Equine

History: signalment, management, onset, treatment attempts

Clinical exam: general TPR, head to tail, all body systems

Dermatological examination: skin (ears, lips prepuce, vulva, feet), record nature and distributions, extent and severity of lesions, pruritus or pain, sate of coat

Equipment for derm examination: sellotape, scissors, microscopy slides, paraffin oil and pipette, scalpel blades, artery forceps, denture toothbrush, petri dish, LA, biopsy punch, microbiological swabs, sampling pots

Itch: lice, winter coats

Signs: self-inflected trauma, hair loss, moth eaten appearence, lice visible with magnifying glass

Treatment: Cyrpemethrin spray or Piperonyl butoxide bathe

Allergic skin disease: insect bite hypersensitivity

Signs: pruritus, signs worsen with age, no predisposition

Diag: signs + seasonality, brushing to eliminate other arthropods, response to management, skin biopsyu reveals eosinophilic infiltrate

Management: Barrier (Boett rug and stabling) and Washing (sooth and repair skin barrier)

Treatment: Benzyl benzoate and premethrin pour on, Antiinflam (hydrocortisone)

Urticaria: multiple causes (hypersensitivity, bites, infections, cold induced, cholinergic etc.)

Signs: multiple raised oedematous plaques, usually non pruritic

Differential: dermatophyte (fungal PCR to rule out), insect bites (clip to examine site), erythema multiforme

Diag: clinical recognition, biopsy possible if no response to treatment

Treat: Dexamethasone IV one off dose if warranted, otherwise clears without intervention

Pastern dermatitis: Mud fever

Signs: non-pigmented skin, oedema, scaling/exudation, pain on palpation, lameness

Diag: history, recognition, if unclear; bacterial swab/hair brush/skin scrape/biopsy

Management: keep skin clean, clip feathers, keep covered if photosensitisation, bathe with disinfectant, rinse, dry

Medical: antifungal (lime sulphur), bacterial (silver sulphadiazine), topical steroids, antibiotics (culture and sensitivity based).

Signs: raised HR/RR, bilateral forelimb lameness, leaning back on heals, digital pulses, increased hoof temperature, pain on hoof tester

NSAID: Phenylbutazone IV or PO

Adjunt: paracetamol (not licensed)

If insufficient: butorphanol 

Radiographs

Farriery

Deep digital flexor tendon tenotomy salvage procedure

Digit

Abscess: FB, sequestrum, keratoma, laminits, quittor

Foreign body: radiograph, debride and follow draining tract

Sequestrum: radiograph, surgical debride

Keratoma: onion like appearence, radiograph, surgical removal under GA, prognosis is good

Quittor: necrosis of collateral cartilage, non healing wound with a draining tract above the coronary band, contrast material radigraph, treated with surgical debridement and antibiotic therapy

White line disease: seperation of the sole from hoof wall, lameness and hoofwall crumbling seen, diagnosis by appearence and radiography, treatment by debriding and stabilising the foof

Canker: hypertrophy of the dermis horn, vegatitive moist white mass, treated with surgical debridement and topical metronidazole

Foot

Lameness improved by: palmar digital nerve block, abaxial sesamoid nerve block, DPJ block, navicular bursa

Approach: clinical exam, static and dynamic foot balance, diagnostic test (hoof testers, distal limb flexion, diagnostic analgesia), diagnostic imaging (radiography, ultrasound, scintigraphy, MRI)

Dorsopalmar and lateromedial imbalance radiographs: shoes on, feet flat, weight bearing on block

Navicular syndrome: middle aged horse, bilateral shortened stride, worse on hard, intermittent, insidious

Contributing: upright conformation and poor footbalance

Aetiology: biomechanical forces, repetitive trauma, movement of the DDFT and navicular bone, bone remodelling due to load

Path: alteration of palmar fibrocartilage, increase force on subchondral bone, adhesion of navicular fibrocartilage to DDFT

Radiography: synovial fossae, cyst fromation, enthesiophytes, osteophytes, flexor cortex abnormalities, medullary abnormalities

Treat: Farriery, NSAID/corticosteroids, stem cells, bisphosphonates

Salvage: palmar digital neurectomy

DDFT tear:

Unilateral forelimb lame, acute

Abaxial sesamoid nerve block positive

Do MRI

Impar ligament desmitis:

Same as DDFT

Articular pain

OA:

DIP and PIP

Present: mild lame, bilateral, progressive

Diagnostic analgesia of articular structure

Imaging: radiographic abnormalities

DIP joint collateral ligament

Worse on circle

Variable blocking pattern

MRI

Cranial nerves:

The eye for (2,3,4,5,6,7)

Head posture, nystagmus, gait (8)

Swallow and tongoue (9,10,11,12)

Cerebrum: depression/coma/seizure/circling/blind, mild ataxia, no CN involvement

Brain Stem: depression/circling/headtilt, ataxia/weak/quadruperesis, CN involved

Cerebellum: intention tremor/menace, dysmetria/spasticity, no CN involve

Spinal cord UMN: Typically CVM

Loss of proprioception, paresis or motor weakness, los of sensation

Gait and posture assess: ataxia, weak, reflexia, atrophy with LMN deficit

UMN: Spinal cord and brainstem, Increased muscle tone, Increased reflexes, No atrophy, Variable weakness and sensory loss

LMN: Spinal cord grey matter and peripheral nerves, Decreased muscle tone, Decreased reflexes, Muscle atrophy, Sensory loss

Ataxia/proprioceptive: co-ordination, swaying, excessive limb movement, weaving, abduction/adduction, crossing of limbs; exaggerated by tight circles, raising head

Weakness: hoof wear, tail pull (rest = LMN, dynamic = UMN)

Weak and no ataxia: neuromucular (EMND)

Localised weak: peripheral or LMN

Weak and ataxia: UMN

Conditions: Spinal trauma, CVM (CT +- contrast), EHV-1 (NP swab PCR), EMND (vit E, tail bipsy of tail head), C. botulinum, C. tetani (vaccine?)

Acute: 

Signs: dull, tachycardia, saliva drool, colic, muscle tremors, SI distenstion and nasogastric reflux, dehydration, pyrexia

Bilateral ptosis, dry scant faces covered in mucous 

Small intestine distension

Dry faeces coated with inspissated mucus and epithelaial debris

Phenylephrine test: false positives= sedation, botulism; false negatives = excitement

DDx = other colic, oesophageal choke, botulism, haemabdomen, hypocalcaemia, EMND

Diagnosis based on clinical signs

Improved accuracy: monitor profress if welfare permits (provide gastric reflux, analgesia, IVFT), don't monitor if colic

Exploratory laprotomy: rule out surgical disorders, economic and welfare considerations

Microscopic ileal biopsy: time delay and resources but highly sensitive and specific if formalin fixed

Chronic

Signs: marked weightloss, dysphagia, rhinitis sicca, diffuse weak, low head carry, muscle tremor, elephant on a ball

Medical treat: nursing, NSAID, Ompeprazole, antibiotics (aspiration pneumonia, severe rhinitis sicca, diarrhoea (metronidazole)), appetite stims, fluids

Manage co grazing: house all co-grazing for 2-4 weeks (if not possible then house high risk or move to another pasture), manually collect faeces, avoid ivermectin, supplement forage.

AKI/ARF

Signs: oliguric can present with colic, uraemia causes anorexia and depression, obstructive renal failure or rupture lead to stranguria/abdo distension/colic, acute septic nephritis 

Diagnostics: history + clinical signs, azotaemia (urea and creatinine/SDMA), isothenuria, hypochloraemia and hyponatraemia, potassium variable, reduced dietary intake

Potassium high when acute renal failure, prerenal azotaemia, obstructive nephropathy and uroabdomen

Prerenal hyperkalaemia will resolve quickly following fluid therapy.

If potassium dangerously high then adminsiter glucose/insulin

High magnesium with renal or prerenal azotaemia

Calcium typically increased in chronic renal failure

US typically unremarkable unless obstruction in AKI/ARF

Urinalysis: protein urea if glomerulopathy

Pre renal vs renal: USG, if azotaemia + raised USG then likely pre-renal

Treatment:

Fluid therapy: 1st line, crystalloids (gold standard in polyuric), monitor for a large urination volume to assume intravascular volume restored.

If no urine or little urine after fluid -> inspect bladder to exclude obstruction. Fluid therapy no longer gold standard, overhydration, STOP and try a single dose of furosemide. May need vasopressors

Irreversible, chronic, disease of kidneys (longer than 3 months)

Less common

Signs: weight loss, PUPD, peripheral oedema, dull hair, poor performance, poor appetite, oral changes, changes in mentation

Diagnosis:

Azotaemia + Hypercalcaemia

Mild anaemia, hypoalbuminaemia

Urinalysis: renal casts and tubular epithelial cells, erythrocytes and leucocytes, neoplastic cells, proteinuria = glomerulonephritis

Ultrasound: hydronephrosis, poor corticomedullary definition, nephroliths, DONT biopsy

Treatment:

Symptomatic, unless septic pyelonephritis (antibiotic)

Post infection glomerulonephritis - corticosteroids +- concurrent abx

avoid dehydration and toxic drugs

High energy diet with low calcium (veg oil)

Urolithiasis - shock wave lithotripsy or nephrotomy if causing issues

Poor prognosis 

Types of colic: Smooth muscle spasm, inflammation (colitis and ulceration), Distenstion (impaction and gas accumulation), Obstruction (impaction), Tension on the mesentery (Displacement), Tissue congestion/infarction/necrosis (torsion/volvulus/strangulation)

Accurately assess severity not the type.

Spasmoidic

Smooth muscle, HR normal, gut sounds increased on ausculate, mild/moderate pain, off food, no signs of faeces, managed on yard, Buscopan response within 5 mins, with phenylbutazone or meloxicam

Referral: persistent pain despite analgesia, progressive abdominal distension, tachycardia, signs of hypovolaemia, absent borborygmi, abnormal rectal finding, gastric reflux

Avoid FLUNIXIN if unsure

Prepare for refer: nasogastric tube, analgesia after speeking to hospital, report treatment admined and ETA to hospital, give clear directions to owner

Referral exam

Observation: level of pain, establish baseline, external assessment

History: signalment, colic history, pregnancy, dental, worming

CVS assessment: TPR, pulse quality, peripheral skin temp, MM, Skin turgor, PCV

GI auscultate: hyper/hypomotility, caecal contractility, tympany, sand

Ultrasonography: concerns with rectal (small, lack restraint, excess strain, rectal tear, pregnancy), low frequency curvilinear transducer 30 cm depth, FLASH technique

Abdominocentesis: right of midline, clip, aseptic prep, 20g 1 1/2 inch needle collected into EDTA. Look for:

serosanguinous colour change, increased protein - Serosal compromise, leakage of blood components

increased lactate - anaerobic tissue metabolism

presence of ingesta - rupture of GI tract

High WBC count - Peritonitis

Rectal exam: spasmolytic lubricate sedative, examine faeces, systematic (clockwise from left dorsal; spleen, left kidney, arota, mesentery, duodenum, caecum, inguinal ring, pelvic flex, left dorsal colon, small colon, inguinal ring). Can find: distended SI, displaced intestine, tympany, taunt mesentery, impaction

Surgery 

Emergency

When is surgery needed: pain not controlled by analgesia, gastric reflux over 4L yellow, Rectal abnormalities, absent intestinal sounds, peritoneal fluid increased TP or presence of RBC and neutrophils

Ex-Lap:

examine SI, examine LI, evaluate gut viability

Strangulation obstruct: vasc compromised, damage mucosal barreir, endotoxins damage endothelium, endotoxic shock

Bowel resection: max 8m, end-end anastomoses, ileocaecal and jejunocaecal anastomoses

Post op care

Monitor + fluids: 

q4hr colic check + PCV/TP

Check IV catheter and fluids are running

2 gastric reflux checks

2x maintenece fluids guided by PCV/TP

Food and water

After resection: 24 hours oral fluids, walk to grass 24-48 hrs

Analgesia:

Flunixin 1.1mg/kg IV BID

Antibiotic: procaine penicillin 20,000iu/kg IM BID, Genamicin 8.8 mg/kg IV SID, +- metronidazole 

Rehab: 6w box, 6w small paddock

Complications: 

48hrs: surgical pain, ischaemic bowel, reperfusion injury bowel, leakage at enterotomy site, post op ileaus, recurrent displace

2-7 days: obstruction at anastamosis, delayed adaptation, peritonitis, large colon impact, ulcers

Over 7 days: adhesions, recurrence of previous problem

Incisional infect: C+S, drain and lavage, abdo bandage

Incisional hernia: small leave, hernia belt, box rest, herniorrhaphy

Thrombophlebitis: C+S, abx, DMSO/Diclofenac topical, US monitor, NSAID

Post op ileus: no gut sounds + reflux, nasogastric decompress, polymixin/flunixin, prokinetic?

History

background, complaint, time of onset, any other investigations

Clinical exam:

1. Static assessment: distance first, then palpate nose to tail

2. Dynamic: straight line, lunge hard and soft

DDX: back/scroilliac pain, muscle, orthopaedic, GI disorder, Cardiac disease, lower airway, neruo

Ortho:

Hand off (conformation, shoes, muscle tone), Hands on (each limb, back, neck, muscle), Dynamic exam

Straight line hard (walk, fig 8, trot, hip hike, head nod, stride length, foot flight)

Lunge on soft ( walk, trot, canter)

Lunge on Hard (trot)

Write DDx

Diagnostic anaesthesia (palmar digital/abaxial sesamoid)

Foot radiograph (foot balance, upright view, skyline)

MRI (standing low field, anaesthetised high field)

Corrective shoeing or corrective excercise

Back/SI Pain

Back palpate: muscles, sensitivity, flexion

Back movement: Dynamic exam, canter

Primary back: Kissing spine, OA, Spondylosis, enthesopathy

Secondary back: muscle pain associated with hindlimb lame, incorrect saddle fit, heavy rider

Primary SI: OA, soft tissue injury

Secondary: hindlimb lame

Back: Radiography (thoracolumbar)/ US, Diagnostic anaesthesia

SI: Nuclear scintigraphy/rectal US/radiograph/CT, Diagnostic anaesthesia, trial medication (methylprednisolone acetate)

Medication for short term: corticosteroids

Rehabilitation for long term: physio

Surgery if failed: interspinous ligament desmotomy, cranial wedge resection, partial resection

GI Disorders:

History clinical exam 

Gastroscopy (3m endoscope, mouth gag, dark room. starve for 16 hrs, water out for 3hrs, sedate IV)

Squamous ulcer: omeprazole (oral 4mg/kg PO SID, injectable 2g IM q5-7 days, sucralfate 12-20 mg/kg PO BID second line)

Glandular ulcer: misoprostol (5ug/kg, tablet/paste, 1 hour after omeprazole, 4w initial course), Omeprazol, Corticosteroids (IBD)

Feed: ad lib froage, limit concentrate, handful of hay before riding

Manage: daily horse horse contact, red stress, avoid NSAID long term, avoid intense excercise during treatment

Upper resp

Treadmill; keep going until diag/fatigue, additional tests, dynamic bloods, but higher cost

Overground scope: home, lower cost, more convenient, but not able to replicate conditions 

Lower resp

Examine airways

Tracheal wash: head up, endoscope into 1/3 trachea, advance tube, sterile saline 20ml, aspirate

BAL: gastroscope 3m or BAL tube, 300ml saline, sedate, extend head, tube as far as it will go, instill and aspirate

Cytology on both, or culture on tracheal

Excercise induced pulmon haemorrhage: blood on endoscope, haemosiderophages after cytology

Treat: Furosemide 1mg/kg IV, cant be done on raceday in UK

Cardiac exam

Rate, rythm, murmur

Auscultate both sides, then ECG, then Echo

Afib: oral quinidine, transvenous electrocardioversion

Ongoing monitoring; hr, palpate, auscultate, vet exam q6m

Muscle

Over exert, RER, PSSM, Hyperkalaemia periodic paralysis

Blood sample (CK/AST, rest, post exercise), Urine (analysis, electrolyte clearance), muscle biopsy (gluteal/semimembranous), genetic testing (hair pluck/blood)

TX RER: acute (Phenylbutazone, Fluids), chronic (Dantrolene, before excercise), regular excercise, diet (low carb, high fat), avoid stress

Neuro

Limb position

Foot placement

DDx: cervical spine path (OA, CVM), motor neuron disease

Radiographs (lateral and oblique) 

Ultrasound

CT +- myelogram

OA: intra-articular medication with corticosteroids, gentle routine excercise, systemic NSAID

Fracture: conservative rest, surgical stabilisation

CVM: conservative, surgical, avoid high energy diet in yound with type 1