily inspection
Clinical examination
Area of interest | Parts considered | Detailed observation and reporting | Instruction |
---|---|---|---|
General | Oversight | Development related to age and sex. Nutritional state, quality of the hair coat. Behavioural features and locomotor abnormalities. | Observe animal in home cage/pen and in response to stimuli; next, handle it as needed. |
Head | Head (total) | Observe for shape, relative size of parts and symmetry, hair cover, position before you focus on details below. | You need to see both sides and the view from the front. |
Nasal orifices | Opening, colour, moisture, any discharge, any asymmetry, any respiratory sounds. | View from the front, do not handle without reason, compare with normal aspect for the species. | |
Mouth (lips, cheek, teeth, gums, tongue, cheek pouches) | Position, texture, colour, moisture, any wounds or deformities, abnormal discharge. | The lips may be lifted manually but the jaws need not be opened. Note any other features such as smell. Cheek pouches (dependent on species) may extend to the side of the neck and be empty or filled (e.g. with food). | |
Eyes, eyelids | Position, size of the eyeball, position and close fit of the eyelids. Moisture, reflection, transparency of cornea, size and shape of pupil, any discolorations or discharge. | Be familiar with species-specific features such as pigmentation of the iris and form of the pupil, as well as reflection of light within the eye, in some species. Abnormalities may occur unilaterally or symmetrically (note). | |
Ear (pinna, ear canal) | Shape, thickness, position of the external ear (pinna), inspection of the ear canal, any abnormal content or discharge. | There is a lot of variation between species and even within species (e.g. different breeds of dogs, pigs, rabbits), thus, the observer must be familiar with the normal presentation. Inspect for symmetry, ear movements, inspect the ear canal without or with handling of the pinna. | |
Neck | Part between head and shoulders | Mobility, shape, any wounds or masses, any guttural sounds. | Mobility is checked by observing the animal moving its head. The dorsal side consists of vertebral column, ligaments and muscles. The skin is loose in most species and then the preferred site to check on dehydration by observing the sliding back of the skin after picking up a skinfold. The ventral side contains a lot of different organs (lymph nodes, salivary glands, oesophagus, larynx, trachea, thyroid gland) that warrant a careful inspection and sometimes gentle palpation. |
Trunk | Back | Position, symmetry, muscles. | The back has a thoracic part connected to the ribs, and a lumbar part where ribs are absent, connecting the thoracic part to the pelvis. The relative length and flexibility of the lumbar part varies between species. The position of the back (flexion up or down, or sideways) must be noted. The visibility of the spine depends on the amount of musculature and subcutaneous fat and is indicative of the nutritional state of the animal. |
Thorax | Shape, respiratory movements. | The frontal part of the rib cage is covered by the shoulders that are part of the trunk but technically the upper (most proximal) part of the front limbs. The area between the thorax and the front limb is the axilla (‘armpit’). The thorax contains the heart and the lungs. Behind the shoulders, the ribs are superficial and allow for observation of the shape of the chest and respiratory movements. In some species, mammary glands are present at the ventral and lateral aspects of the thorax. | |
Abdomen | Shape, tension, superficial structures, (respiratory) movements. | The abdomen contains many vital organs such as the gastrointestinal tract, liver, spleen, and urogenital organs. Internally, it is separated from the thorax by the diaphragm which extends forward. Seen from the side, the lungs extend backwards between the diaphragm and the ribs. Parts of the abdomen are only covered by skin and muscles, in the flanks (lumbar area, caudal to the ribs and ventral to the lumbar spine) and ventrally (between the sternum and the pelvis). The shape and tension can be evaluated in these areas. The abdominal wall moves with respiration and sometimes (movements of) abdominal organs can be seen. Superficial structures are the mammary glands and the preputial opening in males (species-dependent). | |
Pelvis | Shape and symmetry of skeleton and muscles of the pelvis. Structures of the perineum: size, shape, colour, any discharge. Structures of the groin, with special attention to mammary glands in this area, and inguinal lymph nodes. | The pelvis is the bony structure that connects the hindlimbs to the trunk. The outside is covered by large muscles of the limb and is best observed from the back, the side or from behind. Inside is a canal where the rectum and urogenital organs pass backwards to end at the perineum, where muscles and skin contain their openings. Between the hindlimb and abdomen lies the inguinal area (the groin) where major blood vessels pass and – sometimes prominent – inguinal lymph nodes are located. The structures are best observed from behind or from the ventral side and their arrangement differs between species and sexes. | |
Limbs | Front limbs | Position, motility, any wounds or deformities, abnormal muscle tone or muscle mass, proper use (versus lameness). | The upper part (the shoulder) is part of the trunk. Although the general design is conserved across species, there are major adaptations to the use (locomotion: flight, walking on toe or sole of the foot; other use such as holding objects). The observer needs to be familiar with species-specific features. To indicate the site of a lesion, use proximal (closer to the trunk) or distal (towards the end of the extremity), medial (inside) or lateral (outside), anterior (side of the head) or posterior (side towards the tail), and for the foot dorsal for the upper side and palmar for the side towards the ground. |
Hindlimbs | Position, motility, any wounds or deformities, abnormal muscle tone or muscle mass, proper use (versus lameness). | Although the general design is conserved across species, there are major adaptations to the use (walking on toe or sole of the foot). The observer needs to be familiar with species-specific features. To indicate the site of the lesion, terminology is the same as for the front limb, except the underside of the foot that is referred to as plantar. | |
Tail | Position, motility, tension (laxness or rigidity), any wounds or deformities. | The skeleton of the tail is the most caudal part of the spine and is rudimentary in some species. However, many species have a longer tail which can be moved by muscles and long tendons. The skin can be sparsely haired or covered with fur or plume, dependent on the species. Handle the tail to detect abnormal tension. |
Users
Animal care staff
Investigator
Veterinarian
Education and training
Means of registration
General sheets
Creating your own glossaries by a step-wise approach |
1. Identify the areas of application (a) Species (b) Animals in colony (stock and/or breeding) (c) Specific research models |
2. Find out what notes have been made in the past |
3. Cluster these notes to combine similar observations |
4. Discuss the analysis as a group, and agree (a) What these descriptions actually describe (b) Which clusters you select to translate to your initial glossary (c) What items from the reference glossary would suit your purpose (d) What common terminology will be used in connection with the scientific term (e) Which qualifiers should be reported for each term |
5. Agree on one or more formats to start data collection (a) Paper forms, per day or per (group of) animal(s) (b) Simple generic software |
6. Train all users on (a) The proper application of the glossary (use reference pictures if you have them) (b) The use of the registration format (c) Clinical observation and examination |
7. Celebrate the start of using the initial glossary |
8. Review and analyse the outcomes after a few months |
9. Discuss the outcomes and findings as a group |
10. Adapt your glossary/registration format accordingly |
11. Start thinking of making the system more capacious and/or efficient (e.g. the use of sophisticated automation). |
Score sheets – tailored for project
Automated databases
Systems
Animals
Record keeping
Writing and reading
Notifications
Recent history
Context
The glossary
Terms, definitions, descriptions and qualifiers
Clinical sign | Definition | Clinical description | Detailed reporting | Background information |
---|---|---|---|---|
General signs | ||||
Oedemaoedematous | The abnormal accumulation of fluid in tissues. | Soft swelling of tissues, can be seen when it occurs in superficial tissues. Typically, oedematous tissue will ‘pit’ when gently compressed and the tissue will remain compressed for a while after withdrawal of external pressure. | Indicate the site(s) and size of the lesion and its chronicity. | Oedema can occur in a variety of organs and tissues secondary to a traumatic or pathological cause. Superficial oedema typically occurs locally after trauma or by a systemic cause in places that vary by species. Systemic causes include circulatory failure or low blood protein concentration (hypoproteinaemia). |
Distended abdomen | An abdomen abnormally enlarged. | The enlarged abdomen extends beyond normal body contours (best seen from the ventral or dorsal side of the animal). | It must be determined if it is symmetrical or unsymmetrical, painful, rigid and (in larger animals) if there is a fluid thrill in percussion or not. | A distended abdomen is physiological in obesity or pregnancy. Pathological causes include fluid in the peritoneal cavity, intra-abdominal cysts or masses, enlarged organs, or bloated gastrointestinal tract. |
Ascitesascitic | Abnormal accumulation of fluid in the peritoneal cavity characterized by a distended abdomen and fluid thrill upon percussion. | A distended abdomen and fluid thrill upon gentle percussion of the abdomen. | Must be differentiated from other causes of distended abdomen (pregnancy, solid mass). If differentiation is not possible, report ‘distended abdomen’. | Ascites may result from a condition primarily affecting the peritoneum or may be secondary to liver, cardiac or kidney disease. |
Pallor (generalized)pale | Pallor is an abnormally light colour of skin or mucosae. | Generalized pallor is typically symmetric and may affect all parts of the body. Paleness can be observed in mucous membranes, the unpigmented eyes of albino animals and in hairless areas. | Record the location where paleness was most clearly observed. Indicate the degree of pallor and the chronicity of the condition, as well as any secondary signs such as weakness, exercise intolerance, cold extremities and tachycardia. | Pallor demonstrates a lack of peripheral blood circulation or anaemia. Anaemia can be diagnosed by blood analysis which can also reveal the nature of the condition (excessive loss of red blood cells or lack of blood cell formation) |
Terminology from glossary in alphabetical order | |||
---|---|---|---|
Abortion | Dwarfism/Dwarf | Hypopigmentation | Pica |
Agalactia | Dysbasia | Hypopyon | Piloerection |
Aggression | Dyskinesia | Hypothermia | Plantigrade, walking |
Agoraphobia | Dysmetria | Hypotony | Pollakiuria |
Alopecia | Dysphagia | Hypotrichosis | Polydipsia |
Anaesthesia | Dysphoria | Polyphagia | |
Analgesia | Dyspigmentation | Icterus | Polyuria |
Anisocoria | Dyspnoea | Poor coat condition | |
Ankyloblepharon | Dysstasia | Kyphosis | Preputial discharge |
Anorexia | Dystocia | Pruritus | |
Anuria | Dysuria | Lagophthalmos | Ptyalism |
Apathy | Lameness | Pustule | |
Aphacia | Ecchymosis | Lethargy | |
Arthrophyma | Ectropion | Leukocoria | Rearing |
Ascites | Emaciation | Leukoderma | Rectal prolapse |
Ataxia | Enophthalmos | Leukotrichia | Regurgitation |
Atocia | Entropion | Rhinorrhoea | |
Atony | Epileptic seizures | Macule | |
Epiphora | Malocclusion | Scab | |
Blepharoptosis | Epistaxis | Malodour | Scar |
Blepharospasm | Erosion | Mass | Sneeze |
Blindness | Erythema | Mastitis | Spasm, clonic |
Bradycardia | Erythruria | Melena | Spasm, tonic |
Bradypnoea | Exophthalmos | Microphthalmos | Strabismus |
Buphthalmos | Miosis | Stranguria | |
Food or water intake abnormal | Mydriasis | Subcutaneous emphysema | |
Cachexia | Synechiae | ||
Cannibalism | Haematemesis | Nasal discharge | |
Chromaturia | Haematochezia | Nystagmus | Tachycardia |
Chromodacryorrhea | Haemoptysis | Tachypnoea | |
Circling | Haemorrhage | Obesity | Tenesmus |
Coloboma | Hair dyschromia | Ocular hyperaemia | Tetraparesis |
Coma | Halitosis | Oedema | Tetraplegia |
Congenital malformation | Head intentional tremor | Oligodipsia | Trauma |
Constipation | Head rotation | Oligophagia | Tremor |
Coprophagia | Hemiparesis | Oliguria | Trismus |
Corneal cellular infiltration | Hemiplegia | Onychopathy | Tumour |
Corneal oedema | Hyperaemia | Ophthalmorrhage | |
Corneal pigmentation | Hyperaesthesia | Opisthotonos | Ulcer |
Corneal scarring | Hyperalgesia | Otitis (externa) | Unkempt hair |
Corneal ulcer | Hyperexcitability | ||
Corneal vascularization | Hyperkeratosis | Pachyderma | Vaginal discharge |
Cough | Hyperkinesia | Pallor (generalized) | Vaginal prolapse |
Crust | Hypermetria | Papule | Vesicle |
Cyanosis | Hyperpigmentation | Paralysis | Vocalization |
Hyperthermia | Paraparesis | Vomit or emesis | |
Deafness | Hypertony | Paraplegia | |
Dehydration | Hyphaema | Paresis | Wound |
Diarrhoea | Hypoaesthesia | Petechia | |
Distended abdomen | Hypoalgesia | Photophobia | Xeroderma |
Distichiasis | Hypokinesia | Phthisis bulbi | Xerophthalmia |
Translation of clinical signs to severity
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