Admissions, Medical Records, and Physical Examinations for Large Animals

Admissions, Medical Records, and Physical Examinations for Large Animals


Although all large animals have the potential to be kept at a veterinary clinic for treatment, horse and young animals are kept most often. The following admissions and medical records can be used in any location, and blanks can be provided to producers, allowing them to maintain a thorough record of the animal’s treatments and health on the farm.

Animals usually arrive at the clinic accompanied by their owners, although sometimes employees or family members of the owner, horse trainers, or agents arrive with the animal. In the case of professional transportation companies—used primarily with horses—the owner/agent rarely travels with the horse, and the van driver may be the only person arriving with the animal. Therefore, determining who is in charge of the decision-making processes for the animal is important. Depending on the circumstance, the owner, trainer, employee, family member, or agent of the animal may be responsible for the decisions. Determine who this person is and obtain his or her contact information (e.g., phone numbers). Treatment is often delayed until permission can be obtained from the owner or agent, so accurate information is essential, especially for emergency cases.

Horses are often transported with protective gear such as leg wraps, head bumpers, or blankets. Much of this gear is not necessary during the hospital stay and should be sent home with the owner/transporter. If this is not possible, place these items in a plastic bag or storage bin and mark it clearly with the horse’s name so that the items can be returned when the horse is discharged. Loss of these items, although they usually are not expensive, might make the hospital seem disorganized and result in poor client public relations.

Loading and Unloading Livestock and Horses

One of the most dangerous situations a technician can be involved in is loading and unloading livestock or horses from trailers. Working as a veterinary technician, at some point in your career you will be loading and unloading livestock or horses.

Most horses are trained to load and unload from trailers. Most likely you will not be involved in the loading or unloading of these animals because the owners will be present and take on the responsibility themselves. However, in some cases the person dropping off the animals does not have much experience with horses, and you may be enlisted to help in the loading or unloading process. In addition, the veterinary professional may be asked to assist with the loading or unloading of animals that are not trained to load or unload. The most important factor when loading or unloading horses is patience.

In the ideal situation, the horse loads or unloads uneventfully and calmly. Some horses jump into or out of trailers, possibly landing on the handler. This is a dangerous situation, and technicians should be aware of this possible behavior whenever handling horses around trailers.

The two most common trailer designs into which horses are loaded are ramp trailers and step-up trailers (Fig. 5-1). Ramp trailers often have back doors that lower to the ground, doubling as a ramp. The horse is walked up the ramp into the trailer. Step-up trailers require the animal to step up into the trailer to load. With these types of trailers, horses are more likely to jump in or out of the trailer when loading or unloading.

When loading a horse onto a trailer, you should remain calm (horses often sense fear in their handlers, most likely causing a more dangerous situation) and walk at the level of the poll (Fig. 5-2). Do not pause or hesitate when you reach the point at which the horse will have to step up or onto the ramp. Pausing or hesitating gives the horse a split second to think about what it is being asked to do. If you hesitate, continued attempts may be much more difficult. If the situation calls for redirection, never stop moving; keep forward movement and circle the horse back around to try again. If the horse is not going to load smoothly, the horse most likely will pull back on the lead rope once it is asked to step onto the ramp or into the trailer. Young horses or horses with a lack of training may pull back when they approach the trailer or even when they are inside the trailer. A horse that pulls back inside the trailer can cause a very dangerous situation because it may rear or lunge forward on top of the handler. To avoid this situation, never place yourself in front of the horse. You should always lead from the poll.

Trailer layouts include two-horse trailers (Fig. 5-3), stock trailers, and slant-load trailers. A two-horse trailer will not allow you to enter the trailer with the horse. In this type of trailer, the animals have to enter themselves. You will need to lead the horse to the trailer with forward motion and then give slack in the lead rope to allow for entrance. Some horses are used to having the lead rope draped over the neck as they load onto the trailer. Once the animal is loaded, the gate on the back of the trailer should be calmly but quickly closed to prevent the horse from backing off the trailer.

In a stock trailer, the horse will have a lot of room to move laterally inside the trailer. The horse is secured to a side wall once it is inside. In this type of trailer, the technician steps inside the trailer with the horse while loading and confidently leads it to the location where it will be tied and secured with trailer straps. Lead ropes are often used to secure horses inside trailers, though cross ties are the safest method for doing so. If a lead rope is used to secure the horse inside a trailer, it is important to tie it with a quick-release knot. When you are securing the horse inside a trailer, remember to leave no more than a foot and a half of slack in the rope. If the horse were to pull back after the rope is secured, the rope could trap the handler inside the trailer between the wall of the trailer and the rope, causing a dangerous situation. Horses should always be secured in a trailer with trailer ties or lead ropes if possible. The safety of the technician, owner, and veterinarian are the most important aspect of loading, and safety should always be considered first. If tying a horse in the trailer is determined to be too dangerous, you may have to leave the horse untied and free to move around throughout part of the trailer. Most of these types of trailers have partitions that separate the trailer into halves or thirds (Fig. 5-4); if used, the partition should be calmly but quickly closed to prevent escape of the horse.

In a slant-load trailer (Fig. 5-5), the horse may be asked to load through a narrow area at the back of the trailer and then stand at an angle within the trailer. Once the horse is in the proper position, a partition is closed to allow another horse to be loaded beside it or to secure the animal from lateral movement during the ride. Extreme care should be taken when closing partitions in slant-load trailers because the handler often is in proximity of the animal’s hindlimbs.

When unloading a horse from any of these trailers, the safest way to ask the horse to exit the trailer is to back it out of the trailer (Fig. 5-6). Extreme care should be taken when doing so because a horse often reacts by lunging forward when stepping off or onto the ramp. Always keep your eyes open and your attention on the horse. Horses that are allowed to walk off a trailer in a forward motion may often jump off trailers, with the potential for causing severe injury if they were to jump on the handler.

When problems arise while attempting to load or unload a horse from a trailer, the best approach is preparation. People have thousands of ideas and tips for getting a horse to load on a trailer. In your preparation, have a conversation with the veterinarian in advance of any of these situations to determine the veterinarian’s wishes and ideas about loading techniques before any incidents occur.

When livestock are loaded onto trailers, there is still an element of danger associated with the procedure. However, gates and alleyways tend to make the job easier. The most important aspect to remember when loading livestock is their point of balance; if you are behind the animal, the animal will move forward. By providing a narrow alleyway and encouraging the animal to move forward from behind, the animal will most likely load uneventfully. The animal may hesitate when loading onto the trailer, but noise or a light tap with a paddle will usually encourage the animal to load. The most common problem that occurs when loading livestock onto trailers is trying to load an animal through an alleyway that is too wide. If the animal has the ability to turn around in the alleyway, it will most likely choose this route instead of the trailer. Adjustable alleyways set to the proper width can make loading a smoother process (Figs. 5-7 and 5-8). Remember that stress decreases production, so loading and unloading livestock should always be done calmly.

Medical Records

The medical record should be started immediately when the animal arrives. Time can be saved by filling out basic information over the telephone when the owner/agent or referring veterinarian makes the animal’s appointment. The basic information should include patient signalment and billing information. A treatment authorization form is advisable because it is a cost estimate form. Cost estimates can help prevent misunderstandings with the owner/agent, especially when a complicated medical or surgical case is to be treated. The cost of diagnosis and treatment of large animals usually far exceeds the cost of comparable procedures in small animals, primarily because of the large body weight and number of staff required to care for large animals. For example, pharmacy charges for use of the same drug in a horse versus a large dog may be 10 to 25 times higher for each dose of the drug in the horse due to body weight alone. Many hospitals also include a charge sheet in the medical record so that each procedure performed and related supplies can be tracked for billing purposes.

One aspect unique to the horse industry is the widespread use of insurance. Although small animal insurance is becoming more commonplace, equine insurance has existed for many years. Equine insurance has three common types. Mortality insurance covers the value of the horse in case of death. The insurance company pays the owner the estimated worth of the horse if it dies, although there may be exclusions for certain causes of death. Because of the potential for fraud, it is sometimes necessary to get permission from the insurance company before treatment and/or euthanasia is performed. Surgical insurance covers specific costs of surgery and hospitalization, with some limitations, similar to human health insurance policies. Permission from the insurance company must often be obtained before elective and some emergency surgeries are performed. Loss of use insurance states specifically the intended use of the horse, and if the horse cannot perform its intended use because of illness/injury, the owner may be reimbursed. Insurance companies must often be included in the decision-making processes for the patient; therefore, it is important to obtain this information as part of the medical record.

A basic physical examination form or patient flow sheet should be included for all animals for recording temperature, pulse, respiration, bowel movement/urination, and food/ water consumption information. Monitoring these parameters is vital even in healthy animals. When animals are moved to a clinic/hospital environment, they typically are stressed by the transportation and by their placement in an unfamiliar environment. The water and food sources likely are different from their home farm, and their intake may change and lead to gastrointestinal (GI) problems. Equally important to the animal’s “intake” is its “output”; defecations and urinations are important to note. A history of temperature, respiration, and heart rate while the animal is at the clinic is important diagnostic information.

A treatment form is useful for recording and planning diagnostics and treatments and should provide a place for the technician/clinician to initial each procedure as it is performed. Other parts of the medical record depend on the nature of the case and may include radiology, ultrasound, endoscopy and laboratory reports, surgical procedures, and other pertinent information. Treatment records should accurately identify each animal treated, the type of medication, the dose and route that the medication was given, and the withholding time (if any) that was recommended to the farmer. Recording the drug lot numbers is also advisable.

Medicating any food production animal is often complicated by the production of meat and milk products destined for human consumption. In order to prevent certain drugs and other chemicals (e.g., pesticides) from entering the human food chain, withdrawal intervals (withdrawal times) have been established for many of the substances used in food-producing animals. The withdrawal interval is the time between administration of a known dose of a drug or chemical to an animal and the time that the animal’s meat, milk, or eggs are presumably safe for human consumption. The U.S. Food and Drug Administration (FDA) is the agency responsible for drug approval and for establishing withdrawal intervals for drugs approved for use in food animals, based on scientific evidence. Withdrawal intervals are printed on the labels of approved substances. Residue-contaminated meat or milk has significant economic and legal consequences for the farmer, and sometimes the farmer may see the veterinarian (and veterinary staff) as being responsible for contamination by failing to follow proper procedures or giving inaccurate advice.

Many drugs are not approved for use in food animals but may be desirable or necessary to use in certain situations. This is referred to as extralabel drug use. Withdrawal intervals are not printed on the labels of such drugs. In order to guide veterinarians on the extralabel use of drugs in food animal species, the Food Animal Residue Avoidance and Depletion Program (FARAD) is a convenient source of information. FARAD is the primary resource for recommendations for withdrawal times after extralabel drug use in food animals. It is a computer-based “decision support system” that provides current label information on withdrawal times of approved drugs, a database of scientific articles with data on drug residues and pharmacokinetics of nonapproved drugs, and official tolerances of drug and pesticide residues in meat, milk, and eggs. (FARAD may be contacted at or by phone at 1-888-USFARAD. FARAD is sponsored through the US Department of Agriculture [USDA]).

A form for recording client communications is important for documentation. All client communications should be summarized; the time, date, and method of communication recorded; and the form signed.

If euthanasia is to be performed, a euthanasia consent form should be included. If the owner/agent is not available to sign the euthanasia form, permission can be verbally obtained over the phone. Facsimile communication is another means for obtaining necessary signatures. Sometimes the need for euthanasia is not immediately known but becomes necessary later, with little notice. For example, the animal in an emergency situation may suddenly “crash and burn” and require immediate euthanasia to prevent suffering; the time delay involved in trying to contact the owner/agent may result in unnecessary suffering. In these cases, having the owner/agent sign a euthanasia consent form when the animal first arrives at the hospital allows the clinician to humanely euthanize the animal in a truly crisis situation, then contact the owner after dealing with the crisis.

The medical record can be kept on a clipboard or in a binder and placed on the patient’s stall door or kept in a central nursing station of the hospital. Patient confidentiality should be considered when choosing a location for the patient’s medical record. Procedures, medications, and diagnostic test results are not intended to be public information. If the hospital allows visitors, and most do, the reputation of a farm, ranch, horse, trainer, or stable may be jeopardized if this private information becomes public. The medical record should be in a form that allows it to travel around the hospital with the animal for its various procedures but be accessed only by hospital personnel.

Patient Identification

No matter what document you are filling out, each document should have a patient identification (ID) area on the form. Patient ID should be performed during the admissions process.

Proper patient ID is essential; surgery and even euthanasia have been performed on the wrong animal because of inadequate or inaccurate ID. It is important not only to record an animal’s markings in the medical record but to have some method of identifying the animal itself and the animal’s housing (e.g., stall, crate, or pen). It is common practice to place a card on the housing door or gate as a form of patient ID. The patient’s signalment is usually recorded on the card; again, be sensitive to issues of confidentiality when displaying this information. To identify a patient, patient ID tags can be made. (Small animal plastic ID collars are well suited for this use.) Form the ID tag or band into a circle, and tape or braid it to the animal’s mane, forelock, tail, pastern, or halter.

Patients are described by sex, breed, age, permanent or temporary ID, coat color, and markings. Descriptions in the patient signalment of color and natural markings may not be enough to distinguish an individual animal; for example, a description of a black Angus cow on a purebred Angus ranch would not be very informative considering almost all of the animals on this operation are black cows. Therefore, an effort must be made to identify each animal as specifically as possible.

Technicians should be familiar with the proper terms for the species being housed. A table of common terminology for each species can be found at the beginning of each species section. Slight variations in these terms may exist among different breeds, geographic locations, and common jargon.

Markings may be natural or artificial (manmade). Artificial ID can be temporary or permanent. Temporary artificial forms of ID include panel tags, electronic identification tags (EID), metal clips, collars, ankle bands, temporary marking paint, brisket tags, and tail tags. Common forms of permanent artificial ID include lip tattoos, freeze brands, hot brands, ear notching, and microchips. Natural markings include hair color, color patterns, scars, hair whorls, muscle indentations, and chestnuts. Natural markings should be defined for all large animals, but they are often defined more extensively in horses. Colors are kept fairly simple for other livestock considering most animals of the same breed look almost exactly the same.

Panel Tags

Panel tags are commonly used as a form of ID in cattle, swine, sheep, and goats. The tags can be placed in the middle third of the ear and worn like an earring (Fig. 5-9). Individual producers use a variety of tag colors, sizes, and number/letter systems to identify each individual animal. No set numbering or lettering system is used in any species of livestock, so technicians should not assume that the way one producer uses a tag is the same way every other producer uses the tags. These tags can easily be removed if the animal is sold, and the animal can be retagged with a tag relevant to the new producer’s system (Fig. 5-10). Panel tags can easily be ripped out or removed, making it a temporary form of ID.

Electronic Identification Tags

Electronic ID tags are becoming more popular. The USDA is implementing the National Animal Identification System. This system will help animal health officials more effectively track animals during a disease outbreak and quickly find other animals that may be infected. The system will be put into place in three phases. The first phase is premises registration. The USDA is asking producers to register their farms and ranches as locations where livestock are raised. The second phase is animal identification. The electronic ID tags are placed in all livestock and stay with the animal until death (Fig. 5-11). The third stage of the system is an animal tracking database where information about the livestock will be stored. The system is in the beginning of implementation and is not fully underway.

Dairy producers have in place a system known as the National Farm Identification and Records System. It is a voluntary system for maintaining records within the dairy industry. Some producers are using it as a means of gathering better information about their herds.

Metal Clips

Metal clips are commonly used in cattle as a more secure form of ID. They are less likely to be ripped out than panel tags but are not as easy to read from a distance (Fig. 5-12). In order to read metal clips, the cattle must be restrained. These metal clips are also placed in heifers that have been vaccinated for brucellosis. Other livestock such as sheep and goats may also be identified using metal clips.


Collars are commonly used in goats and dairy cattle (Fig. 5-13). Some collars carry an electronic device that allows automated equipment to identify the individual animal, record milking yields, or control the animal’s diet (Fig. 5-14).

Ankle Bands

Ankle bands are commonly used in dairy cattle (Fig. 5-15). They can be numbered, but most often a color is used to signify a group or a problem with the animal.

Hot Brands and Freeze Brands

Brands may be required by certain breed registries. Some producers have their own brands for ID of animals that belong to their farm or ranch. Often registries mandate the type, configuration, and location of the brand. However, any owner can brand an animal with a symbol of his or her choice wherever he or she prefers. Brands are usually placed on the side of the neck, over the triceps muscle on the forelimb, or on the hip/thigh area of the hindlimb. The two types of branding are freeze branding and hot branding (Fig. 5-20). Freeze branding destroys the hair pigment, which is derived from cells called melanocytes. Freeze branding uses branding irons dipped in liquid nitrogen. The iron is applied for a predetermined time necessary to kill the melanocytes but spares the follicle cells that grow the hair (Fig. 5-21). The hair eventually grows back white (no pigment) in several months (Fig. 5-22). Gray horses can be freeze branded, but the iron is applied longer to kill not only melanocytes but also the hair follicles so that hair does not regrow. The result is a bald brand. In horses, freeze brands can be placed high along the crest of the neck and may be obscured by the mane. Be sure to look beneath the mane for freeze brands and other markings. Hot branding is considered by some to be more painful than freeze branding, which numbs the nerves within seconds of application of the freeze branding iron. However, many people who have performed hot brand procedures maintain that the discomfort of the animal is minimal during the procedure and is comparable to that produced by freeze branding. The goal of hot branding is to kill the hair follicles, producing a hairless scar.


Microchips can be placed in any large animal, but because of the cost associated with microchipping the only species in which they are commonly used is the horse. Microchips can be inserted subcutaneously in horses and are usually placed in the neck area (Fig. 5-23). Microchips are encoded for the individual horse and require a special sensor to scan the horse and read the ID code. This form of ID is gaining popularity in the horse world. In ruminants you may see use of rumen boluses that contain a microchip as a form of ID.


Markings should be recorded for all livestock; however, markings are most useful in the horse. The six “markings” on domestic animals are the four legs, the head, and the tail. Markings are usually white and are described as such. In particular, white markings are the most distinguishing (Fig. 5-24A and B). Leg and face markings are often described subjectively; for example, what one person calls a “full sock” is a “low stocking” to another, and this may be problematic. There is no standard level at which a sock becomes a stocking, a coronet becomes a pastern, and so on. Similar confusion exists with facial markings (i.e., no standard landmarks for strictly defining strips, stripes, and blazes). To minimize confusion, it is preferable to either use a diagram to draw and label the markings (Fig. 5-25) or use a camera to photograph the animal for definitive ID. Drawings should be as accurate as possible; for example, stars are not always in a perfect diamond shape, although they are often drawn that way. Stars are usually irregular in shape; in addition, they may be located above, at, or below eye level. These details are important. Facial markings are often continuous; for example, a star may be continuous with a strip or stripe. When describing continuous facial markings, use a dash between the markings (e.g., star–strip, star–strip–snip). Photographs are especially useful for breeds with complicated coat patterns, such as Paint Horses, Appaloosas, and Pintos, which are difficult to draw accurately. A lack of markings on a leg or face is also be recorded for accuracy and to prevent fraudulent altering of medical records. Clearly indicate which body part lacks the markings and write “none” (e.g., left forelimb—none). Within a clinic it can be beneficial to communicate a standard description for each marking. Box 5-1 lists standard marking descriptions.

Coat Color

Coat color should be identified as a form of ID for every animal. In most livestock species the colors are relatively simple, for example, red or black. However, with horses the color may not be straightforward. With more than 400 breeds of horses, there is no standard universal definition for coat color.

Coat color should always be recorded, although it is not a highly individual feature (Fig. 5-26). Coat colors are not often distinguishing, especially among several breeds with little variation in coat color (e.g., most Standardbreds are bay). Each horse breed registry defines its own acceptable and unacceptable coat colors and patterns, and these definitions may not be in agreement with other breeds. Foals present another challenge because a foal’s coat color may be a different color from its eventual adult coat. The best example of this is the gray coat color; these horses usually are born black and lighten to gray with age, eventually progressing to what appears to be pure white. For purposes of patient ID, record the coat color at the time of admission, not the anticipated adult color.

The following is a generalized overview of color. It may not work for every breed association and is not a complete list of colors.

Hair Whorls

Hair whorls are often used as a form of ID in horses. All horses have hair whorls (also known as swirls or cowlicks), which can be used for ID purposes (Fig. 5-37). Certain whorl locations are common to all horses, so whorls at these locations are not considered distinguishing features of an individual. Whorls on the flanks and over the trachea are common to all horses and seldom are helpful in definitive ID. However, some whorls occur at locations that are useful for ID. All horses have at least one whorl on the forehead between the eyes, but the whorl may be located above, below, or at the level of the eyes. The whorl may be right or left of midline and some horses may have two or even three whorls in this area. When properly recorded, the forehead whorls are useful. The other areas to check for distinguishing whorls are along the crest of the neck and along the jugular grooves. Do not assume that if there is a whorl on one side of the horse there will be a corresponding whorl on the other side. The standard written symbol for whorls is a simple “X” recorded on the horse’s diagram or photo.


Chestnuts occur on the medial aspect of all limbs (Fig. 5-39). Chestnuts are the evolutionary remnants of the digital pad of the first digit. They are small (1–3 cm), ovoid raised areas of cornified tissue proximal to the carpus on the forelimbs and at the level of the tarsus on the hindlimbs. They are seldom useful for ID purposes.

History and Basic Physical Examination of Horses

The history and physical examination are the most important part of the animal’s record and serve as the starting point for identifying the patient’s problems. “Problems” are any conditions that require medical or surgical treatment or that compromise the quality of life. Most clinicians use a problem-oriented approach to diagnosis and treatment; this provides a logical method to work through any medical or surgical case. A thorough history and a complete physical examination are essential for successful problem solving.


The physical examination process always begins with taking the history and inspecting the animal’s environment. Because large animals are usually kept in herd situations, conditions affecting one animal may have consequences for the others on the farm. The history should focus not only on the individual but also on the management of the entire group. Food and water sources, pasture management, herd health programs, introduction of new animals, feeding practices, toxin exposure, and environmental stresses are among the factors that should be explored. Many owners attempt treatment of animals before they call the veterinarian, and they should be asked about any treatments and/or medications that the patient was given. This is fairly common in large animal practice, especially with production animals; economics often dictate whether the owner calls the veterinarian immediately or attempts to solve the problem independently. Owners may be reluctant to admit this information and may need to be asked specifically whether they have treated the animal and what they may have attempted for treatment.

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Aug 11, 2016 | Posted by in INTERNAL MEDICINE | Comments Off on Admissions, Medical Records, and Physical Examinations for Large Animals

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