Physical Examination Record
Preparation for the initial contact time with the client and patient should begin with a system of record keeping. Ambulatory records are usually more flexible than “in-house” hospital admission forms.
Both field and clinic forms should include designated spaces for the client or agent’s address and phone number. An area for the complete signalment (name, sex, breed, color, age, reproductive status), including an estimated weight, should be provided. If the patient is unnamed, as with foals, it should be listed in the dam’s name with the year of birth (e.g., Curious ’06). The sire’s name should not be used because more than one foal per year would be expected from a stallion’s crop. Whenever surrogate mares produce multiple foals from a single embryo transfer dam, a new system of naming and identification will have to be incorporated. Additional identification of the patient may include a lip tattoo, freeze brand, or microchip number and, if available, should be noted in the horse’s record. Thoroughbred racehorses are tattooed under the lip with a letter, denoting the year foaled, followed by four or five numbers. Thoroughbreds foaled in 1997 have “A” as the first character in their tattoo, followed by those foaled in 1998 with a “B” as the first letter, and so on. Once the end of the alphabet is reached, the process is repeated. Numbering and lettering schemes used for lip tattoos and freeze marks vary, depending on breed registry, so one should consider breed or discipline carefully when using the number for aging or identification purposes. As of 2013, horses competing in U.S. Equestrian Federation (USEF)-sanctioned events for the first time are required to have microchips as part of their passport identification. ISO 11784- and ISO 11785-compliant microchips (resQ, Bayer Healthcare, LLC, Shawnee Mission, Kan; HomeAgain, Merck Animal Health USA, Madison, NJ.), the same as those required by the U.S. Department of Agriculture’s voluntary Animal Disease Traceability program (previously the National Animal Identification System), must be used.1 Microchips should be located on the near side of the horse, in the nuchal ligament, approximately 3 to 4 cm below the crest, in the middle third of the neck.
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