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M. Gnar, M.B.A., M.B.B.S., M.H.S.

Medical Instructor, University of New England College of Osteopathic Medicine

Pregnancy diagnosis by rectal palpation Details are beyond the scope of this book. The main findings may be summarised as follows: 35 days ­ unilateral enlargement of the pregnant horn; presence of corpus luteum on the ipsilateral ovary 42 days ­ palpation of amniotic vesicle (2 to 3 cm in diameter) in the pregnant horn 42­70 days ­ palpation of membrane slip. The additional chorioallantoic membrane slipping independently of the uterine wall is palpable at this stage. At this stage they are 3 to 4 cm in diameter, increasing to 6 to 8 cm towards the end of pregnancy. They are initially quite close together but later, as allantoic fluid volume increases, they move further apart. Cotyledons are readily detected by advancing the hand as far forward as possible per rectum and then moving the palm backwards and downwards stroking the dorsal wall of the uterus. The cotyledons are palpated as elevations in the uterine wall 150 days ­ fremitus palpable in the middle uterine artery on the pregnant side 240 days ­ bilateral fremitus palpable; the exact timing is variable the fetus, which is very small, is not palpable within the tense amniotic vesicle in the first 10 weeks of pregnancy. In the last 4 weeks of pregnancy the calf is usually readily palpable as it increases in size. In the last few days of pregnancy the feet of the calf often enter the pelvis in preparation for birth. Occasionally, if the calf is very large and heavy, in late pregnancy it may slip under the caudal parts of the rumen and cannot be palpated per rectum. Ovaries In non-pregnant animals these are located on the pelvic floor approximately level with and quite close to the junction of the body and horns of the uterus (Fig. In searching for them per rectum the clinician should remain in manual contact with the uterus to which they are attached. Maintaining contact with the uterus enables the clinician to limit the area in which the ovaries may be sought. Occasionally one ovary, often the left, is not immediately palpable and may have slipped under the anterior border of the broad ligament. Digital pressure exerted in a downward and anterior direction on the broad ligament will usually cause the ovary to move back into a palpable position. The cow has a mature follicle on her left ovary and the regressing corpus luteum from the previous cycle on her right ovary. The ovaries are firmer than adjacent tissues and one, currently the more active ovary, is larger than the other. As much of the ovarian surface as possible is explored, testing for shape and consistency. Ovarian follicles are fluid filled and readily compressible, with a smooth surface often rising just above the ovarian surface. More than one follicle may be present, but as oestrus approaches a single follicle may become dominant and grow faster than the others. Immediately after ovulation a small depression may be palpated at the site of ovulation. This is later palpable as the spongy corpus rubrum which later becomes luteinised as the corpus luteum. Corpora lutea project from the ovarian surface and are firm and non-compressible to the touch (Fig. It hardens with age and sinks back into the ovarian stroma but may still be palpable as a small corpus albicans after it ceases to be active. Ovulation may occur sequentially on the same ovary or alternate between the two ovaries. The absence of follicles or corpora lutea may suggest that the patient is in anoestrus. A further rectal examination should be made 10 to 14 days later to confirm or refute the absence of cyclical ovarian activity. Further evaluation of the ovaries by ultrasonography and a plasma or milk progesterone profile of the patient are extremely useful in confirming the physiological state of the ovaries. Cystic ovarian disease Ovarian cysts are very common in dairy cattle and can be readily diagnosed on rectal examination. In most cases a single ovary is involved, but occasionally bilateral cysts are seen. Ovaries containing cysts may be grossly enlarged and their overall diameter may occasionally exceed 5 to 6 cm. Ovarian cysts are broadly classified into two main groups whose clinical and diagnostic features are summarised below.

When standing the animal adopts a characteristic cross-legged posture of the forelimbs to take the weight on the lateral claw and off the fractured medial claw (Fig. Septic arthritis of the distal interphalangeal joint this produces lameness of rapidly increasing severity. There is swelling of the proximal soft tissue just above the coronary band which is hot and painful on palpation. A fistulus tract may be present just above the coronary band or at the point of penetration in the interdigital space (Fig. Arthrocentesis of the dorsal pouch of the joint capsule is possible in a well restrained animal, preferably using intravenous regional anaesthesia. In an established infection the joint space will be increased when compared with the same uninfected joint on the opposite leg. There is usually severe ascending diffuse swelling on the flexor aspect of the distal limb along the course of the infected tendon sheath. Rupture of the deep digital tendon results in an upward tilting of the affected claw. Ultrasonography will reveal the presence of abnormalities such as enlargement of the tendon sheath, abscessation and tendon rupture. Limbs Anatomy the forelimb is composed of the scapula, humerus, radius, ulna, carpi, metacarpi and phalanges. The joints in the forelimb are the shoulder, elbow, antebrachiocarpal, intercarpal, carpometacarpal, metacarpophalangeal, proximal interphalangeal and distal interphalangeal (Fig. The hind limb is composed of the femur, patella, tibia, fibula, tarsi, metatarsi and phalanges. The joints in the hind limb are hip, stifle, hock (tarsocrural, intertarsal, tarsometatarsal), metatarsophalangeal, proximal interphalangeal and distal interphalangeal (Fig. The pelvic bones are attached to the axial skeleton at the sacrum by the sacroiliac joints, one on each side (Fig. Comparative radiography demonstrating lucency and sclerotic bone is diagnostically useful. Further investigations If the site of lameness in the foot cannot be identified, a block can be placed on one of the claws of the affected limb. If the lameness gets worse this suggests the lesion is located in the claw with the block. If the lameness improves this suggests the block has been placed on the limb without the lesion. If the cause of the foot lameness cannot be identified visually, then palpation, compression using hoof testers, percussion with a small hammer and manipulation, may be required to identify the seat of lameness. Clinical examination of the limbs Most cases of bovine lameness involve the foot; none the less, upper limb lameness in cattle is quite common. A full clinical examination of the whole limb should be made in every case of lameness to ensure that no lesion is overlooked. Upper limb lameness may be caused by infection or injury to one or more of the following tissues: bones, joints, ligaments, tendons, muscles, skin, subcutis or nerves. The bones, joints, ligaments, muscles and tendon sheaths are examined concurrently as the leg is ascended. The techniques used include visual inspection, palpation, manipulation, manipulation with auscultation, flexion and extension of the joint. The structures should be assessed for pain, swelling, heat, deformation, abnormal texture, atrophy, reduced movement, abnormal movement and crepitus. Joints Bones Joints Lameness and altered stance are a features of conditions affecting the joints. Enlargement due to joint capsule distention or apparent enlargements of a joint due to bone abnormalities can be detected visually. Severe enlargement will be obvious, whereas mild enlargement may be more easily appreciated by comparison with the normal joint on the opposite limb. Palpation may reveal an enlarged joint capsule from the increase in synovial fluid within the affected joint, and heat and pain may be apparent. Manipulation may induce severe pain and crepitus due to abnormal periarticular bone or articular cartilage erosion. Rectal palpation is useful when trying to characterise abnormalities of the sacroiliac region and the hip joint. Scapula Shoulder Humerus Apparent joint enlargement this may be caused Elbow by abnormalities of the growth plates (physitis), soft tissue (cellulitis) or tendon sheaths (tenosynovitis).

A diverticulum (d-vr-tihck-yoo-luhm) is a pouch occurring on the wall of a tubular organ; diverticula are pouches occurring on the wall of a tubular organ. Evisceration is used to describe the exposure of internal organs after unsuccessful surgical closure of the abdomen (or another area containing organs). Gastric dilatation volvulus is a term commonly used to describe a condition in deep-chested dogs in which the stomach fills with air, expands, and twists on itself. Because the stomach is "attached" at only two points, it should be more accurately described as a torsion. A descriptive term usually is applied in front of it; for example, fecal incontinence is the inability to control bowel movements. Gut Instincts 127 (a) Figure 6­30 Jaundice is the yellow discoloration of the skin and mucous membranes. The prefix mal- means bad, and occlusion means any contact between the chewing surfaces of the teeth. Obstructions usually are preceded by a term that describes its location, as in intestinal obstruction (Figure 6­32). Oronasal fistulas may be congenital, traumatic, or associated with dental disease. Inflammation is a localized protective response elicited by injury or destruction of tissue. The signs of inflammation are heat, redness, pain, swelling, and loss of function. In the gastrointestinal system, it is used to refer to the mixed colony of bacteria, leukocytes, and salivary products that adhere to the tooth enamel; also called dental plaque. In a portosystemic (poor-t-sihs-tehm-ihck) shunt, blood vessels bypass the liver and the blood is not detoxified properly. For example, a pyloric stenosis is narrowing of the pylorus as it leads into the duodenum. Tenesmus also means painful, ineffective urination but is rarely used in this context. Gut Instincts 129 Mesentery Intestine Volvulus colotomy (k-loht-m) = surgical incision into the colon. Volvulus is a twist around the long axis of the mesentery; torsion is a twist around the long axis of the gut. Procedures: Digestive System Procedures performed on the digestive system include the following: abdominocentesis (ahb-dohm-ihn-sehn-t-sihs) = surgical puncture to remove fluid from the abdomen. Figure 6­35 A displaced abomasum is repaired surgically with a procedure called an abomasopexy Figure 6­36 A rumen fistula is an artificial opening created between the rumen and the body surface. A ruminant that has an artificial opening created between the rumen and the body surface has a rumen fistula (Figure 6­36). A perianal fistula (pehr-ih-nahl fihsh-too-lah) is an abnormal passage around the caudal opening of the gastrointestinal tract. To clarify the extent of the excision, the term partial gastrectomy is used to denote surgical removal of part of the stomach. The suffix -stomy means surgical production of an opening between an organ and a body surface. Effluent (ehf-floo-ehnt) means discharge and an effluent flow from the stoma created by a -stomy surgery. Gut Instincts 131 trocarization (tr-kahr-ih-z-shuhn) = insertion of a pointed instrument (trocar) into a body cavity or an organ. The trocar usually is inside a cannula so that once the trocar penetrates the membrane, it can be withdrawn and the cannula remains in place. Trocar- ization usually is performed for acute cases of bloat to relieve pressure. When trocarization is performed for treatment of ruminal bloat, it may be called ruminal paracentesis (pahr-ah-sehn-t-sihs). The muscular, wavelike movement used to transport food through the digestive system is a. The part of the tooth that contains a rich supply of nerves and blood vessels is the a. The formation of a new opening from the large intestine to the surface of the body is known as a(n) a. R Y O A D O A T E O S O L E M Y O T L H A A T A E Y T T O N D N O T C M X S Y A X T M N Y M O N G N A N T O I M S E Y C E S N D O O T A N E O T T H O E S E P O C H I O T M A P N O A M I E O O C T O O B M R T A O T A N L N A N Y T N O N O O S O R R O T Y E M A C A D C A O T T O M O A M D A M O T I E S N Y S L A P A R O T O M Y O I O I N Y N N A O N T T T O A O Y T O N Y D S O N T E E T L M S Y Y E Y T T O B N N I N M D T Y E T H E C G O U E S E E A T Y T O M T N T S O O S M N A T B H I H S P T N B Y E A A A A C S C N E S N T Y S M L Y A T I O M A O M O A A Y T X T O Y M O T S O L O C N E O A G R G C G E T R N I Y M T T E O Y E O T A N M C A A I T R E A M C O E N O I S B C I G Y T O P N O A A C B A I T T A I O S I D C N H E O O E Y O C T S S I S E T N E C O N I M O D B A M T N T O I N T A T N O O G P R Y H T S T O E O T I M I N T N E N O D T S E T N T N T O N A N O Y T O E A B D A M Y Y S S C N T E B T A G N N M O N A S O G A S T R I C I N T U B A T I O N surgical connection between two tubular or hollow organs surgical incision into the abdomen surgical removal of all or part of the stomach produces vomiting to remove (teeth) surgical repair of the anus surgical production of an artificial opening between the portion of the large intestine between the cecum and rectum and the body surface surgical fixation in ruminants of the fourth stomach compartment to the abdominal wall removing tissue to examine substance that prevents frequent and extremely liquid stool Copyright 2009 Cengage Learning, Inc.

Syndromes

• Shock
• Within 48 hours of quitting: Your nerve endings begin to regrow. Your senses of smell and taste begin to return to normal.
• Genital herpes
• Diabetes insipidus -- a condition in which the kidneys are not able to conserve water
• Use of certain medicines, including methyldopa, penicillin, and quinidine
• Salivary gland tumors
• The time the person was exposed to the toxin

This is followed by static acquisition for 5 min in the lateral and anterior projections. If the nodes are still not seen, static images should be repeated after two hours. A transmission scan is recommended using either 99mTc or 57Co flood sources to outline the body contours. Display of data Attention should be paid to the following points: - Dynamic images are summed and displayed representing 1 or 2 min each. Intra-operative procedures the intra-operative procedures are summarized below: (a) the surgeon injects Methylene Blue (Blue Patent V) around the breast mass. Using a surgical probe (radiation detection), the surgeon locates the sentinel node in the axilla and determines that it is the same node visualized with the Methylene Blue technique to trace the lymphatic system. Any node with activity higher than twice the background activity should be excised. If the primary tumour was not removed and the purpose of surgery is only to excise the sentinel node, the site of injection should be shielded with lead in order to decrease the background activity and to avoid saturation and electronic jamming of the detector. Internal mammary lymph nodes can be excised from the third and fourth intercostal space next to the outer border of the sternum. Patient selection Only cases with the following characteristics should be investigated: - Early stage malignant melanomas of the skin of no more than 3 mm in thickness; - No invasion of the subcutaneous tissue and no clinically palpable regional lymph nodes present; - Referral usually after an excisional biopsy or a wide surgical excision of the lesion. Radiopharmaceuticals the following radiopharmaceuticals are used for sentinel node localization: - Technetium-99m antimony tin colloid; 350 5. These can be used for fast visualization of the lymphatic channels and sentinel nodes provided the patient is due to enter the operating room soon. The first node seen after injection is the sentinel node and this should be properly marked on the skin. The following procedure should be observed: (a) Route of injection: -Intradermal injections, within 1 cm of the edge of the lesion or the scar at four corners and 90o apart, can be used. Mode of acquisition: -An anterior dynamic image should be taken every 30 s for 45 min, followed by static images for 5 min in the anterior and lateral projections. Region to be imaged: Depending on the location of the lesion, clinical judgement should be used in identifying the region to be imaged. Markers over the site of the sentinel node should be attempted using a point 57Co source, and an ink mark on the skin should be performed. Reporting: Details should be included on the site of injection and the radiopharmaceutical used, as well as on the location and number of sentinel nodes visualized. Preparation for the surgical probe: -The battery of the probe should be fully charged. Most probes are currently covered by disposable, sterile plastic tubing for use in the operating room, usually supplied by the manufacturer or obtained commercially. Principle Radioimmunodetection or radioimmunoscintigraphy uses tumour targeting antibodies or antibody fragments, labelled with a radionuclide suitable for external imaging, for the detection of specific cancers. Monoclonal antibodies have been developed against a variety of antigens associated with tumours and have been shown to target tumours with minimal side effects. Numerous radionuclides suitable for external imaging have been conjugated to antibodies, or antibody fragments, and the radioimmunoconjugates have been shown to be stable in vivo. Antibody fragments have been conjugated with 99mTc, allowing same or next day imaging. Intact immunoglobulin conjugated with 111 In permits imaging as late as a week after administration. Clinical indications Radioimmunoscintigraphy has been shown to be of benefit in the detection of occult disease, in the management of patients with potentially resectable disease, and for the evaluation of lesion recurrence and therapeutic response. Radiolabelled antibody imaging in prostate cancer has been shown to be useful in risk stratification and in patient selection for loco-regional therapy. Contraindications the following points should be borne in mind: - Pregnancy and/or lactation is an absolute contraindication.