Case Log Examples Large Animal Internal Medicine Case Log #1

Case Log Examples Large Animal Internal Medicine
Case Log #1
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Thoroughbred
Age: 3 months
Sex: female
Weight in kg: 189kg
Diagnosis: Lawsonia (PCR Positive)
Advanced Skills & Procedures I performed: plasma transfusion, implement isolation
protocol, full physical exam
Advanced Skills & Procedures I assisted: ultrasound imaging and measurement of
intestinal tract wall
Outcome: discharged
Case Log #2
Date: 00/00/0000
Patient ID XXX
Species/Breed: Camelid/alpaca
Age: 20 years
Sex: female
Weight in kg: Unavailable
Diagnosis: Neoplasia
Advanced Skills & Procedures I performed: drug/fluid calculation and
preparation/administration (oxytetracycline, thiamine, dexamethasone, diazepam,
etc.)
Advanced Skills & Procedures I assisted: Neurologic exam, lumbo-sacral spinal tap
Outcome: Euthanized
Case Log #3
Date: 00/00/0000
Patient ID XXX
Species/Breed: Bovine/Holstein
Age: 6 years
Sex: female
Weight in kg: Unavailable
Diagnosis: Lymphoma
Advanced Skills & Procedures I performed: passed Kingman tube and refluxed
rumen contents (40 gallons), provided nursing care to downer animal, pain
assessment and management, physical exam
Advanced Skills & Procedures I assisted: placement and management of downer
cow in sling
Outcome: Euthanized
Case Log #4
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Saddlebred
Age: 7 years
Sex: castrated male
Weight in kg: 430kg
Diagnosis: Pleural pneumonia
Advanced Skills & Procedures I performed: full physical exam, sample collection and
handling for cytology evaluation
Advanced Skills & Procedures I assisted: thoracic radiographs, transtracheal wash,
trocar chest tube placement
Outcome: Euthanized
Case Log #5
Date: 00/00/0000
Patient ID XXX
Species/Breed: Camelid/camel
Age: 1 day
Sex: male
Weight in kg: Unavailable
Diagnosis: Failure of passive transfer
Advanced Skills & Procedures I performed: plasma transfusion, administered
feedings via nasogastric tube, reverse isolation protocols, physical exam, restraint
Advanced Skills & Procedures I assisted: placement of nasogastric feeding tube
Outcome: discharged
Case Log Examples Equine Internal Medicine
Case Log #1
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Clydesdale
Age: 6 years
Sex: Female
Weight in kg: 845kg
Diagnosis: Retained placenta
Advanced Skills & Procedures I performed: oxytocin infusion preparation and
administration, full physical exam
Advanced Skills & Procedures I assisted: intrauterine flushing
Outcome: discharged
Case Log #2
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Clydesdale
Age: 8 years
Sex: Female
Weight in kg: 783kg
Diagnosis: Fever and colic of unknown origin
Advanced Skills & Procedures I performed: cephalic catheter placement and
monitoring for thrombophlebitis and abortion, full physical exam, pain assessment
Advanced Skills & Procedures I assisted: complete ultrasound
Outcome: discharged
Case Log #3
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Fresian
Age: 10 years
Sex: female
Weight in kg: 614kg
Diagnosis: Suspect Equine Protozoal Myeloencephalitis (based on positive Western
Blot and physical exam
Advanced Skills & Procedures I performed: long-term over-the-wire jugular catheter
placement, DMSO preparation and administration, physical exam
Advanced Skills & Procedures I assisted: neurologic exam
Outcome: discharged
Case Log #4
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Quarterhorse
Age: 6 years
Sex: female
Weight in kg: 450kg
Diagnosis: Equine Herpes Virus
Advanced Skills & Procedures I performed: prepared and administered DMSO and
thiamine infusions, performed full physical exam, management of patient in sling,
collected and handled CSF for analysis/cytology
Advanced Skills & Procedures I assisted: removal of down anesthetized horse from
trailer, atlanto-occipital spinal tap, placement in sling, urinary catheterization
Outcome: discharged
Case Log #5
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Quarterhorse
Age: 5 years
Sex: male
Weight in kg: 448kg
Diagnosis: Pleural pneumonia
Advanced Skills & Procedures I performed: setup and administration of oxygen via
nasal cannula, maintenance of indwelling chest tube drains, proper collection and
handling of fluid samples for cytology evaluation, arterial blood gas collection and
analysis, physical exam
Advanced Skills & Procedures I assisted: thoracic ultrasound, thoracic
trocharization, abdominocentesis
Outcome: discharged
Case Log #6
Date: 00/00/0000
Patient ID XXX
Species/Breed: Equine/Belgian
Age: 3 days
Sex: female
Weight in kg: 60kg
Diagnosis: Sepsis, neonatal maladjustment syndrome
Advanced Skills & Procedures I performed: cleaned and bandaged wounds on
extremities, fluorescein stain eyes, plasma transfusion, calculated and prepared
antibiotics pantoprazole, magnesium sulfate CRI, thiamine CRI, 20% dextrose CRI,
setup and maintained foal on multiple fluid lines, feedings via nasogastric tube,
implemented reverse isolation protocols, restraint, physical exam
Advanced Skills & Procedures I assisted: nasogastric feeding tube placement,
arterial blood gas
Outcome: Euthanized
Case Log Examples Production Animal Internal Medicine
Case Log #1
Date: 00/00/0000
Patient ID XXX
Species/Breed: Camelid/alpaca
Age: 3 weeks
Sex: female
Weight in kg: Unavailable
Diagnosis: Failure of passive transfer, septicemia, cryptosporidium infection
Advanced Skills & Procedures I performed: long-term over-the-wire jugular catheter
placement, plasma transfusion, venous blood gas, neonatal reverse isolation
protocol, neonatal restraint and physical exam
Advanced Skills & Procedures I assisted: complete ultrasound
Outcome: Discharged
Case Log #2
Date: 00/00/0000
Patient ID XXX
Species/Breed: Bovine/Holstein
Age: 7 years
Sex: female
Weight in kg: 750kg
Diagnosis: Hardware disease, reticular abscess, peritonitis
Advanced Skills & Procedures I performed: full physical exam, pain assessment and
management
Advanced Skills & Procedures I assisted: ultrasound exam of thorax, instructed
student placement of long-term over-the-wire jugular catheter
Outcome: Discharged
Case Log #3
Date: 00/00/0000
Patient ID XXX
Species/Breed: Bovine/Holstein
Age: 3 years
Sex: female
Weight in kg: 568kg
Diagnosis: Outflow obstruction due to Hemorrhagic Bowel Syndrome
Advanced Skills & Procedures I performed: obtained and handled samples for milk
culture and cytology, administered magnesium sulfate and fresh cow drench via
orogastric tube, full physical exam
Advanced Skills & Procedures I assisted: complete ultrasound, abdominocentesis
Outcome: Discharged
Case Log #4
Date: 00/00/0000
Patient ID XXX
Species/Breed: Bovine/Polled Hereford
Age: 5 months
Sex: male
Weight in kg: 216kg
Diagnosis: Pulmonary hypertension
Advanced Skills & Procedures I performed: collected and processed samples for
cytology
Advanced Skills & Procedures I assisted: radiographs of thorax, complete
ultrasound, cardiac ultrasound, abdominocentesis
Outcome: Euthanized
Case Log #5
Date: 00/00/0000
Patient ID XXX
Species/Breed: Bovine/Holstein
Age: 4 years
Sex: female
Weight in kg: 695kg
Diagnosis: Lumpy jaw due to Actinomyces bovis
Advanced Skills & Procedures I performed: collection and handling of tissue samples
Advanced Skills & Procedures I assisted: radiographs of mandible, tissue biopsy
Outcome: Discharged
Case Log #6
Date: 00/00/0000
Patient ID XXX
Species/Breed: Camelid/Llama
Age: 22 years
Sex: female
Weight in kg: 182kg
Diagnosis: Hypoproteinemia of undetermined etiology
Advanced Skills & Procedures I performed: physical exam
Advanced Skills & Procedures I assisted: transport and positioning of downer
animal in sling, complete ultrasound
Outcome: Euthanized