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) |
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