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CASE RECORD (LARGE ANIMAL) - Guidelines

DEPARTMENT OF CLINICAL MEDICINE & SURGERY
By Prof. Dr. Mumtaz Ahmad Khan

Outdoor Clinic Regd. No. …………………………………………………………………..……………... Dated: ……………………..………….………..

Owner’s Name/Address/Phone No. …..………………………………………………..….……………………………..……………………………………

……………..………………………………………………………………………………………………………….…………………...………………………………………

ANIMAL DATA - Species: ………………..………………..…... Breed: ………………….…………………….. Age: ………….….…..……………

SEX: (Male ⃝, Female ⃝), Body Color: ……….……………...…… Body Marking: ..…………………………………….……………..……..

Identification (No.): ……………………………. Body Condition ……….…………………..……………... Body Weight: .……………….….

Purpose: .…………………………. Total No. of Animals: ……………………….…. Types of Animals: .………………………………………..

HISTORY OF ILLNESS – (Main Presenting Complaint) …..…………….……………..…..…….…………………………………..………………….

…………………………………………………………………………………………………………..……………………………………………………………………….…

………………………………………………………………………………………………………………………………………………………………………………………

DURATION OF ILLNESS - (…………….………… Days), Disease at Increment ⃝, -Decrement ⃝, Static ⃝, Others ……………..

APPETITE – Normal ⃝, Decreased ⃝, (Gradual ⃝, Sudden ⃝), Total absent ⃝, Inability to eat ⃝, Increased

appetite ⃝, Depraved appetite ⃝, Others …………………………………………………………………………………………………………………..

WATER INTAKE – Normal ⃝, Decreased ⃝, Nil ⃝, Inability ⃝, Increased ⃝, Source of water: ………………..……………….

RUMINATION – Normal ⃝, Decreased ⃝, Absent ⃝, Inability ⃝, Difficulty ⃝. Others .………………….….…………..…………

DEFECATION – Normal ⃝, Decreased ⃝, Increased ⃝, Straining ⃝, Inability ⃝, Others: ………………………………….……..

URINATION – Normal ⃝, Decreased ⃝, Increased ⃝, Dysuria ⃝, Dribbling ⃝, Inability ⃝, Others: …………………….….

MILK – Dry Animal ⃝, Milking Animal ⃝, Decreased ⃝, (Sudden ⃝, Gradual ⃝), From …………… Lit. To …..….……. Lit.

MILK TASTE - Normal ⃝, Salty ⃝, Bitter ⃝, COLOR: Normal ⃝, yellowish ⃝, Greenish ⃝, Blood tinged ⃝, Watery ⃝,

MILK CONSISTENCY: Normal ⃝, Flakes ⃝, Watery ⃝, Thick curd like ⃝, Blood clots ⃝, Others ………………………..………..

REPRODUCTIVE STATUS: Pregnant ⃝, Gestation in month …………….. , Non Pregnant ⃝, Cyclic ⃝, Non Cyclic ⃝,
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DETAILS OF LAST CALVING: Date of Calving ……………………………. Normal ⃝; PARTURIENT PROBLEM ⃝ (Dystocia ⃝,

Retention of fetal membrane ⃝, Uterine Prolapse ⃝, Vaginal Prolapse ⃝, Abortion ⃝ (Months in Gestation …………..).

FERTILITY RECORD; ESTROUS CYCLE – Regular ⃝, Irregular ⃝. INTER ESTROUS INTERVAL; Normal ⃝, Prolonged ⃝ (>

24 days), Short ⃝ (< 18 days). ESTRUS LENGTH; Normal ⃝, Increased ⃝ (>18 hrs.), Decreased ⃝. SERVICES PER

CONCEPTION; ……………………………….. PARITY; Uniparous ⃝, Multiparous ⃝ (No …………….), SERVICE DETAILS; Natural

mating ⃝, A.I. ⃝, Date of last Service ………………………. Previous breeding problem with details of treatment, ……..…….

…………………………………………………………………………………………………………………..………………………………………………..…………………..

TYPE & AMOUNT OF GREEN FEED/DAY: ……………………….………………………………………………………………………………………………..

TYPE & AMOUNT OF CONCENTRATE/DAY: …………………….………………………………………………………………………………………………

SALT/MINERAL SUPPLEMENT (with amount): ……………………….………………..…………………………………………………………………….

LAST VACCINATION (within 1 year) – Types & Date: ………………………………..……………….……………….……………………..............

LAST DEWORMING (within 1 year) – Types & Date: …..…………………………………………………………..….………………………………….

PRE-MEDICATION – Drugs / Doses / Repetitions / etc. …………………………………………………………………………………..……………..

………………………………………………………..………………………………………………………………………………………………………………................

TREATMENT RESPONSE: ……………….…………….………………………………………………………………………………………………………………….

MORBIDITY (Total Animals Sick): ……..………..………… MORTALITY (Total deaths): ……………………………..……………………………

DISEASE OUTBREAK AT ADJACENT FARMS/LOCALITY: …………………………………..….………………………………………….………………

PREVIOUS ILLNESS (within 1 year) Type: ..….…………………………….……………………………..……….……….. Date: ………………………..

MEDICINE USED: ……………………...………………..……………………………………………………………………..…………..……………………………..

TREATMENT RESPONSE: ……………………....………………………………………………………………………………………..…………………………….

ENVIRONMENT/MANAGEMENT: FLOOR – (Earthen ⃝, Concrete⃝, Brick ⃝), SHED – (Open ⃝, Controlled shed ⃝,

Semi-Controlled shed ⃝), Approximate Shed Space: …………………….…..……….…………………………………………………………………

REMARKS: .….………………………………………………………………..……………………………………………………………………………………………....

GENERAL INSPECTION OF ANIMAL (Examine the animal at distance)

BODY CONDITION – Average ⃝, Thin ⃝, Poor ⃝, Emaciated ⃝, Hide bound ⃝, Cachectic ⃝, Fare ⃝, Good ⃝, Fat ⃝,
Obese ⃝, Others: .…………………………..…………………………..…………………………………………………………………………………………………
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GENERAL BEHAVIOR – Normal ⃝, Docile ⃝, Vicious ⃝, Bright ⃝, Depressed ⃝, Stupor ⃝, Somnolence ⃝, Dummy ⃝,
Comatose ⃝, Restless ⃝, Circling ⃝, Hyperesthetic ⃝, Maniac ⃝, Frenzy ⃝, Spastic ⃝, Convulsion ⃝ (Tonic ⃝,
Clonic ⃝), Butting ⃝, Bellowing ⃝, Grunting ⃝, Yawning ⃝, Others:
.……………….……………………………………………………..……….…

POSTURE – Normal ⃝, Arched Back ⃝ (Upward ⃝, Downward ⃝), Abduction ⃝ (Forelegs ⃝, Hind legs ⃝, All legs ⃝),
Gaunt ⃝, Shifting weight ⃝, Constant sitting ⃝, Recumbency ⃝ (Lateral ⃝, Sternal ⃝), Complete Paralysis ⃝, Dog
Sitting ⃝, Extended Forelegs ⃝, Frequent Sitting & Standing ⃝, Rolling ⃝, Flank Watching ⃝, Stargazing ⃝, Forelimb
crossing ⃝, Keeping up - Carpal joint ⃝, Hock joint ⃝ Pointing ⃝ (Right Front ⃝, Right Hind ⃝, Left Front ⃝, Left
Hind ⃝), Others:
.………..……………………………………….…………………………….………………………………………………………………………………….

GAIT – Normal ⃝, Disinclined to walk ⃝, Lameness ⃝ (Right Front ⃝, Right Hind ⃝, Left Front ⃝, Left Hind ⃝, All
legs ⃝), Stiff gait ⃝, Stumbling ⃝, Jerky ⃝, Goose Stepping ⃝, Knuckling ⃝, Ataxia ⃝, Incoordination ⃝, Paresis ⃝,
Others: …………………………………………………………………………..………………………………..……………………………………………………………

DEFECATION – Normal ⃝, scanty ⃝, Massive amount ⃝, Inability ⃝, Incontinency ⃝, Frequency (Less ⃝,

Normal ⃝, Moderate ⃝ Increased ⃝, Severe Increased ⃝), Straining ⃝, Rectal Prolapse ⃝, Others: ……..……………….

URINATION – Normal ⃝, Oliguria ⃝, Polyuria ⃝, Dysuria ⃝, Anuria ⃝, Dribbling ⃝, Incontinency ⃝, Others: ………..

EATING – Normal ⃝, Inability in Prehension ⃝, Inability to Chewing ⃝, Cud dropping ⃝, Inability in Swallowing ⃝,
Regurgitation (Mouth ⃝, Nostrils ⃝); Others: ..…………………………………………………………………………………………………………….

VOICE – Normal ⃝, Constant Mooing ⃝, Changed ⃝, Grunting ⃝, Bellowing ⃝, Others: ………………………………………….

COUGHING – Absent ⃝, Present ⃝ (Mild ⃝, Moderate ⃝, Severe ⃝), Dry ⃝, Productive ⃝, Paroxysmal ⃝,
Frequent ⃝, Infrequent ⃝, Soft ⃝, Painful ⃝, Short Protracted ⃝, Deep ⃝), Others:
……………………………………………….………………

VISUAL EXAMINATION (Close inspection of body organs by making a complete round of the animal)

FACE – Normal ⃝, Symmetrical ⃝, Asymmetrical ⃝, Head Tilt ⃝, Facial Paralysis ⃝, Facial Rigidity ⃝, Hanging (Jaw ⃝,
Lips ⃝, Tongue ⃝), Enlarged Mandible (Right ⃝, Left ⃝, Both ⃝). Others: .………………………………………………….…………….

EARS –Normal ⃝, Dropped ⃝, Erect ⃝, Exudation ⃝, Blood ⃝, Parasites (Ticks ⃝, Lice ⃝, Right ⃝, Left ⃝, Both ⃝),
Others: ………..…………….……………………………………………………………………………………………………………………………………….…………..
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EYES –Normal ⃝, Sunken-in ⃝, Bulged out ⃝, Lacrimation ⃝, Exudation ⃝, Wound ⃝, Neoplasia ⃝, Blindness ⃝,
Cataract ⃝, Closed ⃝,Prolapsed 3rd eyelid ⃝, Strabismus ⃝, Repeated Blinking ⃝; SCLERA - (Normal ⃝, Icteric ⃝,
Opaque ⃝, Ulcers ⃝), (Right ⃝, Left ⃝, Both Eyes ⃝), Others: …………………………..……….……...........................................

HORNS – Normal ⃝, Polled ⃝, Fractured/Broken ⃝, Exudation ⃝, Sinusitis ⃝, Tumor ⃝, Mal-directed ⃝, (Right ⃝,

Left ⃝, Both Horns ⃝), Others ……………………………….………………………………………………….………..…………………………………………

MUZZLE – Normal ⃝ Moist ⃝, Dry ⃝, Scaly ⃝, Ulcerative ⃝, Vesicles ⃝, Pustules ⃝, Others: .…………………………………

NOSTRILS – Clean normal ⃝, Discharge ⃝, (Serous ⃝, Mucous ⃝, Muco-purulent ⃝, Purulent ⃝, Putrefactive ⃝,

Serosanguineous ⃝, Hemorrhagic ⃝, Vomitus ingesta ⃝), Vesicles ⃝, Pustules ⃝, Ulcers ⃝, Necrosis ⃝, Tumor ⃝,
(Right ⃝, Left ⃝, Both Nostrils ⃝), Others: ……………………………………………………………….…………………………………………………

MOUTH – Normal ⃝, Salivation ⃝, Frothiness ⃝, (Mild ⃝, Moderate ⃝, Severe ⃝), Feed Hanging ⃝, Cud-
Dropping ⃝, ODOR - (Nil ⃝, Putrid ⃝, Acetone ⃝); Others:
………………………………………………………..……..……………………………………..

CHEEKS – Normal ⃝, Swollen ⃝, Fracture ⃝, Wound ⃝, Abscess ⃝, Tumor ⃝, (Right ⃝, Left ⃝, Both Sides ⃝);

THROAT – Normal ⃝, Swollen ⃝, Abscess ⃝, Wound ⃝, Edema ⃝, (Right ⃝, Left ⃝, Both ⃝); Others: .………………….

NECK –Normal ⃝, Jugular vein distension ⃝, Any swelling ⃝, Lymph-node enlargement ⃝, Abscess ⃝, Wound ⃝,
Yoke gall ⃝, (Right ⃝, Left ⃝, Both Sides ⃝); Others: .………………………………………………………………………………….……………….

THORAX –Normal ⃝, Brisket edema ⃝, Heaves line ⃝, Abscess ⃝, Tumor ⃝, Breathing actions (Regular ⃝,
Irregular ⃝), Dyspnea ⃝, (Inspiratory ⃝, Expiratory ⃝), Respiration (Normal ⃝, Fast ⃝, Slow ⃝, (Right ⃝, Left ⃝,
Both ⃝), ABDOMEN –Normal ⃝, Distended ⃝, Tucked-up ⃝, Body Arched ⃝ (Upward ⃝, Downward ⃝), Gaunt ⃝;
POSTERIOR BODY SHAPE - (Normal ⃝, Apple ⃝, Pear ⃝, Papple ⃝, Pot-belly ⃝), Wound ⃝, Abscess ⃝; HERNIA -
(Umbilical ⃝, Ventral ⃝), Neoplasia ⃝, MAMMARY VEIN - (Normal ⃝, Varicose ⃝, Distended ⃝), (Left ⃝, Right ⃝,
Both ⃝, Upper ⃝, Lower ⃝), Others:
……………………………………………..………………………..………………………………………………………………………….

UDDER –Normal ⃝, Symmetrical ⃝, Asymmetrical ⃝, Swollen ⃝, Wound ⃝, Abscess ⃝, Dropped ⃝,Shrunken ⃝,

(Right Front ⃝, Right Hind ⃝, Left Front ⃝, Left Hind ⃝, All ⃝), Others ..…………………………………………………………………….

TEATS – Normal symmetrical ⃝, Asymmetrical ⃝, Swollen ⃝, Wound ⃝, Gangrene ⃝, Teat fistula ⃝, Incontinency of
Milk ⃝, Superfluous teat ⃝, (Right Front ⃝, Right Hind ⃝, Left Front ⃝, Left Hind ⃝, All ⃝), Others …..…………………...

ANUS; Sinking of the Anus ⃝, Atresia Ani ⃝, Inconsistency of Feces ⃝, Perineal Hernia ⃝. Others ………….…………………
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GENITALIA – FEMALE: Normal ⃝, DISCHARGE (Serous ⃝, Mucoid ⃝, Purulent ⃝, Hemorrhagic ⃝); AMOUNT
(Copious ⃝, Scanty ⃝); LESIONS (Wound ⃝, Vesicles ⃝, Pustule ⃝, Tumor ⃝, Polyps ⃝, VULVA - POSITION;
Normal ⃝, Vulva sinking-in ⃝, Vulva sinking-out ⃝, Asymmetry of Vulval lips ⃝, Vulvitis ⃝, Atresia Vulvi ⃝).
PROLAPSE; Vaginal Prolapse ⃝, Cervico-Vaginal Prolapse ⃝, Cervical Prolapse ⃝, Uterine Prolapse ⃝, Retained
Placenta ⃝, Others: ………

GENITALIA (MALE) – SCROTUM/TESTIS; Normal ⃝, Orchitis ⃝, Monorchid ⃝, Testicular hypoplasia ⃝, Scrotal

hernia ⃝, Abscess ⃝, Laceration ⃝, Castrated ⃝, Non-castrated ⃝, PENIS; Phimosis ⃝, Paraphimosis ⃝, Spiral
deviation ⃝, Ventral deviation ⃝, Tumor/Fibropapilloma ⃝, Wound ⃝, Vesicles ⃝. PREPUCE; Prolapsed prepuce ⃝,
Crystals on Preputial hair ⃝, Pervious urachus ⃝, Preputial lesions (Tumor/Warts ⃝, Vesicles ⃝, Pustules ⃝,
Inflamed ⃝),

Others; ………………………………………………………………………………….…………………………………………………………………………………..….…

LEGS – Normal Symmetrical ⃝, Asymmetrical ⃝, Abduction ⃝, Capped elbow ⃝, Inflamed joints ⃝ (Hock ⃝,
Elbow ⃝, Shoulder ⃝, Carpal ⃝, Fetlock ⃝, Pastern ⃝, Coronet ⃝), Bending of long bone ⃝ (Inward ⃝, Outward ⃝),
Stiff gait ⃝, Fracture/Luxation ⃝, Foot-rot ⃝, Foot Abscess ⃝, Overgrown hoof ⃝, (Right Front ⃝, Right Hind ⃝, Left
Front ⃝, Left Hind ⃝, All Legs ⃝,) Others:
………………………..…………………….…………....................................................................

TAIL – Normal ⃝, Movements (Yes ⃝, No ⃝), Gangrene ⃝, Wound ⃝, Fracture ⃝, Other: ………..….…………………….…..

LYMPH NODES – Normal Not-Visible ⃝, Inflamed ⃝, Abscessation ⃝, (Parotid ⃝, Retropharyngeal ⃝,

Submandibular ⃝, Pre-scapular ⃝, Pre-crural/Pre-femoral ⃝, Supra-mammary ⃝, Axillary (calves) ⃝, Inguinal ⃝,
(Left ⃝, Right ⃝, Both ⃝) Others:
..………………….…………………………………………………………………………………………………………………….………………….

SKIN – Normal ⃝, LESION TYPES - (Papules ⃝, Nodules ⃝, Pustules ⃝, Vesicles ⃝, Scabs ⃝, Scaliness ⃝, Erosions ⃝,
Ulcers ⃝, Lacerations ⃝, Scars ⃝, Wound ⃝, Neoplasm ⃝, Abscess ⃝, Melanomas ⃝, Warts ⃝, Sweating ⃝, Dry-
coat ⃝, Hernia ⃝, S/C Edema ⃝, Leukoderma ⃝, Greasiness ⃝, Thickened ⃝, Inelastic ⃝), Pruritus ⃝, Urticarial
swelling ⃝, Ringworm ⃝, LESION-SHAPE (Circumscribed ⃝, Diffuse ⃝, Single ⃝, Multiple ⃝); LOCATION OF LESIONS -
Generalized ⃝, Head and neck ⃝, Shoulders ⃝, Thorax ⃝, Back ⃝, Abdomen ⃝, Tail ⃝, Genitalia ⃝, Perineum ⃝,
Udder ⃝, Teats ⃝, Legs ⃝, Feet ⃝), (Right ⃝ or Left ⃝); ECTOPARASITES (Ticks ⃝, Lice ⃝, Mites ⃝, Maggots ⃝);

Others: ……………..…….…………..............................................................................................................................................

HAIRS – Normal ⃝, Alopecia ⃝, (Localized ⃝, Generalized ⃝) Hypotrichia ⃝, Hypertrichia ⃝, Others: …….…..…….….

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FECES – Normal ⃝, Loose ⃝, Watery ⃝, Melena ⃝, Mucous ⃝, Fibrin ⃝, Tissue Casts ⃝, Homogenous ⃝, Semi-
digested ⃝, Firm ⃝, Dry ⃝, Dry-mucous coated ⃝, Malodorous ⃝, Others: ………………………….………..….…………………..

URINE – Color (Normal ⃝, Yellowish ⃝, Dark Yellow ⃝, Roseate ⃝, Red ⃝, Brown ⃝, Blackish ⃝, Turbid ⃝,
QUANTITY - (Normal ⃝, Reduce ⃝, Excessive ⃝). Other: ……………………………………………………………….…………………………….

PHYSICAL EXAMINATION (Methods) - PALPATION (Consistency, Size, Heat, Pain, Sensitivity), PERCUSSION (Tapping
with finger or Pleximeter & Hammer – Sound, Density), AUSCULTATION (Listening - by Stethoscope – Intensity,
Rhythm, Rate), COMBINED AUSCULTATION AND PERCUSSION, MANIPULATION (Moving – Pain), BALLOTTEMENT (Re-
bounce of Internal Structure), SUCCESSION (Shaken – Auscultate Splashing Sounds).

NB: Restraint the animal properly before examination.

TEMPERATURE: ……..……..……. (0F ⃝, 0C ⃝), HEART/PULSE: …………......... /bpm. RESPIRATION: ………....……. /bpm.

AUSCULTATION OF LUNGS - RESPIRATORY SOUND - Normal ⃝, Harsh ⃝, Wheezes ⃝, Crackles ⃝, Pleuritic

frictions ⃝, (Right ⃝, Left ⃝, Both ⃝, Upper ⃝, Lower ⃝), Others:
……………………………………………………………………………………..

RESPIRATORY NOISES - Sneezing ⃝, Snoring ⃝, Snuffing ⃝, Roaring ⃝, Grunting ⃝, Coughing ⃝, Yawning ⃝;

AUSCULTATION OF HEART SOUNDS – Audible ⃝, Un-audible ⃝, Rhythmic ⃝, Arrhythmic ⃝, Tachycardia ⃝,
Bradycardia`⃝; FIBRILLATION – (Auricular ⃝, Ventricular ⃝); ABNORMAL SOUNDS - (Friction ⃝, Muffled ⃝,
Splashing ⃝, Peristaltic ⃝); MURMURS – (Pulmonic valve ⃝, Aortic valve ⃝, Mitral valve ⃝, Tricuspid valve ⃝,
Loud ⃝, Dull ⃝, at-Rest ⃝, Post-exercise ⃝); Displaced Heart Sound ⃝; Others:
………………………………………….……….…………………………….

RUMINAL MOTILITY – Normal ⃝ (3/2 minutes), Increased to …………………… /min. Decreased to…………….. /min.

RUMEN SOUNDS (Weak ⃝, Moderate ⃝, Strong ⃝, Absent ⃝), Borborygmi ⃝, Others: …………..………………….…………..

RUMEN CONSISTENCY - Normal ⃝, Doughy ⃝, Splashy ⃝, Gas filled ⃝, Gas capped ⃝, Firm ⃝), Others: …………..……

RUMEN DISTENSION – Nil ⃝, Gas ⃝, Feed ⃝, Fluid ⃝, Fetus ⃝, Sunken ⃝, Others: …………………….…….…..….…………….

PINGS – None ⃝, Present ⃝, Ruminal ⃝, Abomasal ⃝ (Right ⃝, Left ⃝), Spiral Colon ⃝, Caecal ⃝, Pneumo-
Peritoneal ⃝, Pneumo-urethral ⃝; Others: …………………………………..………………………………………………………………….…………..

GRUNT TEST – Negative ⃝, Positive ⃝, (Xiphoid palpation ⃝, Wither pinch ⃝, Down-hill walking ⃝), Loud Grunt ⃝,
Mild Grunt ⃝; Others ………………………………………………………………………….……………………………………………………………….………..
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SKIN – Normal ⃝ (Warm), Cold ⃝, Hot ⃝, Dry ⃝, Hypersensitive to touch ⃝, SKIN TENTING TIME (Normal ⃝,
Increased ⃝, Decreased ⃝), Dehydration ⃝, (1-5% ⃝, 6-8% ⃝, 9-10% ⃝, 11-12% ⃝), Others: …………..………….………..

EARS –Warm ⃝, Cold ⃝, Hot ⃝, HEARING - (Present ⃝, Absent ⃝)-(Right ⃝, Left ⃝, Both ⃝), Others: …………....……

EYES – CONJUNCTIVA (Normal pinkish ⃝, Pale anemic ⃝, Icteric ⃝, Congested ⃝, Bright red ⃝, Cyanotic ⃝,
Brownish ⃝, Dark Blackish ⃝, Greyish-Muddy ⃝, Petechiation ⃝, Hemorrhage ⃝), (Right ⃝, Left ⃝, Both ⃝), Others:
…………

ORAL CAVITY – MUCOSA - (Normal ⃝, Pale anemic ⃝, Icteric ⃝, Congested ⃝, Brown ⃝, Cyanotic ⃝,
Hemorrhagic ⃝), LESIONS - (None ⃝, Vesicles ⃝, Pustules ⃝, Ulcers ⃝, Erosions ⃝, Diphtheric membrane ⃝,
Wound ⃝, Catarrhal ⃝, Velvety deposits ⃝), Molars ⃝/Premolars ⃝ (Normal ⃝, Irregular ⃝, Overgrown edges ⃝),
TONGUE MOVEMENT (Normal ⃝, Decreased ⃝, Absent ⃝); TONGUE CONSISTENCY - (Soft ⃝, firm ⃝, Hard ⃝);
CAPILLARY REFILL TIME - Normal (< 2 seconds), Increased (………………..…). Others:
………………………………..…………………………………………………………….

NOSTRILS – Normal glistening ⃝, Dry ⃝, Ulceration ⃝, Erosion ⃝, Bone (septal) Necrosis ⃝, Neoplasia ⃝, Others: …

THROAT – Normal ⃝, Swollen ⃝ (Hot ⃝, Cold ⃝, Soft ⃝, Firm ⃝, Hard ⃝, Painful ⃝, Painless ⃝), Submandibular
Edema ⃝, Others: ……………………………………………………………………………..………………………….………………………………………………

LYMPH NODES – Normal ⃝, Swollen ⃝ (Hot ⃝, Cold ⃝, Soft ⃝, Firm ⃝, Hard ⃝, Painful ⃝, Painless ⃝),
Suppuration ⃝, Ulceration ⃝, Right ⃝, Left ⃝, Both Sides ⃝, Submandibular ⃝, Parotid ⃝, Retropharyngeal ⃝,
Prescapular ⃝, Precrural (Pre-femoral) ⃝, Supramammary ⃝, Axillary (calves) ⃝, Inguinal ⃝, Internal iliac (by rectal
exam) ⃝.

LIMBS – Normal ⃝, Swollen (Hot ⃝, Cold ⃝, Soft ⃝, Firm ⃝, Hard ⃝, Painful ⃝, Painless ⃝), Right ⃝, Left ⃝,
Both ⃝, Others:
………………………………………………………………………………………………………………….………………..................................

JOINTS – Normal ⃝, Swollen ⃝ (Hot ⃝, Cold ⃝, Soft ⃝, Firm ⃝, Hard ⃝, Painful ⃝, Painless ⃝), Name of Joints
……………………………………………… Others: …………………………………………………………………..…………………….………………………………

BONE – Normal ⃝, Fracture ⃝, (Simple ⃝, Compound ⃝), Name of Bone ………..…………………………………………………..….

MUSCLES – Normal ⃝, Pain at Palpation ⃝, Swelling ⃝, Edematous ⃝, Emphysematous ⃝, Hard ⃝, Name of the
Muscles …………………………………………………………………………………… Others: ……………………………………..……………………………...

FEET – Normal ⃝, Overgrown ⃝, Swollen ⃝ (Hot ⃝, Cold ⃝, Soft ⃝, Firm ⃝, Hard ⃝, Painful ⃝, Painless ⃝), (Right
Front ⃝, Right Hind ⃝, Left Front ⃝, Left Hind ⃝, All ⃝), Others: ……………………………………………………………………………..
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UDDER –Normal ⃝, Swollen ⃝ (Warm ⃝, Hot ⃝, Cold ⃝, Soft ⃝, Firm ⃝, Hard ⃝, Painful ⃝, Painless ⃝), (Right
Front ⃝, Right Hind ⃝, Left Front ⃝, Left Hind ⃝, All ⃝), Others: ………………………………….………….……………………………..

MILK –Normal ⃝, Abnormal ⃝ (Flakes ⃝, Curd like ⃝, Thin Watery ⃝, Purulent ⃝, Blood in milk ⃝, Blood clots ⃝,
Malodorous ⃝), TASTE - (Normal- sweet ⃝, Salty ⃝, Bitter ⃝, Unpleasant ⃝), NO MILK IN TEAT ⃝, (Right Front ⃝,
Right Hind ⃝, Left Front ⃝, Left Hind ⃝, All ⃝), Others: …………………………………………………………………………………………….

TAIL – Normal ⃝, Flaccid ⃝, Warm ⃝, Cold ⃝, Fractured ⃝, Gangrene ⃝, Others: …………………………………….……………

RECTAL EXAMINATON:

PELVIS; Normal ⃝, Fractured (Ileum ⃝, Ischium ⃝, Pubis ⃝), Dislocation/Fracture of head of Femur ⃝. Others, ....

REPRODUCTIVE SYSTEM – FEMALE; CERVIX – Normal ⃝ (firm, cylindrical, freely movable), Dilated ⃝, Closed ⃝,
Cervicitis ⃝, Cervical adhesions ⃝, S-Shaped Cervix ⃝, Double Cervix ⃝, Absence of Cervix ⃝, Cervical tumor ⃝,
Fixation of Cervix ⃝), UTERIEN HORN - (Normal ⃝, Gravid ⃝ (Right ⃝ or Left horn ⃝), Amniotic vesicle ⃝, Amniotic
membrane ⃝, Fetus ⃝, Placentomes ⃝, Fremitus ⃝, Duration of Pregnancy ……….………. ), Ectopic Pregnancy ⃝, Non-
Gravid ⃝, Firm ⃝, Flaccid ⃝, Fluctuating ⃝, Uterine Torsion ⃝ (left ⃝, or Right ⃝), Uterine Tumor ⃝, Asymmetric
Horns ⃝, Mummified Fetus ⃝, Macerated Fetus ⃝, Dropsy of Fetal membrane/Fetus ⃝), Uterine position (Within
Pelvis ⃝, Descending ⃝, Ascending ⃝; OVIDUCT - (Normal ⃝, Salpingitis ⃝); OVARIES - Normal ⃝, Hypoplasia ⃝,
Oophoritis ⃝, Ovario-bursal adhesions ⃝, Granulosa cell Tumor ⃝; CORPUS LUTEUM - (Active ⃝, Inactive ⃝,
Persistent ⃝), GRAAFIAN FOLLICLE - (Present ⃝, Absent ⃝); OVARIAN CYST - (Follicular ⃝, Luteal ⃝), Ovarian
Bursitis ⃝; BROAD LIGAMENT – Normally placed ⃝, Over lapped ⃝; FREMITUS – MIDDLE UTERINE ARTERY –
Present ⃝, Absent ⃝; PUDENDAL ARTERY – Present ⃝, Absent ⃝, INTERNAL ILIAC ARTERY – Present ⃝, Absent ⃝;

Others: ……………………………………………………………………………………………………………………………………………….………….………………

PER VAGINAL EXAMINATION - VAGINA - (Normal ⃝, Short (Less than 5 cm ⃝, Uro-vagina ⃝); VAGINAL WALL –
(Vaginitis ⃝, Wound ⃝, Ulcer ⃝, Pustules ⃝, Vesicles ⃝, Tumor ⃝); VAGINAL CONTENTS – CLITORIS – (Normal ⃝,
Prominent along with long hairs ⃝); HYMENAL REMNANTS – (Present ⃝, Absent ⃝); CERVIX – (Normal ⃝, Double
Cervix ⃝, Partial prolapse of the caudal part of the cervical canal ⃝, Segmental laceration ⃝); EXTERNAL OS –
(Open ⃝, Close ⃝); DISCHARGE – (Clear stringy ⃝, Red watery ⃝, Mucopurulent ⃝, Purulent ⃝, Placental debris ⃝).

REPRODUCTIVE SYSTEM – MALE (Inside The Rectum); ACCESSARY SEX GLANDS - (Prostate gland/Seminal
Vesicle/Ampulla) – Normal ⃝, Enlarged ⃝, Painful ⃝), Others ……………………………………………………………………………………

MALE (Outside The Rectum); PREPUCE (Posthitis – firm ⃝, Soft ⃝, Warm ⃝, Cold ⃝, Constricted orifice ⃝); GLANS
PENIS - (Persistent Penile Frenulum ⃝, Fractured Penis ⃝, Ruptured Urethra ⃝, Balanitis ⃝, Fibropapilloma ⃝, Other
Tumor ⃝; SCROTUM - (Warm ⃝, Cold ⃝, Painful ⃝, Necrotic ⃝, Mobility of Scrotum ⃝, Fluid in Scrotum ⃝, Scrotal
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Hernia (Reducible ⃝, Irreducible ⃝), Inguinal Hernia ⃝, TESTIS - (Firm ⃝, Soft ⃝, Painful ⃝, Enlarged ⃝,
Hypoplastic ⃝, Atrophied ⃝, Spermatocele ⃝, Sperm-Granuloma ⃝; Epididymis (Enlarged ⃝, Painful ⃝, Segmental
Aplasia ⃝, Detached ⃝; SPERMATIC CORD - (Normal ⃝, Thickened ⃝, Loss of Mobility ⃝, Painful ⃝, Others;
…………..……………

URINARY SYSTEM; PELVIC URETHRA (Fremitus ⃝, Hard Mass ⃝); URINARY BLADDER - (Urine filled ⃝, Empty ⃝, Thick
Walled ⃝, Hard Mass ⃝, Soft Mass ⃝); URETERS - (Normal ⃝, Thickened ⃝, Fluid Filled ⃝, Hard Mass ⃝), KIDNEYS -
(Normal/Lobulated ⃝, Inflamed/Non-Lobulated ⃝, Painful ⃝), Others; …………………………………………………………………..…

GASTRO-INTESTINAL TRACT; RECTUM - (Feces filled ⃝, Empty ⃝, Rectal Tears ⃝, Recto-Vaginal Fistula ⃝); RUMEN -
(Firm ⃝, Doughy ⃝, Soft Fluctuating ⃝, Gas Filled ⃝), CAECUM/COLON - (Firm ⃝, Soft ⃝, Doughy ⃝, Gas Filled ⃝);
SMALL INTESTINE - (Normal ⃝, Thick walled ⃝, Gas filled ⃝, Obstructed ⃝; MESENTERIC LYMPH NODES; Normal ⃝,
Inflamed ⃝ (R ⃝/L ⃝); LIVER - Normal ⃝, Enlarged with Rounded Edges ⃝; Others; ……………………………………………….

EXERCISE TOLERANCE TEST – Normal ⃝, Intolerance ⃝, (Mild ⃝, Moderate ⃝, Sever ⃝); SUSPECTED PROBLEM IN -
(Lungs ⃝, Cardiovascular ⃝, Musculoskeletal ⃝, CNS ⃝), Others: ………..………………………………….……………….……………….

REVIEW OF SALIENT OBSERVATIONS ……………………………..………………………………….………………………………………………..………

……………………………………………………………………………………………………………………..…………………………………………………………………

ANY OTHER ABNORMALITIES ………………………………………………………………..………………………………..…………………………………….

SITES OF THE LESIONS ……………………………………… SEVERITY OF ILLNESS/LESIONS ……………………….….…………………………….

BODY ORGAN/SYSTEM INVOLVED - (General Systemic States ⃝, Digestive System ⃝, Respiratory System ⃝,
Cardiovascular System ⃝, Urogenital System ⃝, Udder ⃝, Nervous System ⃝, Musculoskeletal System ⃝, Endocrine
System ⃝, Lymphatic System ⃝, Skin ⃝, Others: …………………………………….…………………………………..………………………………

LABORATORY EXAMINATION – Blood ⃝, Urine ⃝, Faeces ⃝, Milk ⃝, Skin scraping ⃝, Pus ⃝, CSF ⃝, Ruminal
contents/Fluid ⃝, Peritoneal Fluid ⃝, ALLERGIC SKIN TEST - (Mallein ⃝, Johnin ⃝, Tuberculin ⃝), Radiograph ⃝,
Ultrasound ⃝, Others: ……………………………….………………………………………………………………………………………………………………….

RESULT/INTERPRETATION OF LAB EXAMINATION(S)..……………….………………………………………………..…………………..............

DIAGNOSIS (Tentative ⃝, Confirmed ⃝) …….…………….………………………………………………………………………………………………….

DIFFERENTIAL DIAGNOSIS …………………………….…………….……………………………………….………………………………………………………..

…………………..……………………………………………………..…………………………………………………………………………….……………………………..

PROGNOSIS – (Good ⃝, Favorable ⃝, Unfavorable ⃝, Grave ⃝, Guarded ⃝, Un-predictable ⃝).

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TREATMENT (Protocol) ……………………………………………………………………………………..…………………………….……………………………

………………………………..……………………………………………………………………………………………………………………….……………………………

…………………………………………………..…………………………………………………………………………………………………….……………………………

……………………………………………………………………..………………………………………………………………………………….…………………………….

TREATMENT COST (Approximate) ……………………………………………………………..………………………………….………………………………

REMARKS ……………………………………………………………………………….…………………………………….……………………………………………….

……………………………………………………………………………………………………..………………………………………………………………………………..

NAME OF PHYSICIAN/STUDENT

More mistakes are made by not looking than by not knowing – Anon