What she did was a mirror image of what I teach my trainees for the elbow exam. She first inspected the area for any skin changes, scratches or other signs of injury. Then she lightly palpated the joint, taking great care to observe Lexi’s reactions when pressing on her joint. She examined the other front leg, comparing one to the other, carefully trying to find any swelling or tenderness. And then, lastly, she gingerly placed her thumb and fingers on opposite sides of the elbow and assessed for range of motion.
All the while, she was talking out loud and explaining what she was seeing, feeling and thinking. It struck me that, at least among vertebrates, the principles of the physical examination are pretty much the same—functional testing in situations most closely resembling real-life conditions, close observation with every maneuver, comparison of active vs. passive range of motion and contrasting affected joints against unaffected ones.
Keep Patients in the Driver’s Seat (with the Windows Down)
At that point, Dr. N turned to me and explained that an X-ray was probably necessary. Lexi was whisked to the back, and within a few minutes, that plain X-ray was placed on the screen. What’s notable here is that the time I was in the room without Lexi wasn’t seen as idle. As a veterinary tech had come to take Lexi away, I was handed a shiny brochure explaining canine arthritis. The brochure had the right balance between being comprehensive and comprehensible. Everything was laid out at probably a fifth grade reading level with lots of diagrams. It certainly kept me occupied as I waited for Lexi to return.
Thankfully, the radiographs were within normal limits. Perhaps a bit of soft tissue swelling was present but there were no structural defects. But what was surprising was that Dr. N didn’t downplay the normalness of the X-rays. She actually preempted the discussion by mentioning that radiographic changes of canine arthritis can be delayed and that the absence of significant findings doesn’t take away from Lexi’s apparent symptoms. That validation was a tiny thing, but an important step. I noticed that my palms were slightly sweaty; even though I didn’t feel very stressed, certainly I was in a fight-or-flight response. Having my unspoken concerns validated was comforting.
In the end, the encounter was mostly reassuring—perhaps a self-limited ligamental issue was at the root of Lexi’s distress. Dr. N offered a CT scan and a referral to a specialist—but not having pet insurance, I deferred. (I choked back the temptation to nervously utter a corny dad joke about CAT scans on dogs, but anyway.) All the while, I realized we were engaging in shared decision making. Dr. N was probing my interest in various options and was even-handed without framing things in a way that was coercive.
