Polio Ence PH Loma Laci A

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CASE RECORDING

VETERINARY HOSPITAL CASE RECORDING PERFORMA

20231114/SACS/16
O.P.D No./I.P. No.:__________________ Dated:__________________
14-NOV-2023 Owner’s
name:__________________________
Arshad Iqbal
Address:______________________________________________________
Shahdara

Damani
Ovine(Sheep) Breed:____________
Animal specie:__________ Sex:______
Male

Color/Identification:___________________________________
White color with no distinct markings Weight:_________
58 Kg

Temperature:__________________
103.8 F

85 bpm 17 rpm
Pulse rate:__________________ Respiration rate:__________________
Body condition : Emaciated/ Thin/ Normal/ Overweight

General Attitude : Normal/ Depressed/ Comatose/ Convulsive/ Recumbent

Body Shape : Normal/ Arched/ Gaunt/ Pear/ Sway back

Gait : Normal/ Lame/ Stiff/ Paresis/ Paralysis/ Sole abscess/ Fracture/ Injury/ Foot Rot/ Digital cyst/ Other

Hydration : Normal/ Mild dehydration/ moderate dehydration/severe dehydration

Skin : Normal/ Ring worm/ Dermatitis/ Ectoparasites/ other

Cranial Nerve : Normal/ Head Tilt/ Nystagmus/ Facial paralysis/ weak jaw/ Dropped tongue/ Star gazing

Conjuctiva : Pink/ White/ Congested/ Hyperemic/ Yellow/ Bluish/ Other:________________________

Sclera : Normal/ Pale/ Icterus/ Congested

Ears : Warm/ Cold/ Otitis/ Smell/ Itching/ Hematoma

Eye : Normal/ Conjunctivitis/ Uveitis/ Blindness/ Tearing/ Keratitis/ Miosis/Mydriasis/other

Nose : Normal/ Dirty/ Moist/ Scaly/ Serous discharges/Mucoid discharges/ Bloody Discharges/Others

Mouth : Normal/Excess salivation/ Ulcer/Erosion/ Vesicles/ pale mucosa/Bluish Mucosa/ Yellowish mucosa

Tongue : Normal/ Ulcer/ Erosion/ White coating/ Vesicles/ Hard/ Pale/Bluish/Yellow Lymph nodes

: Normal/ Enlarged

Jugular Vein : Normal/ Distended/ Pulsation/ Phlebitis

Mammary Vein : Normal/ Distended/ Pulsation

Bottle jaw : Present/ Absent

Brisket edema : Present/ Absent

Dyspnea : Absent/ Mild/ Moderate/ Severe

Cough : Absent/ Mild/ Occasional/ Paroxysms/ Marked


Breath : Normal/ Foul/ Sweet

Breathing Sound : Normal/ Expiratory grunt/ Adventitious sound

Percussion of chest : Normal/ Dull/ Other

Rumen motility : Normal/ More/ Less

Rumen contents : Gas/ Fluid/ Doughy/ Empty/ Impacted/ pH change

Xiphoid pain : Negative/ Equivocal/ Post grunt

Feces : Normal/ Wary/ Hard/ Bloody/ black/Mucoid/ Fibrin/ Parasites/ Other

Rectal exam : None/ Abnormalities:____________________________________

Anal gland (dog) : Normal/ Impacted

Urine : Normal looking/ Colored/ Bloody/ Ketone +ve / Ketone –ve/

Glucose +ve/ Glucose –ve/ pH/ Other:__________________

Uterus : Normal/ Non Pregnant/ preg 1/ preg2/ preg3/ preg 4/ preg 5/ preg6/ Preg 7/ preg 8

/preg 9/ Retained placenta/ Pyometra / Metritis/ Prolapse/ Other:__________________


Nill
Other Abnormalities :______________________________________________________
Polioencephalomalacia (PEM), a neurological disorder in sheep often associated with thiamine (Vitamin B1)
Tentative Diagnosis :______________________________________________________
deficiency, presenting symptoms similar to White Muscle Disease but with neurological manifestations.

Laboratory Examination :______________________________________________________

Stool:_____________________________________
Thiamine levels
Blood:____________________________________

Urine:____________________________________

Milk:____________________________________

Sputum/Nasal Discharge:____________________________________

Exudate:____________________________________

Skin Scrapings:_______________________________
Cerebrospinal Fluid (CSF) Analysis: To assess neurological changes
Others:____________________________________
Polioencephalomalacia (PEM) due to thiamine deficiency,
leading to neurological symptoms and muscular stiffness.
Confirmatory Diagnosis :___________________________________ Prognosis:__________
Favorable with prompt treatment.

Administer thiamine injections (dosage: as per veterinary recommendation) , Ensure adequate intake of thiamine-
Treatment : ___________________________________________________________
rich feed or supplements , Provide supportive therapy for neurological symptoms, if severe

Signature of Clinician Minahil


: _______________

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