Clinical examination

This chapter can be used as a check list for complete clinical examination. It will not always be necessary to perform the complete examination as described here. However it is always better to collect more information than strictly required than leaving out the essential ones. An excellent description of the complete clinical examination is written by E. Wiedner (2015).

 

Elephants may live 50-70 years and most will experience health problems at some point in their lives. Determining the exact causes of a problem - the definitive diagnosis - can be a challenging task. Because of the elephant’s size we cannot use all of the diagnostic tools and technologies that are available for domestic species. Although some limitations exist, the approach to patient evaluation is the same for elephants as for other large mammals. This is the typical sequence of events when we are presented with a sick elephant. We start with a history and perform a physical exam.  If the history and physical exam are not enough to arrive at a diagnosis then we need to run lab tests. We make a list of all the things that could be causing the problem – the differential diagnosis. We use all of the information we have to arrive at a final diagnosis and then we develop a therapeutic.

1. History

It is important to get as much information about the history of the animal as is available. The information consists of the elements that are directly related to the animal and its surrounding and elements related to the presence of a disease. (Some) symptoms may be absent at the time of clinical examination, but may have been observed by the caretaker. Describe each symptom as clearly as possible.

Animal data:

  • Age

  • Gender

  • ID-number

  • Body weight

  • Reproduction history and current status

  • Management related data (single kept, part of a herd, part of bachelor group, natural- or hand-raised, previous diseases history, free/protected contact)

  • Disease monitoring history (TB, parasites, Salmonella, EEHV)

  • Characteristic normal behavior

Recent disease history:

  • Symptoms observed (apatite, drinking, alert/inactive/slow/lethargic/apathy, weight loss).

  • Has the elephant shown signs of pain (colic or lameness)? Describe the part of the body, expression of the pain, degree of pain, frequency, throwing sand to the painful body part.

  • Defecation: frequency, amount per defecation, description of feces (soft, firm, watery, smelly, size of bolus, well/poor digested)

  • Urination: frequency, amount per urination, description of urine (color, clarity, smell).

  • When did the elephant loose its most recent dental element?

  • Respiration: increased/decreased rate, coughing, discharge from trunk (describe)

  • Salivation: free dropping saliva from the mouth?

  • Has there been discharge from the temporal gland recently? Describe if seen.

  • Discharge from vulva or penis? Describe if seen.

  • Has the elephant been regurgitating food or fluids? If so: describe.

  • Has the elephant shown signs of bloat?

  • Has the elephant shown signs of edema (ventral part of abdomen, head, neck, leg)?

  • Have there been signs of ‘hiccup’ or other forms of rhythmic muscle spasms?

  • Has there been a temporary or permanent swelling in the perineal area?

  • When were the above desribed symptoms seen for the first time? Continuous or sporadic?

  • Has there been any other disease symptom not yet described here?

  • Are other animals showing similar or different symptoms? If yes, describe. Since when?

  • Have there been traumatic interactions with other elephants?

  • Have there been traumatic interactions with humans?

 

Additional questions for calves:

  • Has there been discharge from the umbilicus (navel)

  • How long took it before the calf was standing unsupported after it was born?

  • How long took it before the calf was drinking after it was born?

  • Was the calf rejected by the mother? Describe.

  • Was the calf accepted in the herd? Describe.

 

Additional questions for reproductive females:

  • If the estrous cycle is monitored: describe its pattern (luteal phase, follicular phase, estrous periods, regularity, absence/flatliner, lactation-related anestrous period).

  • When was the last mating?

  • When was the last calving? 

  • Were there any problems in the calving process(es)? If yes: describe.

  • Has the placenta come off completely?

  • Milk production: any historical problems in the milk production? If yes: describe.

              

Additional questions for reproductive male:

  • Has the bull produced offspring before? When, how often?

  • Musth periods: age of first musth, frequency of musth, musth behavior, draining temporal gland, swelling bulbo-urethral gland.

 

2. Physical Examination

Start with observing the elephant from a longer distance before making contact with the animal. Evaluate its behavior with its caretaker and herd mates (alert, depressed, lethargic, agressive). Describe its posture and demeanors.

Make an assessment of its body condition.

Then get closer and make contact with the animal (voice, feeding). Only start making physical contact by touching and palpation when the animal trusts you. The more the animal trusts you, the more clinical data you may retrieve from your examination. Thoroughly observe the animal from a shorter distance.

Count the respiratory rate in rest (normal value 4-12/minute). As thoracic movements may be hard to distinguish, it maybe necessary to feel the exhaled air streaming from the trunk nostrils.

Look for gross lesions or abnormalities (wounds, swellings, lameness, abnormal position of a body part, vulva/penis discharge, urine loss, edema, draining temporal gland(s), salivation, trembling, spasms, colic, bloat).

Does the elephant stand quietly on 4 legs, or does is it trying to avoid body support on one or more legs? Elephants never stay completely still.

Take the body temperature (normal value 36–37°C /97–99°F) by measuring the thermometer in a freshly passed fecal bolus. The center of the latter provides a more reliable value than rectal insertion would.

Examination of the skin: 

Check for wounds, edema, scars, swellings and warm areas. Verrucous growths are often present in (older) elephants and usually have no clinical implications. The same applies to (large) papillomas in the vulva of old female elephants. However, vesicles an swellings on mucous membranes should always be investigated. Old Asian elephants may loose pigmentation on the edges of the ears, the trunk and even the rest of the body. 

In neonates, the navel should be inspected.

Examination of the feet:

If the animal is well enough trained, it should lift its legs to allow inspection of the nails and pad of each foot. 

Check the nail cuticles. Remember that elephants have sweat glands in their cuticles. Cuticles should not be too short as this may facilitate the invasion of micro-organisms. However, they should also not be too long. Elephants seem to care for their nails by rubbing them along hard objects or their own legs. Overgrown cuticles may result in accumulation of sweat: when trimmed these cuticles or when pressure is exccerted on the cuticles, watery fluid may be discharged (see video).

The nails must be shorter than the pad, so they do not bear weigth when the elephant is standing still. Long nails can easily develop a tear.

The pad of the sole must be thick and have a distinct pattern of grooves. When wear is insufficient, the grooves may become too deep and form an easy entrence for dirt and microbes, which may result in a sole abscess. Too much wear results in a smooth surface and a thin pad, vulnerable for deeper sole lesions.

Examination of the eyes:

Elephants have no nasolacrimal duct, so tears run constantly through skin grooves down their face. The area around the eyes is often wet.

The cornea should be clear.

The iris of an elephant varies in color from tan, yellow, brown or the combinations.

Blepharospasm is a strong indication for ocular disease.

Cataract (white central spot) and keratitis (diffuse, superficial cloudiness of cornea) is frequently seen in elephants. Vision can be checked by passing the light bundle of a flashlight (telephone) from the ear over the eye (blinking reflex). 

Ophthalmoscopy in elephants is quite a challenge, as the animal will usually not allow this kind of close examination that moreover uses a light source.

The eyelashes should be long in order to protect dirt and objects from touching the eye ball. 

Oral examination:

If the elephant is trained to open its mouth, an oral inspection should be done.

The oral mucosa should be wet (shiny aspect) and pink. Lesions in the palate may have been caused by eating branches and are not necessarily associated with disease. They should be distinguished from ulcers and vesicles. Vesicles may be associated with avirus infection, one of these being EEHV.  

The mucosa of the soft palate may contain several small nodules, which are assumed to be lymphoid tissues (see photo).

Tongue: the surface of the tongue should be light pink, smouth and wet.

The molars can only be inspected if the elephant is trained to open its mouth. Lower molars are harder to visualize than upper molars, as the elephant tends to cover them with its tong and cheeks. Check the status of the molars (number, size, position). See also the dentistry chapter.

Tusk examination:

Tusks in most African elephants are present in males and females. The tusks of female Asian elephants are very small or absent and are called tushes.

Tusks should be checked for the presence of cracks, fractures, excessive wear and color. A brown color is an indication that the tusk is not vital anymore. See also the dentistry chapter.

Examination of the circulatory system:

Edema: predeliction areas for edema in elephants are theventral part of abdomen, head, neck, leg.

Congestion of the cornea blood vessels may be an indication for heart failure.

Heart auscultation: pulse 25–30 beats/minute, standing (72–98 in lateral recumbency). The heart beat can best be heard on the left side when the elephant has brought its left front leg forward or has lifted that leg. The heart beat cannot be heard in most elephants over 2500 kg. 

ECG: by using a so called DUO ECG + Digital Stethoscope it may be possible to make an ECG while visualizing the heart beat at the same time, however, this method still needs to be validated (see photo).

Examination of the respiratory system:

Respiratory frequency: 10-12/minute (standing) and 4-5 (sleeping)

Counting the respiratory rate is best done by feeling the expiration air at the tip of the trunk.

Check the type of respiration: abdominal, thoracic, panting, forcing

Has the elephant been coughing?

Auscultation: lung sounds are hard to distinguish auscultation in elephants (only in very young calves). 

Check the smell of the exhaled air for abnormal odour that may be associated with pulmonary disease.

Check the trunk openings for discharge.

Examination of the vulva:

The vulva in elephants in the reproductive age should not prolaps. If possible, the mucosa of the vaginal vestibule should be inspected and should be pink and moist. Sometimes hyperemic areas and/or vesicles can be observed higher up in the vaginal vestibule. This could be an indication of a reactivation process of EEHV, which has no clinical implication for the elephant, but this could be a source of virus shedding.

In old, non-reproductive females the vulva can be prolapsed, exposing the clitoris. The mucosa in these animals is often pale.

Swelling of the vulva can be caused by edema (check by"pitting edema assessment"), hyperplasia or tumors.

The temperature measured by placing the thermometer in the middle of a fresh fecal ball, gives an accurate indication of the elephants body temperature

Blinking reflex using a smartphone's flash light in an asian elephant with chronic keratitis

Auscultation of the heart beat and the ECG in an adult Asian elephant by using a combined electronic stethoscope. The left front leg is lifted. The sound cannot be heart, but visualized by the electronic device.

Visualization of the heart beat and the ECG in the same animal by using a combined electronic stethoscope. The upper line represents the heart beat, while the right part of the lower line represents the ECG. This method still needs to be validated 

Small nodular lumps in the oropharynx are assumed to be lymphoid tissue and can be found in healthy elephant. Whether they increase in size during certain infections is not yet known.

The cuticles, the lengths and the shape of the nails in this adult Asian elephant look very nice. Pedicure was never done in this animal.

The cuticles of this elephant were overgrown and had blocked the draining of the sweat glands. Pressing on the tissue resulted in the release of a "stream" of accumulated clear sweat fluid (for a better view, enlarge the image)

The sole pad of this elephant has the right thickness as can be appreciated from the presence of grooves. 

A swelling of the bulbo-urethral gland is sometimes seen in the perineal area during the musth period

Full vulva relaxation in an old Asian elephant. Note the slightly pale mucosa. 

Firm mass in the vulva of a 19 yr-old nulliparous African elephant. The mass could be retracted into the vaginal vestibule. This animal was a flatliner.

Poor digestion of long fibers in an old Asian elephant with molar problems.

3. Laboratory tests

Feces: 

Points of interest are: amount, frequency of defecation, size (small sizes are seen shortly before parturition), consistency, degree of digestion (long fibers are seen in elephants with molar problems), presence of sand (can be palpated or washed out in a bucket filled water), presence of blood, mucous or parasite.

A fecal sample should be submitted for parasitology or bacteriology an intestinal infection is suspected. These samples should be submitted freshly. In case of a suspicion of intoxication, a large fecal sample should be submitted to a relevant lab (always check the possibilities of the lab before you send the sample).

Urine

Blood

Discharged fluids

Wound swab

Oral swab

Vulva swab

Eye swab

Trunk wash sample

Skin scraping

Biopsy

4. Additional testing:

Ultrasonography: ultrasonographic examination is possible in trained or sedated elephants to assess the reproductive organs and the kidneys, for pregnancy diagnosis and to evaluate abscesses and joints. Measuring the thickness of the foot pad will provide useful information about the degree of wear of the sole.

Transcutaneous ultrasound examination can give some information about the liver, intestines, uterus and fetus, Transcutaneous ultrasound examination to assess the internal organs can only be performed in the small triangular window between the caudal side of the last ribs, the pelvic bones and the ventral midline. For good visualization, it can best be done while water (for example from a hose pipe) is running over the skin of the examination area; the ultrasound probe should be kept in the water stream. Drenching the skin with water before examination is also a good option; the probe should be well provided with ultrasound gel.

Transrectal ultrasonography is used for examination of the reproductive organs, the fetus and the kidneys. The rectum needs to be cleaned out as much as possible by manual removal of the feces. Best results are obtained after fluhing the rectum thoroughly with running water from a hose pipe.

Convex 1-5 MHz probes are best used for transrectal and transcutaneous examination of the abdomen. Linear 5-7.5 probes can be used for visualization of the ovaries during transrectal examination. A probe extender is helpfull far reaching the ovaries.  Special designed metal extenders have been developed. If these are not available, a home made extender can be tried. 

The thickness of the skin and more importantly that of the sole pad can be measured by ultrasound examination. Monitoring this thickness over time can help evaluate treatment started in case of abnormal padthickness.

For pregnancy confirmation, click here.

 

Thermography

Radiography

Gastroscopy

Bronchoscopy and broncho-alveolar lavage

 

5. Differential Diagnosis

 

 

6. Final diagnosis

 

 

7. Therapeutic Plan

References

Wiedner, E. 2015. Proboscidea. In R. E. Miller & M. E. Fowler (Eds.), Fowler´s Zoo and Wild Animal Medicine (Vol. 8). St. Louis, Missouri: Elsevier Saunders.