Small Ruminant Research 92 (2010) 72–77

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Small Ruminant Research

journal homepage: www.elsevier.com/locate/smallrumres

Clinical examination of sheep夽

F.M. Lovatt
Castle Veterinary Surgeons, Montalbo Road, Barnard Castle, Co Durham, DL12 8ED England, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Clinical examination of sheep involves the interpretation of information about both the
Available online 28 April 2010 individual and the flock within the context of the farm environment. It is an art, which relies
on careful observation and the systematic collection of specific data, suggestions of which
Keywords: are presented in tabular format. However, interpretation is subjective with the potential for
Sheep wide variation between clinicians. To ensure that the information is directly transferable,
Diagnosis
clinicians have a responsibility to use repeatable measurements and assessments wherever
Flock
possible. Standard scoring systems and criteria that have been developed primarily for use
Health
Clinical examination in the research environment are reviewed and their relevance to the clinician is discussed.
Scoring In particular, the repeatability of measures is considered.
Measurement © 2010 Elsevier B.V. All rights reserved.
Repeatability

1. Introduction lance, especially where computer based systems are used

(Ganter, 2008; Hosie et al., 2009) or in legal disputes. How-
Clinical examination of sheep is the basic foundation ever, despite emphasising standard systems and criteria,
upon which the clinician must build an investigation of there is no implied suggestion that these are sufficient in
disease or sub-optimal performance. There has previ- isolation. There can be no substitute for a detailed system-
ously been much published on this subject (Sherman and atic examination (Tables 1–3) by an experienced clinician,
Robinson, 1983; Radostits et al., 1994; Hindson and Winter, who has developed the art of interpreting the range of clin-
1995; Clarkson and Winter, 1997; Jackson and Cockcroft, ical signs displayed by sheep.
2002; West et al., 2002; Jackson, 2006); these mainly con- In studies comparing ante-mortem clinical diagnosis
sist of opinionated reviews and recommendations based on with post-mortem findings in dogs, which either had died
the authors’ personal experience in clinical practice. This or were euthanised, there was total disagreement in up to
article aims to consider recent research and to quantify 40% of cases (Kent et al., 2004; Vos et al., 2005). It would not
the clinical examination by highlighting specific scoring be unreasonable to expect an increased number of discrep-
systems that have been established. It will consider the ancies in cases of individual sick sheep. This is perhaps most
repeatability of commonly used measures. relevant in the context of pedigree flocks with high value
The use of standard scoring systems with high repeata- individual sheep; however, sheep clinicians are usually
bility ensures that the information gained from the clinical considering a flock problem and, early in the investigation,
examination is directly transferable and this has obvious post-mortem examinations can be undertaken and often
benefits in terms of flock health planning or disease surveil- be of great value.
When considered in the context of sheep flock health
management, the detailed physical examination of the
夽 This paper is part of the special issue entitled: Sheep diagnostic
individual sheep is essential and highly relevant. However,
medicine, Guest-edited by G.C. Fthenakis, P.G. Gouletsou, V.S. Mavro-
it must not distract the clinician from essential considera-
gianni and I.A. Fragkou. tions, such as the epidemiology, the gathering of a detailed
E-mail address: pfmlovatt@metronet.co.uk. history, and an examination of both the environment and

0921-4488/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.smallrumres.2010.04.020
 F.M. Lovatt / Small Ruminant Research 92 (2010) 72–77 73

Table 1 Table 3
Information that should be included in the specific case history in sheep Summary of issues to be addressed by the clinician in a detailed clini-
flocks. cal examination of an individual sheep (Sherman and Robinson, 1983;
Clarkson and Winter, 1997; Jackson and Cockcroft, 2002).
Signalment How many animals in the various groups?
Breed? Age? Reproductive status? General Body condition score – Scale 1–5. Temperature,
Nutrition Access to grazing? What ration? What pulse (strong/weak/rapid), respiration.
forage? How is this fed? Trough space per Mucous Assessed at eye, oral mucosa or vulval mucosa.
sheep? Any recent changes? membranes FAMACHA© scale. Salmon – pink/pale/icteric/
Water What is available? Do the sheep consume hyperaemic/cyanotic? Capillary refill time – assess
it? Where does it come from? at gum or vulval lips <2 s.
Environment Are the sheep grazing? Size and Lymph nodes Check submandibular, parotid, retropharyngeal,
topography of pasture? Housed? What prescapular, precrural, popliteal and
flooring/bedding? What is the stocking supramammary.
rate? Recent weather conditions? Palpable/symmetrical/enlarged/discharging?
Preventive What is the health status of sheep? Skin/fleece Fleece present/lumpy/matted/stained/wool break?
measures Prophylactic measures? Routine Panniculus reflex. Wounds/skin lesions/pruritus/
treatments? Vaccinations? Details of irritation? Nibble reflex. Maggots, lice, keds, ticks,
timings, dosages and methods of sheep scab lesions? Score alopecia, hypersensitivity
administration. and level of scab infestation. NB normal greasy
Recent stresses Any recent transportation or visits to sales staining of skin/wool due to sebaceous glands:
or shows? Recent gathering for infraorbital, interdigital and inguinal.
management or husbandry procedures? Head Symmetry/swellings/oedema – generalised/
Any mixing with ‘foreign’ sheep? submandibular? Skin lesions – erythematous/
crusty/moist/dry/flaky/pustular? Nares –
symmetrical? Discharge – unilateral or
Table 2
bilateral/character?
Summary of considerations by the clinician during inspection of an indi-
Ears Record tags. Symmetrical/swelling/skin lesions/
vidual sheep from a distance.
discharge/mites?
Behaviour Is there a difference from the rest of the group? Eyes Menace response. Pupillary light reflex. Pupil size
Bright/alert/dull/apathetic/anxious/restless/ and symmetry. Nystagmus/strabismus? Consider
excitable/manic? application of topical local anaesthetic.
Posture Consider carriage, position and symmetry of Epiphora/discharge/blepharospasm/conjunctivitis/
head, body and limbs. Restricted keratitis/corneal opacity/peripheral neovasculation/
movement/back arched/elbows ulceration? Sclera – vessels injected/jaundice?
abducted/head-pressing? Recumbent – Internal examination with ophthalmoscope.
sternal/lateral/opisthotonus? Mouth Oral lesions – vesicular/ulceration/pustular/scabs/
Gait Circling/wandering/wide-based odour? Incisors – deciduous/permanent/number
stance/ataxic/hypometria/hypermetria? Lame? (age)/apposition? Premolars/molars – palpate
How severe? Which leg? Lameness score. through cheek or inspect with gag and torch.
Feeding Eating what is offered? Has food been left? Mandibular swellings/pain/irregularities/sharp
Loss of appetite or ability to eat? Consider edges/food impaction/teeth missing/discharging
prehension/mastication/swallowing. Consider sinuses/drooling/dysphagia/odour?
rumination/eructation. Bloat? Cud-dropping? Neck Inspection of pharynx and larynx with laryngoscope
Defaecation Diarrhoea? Constipation? Tenesmus? Faecal and gag or endoscope. Swellings/injury/stridor/
staining of breach, legs, belly? dysphagia/odour? Blood samples from jugular vein.
Volume/frequency/character of faeces. Thorax Auscultation of heart at 4th to 5th intercostal space
Respiration Rate; allow for increase due to exertion, heat, on both sides. Auscultation and ultrasonography of
stress. Rhythm – three phases (inspiration, lungs. Wheelbarrow test.
expiration, pause) of equal length or Abdomen Assess size, shape, consistency. Ballottement?
abnormal? Depth – increased (hyperpnoea) or Auscultation of rumen over left paralumber fossa –
shallow? Dyspnoea (dilatation of nostrils, head 1–2 primary and 1 secondary contraction per min.
extended, mouth open, abduction of elbows, Auscultation of abomasums and intestines.
grunting noise)? Coughing? Sneezing? Ultrasonography. Faeces – volume/character? Faecal
Grunting? Wheezing? Roaring? sample. Urine – frequency/volume. Urine sample.
Skin/fleece Fleece loss localised/generalised? Pruritus? Limbs Injuries/muscle wasting/paresis/paralysis/skin
Head Eyes – blinking/blepharospasm/discharge? sensation/muscle tone? Consider proprioception
Nasal discharge? Ears drooping? Mouth and reflexes – triceps/patellar/pedal. Palpation of all
dribbling? joints. Pain/stiffness/swelling/temperature? Feet –
coronary band/interdigital space/hoof wall/sole/
white line. Growth/odour/lesions/under-running?
the flock. The condition under investigation may not result Male genitalia Prepuce – swelling/obstruction/pain/crystals? Penis
– free-movement/swelling/pain/colour/external
in individuals that are clinically ill, but may involve a group lesions? Urethral process – free/patent? Scrotum,
of animals that are not reaching target performance. In this testes and epididymides – symmetry/consistency/
situation, it is only helpful to examine abnormal individu- pain/free-movement/vasectomy scars? Measure
als if they clearly represent the whole group, though such circumference. Semen sample.
Female Vulva – discharge/swelling/odour/prolapse/
selection is, by definition, subjective.
genitalia injury/bruising? Normal lochia for 1–3 weeks.
Udder Swelling/colour/pain/symmetry/skin
2. Specific history temperature/skin lesions/patency of teat canal?
Character of milk/secretions? Sample milk.

Most clinical examinations begin with a complaint from

the owner or shepherd and subsequently much of the
74 F.M. Lovatt / Small Ruminant Research 92 (2010) 72–77

investigation of specific history relies on the information A farm that introduces ‘foreign’ sheep into the flock
they provide (Table 1). A successful outcome depends (either through buying-in replacements or subsequently
greatly on the relationship between the shepherd and the to grazing a group away from home) or that has potential
clinician and this may be jeopardised if the clinician is contact with other flocks through the fence or at shows or
either tactless or judgemental. It may be necessary to test sales is at risk of introducing a number of diseases spread
statements for accuracy, particularly those related to the from sheep to sheep. Lists of such diseases with possible
sequence of events or those which may involve neglect or control measures have previously been described (Lovatt,
responsibility issues. 2004; Hosie and Clark, 2007) and it is important that the
With the exception of valuable individual show animals farmer is well aware of them.
or pets, the economics of the sheep industry means that a Currently, a number of farms fail to have basic quaran-
clinician is rarely consulted at the first indication of a prob- tine procedures. Not only is this an important consideration
lem. In this case, the losses to date must be determined in the initial investigation of disease, but it also has severe
by establishing the ‘morbidity rate’ (percentage of animals consequences for the successful implementation of veteri-
clinically affected compared to the number exposed to the nary advice on subsequent preventative measures.
same risk), the ‘case mortality rate’ (percentage of affected
animals which die as a result of the condition) and the ‘pop-
ulation mortality rate’ (percentage of all exposed animals 4. Examination of the flock
that die).
Sheep are flock animals and the observation of a sick
individual within the flock is invaluable (Table 2). Even
once the ill animal has been separated from the flock, there
3. General history and environmental are useful observations which should be made before the
considerations sheep is handled. Indeed, the stress of handling may quickly
disrupt the respiratory rate or a lameness that may be
As a background to the collection of detailed infor- apparent from a distance, may become masked when the
mation on the group of sheep under consideration, it is sheep is subsequently handled in a closely confined situa-
often necessary to understand something of the entire farm tion.
enterprise. However, collating such information is time In the development of indicators for the on-farm assess-
consuming and the farmer may justifiably be concerned ment of sheep welfare, researchers and their expert panel
that the details are a distraction from the presenting com- have identified eight welfare indicators that could be
plaint. For this reason, successful gathering of history is assessed by counting the number of affected sheep from
much aided by the prior involvement of the clinician in the a distance. These indicators were (a) dull demeanour, (b)
preparation of a flock health plan. In addition, this empha- dirty rear, (c) dirty belly, (d) skin irritation, (e) wool loss, (f)
sises the importance of maintaining local expertise, so that excessive panting, (g) coughing and (h) lameness (Phythian
the farm situation can be put in context. As far as possi- et al., 2009). Of these, they only found that inter-observer
ble, the following information should be considered: the reliability was good for the first four, otherwise inconsis-
farm situation, size and layout and its elevation above sea tency or poor reliability were recorded. In their distant
level, geology and soil type. As far as sheep in the farm examination, there was no grading of the severity of con-
are concerned, it is important to consider group numbers, ditions, due to the fact that their pilot studies showed low
breed, age profile and the timing of lambing, as well as to reliability associated with different scores. It should be
understand the details of their nutrition. Also relevant, is pointed out that their observers were not all experienced
any information about other livestock on the farm, other clinicians, from whom one could reasonably expect higher
uses of the land or buildings, what the farm outputs are, reliability.
when and how these are marketed and, most importantly, Various lameness scoring scales have been described.
extensive details of the biosecurity policy of the farm. Two numerical rating systems on a scale ‘0’ (normal move-

Table 4
Locomotion scoring scale – all starred sections are required for score (modified from Kaler et al., 2009).

Score 0 1 2 3 4 5 6

Bears weight evenly on all four feet *

Uneven posture * * * * *
Short stride on one leg compared with others * * * * *
Visible nodding of head in time with short stride *
Excessive head flicking, more than nodding, in time with short stride * * *
Not weight bearing on affected limb when standing * * *
Discomfort when moving * * *
Not weight bearing on affected limb when moving * *
Extreme difficulty rising *
Reluctant to move once standing *
More than one limb affected *
Will not stand or move *
 F.M. Lovatt / Small Ruminant Research 92 (2010) 72–77 75

ment) to ‘4’ (not placing a foot to the ground) have been 5.3. Mouth lesions
used (Ley et al., 1989; Welsh et al., 1993). Welsh et al. (1993)
have reported a ‘good’ repeatability of this method. How- There has been a recent comprehensive review of mouth
ever, neither system includes all levels of lameness severity lesions in sheep focusing on the differential diagnoses of
or deals with lameness in more than one leg. Kaler et al. foot-and-mouth disease (FMD) (Watson, 2004). Following
(2009) have developed a system for use in research situ- the 2001 FMD outbreak in the United Kingdom, studies
ations, which is more comprehensive (and consequently were made of over 19,000 heads of sheep for common
more complex to use), by using a scale from ‘0’ to ‘6’ lesions of the oral mucosa. A variety of mouth lesions
(Table 4). The authors have reported high inter- and intra- were present, though most commonly a healing ulcer of
observer repeatability (>0.9). Although familiarisation with up to 1 cm diameter was seen on the lower gum below the
this system may take time, it appears to be unambiguous incisors. Trauma was identified as the most likely cause in
and to have useful applications for the sheep clinician in 90% of cases, with national prevalence of such lesions esti-
practice. mated at approximately 1% (Watson et al., 2006); however,
on individual farms up to 25% of sheep were found to have
such lesions (De la Rua et al., 2001).
5. Physical examination of individual sheep
5.4. Mucous membrane colour
A full physical examination of the individual sheep
requires a set routine to ensure that nothing is left out
In areas of the southern hemisphere where haemon-
(Table 3). The following parts of the examination have been
chosis is an important disease of small ruminants, a
well documented.
colour chart (FAMACHA© ) is commonly used to com-
pare the degree of anaemia evident at the ocular mucous
5.1. Body condition score membranes. The five categories (‘1’-red non-anaemic to
‘5’-white severely anaemic) have been validated for differ-
Body condition score of sheep has been used for over ent packed cell volumes (Vatta et al., 2001; van Wyk and
40 years, as a quick assessment as to whether the nutri- Bath, 2002; Kaplan et al., 2004). This system has already
tional requirements of the sheep are being met (Jefferies, proved to be a very useful tool for farmers in selective
1961; Russell et al., 1967). It is a well-recognised technique anthelminthic treatment. There are other situations, such
used to make an estimation of muscle and fat cover over as acute fasciolosis, where clinicians could use this system
the lumbar processes on a scoring system of ‘0’ to ‘5’, with as an initial screening tool to categorise severity of illness
each whole score clearly defined (MAFF, 1994). Half scores in different individuals, though as yet this system does not
are widely used and some authors even refer to quarter appear to have been tested in Europe.
scores (e.g., Caldeira et al., 2007), though repeatability stud-
ies for these do not appear to have been published. There 5.5. Pruritus
is undoubted value for individual, experienced clinicians
to use partial scores to compare within small groups or to The ‘nibble reflex’, where a sheep responds to stimu-
assess changes. Phythian et al. (2009) indicated that one lation of the skin over the dorsal sacral area by nibbling,
may favour a simpler three-grade score of ‘fit, fat or thin’ has been used in the clinical diagnosis of highly pruritic
for a more repeatable method of assessing sheep welfare; diseases, such as scrapie or sheep scab. A useful demon-
though, without doubt, this would be too blunt a tool for stration of this response has been described by Konold et
management or clinical purposes. al. (2008). Specific criteria have also been developed by the
United Kingdom’s Veterinary Laboratory Agency. Within
these, there are scoring systems for grading the severity
5.2. Temperature, pulse and respiration of hypersensitivity (scale ‘0’–‘4’), the degree of alopecia
(score ‘0’–‘3’) and the intensity of infestation (score ‘0’–‘3’)
There is quite a wide variation in published reports of in sheep with scab, though there are no reports of repeata-
normal parameters in sheep, particularly in consideration bility of these scores (Bates, 2009).
of respiratory rate and pulse (Radostits et al., 1994; Jackson
and Cockcroft, 2002; Bell, 2008; Cousens et al., 2008; Roger, 5.6. Assessment of lung lesions
2008). Normal temperature can be taken as 38.5–40 ◦ C,
with temperatures above 40 ◦ C indicating hyperthermia. Auscultation of the lungs has long been considered an
Normal respiratory rate is approximately 20 breaths per important component of clinical examination. Its clini-
minute (bpm), though the rate is not a useful parameter cal value has been evaluated by a recent study, which
with levels up to 72 bpm (Bell, 2008) or even 123 bpm recorded lung sounds and compared them to ante-mortem
(Cousens et al., 2008) having been reported in clinically ultrasonography findings and post-mortem pathological
normal sheep. Ambient temperature, age, stress and exer- findings. Increased audibility of normal lung sounds was
cise have a considerable effect on normal levels. Normal associated with hyperventilation, either due to toxaemia or
pulse is generally taken to be between as 70 and 90 bpm, due to management reasons, such as recent handling stress.
with marginally higher levels in lambs though normal lev- Coarse crackles were heard in advanced cases of ovine
els up to 120 (adults) or 160 (lambs) have been reported pulmonary adenocarcinoma, though not closely associated
(Bell, 2008). with the actual distribution of the lesion. However, most
76 F.M. Lovatt / Small Ruminant Research 92 (2010) 72–77

notably, abnormal sounds were not detected in sheep with 7. Collection of samples
focal pleural abscesses, unilateral pyothorax or fibrinous
pleurisy though in the latter two conditions, sounds were At the time of clinical examination, there is usually
attenuated compared to the other, unaffected lung (Scott the opportunity to collect useful samples to aid diagnosis.
and Sargison, 2009; Scott et al., 2010). These can include (a) blood for serological, biochemical or
haematological examination, (b) pus or discharge for cul-
5.7. Foot lesions ture, (c) faeces for culture or the presence of fluke eggs
or a count and speciation of helminth or coccidia eggs,
Foot scoring as a method of quantifying foot lesions has (d) milk for somatic cell counting and/or culture and (e)
been used since the 1970s (Egerton and Roberts, 1971), skin scrapings for culture, parasitological examination or
though recent genetic studies into the resistance to foot-rot microscopic study. Recently, haematological and biochem-
have ensured the development and evaluation of a five- ical references values for sheep have been published by
point scoring system (Conington et al., 2008, 2009; Winter, Aitken (2007) and Roger (2008). Urine can be collected by
2009). This system scores from ‘0’ (normal hoof, no lesion, occluding the nostrils or by catheterisation. It is useful to
infection or irritation), ‘1’ (mild interdigital dermatitis), assess colour and turbidity and to test biochemistry with a
‘2’ (more extensive interdigital dermatitis and necrotising dipstick.
inflammation of interdigital skin), ‘3’ (severe interdigi- Semen can be collected by electro-ejaculation or, prefer-
tal dermatitis and under-running of the horn of the heel ably into an artificial vagina following teasing with an
and sole) to ‘4’ (severe interdigital dermatitis and under- oestrous ewe. The initial evaluation of semen has long been
running of the horn of the heel, sole and walls of the hoof). associated with scoring systems that are simple to use
Following observations of 13,867 sheep, inter- and intra- under practice conditions. Concentration is assessed visu-
observer reliabilities were reported to be high (r = 0.87) ally with consistency measured on a scale of ‘0’ (watery,
for this system, which would suggest it to be a valuable insignificant numbers of spermatozoa) to ‘5’ (thick creamy,
tool for the sheep clinician. Nevertheless, the system has 4.5 × 109 to 6.0 × 109 spermatozoa/ml). Motility of sperm is
been designed to include interdigital dermatitis and foot- assessed under low power in a microscope, without a cov-
rot only and does not take into account other foot lesions. erslip and ranked on a scale of ‘0’ (no motion, all sperm
A scoring system for locomotion is proposed in Table 4. dead) to ‘5’ (dense with rapidly moving wave motion, >90%
of sperm are active) (Evans and Maxwell, 1987).
Skin scrapings taken from sheep suspected to have scab
5.8. Udder
should be taken from the leading edge of scab lesion (at the
most ventral and caudal edge) or if the lesion covers the
An evaluation system has been established for udder
whole animal, from cryptic sites (infraorbital and inguinal
traits in dairy ewes with linear scale systems (score ‘1’–‘9’)
fossae, pinnae, crutch or perineum) (Bates, 2009).
for udder depth, udder attachment, teat placement, teat
size and udder shape with a satisfactory repeatability
(0.57–0.73) reported between observers (De la Fuente et 8. Concluding remarks
al., 1996). Although probably transferable to ewes rearing
lambs, a simpler system with fewer categories would prob- The clinical examination of sheep requires a thorough
ably be more relevant and repeatable. Scoring systems have and systematic approach, in order to ensure that no detail is
been developed to categorise acute ovine mastitis in spe- left out. Although the development of a number of different
cific research projects (Fthenakis, 2000) though these are scoring systems has taken place in research environments,
probably not objective enough for widespread use in the there seems to be no reason why these systems (per-
clinical situation. haps with some modification) cannot be used in clinical
practice, in order to provide frameworks and encourage
6. Ultrasonography standardisation. Indeed, clinicians have a responsibility to
use repeatable measures and assessments wherever pos-
The use of ultrasonography as an aid to the clini- sible. However, now is a timely place to reiterate a point
cal examination of sheep, has been widely reported with made in the introduction – that scoring systems can be no
practical suggestions as to how the clinician can use the substitute for the thorough attention to detail and subse-
technique in adults to examine the thorax, abdomen, scro- quent interpretation that is required of experienced sheep
tum, joints, the contents of a vaginal prolapse or the clinicians. The desire to reduce the science of the clinical
distension of the bladder indicating urethral obstruction examination to scores that can be easily dealt with elec-
(Scott and Gessert, 1998a,b; Macrae and Scott, 1999; Scott tronically must not detract from the continued importance
and Gessert, 2000; Gouletsou et al., 2003; Scott, 2008). Fur- of the essential art of clinical examination.
thermore, ultrasonography can be used in lambs, in order to
determine abomasal diameter and thus indicate colostral
intake (Scott et al., 1997; Scott, 2008). A 5.0 MHz linear Acknowledgements
array scanner (such as is commonly used in early preg-
nancy diagnosis of cattle) can be used to examine the chest Grateful acknowledgements to Agnes Winter and Paul
or abdominal viscera up to a depth of 10 cm, with a sector Roger, whose considered comments greatly improved the
scanner necessary for deeper examination. original manuscript.
 F.M. Lovatt / Small Ruminant Research 92 (2010) 72–77 77

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