ICVA NAVLE Exam Questions

Correct answer: Anemia of chronic disease

Animals with GI neoplasias may have intestinal bleeding contributing to anemia. However, given the lack of acute change in his overall clinical picture and an overtly normal physical exam (except pallor and weight loss), no tachycardia or bounding/weak pulses, you suspect anemia of chronic disease. This type of anemia occurs with a wide array of disease states. It causes mild to moderate normochromic, normocytic, and non-regenerative anemia. It is the number one reason for anemia in animals.

Iron deficiency anemias are rare in most animal species. 

Anemias of chronic disease are the most common type of anemia seen in animals and are non-regenerative by definition. Causes of regenerative anemias include immune-mediated diseases, trauma, and toxins, among other causes.

Correct answer: Gastrojejunostomy

All of the answers are technically feasible. However, if an excision and bypass are required, such as a gastrojejunostomy, or cholecystojejunostomy, are warranted, then the prognosis is very, very guarded, and tumor recurrence is very likely with likely clinical signs remaining after surgery and a poor quality of life.

However, if the tumor is localized only to the stomach and gastric resection is possible, it could be curative for adenocarcinomas or leiomyosarcomas (or related benign tumors). Gastric lymphoma, even if solitary, usually requires follow-up with chemotherapy, even with full removal.

Gastric tumors in dogs and cats are rare (<1% of all neoplasias). Cats most commonly get gastric lymphoma, while adenocarcinomas are the most common in dogs. Generally, by the time we identify the disease, metastasis has likely already developed.

Surgical exploratory isn't wrong to determine if the lesion is resectable. However, it is paramount to ensure one palpates and evaluates the entire GI tract and abdominal structures for abnormalities, including the liver, and biopsies any irregularities. Further, palpation of regional lymph nodes and removal of any with concern is warranted.  

Correct answer: She was a twin with a male

New-world camelids are predisposed to congenital and inherited abnormalities. Issues can include choanal atresia (failure of the inner nares to open during development) being the most common. Other abnormalities can include juvenile cataracts, ventricular septal defects, musculoskeletal defects, and angular limb deformities. Tail defects and umbilical hernias also occur. 

Urogenital defects seem to be much more common in South American camelids. They can include double cervixes, segmental aplasia of the vagina or uterus, and clitoral hypertrophy related to intersex conditions. Males can have hypospadias, ectopic testicles or retained testicles, and even a corkscrew penis. Either sex can be born with atresia ani.

Freemartinism is a specific problem seen in male/female twins. The female twin, if she shares a placental connection with the male during development, is born sterile due to exposure to masculinizing hormones the male produced. Generally, both twins are chimeras (XX/XY). The male remains fertile, while the female's reproductive tract is underdeveloped and she is rendered infertile. 

Mycoplasma haemolamae infections have been reported, and exposure occurs by insect vectors, transplacentally, or via contaminated equipment/needles. Those infected when healthy develop premunity—meaning they are infected but immune, showing organisms in their red blood cells only if stressed or immunosuppressed. This doesn't cause infertility. 

Copper deficiency results in poor growth and an increased risk of infection but doesn't lead to infertility. 

Correct answer: Retinal dysplasia and optic nerve hypoplasia/dysplasia

Feline Panleukopenia Virus (FPV) (AKA Feline Infectious Enteritis, Feline Parvoviral Enteritis) is a parvovirus that causes panleukopenia and enteritis syndromes in wild and domestic feline species globally. Further, it has been found in mink, foxes, and raccoons. It can replicate in ferrets but doesn't cause clinical disease. Usually, infection occurs in cats less than one year of age but can infect any age when unvaccinated. It commonly occurs as outbreaks in shelter-like situations, in barns, feral or stray cat populations, or indoor/outdoor cats without proper vaccination.

If a queen is infected early in pregnancy, she may abort, or the fetus may develop congenital abnormalities. Later in pregnancy, up to one-week post delivery, damage occurs by destroying Purkinje cells and granule precursors in the cerebellum, leading to cerebellar hypoplasia. Signs often begin about two to three weeks of age as kittens start to explore and walk more - with cerebellar ataxia being common. Intention-like tremors are often exacerbated when focusing, like while eating or playing. Most of the time, these patients can do great without complications. However, others may develop hydrocephalus, hydranencephaly, or porencephaly with forebrain changes. Because the virus can also infect non-cerebellar neurons, we can see ocular changes, including:

• Retinal folding
• Retinal dysplasia
• Retinal degeneration
• Optic nerve hypoplasia

Pars plantis represents inflammatory cells in the anterior vitreous in the presence of uveitis. It is a significant finding in uveitis in cats with Feline Immunodeficiency Virus (FIV). However, it is not pathognomonic for it.

Signs of enteritis, such as vomiting and diarrhea, are often evident in older infected cats. Though anorexia, dehydration, and lethargy may also occur, sudden death from peracute infection in young kittens is feasible. Some cats may maintain normal white blood cell counts, while others may have leukopenia (neutropenia +/- lymphopenia). A small subset due to secondary bacterial infections may have an elevated white count. Further, anemias, electrolyte changes, and low albumin may also be present. 

Correct answer: The American Veterinary Medical Association’s (AVMA’s) Principles of Veterinary Medical Ethics

The AVMA’s Principles of Veterinary Medical Ethics outlines the minimally accepted information that must be included in all medical records. Sadly, even these data aren’t always provided. Keeping complete medical records, including all client communications, all signed forms, all discharge information, all prescriptions (written and filled in hospital), all medical care in the appropriate SOAP format, patient’s age, sex, weight, and more all should be included, easily legible, and easily obtained.

Some individual companies have their own specific Code of Ethics and Business Conduct. Still, no particular law or principle in the veterinary field speaks specifically to this.

The veterinary oath does state that we will practice “in keeping with the principles of veterinary medical ethics.” Still, it doesn’t spell out in what way or discuss medical records.

The Principles of Ethical Conduct is an Executive order (#12731) from October 1990 about the Principles of Ethical Conduct for Government Officers and Employees. 

Correct answer: Large numbers of ticks, maggots, or other vectors

The clinical signs above describe a common finding in foot-and-mouth disease (FMD) cases. However, FMD is clinically difficult to distinguish from various diseases in cattle. Those with an asterisk are reportable in the U.S. (+/- globally). These include FMD*, vesicular stomatitis*, rinderpest*, bovine viral diarrhea virus, malignant catarrhal fever*, bovine papular stomatitis, pseudocowpox, infectious bovine rhinotracheitis, and bovine herpes mammillitis. 

Observations and clinical signs that should put you on high alert for a possible novel disease or foreign animal/transboundary disease include: 

1. Unusual (ornate) species of ticks or other vectors not normally present in the region/country
   2. Larvae in wounds
   3. Unusual/unexplained illness/signs
   4. Sudden deaths or loss in the herd
   5. Significant abortion rates in an otherwise healthy herd
   6. Central nervous system signs such as staggering, ataxia, or mental status changes
   7. Severe illness in a large group of animals (high morbidity)
   8. Vessicles, blisters, ulcerations, erosions around the oral cavity or coronary bands (as well as other regions such as teats and nose)
   9. Hemorrhagic septicemias

The farmer did the right thing by calling you out. Now you must contact the proper authorities to ensure a new disease, FAD, or other related condition hasn't made it into the U.S.

The clinical signs described above are common for Foot and Mouth Disease (FMD). However, they are clinically indistinguishable from vesicular stomatitis, and diagnostics are needed to determine the etiology and differentiate it from other vesicle-producing conditions. 

Many diseases can cause sudden abortion or abortion outbreaks that are not FADs. But the presence of vesicles in the oral cavity and coronary bands, the presence of large numbers of abortions, and sudden deaths must give us pause. Triggering an appropriate sequence of events, including notifications up the chain as dictated by your local standard guidelines and state and federal protocols and regulations.  

Correct answer: Apply the cast with the leg held in a slight valgus and flexion

When applying a cast, key concepts include:

1. Casts must span joints above and below the fracture to ensure stability and healing.
2. When applying the cast, hold the affected leg in a slight varus position and flexion.
3. Extend the cast distally, including the toes, but leave the toenails of the middle two digits just barely exposed.
4. Take care to prevent excess padding. Excess padding loosens the splint after the cast padding has been compressed.

Correct answer: Wear a fitted respirator

Proper PPE (Personal Protective Equipment) is regulated and required of all antineoplastic chemotherapeutic agents. These drugs have the potential to be teratogens, carcinogens, or mutagens. Unplanned exposure to the veterinary staff of these agents can occur via:

1. Drug contact with the ski
2. Drug contact with mucus membranes
3. Inhalation of a medication that has been aerosolized during administration or preparation
4. Ingestion

Safe handling practices are crucial to ensure staff safety. Using biosafety cabinets and close-transfer stations for aerosolizing agents is paramount. PPE is advised, including impermeable long-sleeved gowns, booties, hair coverings, goggles or face shields, and chemo-rated gloves (ideally two pairs). Some cytotoxic agents also recommend the use of an appropriately rated respirator. Special care and handling are required while working with these agents. Vincristine is a vinca alkaloid antineoplastic drug most commonly used for hematopoietic cancers, hemangiosarcoma, or lymphoid neoplasias. However, it has a special ability to induce thrombocytosis at low doses. Thus, a single dose given at the start of treatment for ITP can dramatically improve the speed at which the platelet numbers rebound. 

Correct answer: Erysipelothrix rhusiopathiae

Erysipelothrix rhusiopathiae is contagious to humans, though uncommon. Erysipelothrix rhusiopathiae, while negatively affecting the heart, has been shown to cause pericarditis, not myocarditis. This organism is capable of infecting pigs of any age and causing significant economic losses. Relevant species in pigs include E. rhusiopathiae primarily, though E. tonsillarum has been isolated from vegetative endocarditis lesions and in chronic arthritis cases. These bacteria are non-sporulating, not acid-fast, nonmotile, facultative intracellular, facultatively anaerobic, and gram-positive rods.

Though rare in people, it is considered zoonotic. The domestic pig is the largest reservoir, with 30–50% of pigs acting as healthy carriers. The organism is housed in the tonsils and other lymphatic tissues. Shedding occurs by clinical or carrier pigs in the urine, feces, saliva, and nasal mucous for long periods.

Transmission arises via the fecal-oral route directly or via a contaminated environment. Disease in pigs is most likely between three months and three years of age. In pigs, it causes an acute, subacute, and chronic form.

The acute form causes septicemia leading to abortions, lethargy, fever, painful joints, depression, laying down, not wanting to get up, stilted gait, reluctance to move, decreased appetite or anorexia, acute sudden death, and a characteristic firm either pink, purple, or red diamond shaped skin lesion. If non-fatal, lesions vanish in four to seven days.

FMD is an all too familiar, very contagious viral disease of wild and domestic animals (cloven-footed) and others. Lesions are confined to the feet, snout, and inside the mouth with vesicles, and all ages are at risk. It has been eradicated from the U.S. on nine occasions, remaining free since 1929. Since the lesions are indistinguishable from other vesicular diseases, they must always be on a differential list when seen.

FMD is an Apththovirus, with distinct immunological types A, O, C, SAT, 1, 2, 3, and Asian 1. One antigen (Virus Infection-Associated Antigen, or VIA) is common among all and helpful in diagnosis. However, new subtypes continue to develop. Transmission is via aerosolization and direct or indirect contact. The spread has been shown to be far-reaching, at as great as 30 miles with the appropriate weather. Many pigs are then amplifier hosts and shed a tremendous amount, contributing to the widespread dissemination. The virus adheres to the respiratory tract's mucosa, where macrophages transport it to the mucosa, epithelium, and myocardium. There it replicates, leading to viremia. Shortly, vesicles develop (in areas with mechanical stress) on the feet, snout, mouth, and tongue in swine. Vesicles may slough over time. Juveniles and neonatal pigs often develop severe myocardial necrosis leading to sudden death, resulting in classic lesions referred to as "tiger-heart" lesions, which can help with diagnosis (mottled myocardium).

Signs include initially lameness, then fever with chomping and slobbering. Abortion/stillbirths may occur or sudden death. Initially, lesions appear blanched, with small foci on various areas. Once readily apparent, they are vesicles or bullae. Mortality is low except in very young pigs.

PPRSV (Porcine Reproductive and Respiratory Syndrome Virus) is an enveloped RNA virus in the Arteriviridae family. The disease has two clinical phases, the first causing reproductive failure and the second, respiratory disease post-weaning. If a naive herd is infected, not all will develop clinical disease, leading to a persistently infected subpopulation and carrier animal state. Since eradicating Classical Swine Fever, PRRSV is considered the most costly disease in the global swine industry.

Disease transmission occurs via direct contact and through contaminated semen.  Aerosolization and fomite transmission also contribute to disease spread. It is not zoonotic. Experimentally, insect vector transmission can also occur.

Reproductive disease phase: Stillbirths and mummies incidence may be up to 25–35%, and over 10% may abort. Anorexia and lack of milk production can lead to higher preweaning mortality rates of piglets. This form can last one to four months, depending on the health of the pigs at infection and various facility characteristics.

The respiratory phase tends to occur in suckling piglets, and they may develop thumping respirations and conjunctivitis, with interstitial pneumonia on histopath being common. Piglets may be born viremic and serve as another source of transmission. This post-weaning phase may become chronic, causing decreased total weight gain and 10–25% mortality. Other infections may occur concurrently, including Streptococcus suis, Salmonella, Mycoplasma, and swine influenza, among others.

Gilts, sows, or boars may show reproductive abnormalities,  fever, lethargy, waxing and waning, anorexia, and sometimes respiratory distress or vomiting. Mild cyanosis of the ears, vulva, and belly can occur, as well as dyspnea in nursing animals (thumping). Signs may cycle depending on when animals are exposed and shed. Multiple strains may infect a single herd and are not fully cross-protective. 

Young, growing, and finishing pigs may show depression, stunted growth, fever, lethargy, and pneumonia. Sneezing and expiratory dyspnea also may occur along with stunted growth.

Control is key, but there isn’t a single control strategy that works. Ideally, establishing ‘herd immunity’ minimizes transmission and subsequent losses. But quarantine of boars for 60-90 days before introducing them to the females in a negative herd is critical. Vaccination may be utilized as a part of a control strategy. Still, it cannot be the only measure as they are not 100% effective. Depopulation and appropriate cleaning measures then, obtaining all new animals PRRSV free is an option. If one doesn’t want to depopulate, they can close the herd for a minimum of 200 days, stabilizing the herd. But the risk of re-infection is high, and biosecurity protocols must be airtight.

Diagnosis most commonly relies on ELISA measuring the IgG antibodies. However, it cannot assess the level of immunity or predict carrier state animals. Titers are evident seven to ten days post-infection and may persist up to 144 days. Test options also include virus isolation, immunohistochemistry, and PCR. Sampling oral fluid from entire pig populations has been used widely as a screening method.

Modified live vaccines provide some protection and may limit shedding, but no treatment exists. Prevention is paramount.  

PRV, AKA Aujesky’s disease, is a significant disease player in the swine industry. It was eradicated in the U.S. in 2004. It consists of three overlapping clinical syndromes affecting either the nervous, the reproductive, or the respiratory systems. PRV is an alphavirus subfamily of Herpesviridae. It can persist in a carrier (latent state) and easily be destroyed by many disinfectants.

Transmission occurs via contact and exposure to saliva, nasal excretions, urine, and feces. The virus can survive in carrier pigs’ tonsils for several weeks and in the CNS for months. Thus, stress can precipitate recrudescence and subsequent re-shedding. It spreads through direct contact, contaminated food/water, and aerosolization.

Clinical signs vary depending on the age of the pigs affected and the immune status of the dam. Younger appear more affected, while older pigs are more resistant.

Sudden death in the very young may be the only clinical sign. Nursing piglets often show neurological signs. You may see very high fevers, conjunctivitis, anorexia, tremoring, depression, vomiting, foaming at the mouth, dog-sitting, paddling, blindness, seizures, coma, and death within one to three days.

Pigs three to nine weeks of age, already weaned, generally have respiratory signs predominate, such as nasal discharge, sneezing +/- cough, and labored breathing. The mortality in nursing pigs can reach 100% but is lower in this age group. Most survive unless they develop secondary bacterial pneumonia.

Ten weeks to market weight morbidity is high and respiratory signs also predominance. They may be febrile, sneeze, cough, have nasal discharge, have depression, or be anorexic. Some will also develop CNS signs. However, most recover in seven to ten days.

Breeding animals may have respiratory disease with full resolution, though, reproductive failure is possible, including mummified fetuses, stillbirths, or weak pigs,  in the second or third trimesters.

Swine are the natural domestic animal reservoirs. Vaccinations are highly effective, but all ages are susceptible if not vaccinated. In the commercial U.S. swine industry, the disease has been eliminated. However, a reservoir still exists in some feral populations and is prevalent in other countries. If other species, such as sheep, cattle, dogs, cats, or goats (not horses), are kept in close proximity to pigs, they are susceptible, and death usually occurs in aberrant hosts. Several wild rodents, rabbits, and fur-bearing mammals can become infected. It is not zoonotic.

There is no treatment but weaned and older pigs do tend to recover.

Correct answer: Moderate to severe gingivitis with moderate calculus formation

• No gingivitis or tartar evident characterizes a dental grade of 0.
• Minimal to mild gingivitis with the mild formation of plaque characterizes a dental grade of 1.
• Mild to moderate gingivitis with a moderate plaque and calculus formation characterizes a dental grade of 2.
• Moderate to severe gingivitis with moderate calculus formation characterizes a dental grade of 3.
• Severe gingivitis with severe +/- bridging calculus +/- obviously loose teeth characterizes a dental grade of 4.

The COHAT terminology should be used in place of dental cleanings, or dental, so that owners fully comprehend the depth and breadth of what is accomplished during a "dental," the benefits of dental radiography (which should be standard of care; not optional), and are informed of ways to prevent worsening disease. Owners who seek out COHATs when their pet has a grade 1 or 2 ensure that the pet doesn't develop severe disease, is at low risk for systemic spread of disease, and can save teeth and lessen the risk of pain and suffering. Further, the procedure at this stage is also much less costly for the owner.

Correct answer: Werneckiella equi equi

Pediculosis in horses is caused by two types of biting lice (Bovicola equi and Werneckiella equi equi) and a sucking louse, Haematopinus asini. Infestations are most common in the winter due to the breeding cycle of the species. Lice are obligate ectoparasites, thus, species-specific. Pruritus is a hallmark of infestation, with the tail and neck most commonly affected. They can develop patchy and dry coats and alopecia with crusts and ulcerations. They are visible with a simple hand lens. They will come to the surface and be even more readily visible after exercise.

Trombiculidiasis, chiggers, or harvest mites, cause infection/infestation with crusts and papules commonly on the limbs, neck, and face. They are variably pruritic. If found with a lens, you can see the larval mites of Eutrombicula alfreddugesi (North American species of concern) in the late spring to early fall. They are red-orange larvae and six-legged. You can also find them via skin scraping and impression smears.

Finally, Psoroptes species are the causative agent of "mange" in large animals, including horses, though host specificity remains controversial. Psoroptic mange has been eliminated in the U.S. in horses and sheep, though it remains an issue in cattle. The hallmark of mange is also pruritus, which can be severe. Horses most commonly develop lesions at the mane’s base, the tail, ears, and intermandibular regions, then the trunk. These include alopecia, scaling, and crusting. These are not visible with the naked eye or a lens and must be identified on skin scraping/impression smears.  

Correct answer: Chemotherapy

Most exocrine pancreatic tumors are epithelial in origin, arising from the ductal or acinar epithelium (vs. insulinomas which arise from the endocrine pancreas' islet cells). This condition is rare (< 0.05% of cancers in dogs/cats). An association between pancreatitis and the development of this condition has been researched. Clinical signs can include weight loss, appetite changes, weakness, maldigestion, abdominal distension, effusion, vomiting, and icterus. Radiographs, ultrasound, FNA of the mass, and CT or MRI may help identify metastatic disease before considering surgery. Most patients have advanced disease by the time of clinical diagnosis; thus, 50–70% already have metastatic disease in either local lymph nodes or distant sites. Treatment is surgical with a complete pancreatectomy or pancreaticoduodenectomy (Whipple procedure). But cure rates are low, and complications arise. Chemotherapy and radiation aren't of much use (especially without surgery).

Palliative therapy, such as treating current vomiting, rehydration, addressing pain, and periodic abdominocenteses with intracavitary chemotherapy, may be attempted, but results are usually short-lived.

Due to the poor prognosis and high metastasis rates at the time of diagnosis, while surgery can be attempted, intraoperative euthanasia must be brought up to the owners as a possibility before surgery. If the surgeon opens the patient up and carcinomatosis or other signs of metastatic disease exist, the owners need to be updated so that they can make an informed decision.

Correct answer: Pyometra; apply for financial support to permit surgery with you

This patient has a pyometra or an infected uterus. She has an elevated temperature and is likely sicker than the client realizes, especially if she has multiple cats. Further, these animals can be dehydrated, painful, and require supportive care, including fluids and IV antibiotics. She may need nutritional support if she hasn't eaten in a while. The ideal thing for her would be to have the surgery at your facility. This patient would greatly benefit from 24-hour care and may require 24– 48 hours on IVF, IV antibiotics, and ovariohysterectomy to remove the infected uterus. Knowing this, you recommend applying for your hospital's available payment plan options, such as Care Credit or ScratchPay.

Some owners either won't apply for financial assistance, know they will not get approved, or do not want it and request an alternative therapy. Some rescue organizations or humane societies provide low-cost surgery options, including pyometra. However, they do not provide hospitalization or supportive care after surgery; those patients have a higher risk of complications, including death. However, you still must offer this to the owner as an alternative. It is better for the cat to get the care, even if it's not the 100% gold standard, than no care or having the owner euthanize the animal for an otherwise treatable condition.

Oral antibiotics may be beneficial in the short term, but ultimately the uterus must be removed. Luckily, this is an open pyo and, thus, not a true critical emergency that has to be cut at that minute. However, the cat still requires surgery in the near future. If she isn't eating, oral antibiotics will cause GI upset and further dehydration and debilitation.

Pseudopregnancy can occur and doesn't require any therapy. However, it wouldn't cause purulent vulvar discharge or a fever.

By discussing the levels of care available and the associated costs, the client can make an informed decision, knowing the pros and cons of each option. 

Correct answer: High humidity

Coccidial infections in many ruminants are self-limiting and may remain asymptomatic. Clinical signs may debelop, if proper hysbandry and management practices aren't followed secondary to high oocyst environmental contamination. Kids seem to be highly susceptible, and, as a result, this may lead to chronic diarrhea. The causative genus in ruminants is Eimeria sp. Eimeria infections in sheep cause significant economic losses. When clinical signs arise, we can see diarrhea, dehydration, weight loss, wool breaking, anemias, appetite changes, and even death in the young. Those at highest risk are lambs in the one-to-six-month age range, those kept in lambing pens, those raised on feedlots, or those with intensive grazing locales. Risks increase with crowding, stress, weather changes, shipping, and contamination from other animals. Goats show similar signs, though they can also experience constipation and death without ever developing diarrhea.

Measures to reduce exposure and contamination are paramount. The following measures can help control coccidiosis on farms:

• Decrease stocking rates: Reduces exposure to and contamination by oocysts
• Properly dispose of manure: Reduces exposure to and contamination by oocysts
• Elevate feed troughs: Reduces exposure to and contamination by oocysts
• Clean water troughs regularly: Reduces exposure to and contamination by oocysts
• Increase sunlight exposure: Kills oocysts
• Lower the humidity: Kills oocysts
• Properly clean and then disinfect with ammonia, methyl bromide, or formaldehyde
• Prevent rotating all juvenile animals through various different stages
• Place animals in age-matched pens, outside enclosures

The goal is to avoid the need for prophylactic coccidiostatic medication to ensure appropriate antimicrobial stewardship practices and minimize animal exposure to various medications.

Note that eradication is generally not feasible, so practicing key management practices and ensuring safe, appropriately timed deworming protocols is key to minimizing economic and animal losses.

Correct answer: Diazepam 0.5 mg/kg IV

Pyrethrins are common insecticides used in sprays and spot-on therapies in dogs to treat/prevent ear mites, fleas and ticks, and other related organisms. Canine spot-on products often contain 40–50% active ingredients, and it is thought that anything greater than 5–10% can lead to systemic illness in cats due to their glucuronidation metabolism differences.

Exposure can occur when owners apply dog products to cats or when cats are permitted in close contact (grooming, rubbing up against) dogs with applied products. They should be separated long enough for the product to completely dry if used in the same household.

Signs can include drooling, nausea, vomiting, disorientation, tremors, seizures, hyperexcitability, hyperthermia, weakness, tachypnea, or dyspnea.

Tremors most frequently respond to methocarbamol, ideally IV, as oral onset is slower. These tremors are much less responsive to benzodiazepines, and seizure activity is also less well controlled by benzodiazepines. Phenobarbital (4–16 mg/kg IV PRN to effect) or gas anesthesia is much more effective at controlling seizure activity induced by pyrethrin exposure.

Dermal decontamination is absolutely necessary but must be performed after stabilization. once stable enough to bath, bathing in cool water with Dawn®'s original liquid dish soap can help to remove the remaining product and lessen the chance of continued exposure and toxicity. Monitoring needs to include body temperature, hydration status, and sugar levels.

Clinical signs can last for 24–96 hours. The prognosis is usually good with aggressive therapy and decontamination.

Sometimes, however, cost plays a role in care, and some owners cannot afford hospitalization and supportive care. In those animals or in animals whose signs are severe, fail to respond to medications, or are declining, the use of intralipids can be utilized.

An intralipid bolus of 1.5 ml/kg can be administered in severe cases. In milder cases, just the CRI may be utilized 0.25–0.5ml/kg/min.  

Intralipid use may limit the need for anti-tremoring/anti-seizure medications and shorten hospital courses.

While many have used intralipids, they are off-label, and we still lack high-grade evidence supporting their use. Randomized controlled trials ideally are needed to determine more about ideal dosing. Thus, it isn’t usually the first thing we reach for though it has been shown to be beneficial.

Correct answer: Penalties

While there is no definitive way to write an SOP, there are some common things that should be included, and these include:

1. The document's statement of purpose as we want to clarify for what and to whom the document is written and to what end goal. In the case of animal handling, we want to ensure the safety of all personnel, patients, and clients. We want to establish a system for animal handling with options for the "what-ifs" when things go awry. We want to include personal protective equipment such as muzzles but also consider special types of muzzles and animals at higher risk for complications with certain types of muzzles, like brachycephalic breeds.
2. The scope of the SOP, including who it applies to and any necessary supplies, clearly ensures you spell out who is covered in the scope and what is so that everyone understands and nothing is left for interpretation. 
3. The detailed procedure outlines/explanations: We want a section that goes into detail about using various things like leashes/collars, muzzles, tie-gauze, rabies poles, blankets, towels, and other items we may need for restraint. We want to discuss what is acceptable, and what is unacceptable, behaviors or techniques. 
4. We want to have a list of supplies. 
5. We want a list of possible complications, problems, such as bites/scratches, and means to mitigate any issues, including the necessary reporting procedures for injuries. 
6. Often, a list of terms/definitions is included. 
7. Ideally, references are valuable to document why your practice choices to use a device or means of restraint vs. why you don’t. Using medical-based evidence to help guide your protocol shows staff that the information isn’t just put together for fun; it is based on science and something your practice chooses to adhere to.
8. SOPs should be short and developed for individual tasks.

Generally, SOPs do not include penalties for failure to comply. 

Correct answer: Vitamin D₃ supplementation

This patient was being treated for metabolic bone disease, specifically for Nutritional Secondary Hyperparathyroidism (NSHP). This metabolic disorder is, sadly, the most common of the Metabolic Bone Disorders (MBDs) in reptiles and is sometimes called "rubber jaw" because of the softness that develops in the jawbones and the facial deformities that may arise. It results from a combination of factors, including the following:

1. Improper dietary ratios of calcium-phosphorus. This could result from too little vitamin D₃ sources and/or too little calcium supplementation. 
2. Insufficient UVB light exposure in diurnal species (insectivorous and herbivorous lizards and chelonians). Those that are carnivorous or eat living prey and those that have a nocturnal lifestyle rely exclusively on the diet for their vitamin D₃ sources. Vitamin D₃ is required to ensure proper calcium and phosphorus regulation in the body. Diurnal species, as described above, require sunshine to synthesize sufficient amounts of D₃ to aid in metabolism that facilitates calcium absorption from the GI tract. These animals require a UVB source when kept indoors, but if feasible, exposure to true sunlight is always preferred. Vitamin D supplementation is not recommended because there is a very narrow therapeutic window, and vitamin D toxicity occurs easily. 
3. Physical hazards. Provide a safe enclosure and habitats with a lot of padding and minimize climbing obstacles and other activities that could increase the risk of pathological fractures until the bones are able to heal and the osteopenia improves.
4. Vitamin A deficiency. Oral vitamin A supplementation is also advised, as this is key to renal health. Since negative consequences can affect the kidneys (renal secondary hyperparathyroidism) and the bones, vitamin A supplementation is crucial to recovery.

Recheck radiographs and bloodwork (to evaluate calcium levels and renal values) to monitor improvement. 

Prognosis with MBDs in reptiles varies with the degree of systemic illness, the severity of bony and/or renal lesions, the presence and locations of fractures, the return to normal ambulation/function, and the owner's willingness to take part in the recovery process. Euthanasia may need to be considered for animals with fractures causing paralysis/paresis that affects their ability to defecate/urinate/lay eggs.

Correct answer: Normalization of PCV/TS

While monitoring the PCV/TS can help assess rehydration status or for fluid overload, it doesn't fully demonstrate key endpoints we need to ensure that shock resolves/responds to therapy.

Endpoints of resuscitation must also be evaluated in the context of the patient and clinical signs. Not all patients follow the rule books, as this patient didn't. Improvements in only a few parameters don't indicate complete resolution of shock.

Endpoints include the normalization of the:

1. Heart rate
2. Respiratory rate
3. Blood pressure
4. Improvements in pulse quality
5. Improvements in blood lactate concentration
6. Improvement of capillary refill times

Further, while some parameters may normalize, the patient may still have poor oxygen delivery at a subcellular and cellular level. Thus, additional parameters include base excess, lactate, and hemoglobin saturation. Once physical exam parameters improve/ normalize, biochemical endpoints can be evaluated.

Despite aggressive therapy, this patient's low dose micro CRI of dobutamine to improve cardiac output (per a criticalist's recommendations) and intensive management failed to respond as expected. Failing to address the underlying cause rapidly enough or missing the whole picture (unable to obtain an ultrasound until morning) means something may have been missing. It may mean that full resuscitation isn't feasible. Was this a bad pyelonephritis and pancreatitis with gastric wall edema? Was the renal pelvis mineralization clinically significant in this patient? Was there cancer hidden? These owners elected humane euthanasia because of her lack of improvement/stabilization. The renal mineralization, the only noted radiographic abnormality by the radiologist, and normal cardiac size/vasculature, do not provide sufficient information.

Correct answer: The mother is stable, with normal bloodwork

Animals may require a C-section for various reasons:

1. Certain breeds often require them, including Boston terriers, French and English bulldogs (French bulldogs more frequently require this), some mastiff breeds, and Scottish terriers
   2. Animals with previous c-sections may require them for future deliveries
   3. Brachycephalic and small-breed dogs may need them more often than large-breed dogs 
   4. Dystocias (due to malpositioned, maldeveloped, or oversized fetuses)
   5. Small pelvic canals
   6. Uterine inertia
   7. Hypocalcemia (prepartum preeclampsia) is common in animals without prenatal care and not fed an appropriate puppy food or supplemented correctly during pregnancy
   8. Fetal putrification

If the owners do not want to save the uterus and plan to spay the patient during c-section, en bloc OHE (Ovariohysterectomy) can be considered. This means that the uterus is removed before a hysterotomy (incision in the uterus) is made to remove the neonates. This can be done if the mother is not in distress, her electrolytes and other parameters are stable, and the fetuses aren't in distress. If, however, they are in distress, a uterine incision and delivery of the puppies should be undertaken before spaying the patient. Even if the owner has not elected OHE, removal en bloc of the uterus may be needed if the uterus is of questionable health.

Correct answer: Hold on vaccinating for rabies and require a recheck in ten days, at which time you will then booster the vaccine

Each state has different rabies laws, different definitions of what defines animals that are required to have rabies vaccinations, and durations of quarantine for animals who bite someone or are bitten by an unknown or unvaccinated animal. Always check your state's laws and know what is required of you.

Whenever there is a bite wound of unknown origin, we want to boost the rabies vaccination, even if it was recently boostered. This helps lessen the risk of disease. The vaccine is considered safe and effective, and since rabies vaccination reactions are uncommon, the benefits outweigh the risks. But, again, check with your state's laws to ensure this is acceptable.

Rabies is a public health and zoonotic concern. Who you report cases of hoarding, concerns for animal welfare, concerns for failure to oblige to clinical recommendations, and quarantine recommendations may vary from state to state and even local jurisdiction to the local area. However, report this client to someone. People with large numbers of cats often do not understand the significant risks to themselves and others they take on by not vaccinating for rabies, by allowing the intermingling of cats that go inside with those outside, risks of FELV/FIV, and other infectious diseases. These animals may be well taken care of. Still, often they are lacking in veterinary care, parasitic control measures, and warrant welfare checks. Further, if your state has specific laws regarding quarantines, it isn't your job to enforce them or ensure your client complies.

The cat should be kept indoors only for two weeks, the expected duration for the wound to heal (give or take). Keeping the cat indoors with an e-collar protects it from predators, allows the owner to monitor the wound healing, protects it from the elements, and keeps the cat safe. By having them confine it, you suggest quarantine without necessarily using the term. However, in this case, a quarantine would be appropriate and may be required by your state. The cat should be separated from other cats to prevent the spread of disease, allow healing, prevent aggression/behavioral problems, and ensure that this cat eats and drinks well and has normal urination and defecation.

The fact that this pet has a history of rabies vaccination lessens the chance of rabies being a concern but vaccination and quarantine is still recommended. The duration of that quarantine varies with each municipality and laws, ranging from 45 days to up to six months.

Suppose a dog or cat is suspected of having rabies. In that case, this is reportable immediately, and the animal should be isolated or euthanized and tested.

If a dog or cat bites a person, the ten-day period comes in. A health check is done the day the animal bites a person. Then the animal is quarantined at home for ten days, and then another evaluation is required. If the animal dies or is euthanized during those ten days, it needs to be rabies tested. If it remains healthy, it is unlikely to have even been able to transmit rabies, let alone have it. This occurs regardless of the rabies vaccination status of the animal. No vaccination should be provided during the ten days, but it can be boostered after that time if it has lapsed.