Systemic Evaluation PDF

Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE...

Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 I. UNIT TITLE/CHAPTER TITLE SYSTEMIC EVALUATION II. LESSON TITLE SYSTEMIC EVALUATION III. LESSON OVERVIEW Systematic evaluations of different bodily systems are important during physical examination. Based on the history, a more comprehensive examination of systems affected is crucial in making a more accurate diagnosis. IV. DESIRED LEARNING OUTCOMES Evaluate thoroughly the different bodily systems of an animal. Record the findings during evaluation V. LESSON CONTENT DIGESTIVE SYSTEM Physical examination - Identify the abdominal organs during palpation. Intestine, small intestine and UB are easily identifiable in dog unless there is abdominal effusion, abdominal pain or the animal is obese. - Note: Uncooperative patient during physical examination can be sedated. Rough palpation may cause the animal to tense up its abdomen or vocalize mimicking the reaction of an animal with abdominal pain.  Examine oral cavity ◦ Color of the mucous membranes, moisture, and CRT- to assess hydration status. ◦ Presence of gingival masses, ulcerations, inflammation, pigmentary changes or exudate at the gingival margin ◦ teeth calculus, fractured teeth, abnormal wearing, and evidence of pulp exposure. ◦ Presence of extra teeth? – supernumerary or retained deciduous or absence of teeth ◦ With the mouth closed, examine the bite. ◦ abnormal odor coming from the patient’s mouth. ◦ Tongue- evidence of trauma or masses especially when unexplained oral hemorrhage has been observed. ◦ Cleft in the hard palate in the neonates? Defect or masses in the soft palate (if possible) ◦ pharyngeal region- asymmetry, masses, or foreign bodies or evidence of inflammation or trauma. ◦ Tonsils- enlargement or masses.  Examine the neck ◦ Palpate the paratracheal area from the larynx to the thoracic inlet. ◦ Palpate the trachea for collapse, soft cartilage, or flattening. Attempt to elicit a cough by gently encircling the trachea with one hand and applying pressure on the tracheal muscle dorsally. ◦ Evaluate the jugular veins for distention.  Palpate salivary glands (normally palpable), larynx and thyroid gland (not normally palpable). In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 32 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022  Palpate peripheral lymph node and subcutaneous masses Examination of the Abdomen  distention, deformity, displacement, symmetry, and bruising ◦ tympany indicates gastric dilatation or volvulus  Auscultate abdomen to detect intestinal hypermotility or hypomotility  Size and location of the organs and presence of fluid, gas, fetuses, masses or feces.  Sign of pain or guarding of the abdomen. Notes to remember:  Stomach: Normal stomach is rarely palpable. May be palpable behind the ribs to mid-abdomen if the animal had just recently eaten. Overeating may result in a doughy or fluid-filled stomach.  Liver: Difficult to palpate in normal patient. Caudal edges are barely palpable smooth, sharp and well defined. In case of hepatomegaly, liver extends past the costal arch and the edges may be rounded.  Spleen: May not always be palpable, usually palpable if splenomegaly is present. Use gentle palpation on mid-abdominal masses. It is possible to rupture a splenic or hepatic hematoma or hemangiosarcoma.  Mesenteric lymph node: Not usually palpable unless markedly enlarged, as with lymphoma and occasionally in cats with inflammatory bowel disease.  Small intestine: thickness of the bowel wall and the presence of gas, fluid, foreign bodies, masses or pain on palpation. Palpation of an intestinal foreign body frequently produces a painful response  Colon: Determine whether the palpable structure is feces or a mass; apply gentle pressure to test for deformability of the stool. Evaluate quantity and consistency of the feces to aid in the diagnosis of constipation. Rectal Examination - evaluate the colonic mucosa, anal sphincter, anal sacs, pelvic canal bones, muscular support for the rectum, urogenital tract, and luminal contents. Note: However, it is particularly easy to misinterpret mucosal polyps as mucosal folds and to miss partial strictures that are large enough to allow a single digit to pass through easily. Laboratory Evaluation Fecal floatation - Indicated in almost every animal with alimentary tract disease or weight loss, especially in puppies and kittens. - Solutions: salt, sugar, zinc sulfate - Direct fecal examination, although convenient, is not sensitive for nematodes and should not replace flotation techniques. Fecal Indigestion test - Thin fecal smears are stained with the Sudan stain (for fat) or iodine (for starch and muscle fibers) - Quantitated fecal fat analysis is seldom indicated. - Although sensitive for detection of fat malabsorption and maldigestion, it is expensive and unpleasant to perform and does not differentiate malabsorption from Exocrine Pancreas Insufficiency (EPI). Miscellaneous Fecal Analyses - Enzyme-linked Immunosorbent Assay (ELISA) ▪ to detect various antibodies or antigens. ▪ Ex. CPV Kit, CDV Kit, SNAP Giardia Test, ELISAs for detecting cryptosporidial antigens in feces - Electron microscopy ▪ can be used to identify various viral particles (e.g., coronavirus, astrovirus) in feces. Bacterial Fecal Culture In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 33 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 - Seldom indicated in small animals unless a contagious disease is strongly suspected or other test findings (e.g., endoscopy and biopsy) are nondiagnostic. - Pathogens most likely to be cultured from feces from small animals: ✓ Clostridium perfringens ✓ Clostridium difficile ✓ Salmonella spp. ✓ Campylobacter jejuni ✓ Yersinia enterocolitica ✓ Escherichia coli (verotoxin-producing strain) Cytologic Evaluation of Feces - May identify etiologic agents or inflammatory cells. - Thin, air-dried fecal smear is stained with Gram's or a Romanowsky-type stain. ▪ Romanowsky-type stain (e.g., Diff-Quik) identifies cells better than Gram's stain. - Finding of leukocytes in feces indicates the presence of a transmural colonic inflammation instead of just a superficial mucosal inflammation. Radiography of the Alimentary Tract - allows structures to be evaluated that cannot be adequately assessed during physical examination and may detect abnormalities missed by abdominal palpation - Indicated in animals with: o dysphagia, regurgitation, vomiting, abdominal mass or distention, abdominal pain, or acute abdomen. o constipation, weight loss, or anorexia of unknown cause - Plain radiographs should always be obtained before contrast-enhanced radiographs because: Plain radiographs may yield diagnostic findings, contrast-enhanced radiographs may be contraindicated, Plain radiographs are needed to ensure a correct radiographic technique during the contrast procedure. - Contrast-enhanced radiographs to detect abnormalities (e.g., a gastric outflow tract obstruction) that plain radiographs cannot. Ultrasound Exam - Valuable in animals with an acute abdomen, abdominal effusion, vomiting, diarrhea, weight loss, or anorexia of unknown cause and also in those animal with abdominal mass, distention, or pain. - Used to identify pancreatitis, infiltrations in various organs, and intussusceptions that radiography misses. - Used to guide the percutaneous aspiration and biopsy of intra-abdominal lesions that would otherwise require surgery or laparoscopy. - Thickness, echodensity, and homogeneity of organs (e.g., liver, spleen, intestine, stomach, mesenteric lymph nodes, masses) are evaluated. Peritoneal fluid analysis - Fluid is obtained by abdominocentesis or with the use of multifenestrated catheter - If peritoneal inflammation is suspected but abdominal fluid cannot be retrieved, a diagnostic peritoneal lavage may be performed. Digestion and Absorption test Serum Trypsin-Like Immunoreactivity - Most sensitive and specific test for exocrine pancreas insufficiency (EPI) - TLI assay detects circulating proteins produced by a normally functioning exocrine pancreas and is even valid in animals receiving pancreatic enzyme supplements orally. - Primarily indicated in dogs with chronic small intestinal diarrhea or chronic weight loss of unknown origin. In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 34 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 - Increased serum TLI is observed during: o pancreatitis, o renal failure, o severe malnutrition - If EPI is caused by obstruction of the pancreatic ducts (apparently rare) as opposed to acinar cell atrophy or destruction (common), the serum TLI test may not detect maldigestion. - In such cases, a quantitative fecal proteolytic assay is required. - Although primarily used to detect EPI, serum TLI values significantly greater than normal are suggestive of pancreatitis. Serum concentrations of vitamins - Helpful in determining some malabsorptive disorders of the small intestine - Tests may provide evidence of severe small intestinal mucosal disease. Cobalamin - Dietary cobalamin is absorbed in the distal small intestine (ileum). - When ARE is present, bacteria sometimes bind cobalamin and prevent its absorption, decreasing the serum concentrations. - Cobalamin concentrations are usually decreased in dogs with EPI, possibly because of the high incidence of ARE in such animals. - Severe mucosal disease, especially in the region of the ileum, may also cause serum cobalamin concentrations to be decreased Folate - Dietary folate is absorbed in the proximal part of the small intestine (jejunum). - If there are many bacteria in the upper small intestine, these sometimes synthesize and release folate, causing the serum concentrations to be increased. - Also, severe intestinal mucosal disease may decrease absorption, causing lower serum concentrations. - B-complex vitamin supplementation may increase serum folate concentrations. Other Special Tests Measurement of antibodies to 2 M muscle fibers - Can be helpful in dogs with suspected masticatory muscle myositis - The antibodies are typically not found in dogs with polymyositis, whereas most dogs with masticatory myositis have them. Measurement of serum gastrin concentrations - Are measured in animals with signs suggestive of gastrinoma. - Gastrin stimulates gastric acid secretion and is trophic for the gastric mucosa. - Serum for assay of gastrin is harvested from an animal after an overnight fast and rapidly frozen. RESPIRATORY SYSTEM Respiratory disease is evident as one or more of a variety of signs detectable on clinical examination. The signs vary with the etiology of the disease and its anatomic location. ✓ The common signs of respiratory disease are as follows: o Abnormalities in the rate, depth, or ease of breathing o Lethargy or exercise intolerance o Abnormal posture o Abnormal lung sounds o Abnormal respiratory noises o Coughing o Cyanosis o Nasal discharge o Epistaxis and hemoptysis. In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 35 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 Observation - Note for any abnormalities in respiratory rate, depth and ease of breathing - Polypnea, tachypnea, hyperpnea, dyspnea (expiratory, inspiratory), open-mouth breathing - Abnormal posture during respiration Palpation - Evaluate nose and nares - Note for asymmetry or swelling. If a mass or swelling is present, palpate carefully to determine whether it is firm or fluctuant. - Evaluate brachycephalic breeds for stenotic nares. - Palpate the paratracheal area from the larynx to the thoracic inlet. - Palpate the trachea for collapse, soft cartilage, or flattening. - Attempt to elicit a cough by gently encircling the trachea with one hand and applying pressure on the tracheal muscle dorsally (dog, cat) - A cough cannot be induced in normal adult cattle and horses by manual manipulation of the larynx or trachea. If a cough can be induced in an adult horse by manual manipulation of the larynx or trachea, then this indicates airway inflammation and is a reason for further examination of the respiratory tract. Inspection - Note evidence of nasal discharge: unilateral or bilateral. - It may be copious, serous, mucoid, purulent, caseous, streaked with blood, and foul smelling (ozena), or it may contain feed particles. o A copious bilateral serous nasal discharge is characteristic of early inflammation of the nasal cavities such as in viral rhinitis. o A bilateral mucoid discharge suggests inflammation of a few days’ duration. o A bilateral purulent discharge can indicate inflammation in the upper or lower respiratory tract. o A copious bilateral caseous discharge suggests an allergic or bacterial rhinitis. o Foul- smelling nasal discharges are usually associated with necrosis of tissues anywhere in the nasal cavities, the guttural pouch in the horse, or severe necrotic and gangrenous pneumonia. o A bilateral foul-smelling discharge containing feed particles suggests dysphagia, regurgitation, or vomiting. o In most cases, a chronic unilateral nasal discharge suggests a lesion of one nasal cavity. o A bilateral nasal discharge suggests a lesion posterior to the nasal system. Percussion - Percuss the paranasal sinuses for evidence of pain and facial deformity which will aid in the diagnosis of sinusitis o Useful in identifying sinuses that are filled with fluid or tissue Auscultation - Respiratory Rate (RR) – assess visually or auscultate and count breaths per minute - Respiratory rhythm o 3 phases: Inspiration, pause, expiration - Note for respiratory depth / effort – watch degree of chest movement (normal, shallow, deep) - Character – note sounds and any difficulty on inspiration and/or expiration - Normal breath sounds o Soft blowing sounds, longer and louder on inspiration than on expiration, audible over the trachea and lungs - Abnormal lung sounds: o ‘Wheezes’- continuous high pitched hissing heard more often on expiration. Resulting from passage of air through narrowed or partially obstructed airways such as in asthma. o ‘Crackles’- abnormal discontinuous sounds resulting from popping open of small airways or air moving through airway secretions. Heard more commonly on inspiration. It may be heard when there is fluid in the lungs. o Pleuritic friction sounds- “Sandpaper-like” sound; grating; sound close to the surface; on inspiration and expiration; tend to be jerky and not influenced by coughing In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 36 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 oStridor- A harsh, high-pitched sound on inspiration audible with or without stethoscope over the larynx and trachea. o Stertor- Snoring sound (low-pitched, coarse, and raspy) audible without a stethoscope on inspiration and expiration over the pharyngeal and laryngeal areas o Expiratory grunting - Loud grunting on expiration, which is usually forced against a closed glottis with sudden release, audible on auscultation of the thorax, over the trachea, and often audible without the aid of a stethoscope. o ‘Rhonchi’- musical sounds-low or high pitched. o ‘Dull’ lung sounds may indicate pneumonia, or consolidation. o Abnormally quiet or dull areas are suggestive of pleural effusion, pneumothorax, thoracic mass, and pulmonary consolidation. o Listen for noisy breathing at mouth and nares without stethoscope, then auscult at least four different areas of the chest, including right and left ventral and right and left dorsal lung fields. - Coughing o initiated by reflex stimulation of the cough center in the medulla oblongata by irritation of sensory receptors in one of various organs, especially the respiratory tract. The stimulus may originate in the pharynx, larynx, trachea, or bronchi. o May also be initiated by irritation of the esophagus, as in choking o Purpose of coughing: to remove the excess mucus, inflammatory products or foreign material from the respiratory tract distal to the larynx o It indicates the existence of primary or secondary respiratory disease. o Coughing is infrequent in the early stages of respiratory tract disease but can become frequent as the degree of inflammation in the larynx, trachea and bronchi becomes more severe. o The frequency of coughing is an indicator of the severity of lung disease in horses and presumably in other species. ▪ Horses that cough more than four times per hour have increased likelihood of mucus accumulation and higher pleural pressure changes during breathing than do horses that cough fewer than four times per hour. - Cyanosis o Bluish discoloration of the skin, conjunctivae, and visible mucosae caused by an increase in the absolute amount of reduced hemoglobin in the blood o Examination of the oral mucous membrane, skin of the pinna, urogenital mucous membrane (vaginal mucosa is preferred in horse) - Epistaxis and hemoptysis o Epistaxis- in most instances a result of disease of the mucosae of the upper respiratory tract but it may originate anywhere in the upper or lower respiratory tract o Hemoptysis- coughing up of blood. The blood usually originates from hemorrhage in the lower respiratory tract. The presence of hemoptysis is difficult to detect in animals. H o Laboratory evaluation of respiratory tract secretions and exudates - Samples for evaluation can be taken through: o Swabbing the nasal cavities or the pharynx o Collection of fluid from the paranasal sinus o Collection of fluid from the guttural pouch of equidae o Transtracheal aspirate o Tracheal lavage o Bronchoalveolar lavage o Thoracocentesis o Lung biopsy o useful in confirming diagnosis of lung disease by providing tissue for histologic and microbiological examination in cattle, sheep, and horses. o The technique is most useful by providing a histologic diagnosis of diffuse lung diseases or, when used with ultrasonographic guidance or performed by thoracoscopy, for focal disease o Arterial blood gas analysis o Measurement of PaO2, PaCO2, and arterial oxygen content (CaO2) provides valuable information about pulmonary function and oxygen delivery to tissues. In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 37 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 o Medical Imaging - Radiography of the structures of the head and pharynx is also useful to locate lesions of the nasal cavities and paranasal sinuses that might be the origin of a nasal discharge. - Radiography and ultrasonography of animals with suspected lung disease o Ultrasonographic examination of the thorax provides diagnostic information that is not obtained by radiographic examination and is more sensitive than radiography in detecting pulmonary abscesses in foals and is more useful than auscultation in detecting consolidation in lungs of preweaned calves o Examination of the thorax is limited by the presence of ribs and aerated lungs because the sound waves used to create ultrasound images are reflected from these surfaces. o Ultrasonography cannot reveal lesions of the lungs that are not confluent with the visceral pleura. Imaging windows are restricted to the intercostal spaces, but this impediment can be overcome by scanning through adjacent intercostal spaces and angling of the ultrasound beam ▪ scan each intercostal space from dorsal to ventral starting at the 17th intercostal space in horses and the 12th intercostal space in cattle Techniques for advanced evaluation of the respiratory system include the following: - Endoscopy of the upper airways, guttural pouch (in Equidae), trachea, bronchi, and larger bronchioles o Rhinolaryngoscopic examination of horses includes a careful examination of the ventral and middle meatuses, turbinates, region of the nasomaxillary sinus opening (this cannot be visualized directly but discharge from it can be detected), ethmoidal turbinates, nasopharynx, soft palate, guttural pouches, dorsal pharyngeal recess, epiglottis, and larynx. o Pleuroscopy using either rigid or flexible endoscopes enables direct visual inspection of the pleural cavity for the diagnosis of pleural disease - Magnetic Resonance Imaging (MRI o useful in diagnosis of diseases of the head of horses and other large animals o lack of units suitable for examination of large animals precludes routine use of this imaging modality - Computed Tomography o very sensitive and specific for lung disease in companion animals and is technically feasible in calves, foals, and small ruminants o useful in the diagnosis of mediastinal disease in foals o likely to be useful in evaluation of extent, severity and progression of lung disease in calves. o CT imaging of the nasal cavities and paranasal sinuses of horses is useful in the detection of diseases of these structures and of the teeth, pharynx, larynx, and guttural pouches UROGENITAL SYSTEM Primary functions of the urinary system include: 1. elimination of waste products of metabolism 2. maintenance of a constant extracellular environment through conservation and excretion of water and electrolytes 3. production of the hormone erythropoietin, which regulates hematopoiesis 4. production of the enzyme renin, which regulates blood pressure and sodium reabsorption; and 5. metabolism of vitamin D to its active form (1,25-dihydroxycholecalciferol). Diagnosis: Signalment History In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 38 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ changes in water consumption, frequency of urination, volume of urine produced, appearance of urine, and behavior of the animal. ▪ previous and current drug administration, appetite, diet, changes in body weight, and previous illnesses or injuries. Urinary System Physical Examination findings - palpation of the bladder and examination of external genitalia - rectal examination to evaluate the urethra in both sexes and the prostate in male dogs - Rectal examination in cats may not be possible because of their small size; however, the kidneys are generally easier to palpate in cats than in dogs - full neurologic examination on all animals with micturition disorders. - Lack of accessibility limits the value of physical examination of the urinary tract in farm animals Physical examination of the patient with urinary tract disorders may reveal: ▪ urinary incontinence - may be intermittent and only noticed after the animal lies down for prolonged periods, or the incontinence may be more persistent, resulting in urine dribbling. o When urine dribbling is noted, it is important to differentiate true incontinence from dribbling caused by overdistention, such as can be seen with urethral obstruction or neurologic bladder. ▪ lower urinary tract symptoms - signs include pollakiuria, dysuria, stranguria, and hematuria. - Lower urinary tract signs in young dogs and cats are seen most frequently with infections or calculi as a result of a congenital disease. - Hematuria may be the only significant finding in diseases such as renal telangiectasia and idiopathic hematuria. - If hemorrhage is severe, blood clots may form and lead to urinary tract obstruction. - Anemia may also occur in dogs with idiopathic hematuria and renal telangiectasia. ▪ renal insufficiency or failure. Urinalysis - Urine should be evaluated within 30 min, but if this is not possible, it may be refrigerated for no longer than 6 hours o Sample must be allowed to return to room temperature before chemical analysis is done. o Cellular elements and crystal can deteriorate o Crystals may dissolve or form overtime o Chemical parameters can change as urine sits, especially at room temperature - May be collected through spontaneous micturition, manual compression of the urinary bladder, catheterization, or cystocentesis. o Rams, boars, and young calves usually cannot be catheterized without fluoroscopy because of the presence of a suburethral diverticulum and the small diameter of the urethra. ▪ A precurved catheter and fluoroscopic guidance can be used to facilitate catheterization of rams and bucks. o Ewes and sows can be catheterized, but their vulvas are often too small relative to hand size to allow access to the urethra. o Cows can be catheterized relatively simply provided that a fairly rigid, small-diameter (0.5cm) catheter is used, such as an artificial insemination pipette. o Male horses can be catheterized easily if the penis is relaxed. The catheter should be rigid enough to pass through the long urethra but flexible enough to pass around the ischial arch. - A urinalysis should include: o method of collection o urine specific gravity ▪ obtained using refractometer In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 39 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ In healthy animals, SG is highly variable, depending on fluid and electrolyte balance of the body. Interpretation of SG, therefore, depends on the clinical presentation and serum chemistry findings. ▪ In most species, it normally ranges from 1.015 to 1.035 ▪ An animal that is dehydrated or has other causes of prerenal azotemia will have hypersthenuric urine with an SG >1.025–1.040 (depending on species). ▪ Dilute urine in a dehydrated or azotemic animal is abnormal and could be caused by renal failure, hypo- or hyperadrenocorticism, hypercalcemia, diabetes mellitus, hyperthyroidism, and diuretic therapy. ▪ In cases of diabetes insipidus, values 180 mg/dL in most species and >240 mg/dL in cats. ▪ With euglycemia, the amount of filtered glucose is less than the renal threshold, and all of the filtered glucose is reabsorbed in the proximal renal tubules. ▪ Glucosuria can result from hyperglycemia (due to diabetes mellitus, excessive endogenous or exogenous glucocorticoids, hepatocutaneous syndrome, or stress) or In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 41 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ from a proximal renal tubular defect (such as primary renal glucosuria or Fanconi syndrome). If glucosuria is present, blood glucose concentration should be determined. ▪ False-negative results can occur with high urinary concentrations of ascorbic acid or with formaldehyde (a metabolite of the urinary antiseptic, methenamine, which may be used for prevention of bacterial urinary tract infections). ▪ False-positive results may occur if the sample is contaminated with hydrogen peroxide, chlorine, or hypochlorite (bleach). o Ketones ▪ Ketones are produced from fatty acid metabolism and include acetoacetic acid, acetone, and β-hydroxybutyrate. ▪ ketone test pads are used to detects acetone and acetoacetic acid, but not βhydroxybutyrate (which can be measured in blood and urine using a point-of-care instrument or a biochemistry analyzer). ▪ The test pad contains nitroprusside that reacts with acetoacetic acid and acetone to cause a purple color change; it is more sensitive to acetoacetic acid than acetone. ▪ Ketonuria is associated with primary ketosis (ruminants), ketosis secondary to diabetes mellitus (small animals), consumption of low-carbohydrate diets (especially in cats), and occasionally with prolonged fasting or starvation. o bilirubin ictotest ▪ Used of Ictotest® Reagent Tablets to test for the presence of bilirubin in urine. ▪ The presence of bilirubin is an important finding in the evaluation of liver function and a positive detection could be an indication of liver disease o blood ▪ may be present in the urine (hematuria) and hemoglobin may also occur (hemoglobinuria) independent of the erythrocytes ▪ Hemoglubinuria may be a sign of systemic disease whereas hematuria is more likely associated with genitourinary disease ▪ lesions of the kidney, bladder, and proximal urethra cause hemorrhage throughout or toward the end of urination ▪ lesions of the middle and distal urethra results in bleeding at the beginning of urination. ▪ In severe cases of hematuria, blood may be voided as grossly visible clots, but more often hematuria causes a deep red to brown coloration of the urine. ▪ Less severe cases may show only cloudiness that settles to form a red deposit on standing. ▪ Slight hematuria may only be detectable during microscopic examination of the sediment from a centrifuged urine sample ▪ In females, free-flow urine samples may be contaminated by blood from the reproductive tract, and it may be necessary to collect a sample by urethral catheterization to avoid the chance of contamination of the urine occurring in the vagina. o protein ▪ urine does not contain detectable protein; most of the protein that passes through glomerular filter is reabsorbed in the tubules presence of protein in the urine is always considered pathologic except: In time of parturition Following strenuous exercise During the first few days of life Estrus ▪ protein test pad uses a color indicator (tetrabromophenol blue), which detects primarily albumin in urine ▪ Proteinuria can occur from prerenal (fever, strenuous exercise, seizures, extreme environmental temperature, and hyperproteinemia), renal (primarily glomerular and occasionally tubular disease), or postrenal (inflammation, hemorrhage, and infection) causes In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 42 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ ▪ Protein in a concentrated urine sample may not be significant, whereas the same amount in a dilute sample may be significant Urine dipsticks provide a semiquantitative assessment of protein and can be influenced by urine pH. Therefore, they should be used only as a screening test for protein, not as a definitive diagnosis of proteinuria. ▪ A urine protein:creatinine ratio from a single urine sample or from a 24-hr urine sample is required to quantitate the amount of protein in urine. The following International Renal Interest Society (IRIS) guidelines should be used for interpretation of urine protein:creatinine ratios. ✓ Dog 0.5 = proteinuric ✓ Cats 0.4 = proteinuric. ▪ Urine protein:creatinine ratios must be interpreted in the context of other information from the urinalysis. Inflammation and hematuria can falsely increase urine protein:creatinine ratios, although hematuria generally has minimal effects. o Microscopic examination of urine sediment should include RBCs, WBCs, epithelial cells, renal casts, bacteria, yeast, parasitic ova, fat, sperm, and crystals. ▪ RBC can be found in small numbers in normal samples (0-3/HPF), especially in cystocentesis samples and only few WBC are present in normal urine (0-2/HPF). ▪ Determination of leukocytes using urine dipstick leukocyte tests are unreliable in cats ▪ Hematuria can be from prerenal causes when vascular damage occurs, such as trauma to the kidney, septicemia, and purpura hemorrhagica. Renal causes include acute glomerulonephritis, renal infarction, embolism of the renal artery, tubular damage from toxic insult, and pyelonephritis. Postrenal hematuria occurs particularly in urolithiasis and cystitis. ▪ Epithelial cells are larger than erythrocytes and leukocytes. Squamous epithelial cells are found in higher numbers in free catch samples. Largest cells found in urine sediment. They have abundant cytoplasm, small round nuclei, and angular edges. ▪ Both rods and coccoid bacteria can be seen in the urine of patients with a septic process of the urinary tract. Most common type of bacteria- rod-shaped and motile Coccoid bacteria- in chains or organized cluster and non-motile But bacteria found in long standing urine at room temp has no significance. In most cases, when bacteria are present, leukocytes will be present as well. ▪ Yeast usually appears as colorless ovoid bodies that varies in sizes. When present is usually contaminant as yeast infection is rare. Larger than bacteria and are occasionally confused with erythrocytes. ▪ Fungi appear as distinct hyphae that maybe segmented, colored or both; of little significance ▪ Protozoan in urine is also rare and presence maybe due to fecal contamination ▪ Casts are formed elements that are literally “casts” of the tubules in which they form. Hyaline cast o composed of protein and mucoprotein that usually appear in acidic urine and are uncommon in the sediment of urine from larger animals granular casts o most common cast observed in the urine Waxy casts In accordance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational purposes only and not for commercial distribution. NVSU-FR-ICD-05-00 (081220) Page 43 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ o Indicate chronic renal disease with low GFR o Largest casts found in the urine Epithelial cast o indicate acute sloughing of the renal tubular epithelial cells ▪ Parasites: Capillaria plica (bladder worm) Stephanurus dentatus (swine) Dioctophyma renale (giant kidney worm) ▪ Crystals Triple Phosphate or Struvite crystals o Most common crystal seen in companion animal urine o Crystals describe as “coffin lid” Ammonium Biurate crystals Calcium Oxalate crystal Calcium Phosphate Bilirubin crystals Cystine crystals Amorphous crystals Uric Acid Tyrosine Cholesterol Leucine Mucus Note: Reagent strips are adversely affected by moisture and have a limited shelf life. Bottles should be kept tightly capped, and unused strips should be discarded after their expiration date. The use of leukocyte and urobilinogen pads on the dipstick are considered inaccurate (dogs and cats at any rate for the leukocyte pad) or not diagnostically useful (urobilinogen). Aerobic bacterial urine culture - Preferred method of urine collection is cystocentesis and should be sterile - If urine samples are collected by methods other than cystocentesis, a quantitative urine culture should be requested - If the sample is collected by spontaneous micturition or manual compression, significant numbers of bacteria are present if ≥100,000 colony forming units (CFU)/mL of urine in dogs or ≥10,000 CFU/mL of urine in cats are detected. - Samples with >10,000–90,000 CFU/mL in dogs and >1,000–10,000 CFU/mL in cats are suspicious for a UTI. - If the sample is collected by catheterization, ≥10,000 CFU/mL in dogs and ≥1,000 CFU/mL in cats is significant, whereas samples containing 1,000–10,000 CFU/mL in dogs and 100–1,000 CFU/mL in cats are suspicious for a UTI. Serum Chemistry Profile - Evaluation of serum chemistries, including BUN, creatinine, calcium, phosphorus, bicarbonate, and serum electrolytes, is useful in many urinary tract disorders and can provide a crude indication of glomerular filtration rate (GFR). - increases in BUN and creatinine are supportive of renal dysfunction but these tests are influenced by nonrenal factors as well. o dehydration can cause increases in BUN and serum creatinine not associated with renal failure. o BUN can also be influenced by diet and GI bleeding and is considered inferior to creatinine to evaluate GFR. o Serum creatinine levels can be falsely decreased in animals with severe muscle wasting and falsely increased in patients with severe muscle damage. o Although BUN and serum creatinine increase as GFR decreases, this relationship is not linear. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 44 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ ▪ Large changes in GFR early in renal disease cause only small increases in BUN and serum creatinine, whereas small changes in GFR in advanced renal disease may be associated with large changes in BUN and serum creatinine. More sensitive methods to detect renal dysfunction include plasma clearance tests (eg, inulin clearance), radionuclide techniques, endogenous creatinine clearance, and exogenous creatinine clearance. However, these tests are impractical to perform routinely in clinical practice. The iohexol clearance test is a recently developed alternative to detect renal dysfunction. It entails recording an accurate body weight, administering a precise amount of iohexol IV, and accurately timing the collection of blood samples as directed after administration. This test does not require timed collection of urine samples or special equipment. Plasma clearance of exogenous creatinine has also recently been validated for use in dogs. Additional diagnostic tests: - CBC - blood gas analysis for acid-base status - blood pressure - abdominal radiography o to evaluate the size and position of the kidneys and urinary bladder. o may be difficult in emaciated animals or in the presence of peritoneal or retroperitoneal fluid. o Soft tissue mineralization and certain types of calculi may also be visualized on plain radiographs. - contrast studies of the upper and lower urinary tract is typically done with iodinated contrast agents and include: o excretory urography ▪ used as a crude measure of renal function because excretion of the contrast agent depends on renal blood flow, GFR, and tubular reabsorption of water. ▪ Most commonly used to evaluate the kidneys and ureters for position and filling defects. o antegrade pyelography ▪ iodinated contrast is injected directly into the renal pelvis in an attempt to identify lesions of the ureter. o retrograde contrast administration ▪ used to evaluate lesions in the vagina, urethra, urinary bladder, and distal ureters. ▪ involve placement of a balloon catheter distal to the area of interest, followed by administration of an iodinated contrast agent. ▪ With double-contrast cystography, iodinated contrast agent and air are administered through a urinary catheter. This is typically done to evaluate the wall of the urinary bladder for thickening or mass lesions, as well as its contents (e.g., calculi). ▪ Care must be taken when placing any type of urinary catheter in a pediatric patient because of the possible risk of iatrogenic urethral perforation. - transabdominal ultrasonography o used primarily to evaluate the kidneys (size and echotexture), urinary bladder, and proximal urethra. o useful in identifying filling defects o Renal pelvis can be evaluated for dilation, calculi, and mineralization. o Normal ureters are poorly visualized with ultrasound because of their small size, but if they are dilated, as can occur with an obstruction, they can usually be visualized with ultrasound. o Occasionally the opening of the ureters into the urinary bladder can be seen as the expulsion of urine from the ureters into the urinary bladder. o Urinary bladder wall can be assessed for abnormalities and the vesicular contents seen. o Although transabdominal ultrasonography can be used for the proximal urethra in females ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 45 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ and prostatic urethra in males, transrectal ultrasonography is necessary for the more distal portion of the female urethra and prostatic and pelvic portions of the male urethra in the dog. - Endoscopy o allows visualization of the vagina, urethra, and urinary bladder of dogs and cats. o can also be used to aid in obtaining biopsies, in performing urethral injections of collagen in cases of urinary sphincter incompetence, and in performing urethral and vesicular lithotripsy and stone removal. - Renal biopsy o necessary to definitively diagnose many primary renal disorders such as glomerulonephropathies, amyloidosis, and renal dysplasia. o It is also indicated for definitive diagnosis of mass lesions within the urinary tract. o In cases of recurrent urinary tract infections, biopsy of the urinary bladder wall may be indicated to identify deeper tissue infections. - MRI and CT scan o occasionally used when developmental abnormalities are suspected. o Computed tomography using intravenous urography is believed to be superior to traditional contrast radiography for the diagnosis of ectopic ureters. Genital System Physical Examination - Presence of masses or swelling: any change in appearance, character, or size. o Female ▪ Verify if intact or spayed ▪ Examine for presence of vulvar discharges: amount, consistency, color, and odor ▪ Last heat cycle, was it normal cycle?, how long? ▪ Has been bred? Any possibility of accidental breeding? timing of the last or latest heat cycle may elicit insightful information relevant to pseudopregnancy or pyometra. ▪ Previous history of pregnancy, any problems encountered? (ex. Dystocia, abortion, metritis, etc.), how many puppies whelped successfully? ▪ Previous testing done for brucellosis? When? Was the mate tested? ▪ Examination of the mammary glands thoroughly, moving up and down both right and left chains probing for masses, irregularities and evidence of enlarged glands. Enlarged glands producing small amounts of fluid may be an indication of a false pregnancy, a near term pregnancy or an infection in that gland. Masses should be noted as to size, shape and texture o Male ▪ Intact or neutered scrotum of a neutered male should be examined for masses or ulcerations. In the puppy examination, the presence or absence of testicles may indicate a congenital defect ▪ Any difficulty in urinating or defecating ▪ Presence of preputial or penile discharges: amount, consistency, color, and odor ▪ For intact male: Has it been sued for breeding? When was it last bred? Any difficulty in breeding? Were any litters sired? how many puppies in each litter? Previous testing done for brucellosis? When? Was the mate tested? INTEGUMENTARY SYSTEM Diagnosis: ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 46 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ History - A complete general history should be obtained, including information about prior illnesses, vaccinations, husbandry (housing, feeding practices, etc), changes in attitude and food consumption, elimination practices, exposure to other animals, and travel within the past 6–12 months. - Perform detailed dermatologic history. The following information should be obtained: 1. Primary complaint 2. Length of time the problem has been present 3. Age at which the skin disease started (distinct age predilections are seen in many diseases, eg, demodicosis and dermatophytosis in pediatric animals and signs of atopic dermatitis in animals 1–3 years old) 4. Breed (breed predilections include a predisposition of Cocker Spaniels to primary disorders of keratinization, and of terriers to atopic dermatitis) 5. Presence and severity of pruritus (including licking, rubbing, scratching, or chewing behaviors— owners often do not realize licking may be a sign of pruritus) 6. How the disease started and its progression (diseases that begin with pruritus may lead to self- trauma and subsequent development of secondary skin lesions [alopecia, seborrhea] or infections [bacterial or yeast pyoderma]) 7. Type and progression of lesions noted by the owner 8. Evidence of seasonality (suggesting fleas, allergic skin disease, or weather-related diseases) 9. Area on the body the problem was first noticed (ie, regional patterns seen in atopic dermatitis [typically the face and feet], cheyletiellosis [primarily dorsal], scabies [primarily ventral], and endocrine hair loss [usually involves the trunk and spares the head and legs]) 10. Any previous treatments and the responses to such (ie, antibiotic-responsive skin diseases suggest a bacterial cause; pruritus that responds to small doses of glucocorticoids, antihistamines, or essential fatty acids suggests allergic dermatitis) 11. Frequency of bathing and when the last bath was given (recent bathing may obscure or change important clinical lesions, excessive bathing and wetting of the skin can predispose to skin disease) 12. Presence of fleas, ticks, or mites 13. Other contact animals (ie, evidence of contagion, which suggests fleas, scabies, cheyletiellosis, or dermatophytosis) 14. The environment of the animal (housing changes can influence the development of certain skin diseases, eg, contact dermatitis, contagious diseases) 15. Signs or reports of systemic illness (endocrine [eg, hypothyroidism and hyperadrenocorticism] disorders and metabolic diseases [eg, diabetes mellitus, renal disease, liver disease] should be noted, because the skin can be the first place signs of systemic illness are noted) 16. Whether the animal is receiving routine parasiticidal drugs, and if so what class and how frequently Inspection - Many skin diseases are manifestations of systemic diseases such as hypothyroidism, hyperadrenocorticism, hepatocutaneous syndrome, systemic lupus erythematosus. - Inspect the general appearance of the haircoat for luster, fullness, and areas of hair loss. - Note symmetric alopecia as seen with endocrinopathies, such as hyperadrenocorticism, hypothyroidism, or sex hormone imbalances. - Inspect areas of alopecia for broken hairs as seen with pruritic or psychogenic conditions. - Check for erythema as will be seen in allergic or inflammatory conditions. - A good dermatologic examination requires very close inspection of the entire hair coat and skin under strong lighting; flashlights may be necessary to examine the skin of large animals. - It is important to examine the ventrum of the animal, where many primary lesions and cutaneous parasites are found. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 47 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ - Gross lesions can be described as focal, multifocal, or diffuse in distribution, followed by a description of the affected region (eg, mucocutaneous, truncal). On closer inspection, lesions may be further described as primary or secondary. Primary skin lesions include: macules or patches (nonelevated areas of discoloration) papules or plaques (elevated lesions, the latter coalescing) pustules vesicles or bulla (fluid-filled lesions; bulla are bigger) wheals (flat-topped, steep-walled, solid elevations of the skin arising from histamine release) nodules or tumors (large, solid elevations of the skin). Secondary skin lesions include: crusts scales excoriation (areas of self-trauma) ulcers (loss of the epidermis) hyperpigmentation lichenification (increased thickening and hyperpigmentation of the skin) hyperkeratoses Skin lesions may be either primary or secondary, depending on the cause of the disease. These include: alopecia scale and/or crusts follicular casts (plugging of hair follicles with visible keratin) comedones (blackheads) pigment changes erythema Laboratory Procedures Skin scrapping - mainly used to determine the presence or absence of mites - Types of skin scrapping: superficial or deep scrapping Combing of the Hair Coat/ “Flea combing” - may be necessary to find small amounts of flea dirt in the flea allergy dermatitis patient. - useful to collect large amounts of skin debris and trap cutaneous parasites such as ticks, lice, and some mites Hair Trichogram - part of the basic database for all skin diseases. - performed by grasping a group of hairs in the target hair with forceps close to the base gently plucking hairs in the direction of growth. - Hairs are then mounted in mineral oil and examined microscopically. - Microscopic examination of hair shafts can be used to look for evidence of mite infestations, dermatophyte infections, dysplastic hairs, and sometimes, genetic diseases of the hair coat. Cytology - Cutaneous and auricular cytology is helpful to identify bacterial, fungal, and, possibly, neoplastic skin diseases. - When performing impression smears of the skin, the glass slide should be placed directly over the site to be sampled. Alternatively, clear acetate tape can be used to sample the skin. Adequate sampling will produce a “thumb print” from the surface. - At least 4–6 impression smears should be made, stained (Romanowsky-type stain is adequate) and examined microscopically. o For acetate tape samples, specimens are stained and then mounted over a drop of immersion oil and examined. The tape should not be affixed to a glass slide and then stained, which results in poorly stained samples. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 48 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ - In pruritic animals, material should be scraped from beneath nail beds and smeared onto glass slides, stained, and examined cytologically. Fungal Cultures - Dermatophyte infections are best identified with a fungal culture on either dermatophyte test medium or on plain Sabouraud agar. Animals are best sampled using a new toothbrush aggressively combed over the affected lesions. Plates can be incubated at room temperature and finalized at day 14 of culture. Bacterial Cultures - Intact pustules can be cultured by rupturing the pustule with a sterile needle and swabbing the lesion with a sterile culture swab. If an intact pustule cannot be found, the tip of the swab should be moistened with the transport medium, aggressively swabbing the lesional area and being sure to rotate the swab 360° so the entire swab surface is used. - Lesions should not be scrubbed before sampling. - Deep pyodermas are best cultured from a skin biopsy (6–8 mm). - Systemic and topical agents should be withheld for at least 72 hours before sampling. Biopsy - Are indicated in any case that appears severe, unusual, or does not respond to appropriate therapy. - Lesions should not be scrubbed before biopsy, because surface pathology is important in the diagnosis of many skin diseases. - Several samples from a variety of lesions should be submitted for examination. Primary lesions should be sampled whenever possible; otherwise, the report is often not very helpful in making a diagnosis or narrowing a list of differential diagnoses - A 6-mm or 8-mm biopsy punch should be used because samples may shrink as much as 50% in formalin. Routine Blood and Urine Tests - In most dermatologic cases, routine blood and urine tests do not help to make a definitive diagnosis. If systemic signs of illness are present, then a CBC, serum chemistry panel, and urinalysis may be helpful to identify the cause. In dogs with recurrent infections, these tests may identify an underlying subclinical disease. Intradermal Skin Testing - Not necessarily required to make a diagnosis of atopic dermatitis. - A positive intradermal skin test reaction indicates past exposure to a particular allergen. - Inhalant allergies are best diagnosed based on a compatible history, physical examination findings, and judicious use of intradermal skin testing or in vitro testing for allergies. - Intradermal skin testing is recommended for animals in which immunotherapy is indicated because of the severity or duration of allergic signs. - Potential drug interactions that can interfere with testing should be considered before intradermal skin testing is performed. In Vitro Diagnostic Tests - In vitro diagnostic tests (ELISA or RAST tests) are an alternative to intradermal skin testing. - Considered less reliable because of the large number of false-positive reactions, most complications in interpretation are the result of poor patient selection. - in vitro tests reflect exposure and must be interpreted in light of the animal’s clinical signs and history. CIRCULATORY SYSTEM In the examination of animals suspected to have heart disease, it is important to determine the rate, rhythm, and intensity of the individual heart sounds and the rate, rhythm, and amplitude of the arterial pulse, examine for the presence of venous pulsation at the jugular inlet; and identify the point of maximal intensity and timing of murmurs within the cardiac cycle. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 49 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ Auscultation o Should be carried out on both sides of the chest between the 3rd and 6th ribs o Note for the heart sound, intensity of the heart sound, cardiac rate and rhythm o In the horse it is not uncommon to hear four heart sounds on auscultation, whereas two to three heart sounds are heard in ruminants and camelids. o Auscultation of the heart sound ▪ Murmurs can be graded from 1 to 6 according to their intensity or loudness: Grade 1 – very quiet, heard only with difficulty Grade 2 – quiet but easily heard Grade 3 – equal intensity with the normal heart sounds Grade 4 – louder than the normal heart sounds Grade 5 – very loud with a thrill (a vibration) that is palpable through the chest wall Grade 6 – very loud and audible through a stethoscope held just off the chest wall Inspection o Animal is inspected to see if there are any gross signs of cardiac disease or cardiac failure. o Signs of heart failure: ✓ Right-sided heart failure ▪ Are associated with congestion of the peripheral circulation. ▪ They include distension of the jugular veins, brisket and submandibular edema, and less commonly distension of the abdomen by ascites ▪ The hypovolemia of a failing peripheral circulation may result in reduced renal perfusion and lowered urinary output. ▪ Venous congestion in the portal system may result in enlargement of the liver, a reduction in hepatic activity and diarrhea. ▪ Poor exercise tolerance may also be observed, and the animal may appear dull and depressed. ▪ Occasionally in cardiovascular disease cases, signs of collapse with temporary loss in consciousness (syncope) may be seen ✓ Left-sided heart failure ▪ There is pulmonary venous pressure causing edema and decreased elasticity of the lung tissue. Breathing may appear laborious, and the rate and depth of respiration may increase. ▪ The animal may have reduced exercise tolerance, there may be cyanosis of the mucous membranes and the animal may occasionally have a cough. ▪ In advanced cases both sides of the heart are affected and signs of generalized congestive heart failure including diarrhea may be evident. o Color of the mucus membrane ▪ Normally salmon pink in color, the membranes may be cyanotic in cases of terminal heart failure or severe respiratory disease. ▪ Pale mucous membranes indicate poor peripheral perfusion o Capillary refill time ▪ measure of effective cardiac function ▪ Normal: < 2 seconds ▪ CRT of more than 5 seconds is indicative of a poor circulation. It can be caused by cardiovascular disease or by other abnormalities such as dehydration. Palpation o Peripheral pulse ▪ Pulse should be assessed in a number of body locations to check that it does not vary. The pulse may be affected by local inflammation and be strong in areas close to abscesses. Arterial thrombosis, fibrosis and local edema can all reduce the strength of the pulse in an affected area. ▪ It is influenced by many factors and the significance of abnormalities in its rate, rhythm, strength and character must be interpreted with care and in relation to the other clinical findings. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 50 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ ▪ If a peripheral pulse cannot be easily and safely detected the pulse rate can be measured during cardiac auscultation. Pulse deficits – noted when the pulse rate is slower than the heart rate – are uncommon in cattle ▪ Pulse rate Can be assess on the artery located on the posterior medial aspect of the radius and carpus in the horse and cow In horses and cattle, the best artery to determine the pulse rate, rhythm, and amplitude is the descending aorta; this artery is palpated during rectal examination. ▪ Rhythm, strength and character Irregularities of rhythm o Dysrhythmia- seen in some cases of chronic cardiac disease and also in some cases of metabolic disease such as ketosis, also seen in cases where blood potassium rises, including some cases of calf diarrhea and in downer cows with ischemic muscle necrosis o Hard bounding pulse- It indicates a greater stroke volume by the heart. It occurs in response to pain, excitement and resistance to blood flow. o Weak soft pulse- difficult to detect, especially if the animal is restless. It indicates a reduced cardiac output or a loss of blood volume. This type of pulse may also be seen in terminally ill animals, those with heart failure and following severe blood loss. A weak pulse may also be found in cows suffering from milk fever. o Cold extremities- may suggest poor peripheral perfusion o Apex beat of the heart ▪ Can often be seen and readily palpated in the new-born calf but its presence in older animals may indicate a degree of cardiac enlargement. o Jugular filling ▪ In the normal adult horse and cow, the jugular vein will be distended with blood about 5 to 8 cm above the level of the base of the heart when the animal is standing with its head in a normal, nonfeeding alert position. ▪ Blocking venous return in the jugular vein by pressing on the vein near the base of the neck causes rapid distension of the vein in a normal animal. The distension should disappear as soon as pressure on the vein is removed. ▪ Release of digital pressure on a distended jugular vein does not result in it emptying in cases of congestive heart failure. ▪ Distension of the jugular vein can be a sign of right-sided heart failure and should not be present in normal animals. ▪ Distension of the jugular veins may also be observed in animals in which there is a space occupying lesion at the thoracic inlet. ▪ The large external abdominal veins (‘milk veins’) which lie below the level of the heart normally appear full of blood. ▪ In dehydrated animals or those suffering from shock the jugular veins may appear flat and empty. Pressure on the lower extremity of the vein may fail to produce any degree of filling. Electrocardiogram (ECG) o give considerable information on cardiac function and detect structural heart disease; however, it cannot reliably detect focal myocardial disease. o Is of limited value in cattle but can be used to confirm abnormalities of rhythm. The extensive Purkinge network of the bovine heart makes it unlikely that changes in ventricular size can be inferred from an ECG recording. o Echocardiography allows the measurement of cardiac chamber size, wall thickness, global and regional wall movement, and valve structure and function. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220) Page 51 of 27  Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bayombong, Nueva Vizcaya INSTRUCTIONAL MODULE IM No.: IM-VMED1-1STSEM-2021-2022 ▪ o A complete echocardiographic study addresses the following: ▪ (1) presence of morphologic lesions, ▪ (2) motion abnormalities (global or regional), ▪ (3) cardiac chamber and great vessel size, ▪ (4) cardiac valve function, ▪ (5) blood flow disturbances, ▪ (6) global and regional ventricular systolic function, ▪ (7) hemodynamic measurements, and ▪ (8) ventricular diastolic function. Ultrasonographic Evaluation o Useful to detect abnormalities around the heart and some details of its internal structure. o Evidence of fluid within the pericardial sac may be seen as a black non- echogenic area surrounding the heart. o If the contents of the pericardial sac are purulent, flecks of hyperechogenic material may be seen. o Access for ultrasonography to the bovine heart may be difficult since in the lower thorax the ribs are wide and the space between them is very narrow Radiography o Largely confined to neonates o The major limitations of radiography are the inability to obtain dorsoventral radiographs in adult horses and cattle and the frequent presence of pleural fluid and pulmonary disease that obscures the cardiac silhouette on a lateral view. ▪ Size and mass of the bovine heart prevent clear demonstration of the internal divisions of the heart. o An outline of the heart can be delineated radiographically giving an approximate measure of size o Lateral radiographs of neonatal foals or calves, or adult sheep and goats, can be helpful in detecting cardiac enlargement (either dilatation or hypertrophy) that may result from cardiac disease. Specifically, determination of the vertebral heart score (VHS) that compares the cardiac silhouette dimensions with the length of specific thoracic vertebral bodies. Angiocardiography o Can be a diagnostic method of examination in congenital cardiac defects where the passage of contrast media through abnormal routes can be detected. Phonocardiography o Allows the recording and measurement of heart sounds. o A special microphone is placed directly over the various areas of the thorax used for heart auscultation, and the heart sounds are recorded graphically on moving paper or on an oscilloscope. o It can provide considerable information on heart sounds additional to that acquired by stethoscopic examination Cardiac Catheterization o measurement of pressure within the various chambers of the heart and in the inflow and outflow vessels can provide diagnostic information in both acquired and congenital heart disease in large animals. Pericardiocentesis o used to collect and assess pericardial fluid o The needle is inserted through the chest wall into the pericardial sac and fluid is allowed to flow or is aspirated using a syringe. o Fluid, which may be very foul smelling if infection is present, is aspirated for cytology, culture and drainage purposes. Blood Culture o Blood for culture may be taken aseptically from the jugular vein. This can be useful in cases of endocarditis, but repeated samples may be needed as bacterial release from valve lesions may be intermittent. Biomarkers of myocardial injury o serum concentration of cardiac troponin I (cTn-I) and cardiac troponin T (cTnT) isoforms are excellent biomarkers of myocardial injury in large animals because they provide a sensitive and specific indicator of cardiac injury Measurement of Arterial Blood Pressure o Use of oscillometric sphygmomanometry to detect arterial pulsations and therefore simultaneously determine heart rate and systolic, diastolic, and mean arterial pressure. ance with Section 185. Fair Use of a Copyrighted Work of Republic Act 8293, the copyrighted works included in this material may be reproduced for educational only and not for commercial distribution. -ICD-05-00 (081220)