At the moment, the protocols of opening a cow or calf are perhaps the main documents on the basis of which conclusions are drawn about the death of an animal. But the autopsy is carried out not only to identify the causes. Thus, veterinarians can draw conclusions about the correctness of the diagnosis and prescribed treatment. Today we will analyze the issue of drawing up and maintaining such medical documents using a concrete example.
Who makes the documents
It is accepted to call a set of actions by pathoanatomical research, which combine external examination, taking analyzes prior to the autopsy, the actual opening itself and drawing up a protocol with accompanying documents, such as an act and accompanying note.
In medicine, only certified doctors, pathologists or prosectors have the right to deal with such things. According to the existing laws and rules of the Russian Federation, in the field of veterinary medicine, the autopsy of animals is carried out by veterinarians and vets. Concerning the cattle, the livestock specialist can also keep documents with the right to confirm the signature.
If an autopsy is performed for the purpose of routine diagnostic or scientific research, only medical staff is allowed. When it comes to suspicion of an infectious disease or an epidemic, the presence of the owner of the animal and representatives of federal or administrative authorities is obligatory, these persons are not responsible for the 4th and 5th parts of the protocol.
There is also a forensic veterinary autopsy, to which representatives of the investigation or specialists equating to them are invited.
In general, according to the rules, pathological-anatomical studies of such a plan are supposed to be carried out no later than 15 days from the moment of death of the animal. In this case, the corpse should be stored in a special chamber at a low temperature (not higher than 5 degrees). But, the later a cow or calf is cut, the lower the likelihood of making a correct diagnosis.
It is caused by the fact that the processes of corpse decomposition, which inevitably start immediately after death, can be superimposed on changes in the animal's body, caused by any disease. As a result, the clinical picture changes and it is difficult for doctors to reach the truth. Therefore, experts are trying to conduct an autopsy immediately after receiving the primary analyzes.
The initial inspection, and especially analyzes, is a very important point. Indeed, according to the law, it is forbidden to cut animals that have died from such deadly diseases as anthrax or rabies. These animals are opened only by special permission, and not on the premises, but in special clinics in compliance with all precautionary norms.
What parts does the protocol consist of?
The autopsy protocol consists of 5 sections:
- introductory part;
- a description of the condition of the animal before preparation (external examination);
- internal inspection;
- making a diagnosis based on the results obtained in the second part of the study;
- conclusion of the diagnosis.
The style of presentation of information in all these parts should be businesslike, as informative and concise as possible. The description of any assumptions is allowed only in 3 and 4 parts. In this case, it is desirable that assumptions, if possible, be supported by the bases on which they were made.
If an autopsy is caused by a disease, then at the time of opening of the protocol, the owner must deliver the history of the cow. There should be all records relating to treatment, prescribed drugs and the course of the disease in general.
If you do everything according to the letter of the law, the term “autopsy” in the protocol should be replaced by the term “autopsy” or the term “necropsy”, which in this case reflects the same actions.
The introductory part begins with an indication of the affiliation of the animal, its breed, as well as color and, if possible, the exact age. Further it is surely written who exactly performed the autopsy, who conducted the protocol, and which responsible persons were present.
The introductory part concludes with a description that lists the indications on the basis of which the animal was decided to anatomize. This includes the death symptoms and the time of death. In some cases, preparations that were given to the animal are still indicated.
Autopsy protocol calf Hereford red breed with a white head. Death came at the age of 28 days.
Further listed specialists who performed the autopsy.
Anamnesis (information obtained during the examination): until the exacerbation, the animal was kept together with the calves of the breed. Removed from the herd on 10.02.2010, with suspected gastroenterocolitis. Visual inspection revealed hypotrophy (underdevelopment). Prescribed treatment (treatment). On February 16, 2010, shortness of breath appeared, after which the calf died on February 17, 2010.
Examination of the corpse
The description begins with listing all known data on the corpse, up to the position in which the animal lies at the time of the autopsy.
At the time of death, the calf was 28 days old. The sex of the animal is a bull. The accompanying documents are listed under the number number. Weight at the time of death - 40 kg, a breed of Hereford, a red suit with a white head. Build normal, without pathologies, hypotrophy is seen.
The architecture of the corpse: the calf lies on the right side with legs extended.
The next part of the survey describes the condition of the corpse. It indicates the body temperature and the presence or absence of signs of rigor mortis.
Next is a detailed description that begins with a statement of the state of all external and internal openings. In cows, it is the mouth, nasopharynx, anus, and appearance of the genitals. After that, the condition of the skin is described, as well as the horns and hoofs.
An important point is the condition of absolutely all lymph nodes, which can be assessed visually and feel manually. Separate items highlighted the condition of the skeleton of the bone, tendons and joints. External examination ends with a description of only fatal changes, that is, the presence of stains, coagulated blood.
Internal examination - the first part
Internal examination is the most important part of an autopsy. Here the state of all organs is described in detail and consistently.
After opening the abdominal cavity indicates the presence and approximate amount of fluid inside. Have pathologies been found in the state of internal organs and what are these pathologies. Be sure to indicate the color and condition of the serous integuments, as well as the location of the diaphragm.
On examination of the heart, the presence or absence of fluid and the pericardium (appearance) of the organ are indicated. Description of the oral cavity begins with the state of the tongue, its color and the presence of non-characteristic raids. Then the muscles of the tongue and teeth are described.
Autopsy of the pharynx, esophagus and larynx indicates the presence of extraneous masses, the condition and color of the mucous membranes of the organs.
Especially carefully performed autopsy of the lungs. It is important to specify the color of each lung individually and by sector. Is there fluid in the lungs, and what kind of fluid is it. Are traces of inflammation and specifically pus. The same section describes the state and the detected changes in the bronchi.
Internal examination - the second part
Following the lungs there is a step-by-step description of the autopsy of the cardiovascular system. The first to examine the mediastinal lymph nodes, and indicated not only the size but also the type of walls in the section.
The description of the heart begins with indications of its size and shape. On examination of the ventricles, it is necessary to indicate the presence and condition of the blood in them. Behind this is the state of the valves, the color and condition of the myocardium, the proportions of the walls of the ventricles and the endocardium. The cardiac description ends with an assessment of the main blood vessels.
At the opening of the spleen, its volume, appearance and specific dimensions in centimeters are indicated. Separately indicate the color and condition of the capsule.
Autopsy of the liver begins with the gallbladder. It indicates the fullness of its bile, the state of the ducts, the color and consistency of this bile. In addition to a visual assessment of the size of the liver, its dimensions in centimeters must be indicated. As well as color, constitution and type of fabric on the cut.
Internal examination - the third part
The opening of the kidneys begins with a visual assessment of the capsule and how easily it is separated. Indicates the color, constitution and size of the kidney in centimeters. A separate graph is an assessment of the edges of the incision and scraping. The assessment of the kidneys is completed with a description of the color and condition of the renal pelvis and ureters.
When opening the bladder, you need to indicate how much urine was in it, and in what condition this urine was. That is, color, the presence of turbidity and extraneous patches such as flakes. After that, the color of the mucous membrane of the bladder is described.
A description of the autopsy of the stomach begins with an assessment of the contents of the scar. In general, the contents of all parts of the stomach of cattle is given special importance. Along with this, it is important to assess the condition of the mucous membrane of the scar, mesh, book, and abomasum.
Behind a stomach there is a description of a small, ileal and large intestine, and also a rectum. Here the actions are similar. First, the content is assessed, followed by the condition and color of the intestinal mucosa by department.
Internal examination - the fourth part
The condition of the genital organs in calves is assessed in terms of their level of development. In adult cows and bulls indicated the permeability, fullness and external data of the mucous membranes.
In the brain, the state of the blood vessels, namely the level of their fullness, is first assessed. Then the state of gray and white matter is indicated.
The spinal cord is described in approximately the same way. You need to start with the blood vessels and the state of the medulla, plus here it also indicates how clearly the border between gray and white matter is visible.
Inspection of the nose start with the number and assessment of the mucus that is in it. Then the color and changes of the mucous membrane are described. The maxillary and frontal sinuses are described separately, but in the same way: content plus mucous membrane.
Diagnosis, conclusion and supporting documents
In the "diagnosis" section, all diagnoses identified during the autopsy are listed in succession. For example: gastroenteritis, inflammation of the pulmonary system, cardiovascular diseases. It is noted that if you do not take into account the epidemic, the cattle mostly die from intestinal and lung diseases, although there are exceptions.
In the protocol itself, the conclusion consists of several lines — only the most necessary. This section is described in more detail in the act and explanatory note, which are compiled on the basis of the protocol.
The act consists of an introductory part, which is completely copied from the protocol header. For the entry repeated diagnoses and conclusion. The last point in the act are recommendations. This section is filled only by experts and contains recommendations to prevent the death of other animals. An accompanying note is drawn up if any organs are sent for additional research.
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