FARAH
Faculté de Médecine Vétérinaire
Université de Liège
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Declare a case – Owner
Declare a case – Veterinarian
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Declare a case – Veterinarian
Declare a case – Veterinarian
A supprimer
2015-09-11T11:20:34+00:00
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This form is for veterinarians. If you own a horse, there is a
specific form
to report a case.
VETERINARIAN
Fields marked with a * are required
Last name
*
First name
*
Office adress
*
Country
*
Email
*
Phone
Structure
*
Veterinary office
Veterinary clinic
University
Other
Please specify the structure
1. EQUIDAE OWNER
1.1. Last name
1.2. First Name
1.3. Would you mind us to get in touch with them in order to collect epidemiological information ?
Yes, you can
No, you cannot contact the owner
1.4. Adress of the owner
1.5. E-mail of the owner
1.6. Phone of the owner
2. EQUIDAE IDENTIFICATION
2.1 Name of the horse
2.2 Age (specify whether it is months or years) or date of birth
Age or date of birth
2.3 Sex
*
Male
Gelding
Female
2.4. Type
*
Horse
Draught-horse
Pony
Donkey
Zebra
2.5. Breed
2.6. State of stoutness
Cachectic
Thin
Normal weight
Fat
Overweight
3. History
3.1. Has the horse access to pasture?
*
Yes
No
3.2. Postcode of the address of the pasture (or GPS coordinates):
To your knowledge, would the horse have had the possibility to ingest:
3.3. - For Fall: samaras ("Helicopter") from maple trees? :
Yes
No
Do not know
3.4. - For spring: seedlings of maple tree?
Yes
No
Do not know
3.5 - 3.10 Thank you to supplement the information in brackets below
Total number of horses at pasture [ _ ] How many presented abnormal clinical signs: [ _ ] ; how many healthy [ _ ] and how many dead: [ _ ] Current date: [ _ ]
3.11. Has the horse performed any exercise or effort within 48h prior to clinical signs?
Yes
No
3.11.1. Describe:
3.12. Date of the first signs
*
3.13. Time of the first signs
00:00
00:30
01:00
01:30
02:00
02:30
03:00
03:30
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04:30
05:00
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23:00
23:30
Le plus précisément possible
3.14. At the present time, the horse is :
*
Deceased
Survivor
Alive but still sick
I don’t know
3.15. Cause of death
Euthanasia
Natural
3.16. Date of death
3.17. Hour of death
00:00
00:30
01:00
01:30
02:00
02:30
03:00
03:30
04:00
04:30
05:00
05:30
06:00
06:30
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23:00
23:30
3.18. If the horse is alive but currently ill, do you think that the horse will:
Survive
Die
I do not know
4. CLINICAL EXAM
Did you perform a clinical exam of the horse?
*
Yes
No
4.1. Date of the exam
Le plus précisément possible
4.2. Time of the exam
00:00
00:30
01:00
01:30
02:00
02:30
03:00
03:30
04:00
04:30
05:00
05:30
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21:00
21:30
22:00
22:30
23:00
23:30
4.3. Rectal temperature (°C)
4.4. Rectal temperature
Hypothermia (below 37°C)
Normal (37 - 38.5°C)
Hyperthermia (above 38.5°C)
Cardiac system
4.5. Heart rate (beats/Min) :
4.6.
Normal (< 45)
Tachycardia (≥ 45)
4.7. Cardio rythm
Regular
Arrythmia
4.8. Cardio sounds
Normal
Murmur
4.9. Mucous membranes
Normal
Congested
Cyanosed
Ictéric
Respiratory system
4.10. Respiratory rate (Resp./min)
4.11. Respiratory rate
Normal (< 15)
Increased (≥ 15)
4.12. Type of respiration:
Normal
Dyspnoea
DIGESTIVE SYSTEM
4.13. Passed faeces?
Yes
No
4.14. Signs of colic
Yes
No
4.15. Abdominal auscultation (digestive sounds):
Absent
Diminished
Normal
Increased
4.16. Have you passed a naso gastric tube?
Yes
No
4.16.1. If yes did you get any reflux?
Yes
No
4.17. Have you performed a rectal examination?
Yes
No
4.17.1. If yes, did you find: a distended bladder
Yes
No
4.17.2. - any other abnormal findings?
Yes
No
Describe
5. SPECIAL SIGNS (reinforce the suspicion of atypical myopathy and contribute to prognosis):
(reinforce the suspicion of atypical myopathy and contribute to prognosis)
5.1. Weakness
Yes
No
5.2. Stiffness
Yes
No
5.3. Trembling/fasciculation
Yes
No
5.4. Perspiration
Yes
No
5.5. Does/did the horse remain standing up most of the time?
Yes
No, recumbent
5.6. Brown urine
*
Yes
No
Don't know
5.7. Anorexia
Yes
No
5.8. Does/did the horse try to eat
Yes
No
Don’t know
5.9. Dysphagia
Yes
No
5.10. Oesophageal obstruction
Yes
No
Don’t know
5.11. Œdema
Yes
No
5.11.1. Where is the Œdema
5.12. How do you evaluate the suffering of the horse (for example in comparison with the pain induced by colic of the digestive tract)?
No pain
Slight
Medium
Severe
6. LABORATORY TEST
6.1. Blood samples taken:
Yes
No
6.1.1. If so, name of the LABORATORY:
6.2. Can we contact the laboratory to have a copy of the results and / or collect samples for research?
Yes
No
Results of blood samples analysis
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6.3. First measured creatine kinase (CK) serum activities CK (ref. : 50 – 200 UI/L) :
UI/L
6.4. Determination of acylcarnitines profile (NB: determining this profile contributes to confirm or disproof atypical myopathy)
Yes
No
6.4.1. If yes, is the diagnosis confirmed?
Yes
No
Do not know
7. TREATMENTS
7.1. Treatments done?
Yes
No
7.1.1. Kind of treatments
Fluid therapy
Perfusion of glucose
Electrolytes
Diuretics
Vitamins and antioxidants
Diurétiques
Non-steroidal anti-inflammatories
Corticoides
Antibiotic
Active charcoal
Paraffin
Muscle relaxants
Nutritional support
Others
7.1.1.1 Please specify the nutritional support
7.1.1.2. Please specify the treatment
8. NECROPSY
8.1. If the horse has deceased, has a post-mortem examination been performed?
Yes
No
8.1.1. If yes, where?
On site
Other
8.1.1.1. Please specify the place of the examination
8.1.2. Based on the autopsy, the diagnosis is?
Confirmed
Invalidated
Doubtful
Awaiting the results
8.1.3. Do you allow us to contact the institution where the autopsy was performed to receive a copy of the results and / or retrieve samples for research?
Yes
No
9. MISCELLANEOUS
9.1. Were there any other clinical signs present that are not mentioned above?
Yes
No
9.1.1. please describe:
9.2. Results of any other complementary examination/test:
Thank you very much for your collaboration
