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A thorough physical examination is an essential diagnostic modality that may be underutilized in a busy shelter. A complete description of physical examination techniques is beyond the scope of this chapter, but a few key points relevant to utilizing the physical examination as a diagnostic modality should be emphasized. Ideally, every animal will receive a physical examination by a veterinarian on intake or, at some point, before its release from the shelter; this is legally required whenever a medical diagnosis is made, a treatment plan is prescribed, or a surgical procedure is being performed. However, laypersons operating under the guidance of a veterinary‐designed protocol can conduct a purposeful and accurate physical examination in most circumstances on shelter animals. (Shelters should ensure compliance with their state veterinary practice act and any other federal, state, and local regulations.) Physical examination generally includes the collection of both subjective and objective data points that can be assessed together to determine the most appropriate next steps in meeting that patient's individual needs. See Table 4.2.

The patient examination should progress from pure observation and least invasive measures and, as safety and comfort of both the examiner and the patient increase, proceed to an evaluation of areas that require a hands‐on approach or may include manipulation of painful or diseased body parts. Unless an urgent medical need is apparent, an in‐depth evaluation of a presenting complaint or existing condition is generally left until the end of the procedure. This allows the practitioner to have completed the entire physical examination in case a patient's pain or sensitivity to a diseased or injured area limits further evaluation.

Subjective patient assessment typically includes details about the presenting complaint, evaluation of the animal's mental state, food and water consumption, and any obvious signs of pain or discomfort. Assessment of respiratory rate and character should also occur at this time to avoid over‐interpretation of abnormal findings that may be attributed to the stress and/or discomfort of animal handling. This portion of the examination can often be conducted without removing the animal from its primary enclosure. In addition, evaluation for obvious signs of infectious disease and behavioral characteristics should occur prior to handling. This information will alert the handler of any special precautions that may need to be taken to minimize contamination, limit disease transmission, ensure safe handling, and minimize stress.

An objective evaluation includes the systematic evaluation of body parts and organ systems to identify abnormalities and should begin with an assessment of the animal's signalment (e.g. age, sex and neuter status, breed or breed‐type). The body weight should be recorded along with a body condition score and an indication of the scoring system being used (i.e. nine‐point or five‐point scale).

Table 4.1 Clinical case history questions for private and shelter practice.

Category	Private Practice Questions	Shelter Practice Questions
Environment	What percentage of the time does the animal spend inside versus outside? Is there exposure to fields, woods, bodies of water?	Is the pet known to live indoors or outdoors? If outdoors, is there access to shelter that can provide protection from the elements?
Diet	What kind of food is fed? How often? How much? Any changes in appetite?	Is there evidence the animal has regular access to clean, species‐appropriate food? Is there evidence of regular access to a clean water source?
Medical history	What previous medical conditions have been diagnosed, treated, or managed?	Is there evidence of chronic illness or ongoing medical treatment?
Behavioral history	What previous behavioral conditions have been diagnosed, treated, or managed?	Is there a history or evidence of fear, anxiety, or aggression?
Reproductive history	Is the animal neutered or intact? Is there a history of breeding, lactation, and/or successful parturition?	Is there evidence the animal has been neutered (e.g., tattoo, ear tip)? Is there evidence of breeding, lactation, and/or successful parturition?
Vaccination status	Which vaccinations has the animal received? When were vaccinations administered?	Is there history or evidence (i.e., vaccination tag) of prior vaccination?
Current medications	What medications, nutraceuticals, or supplements are given?	Is there a history or evidence of medication administration?
Current condition	What is the presenting complaint?	Are there any injuries or illnesses noted on or prior to presentation?

Generally, one of two methods of conducting the hands‐on portion of the physical examination is employed: the practitioner can utilize a systems‐based approach (i.e. gastrointestinal (GI) system, cardiovascular system, etc.) or a directional approach (i.e. start at the nose and work one's way to the tail). The examiner should develop a method that is comfortable to them and that they can perform consistently so as not to inadvertently omit a particular body part or system. Assessment of hydration status and recording of heart rate, respiratory rate, and body temperature may also be conducted during this phase of examination and should take into account species, breed, age, and environmental considerations. For example, the normal heart rate in puppies and kittens can be considerably higher than that of adults; that of cats is typically higher than that of dogs. Similarly, excitement, stress, and high ambient temperatures can cause temporary increases in body temperature. Finally, if the animal has an obvious wound, injury or disease, or the animal is presented for evaluation of a particular condition, additional examination of those items should be conducted (e.g. wound assessment, orthopedic examination, neurologic examination, etc.). If the physical examination is not conducted by a veterinarian, the findings thus far can be utilized to identify animals in need of veterinary evaluation and treatment. Initial physical examination in the shelter setting typically focuses on the identification of conditions requiring urgent care (e.g. wounds, injuries) and those with signs of infectious disease that could pose a risk to other animals in the population (e.g. respiratory, GI, dermatologic disease). It is important that shelters have detailed standard operating procedures (SOPs) to outline what steps should be taken to ensure appropriate care and further assessment if there is evidence of an infectious disease or condition requiring further veterinary care.

Table 4.2 Physical examination approach, normal findings and common abnormalities.

Examination Phase	Normal Findings	Common Abnormalities
Subjective
Mental state	Alert and responsive Friendly, approachable	Depressed, obtunded, comatose Withdrawn, stereotypic behavior, aggression, hiding, feigning sleep (cats)
Food and water consumption	Empty food and water bowls Evidence of urination and defecation seen or reported	Consistently full food and water bowls, no interest in treats Urination or defecation not seen or reported
Pain/discomfort	Non‐painful	Vocalization, aggression, limping/difficulty walking, intense scratching, shaking of the head, difficulty breathing, panting, licking or guarding
Objective
Injuries/wounds/existing conditions	None	Puncture wounds, lacerations, abrasions, swollen limbs, broken legs
Signs of infectious disease	None	Coughing, sneezing, ocular discharge, nasal discharge, vomiting, diarrhea, hair loss
Body condition score (9‐point scale)	4–5	1–3 (too thin), 6–9 (too heavy)
Hydration	Well‐hydrated	<5% History or evidence of vomiting or diarrhea 5–7% Dry or tacky mucous membranes, delayed capillary refill 8–10% Skin tenting >10% Mental depression, sunken eyes, weak or rapid pulse
Temperaturea	99–102 °F (Canine) 99–101.5 °F (Feline)	<98 °F Canine, Feline >103 °F Canine, >102 °F Feline
Heart ratea	70–120 bpm (Canine) 120–140 bpm (Feline)	<70, >120 bpm (Canine) <120, >140 bpm (Feline)
Respiratory ratea	18–34 bpm (Canine) 16–40 bpm (Feline)	<12, >40 bpm (Canine, Feline)
Organ systems	No abnormalities found	Examples included but not limited to:Ocular, nasal, aural discharge;Heart murmur or arrhythmia;Coughing, sneezing, difficulty breathing;Painful abdomen, vomiting, diarrhea;Hair loss, flaking, crusting, redness of skin

^a Normal heart rate (beats per minute or bpm) and respiratory rate (breaths per minute or bpm) will vary considerably based on age, species, and breed and may exceed the parameters listed. In general, puppies and kittens have higher rates than adult animals and large breed dogs will have lower rates than smaller breeds. Environmental influences such as stress and ambient temperature can also temporarily impact heart rate, respiratory rate and body temperature.