ICVA NAVLE Exam Questions

Correct answer: Withdrawal interval is 168 hours, and testing after

When antibiotics are used in an extra-label-use manner, one looks at the Withdrawal Time Interval (WDI). This is a scientifically-derived recommended withholding time for a drug in food animals, which differs from the WDT or official withdrawal time for a drug. WDTs are set by the FDA for all officially labeled uses of drugs used in food animals. They can be found in the VetGram or at the FDA's Center for Veterinary Medicine. Because we are using this off-label, a WDI, not a WDT, is appropriate. For intrauterine dosing of < 2 grams of oxytetracycline, a single dose requires 28 days meat withdrawal interval and a 72-hour milk window with testing after that 72 hours. For doses, 4–6 grams, the WDI for meat is 35 days, and for milk, 192 hours, and then test for drug residues.

Correct answer: The use of barrier protections will help decrease the spread of disease by up to 75%

Even in veterinary hospitals, we cannot rely on PPE alone to guarantee we will not spread disease from one location or animal to another. A systematic review in veterinary hospitals showed that 25–100% of locations still had contamination despite appropriate PPE. Further, using PPE properly can be costly, but cutting corners leads to higher transmission rates and the spread of disease. Additionally, educating staff on the importance of these barriers, not cutting corners, and how to properly use the equipment is paramount.

Barrier gowns, ideally, should be disposable and single-use. It isn't recommended that they even be reused on the same patient. Ensure to use impermeable gowns for concerns with discharge, abscesses, feces, saliva, etc. (e.g., respiratory infections and GI diseases especially). If reusable gowns must be used, they must be properly laundered with an appropriate detergent that will effectively kill organisms of concern and should be washed between each use. When putting gowns on and off, only touch the external surface so that you don't contaminate yourself or the inside of the gown.

Face protection, including glasses/face shield/goggles, may be needed for splash protection. Face masks should, ideally, be worn at all times to protect yourself from exposure to mucus membranes. Thankfully, the organisms we are generally talking about in cats are species-specific. Still, cats are susceptible to human flu and even COVID, so a mask can protect the animals too.

Finally, footwear ideally should include appropriate, easily cleanable shoes. Safety shoes may be needed depending on the type of shelter, environment, and equipment. Closed-toe shoes should always be worn when working around animals. When animals are sick and you are entering/exiting their care area, disposable booties, and footmats or footbaths need to be provided and utilized properly.

Correct answer: Nitroimidazoles

Antibiotics that can be safely used in guinea pigs include metronidazole (a nitroimidazole antibiotic), fluoroquinolones (such as enrofloxacin), chloramphenicol, trimethoprim-sulfamethoxazole, and a few others. However, beta-lactams, like the penicillins and related derivatives, macrolide antibiotics like azithromycin, and lincosamides like clindamycin can be lethal and must be avoided. Beyond appropriate antimicrobial stewardship, it is essential to know and understand the species you work with to ensure safe antibiotic choices and to only reach for them when absolutely necessary.

Guinea pigs are susceptible to changes in gut bacteria, with an increase in the gram negatives and a decrease in the gram positives. In some species, this leads to dysbiosis and may trigger diarrhea. However, in guinea pigs, it can lead to lethal enterotoxemia, because of an overgrowth of Clostridial organisms. We can see C. difficile develop, and the toxin production causes a systemic wide response. If it develops, high-fiber diets may be used to prevent ileus. Cholestyramine may help bind the toxins, but these antibiotics must not be used to prevent this life-threatening illness.

Clostridium pilliforme does cause disease in guinea pigs, but not enterotoxemia. Instead, it causes Tyzzer's disease, though this occurs more commonly in small rodents. It can lead to diarrhea, poor coat quality, and depression. Transmission occurs not by antibiotic dysbiosis and overgrowth but by the fecal-oral route. Some animals may remain asymptomatic carriers and, when immunosuppressed, demonstrate clinical signs. Because it is an intracellular organism, premortem diagnosis is difficult. Prevention is key, as treatment is usually not effective. 

Correct answer: Ergonomic equipment and furniture

Common safety hazards/risks seen in veterinary practice (large and small animals) include:

1. Failing to have a formal safety program
2. Lacking proper bite prevention and patient handling protocols. You need to have your procedure for aggressive dogs and fearful cats in place before trouble arises. Know ahead of time if you will simply have them go home and give them pre-medications to give one to two hours before the visit and try again or if you will sedate them and if you can do so safely both for the patient and your staff).
3. Monitor for any trip, slip, or fall risks like wet floors. Make sure to use wet floor signs and caution signs when appropriate.
4. Mishandling of hazardous materials, chemicals, and medications (e.g., chemotherapeutics)
5. Improper ergonomics - This goes for everything from the chairs the client service representatives and all staff use, to the furniture in the waiting room, to the ability to adjust table heights when working with various-sized animals, to the surgery table adjustment capabilities, and more. Further, having protocols for proper lifting techniques and maximum weight permitted to be lifted by a single employee. The goal is to maintain a healthy staff and prevent injuries.

In addition to those above, we want to ensure we avoid excess heat or too cold temperatures, minimize radiation exposure, and protect the eyes when using lasers. We want to remain safe from punctures or contamination with dust or other airborne risks. We want to have proper protocols for sharps and how to address any needlesticks or injuries in the workplace.

Many people forget about the noise risks, but monitoring the decibels in kennels with barks or other confined spaces is important. Recognize the noise risk if you frequently handle swine (who we all know love to scream). Also, be mindful of staff working around loud equipment as they may be at risk for hearing issues.

Correct answer: Chronic pyelonephritis

Given the patient's age, lack of systemic clinical signs, the findings on bloodwork (azotemia and leukocytosis with a left shift) and the findings on a sterile urine sample, chronic pyelonephritis is the most likely etiology. Taken together with the small kidneys bilaterally, this suggests a degree of chronic renal change and is more supportive of chronic vs. acute pyelonephritis. While infections in cats occur very infrequently, they are common in cats that are very young, immunosuppressed, or have underlying kidney disease. Further, renal lymphoma in cats is often associated with FeLV infection and manifests with bilateral renomegaly, not small kidneys. We cannot fully rule out Transitional Cell Carcinoma (TCC) in this patient without imaging. However, most patients with TCC have clinical signs for weeks to months, not a sudden acute onset of hematuria and pollakiuria. No transitional cells were noted, but an abdominal ultrasound would be needed to evaluate the kidneys and rest of the urinary tract system to determine if there is an underlying trigger for the obvious kidney infection.

This patient should be hospitalized on IV fluids and IV antibiotics to help flush out the kidneys and start antibiotics pending urine culture. Starting a broad-spectrum antibiotic based on common etiologies seen in pyelonephritis in your area is warranted to ensure you practice proper antimicrobial stewardship.

Correct answer: Ability to treat only infected animals, sparing others from unnecessary antimicrobial use

The goal of treating commercial poultry flocks is to provide a cure. Generally, for infectious diseases, this means curing the entire flock of the current illness (though this depends on the disease type at hand). Therapy success requires keeping in mind numerous key factors and principles of judicious use. Treating an individual animal to spare antibiotic use fails to solve the antimicrobial resistance concerns as it also fails to resolve the disease state and may increase the risk of resistance. 

Judicious use principles are critical in determining whether to treat a flock. Avoiding antimicrobial resistance and keeping our food sources safe and healthy are paramount.

The decision to use antimicrobials includes consideration of various factors, including:

• Laboratory results
• Medical knowledge
• Flock information, such as size, purpose, and age group 
• Bacterial culture (or related testing if viral or parasitic in nature)
• The results of a skilled physical exam, including pre- and post-mortem evaluations
• Recognition that all birds affected need to be treated, including those that

           o   Show clinical signs

           o   Have subacute infections

           o   Are not yet infected but are susceptible

Finally, ensure the producers and all involved are properly informed about withdrawal times.

Because the rapid spread of some diseases necessitates instituting therapy before results are available, due diligence is required to determine whether therapy should be continued or changed, or whether depopulation or other similar measures are warranted. This strategic use of antimicrobials in severe disease anticipation is considered justifiable based on good husbandry practices.

Always make sure you:

• Treat for only as long as necessary
• Base therapy on current standard recommendations and clinical evidence 
• Confine appropriate antimicrobial use to clinically relevant cases (for example, uncomplicated viral infections do not require antibiotics)

Judicious use principles are established by the AVMA and the American Association of Avian Pathologists (AAAP).

Our goal needs to be to minimize resistance while optimizing therapy efficacy. 

Correct answer: First three weeks of life

Normally, mom's grooming helps to stimulate infants to go to the bathroom. However, without a mom's gentle tongue, humans need to stimulate neonates to go to the bathroom, generally for the first three weeks of life. You can use a cotton swab, finger, or tissue and softly rub the genital area. Rubbing the anal area accomplishes the same thing for stool. Normal infants have loose but not liquid stools. If they aren't defecating and you are concerned about constipation, you can always take the tip of a thermometer and place it in the rectum. This will often stimulate them to go.

Correct answer: 5%

Not all overtime is bad. When overtime is necessary due to high caseloads, staffing shortages, emergency patients, or other necessities, overtime is valuable. It makes more sense to pay one staff member time and a half for the few hours they stay over than to pay an entire shift for one person, who is only needed for one to three hours' worth of work. Overtime should account for roughly 5% of your personnel expenditure if used appropriately to enhance worker efficiency.

Correct answer: Common groundsel (Senecio vulgaris)

Plants causing pyrrolizidine alkaloid toxicosis (AKA Seneciosis, Senecio Poisoning, Ragwort Toxicity) (PA), such as is seen with various Senecio species, leads to liver failure. Numerous species of plants and multiple genera contain the PA compounds of concern. Usually, the plants of concern aren't intentionally eaten, not very palatable. Thus, we see chronic, delayed, and progressive toxicity and changes leading eventually to liver failure. The fact that sheep previously grazed the same area without issue can be attributed to their being much less susceptible to the toxic effects.

Sadly, various plants cause liver toxicity. Two common species of concern include Senecia species, which contaminate first-cut alfalfa, and Amsinckia intermedia, common with oat hay fields. The key hallmark change seen with PA toxicity is hepatic megalocytosis (in combination with a small, fibrotic liver). Though aflatoxicosis can also cause this, thus, it is not considered pathognomonic. Still, while other plants cause liver toxicity, it doesn't present the same way. These patients will also have non-specific changes, including biliary hyperplasia early on in the disease with fibrosis and hepatocyte necrosis.

Various species can develop PA toxicity, including horses and dogs.

With Whitebrush (Aloysia gratissima), we generally see fatty degeneration.  

With Cocklebur (Xanthium orientale), we see hemorrhagic, centrilobular necrosis.

We see liver necrosis and cardiac lesions in Cottonseed (Gossypium spp.) secondary to gossypol pigment. With this toxin, liver damage occurs secondary to cardiac failure and is not a primary liver problem. 

Identifying the plant of concern and developing a management strategy to prevent growth and or prevent consumption will be paramount to prevent future outbreaks/issues. 

Correct answer: You can utilize teleradiology services more frequently if you perform more ultrasounds

Ultrasounds are often underutilized in many practices. As a result, many practice owners fail to update to newer technologies and better machines. However, with a good quality ultrasound machine, you can provide many value-added benefits to an array of clients and make money for years after it has been paid off.

While true, one could submit still images of aFAST/tFAST scans, for example, a picture of a gallbladder with a halo sign, to confirm a possible suspicion of anaphylaxis or other abnormalities in a given patient. This isn't considered standard for these types of scans. A full ultrasound isn't completed when doing this type of scan. It is brief (often two to five minutes in length). It may often be a quick way to determine if a patient has free fluid in a body cavity, if there is a blatant mass somewhere, or for monitoring for signs of fluid overload. Providing these images to a radiology service can be costly to the client with a low yield as the images are static, likely few and far between, and not the goal of the aFAST and tFAST scans.

Generally, teleradiology is used when complete abdominal or thoracic ultrasounds are performed by a general practitioner with advanced training in ultrasound (complete), and then full scans are submitted. It is not the gold standard, which would be a specialist performing the procedure. However, someone trained in complete ultrasound techniques and skilled may be able to perform a proficient evaluation in most cases and confirm concerns or diagnoses with teleradiology, though when they do not see the images in real-time, they lack the 3-D component and cannot always be definitive with their diagnoses.

However, things you could say to increase the likelihood your boss will jump on the new purchase bandwagon may include: 

1. You can suggest that you offer an aFAST scan on every emergency, sick, and wellness patient for a very small fee, saying you are trying it to gain experience (e.g., $20) so that you can gain experience and learn normals and abnormals, and maybe even catch something on a wellness visit that you weren't expecting but that will lead to additional diagnostics and income to the practice. 
2. If your practice currently doesn't charge for cystocentesis when obtaining urine samples, or doesn't do so consistently, use the machine for all cystocenteses (even if not needed) to improve your technique for a set period of time and then start charging for them when proficient. 
3. Offer to develop a marketing plan demonstrating the benefits of an aFAST or tFAST scan under various situations/circumstances. This could be a pamphlet on the benefits, with images of what may be identified and how it can help improve the healthcare provided to a client.

You can always talk to your boss about leasing options vs. purchasing if the proposed use and increased revenue don't pan out.

When leasing or purchasing new equipment, you want to ensure to choose products that will garner revenue and provide an added benefit to the practice and your patients.

Correct answer: Cat bites are more traumatic than dog bites and, thus, more likely to become infected

Cat bite wounds are less traumatic than dogs, though they tend to penetrate deeper. Further, they are more susceptible to causing infection than dog bites. The recommendation for any owner bitten or scratched by a pet is always to tell them to seek medical care. However, with cat bites, it is essential. They can get infected very quickly and lead to systemic involvement within hours. While P. multocida is the most common isolate in dog and cat bites (75% of wounds), infection is usually polymicrobial.

Other organisms identified in cat bites may include Staph species, including S. aureus, Neisseria, and Moraxella. Though numerous other organisms can be associated with human infection as well.

Cat bites, more than dogs, often lead to anaerobic infection. The antimicrobial selected for therapy must include broad-spectrum coverage when being treated for a cat bite to ensure anaerobes are addressed. Ensure the physician evaluating you knows the common feline pathogens in bite wounds and prescribes appropriately.

Do not wait until your shift ends or do more things before seeking care. Infection can track from the bite, say if on the hand, or up the arm, in just a few hours. Do not take the chance.

Correct answer: Excisional removal

In cats, all tumors should be considered malignant and evaluated ASAP. This owner, however, describes to you a classic hemangioma. They are rarely seen in cats and can be found on the extremities, head, or abdomen. They start as single or multiple small red-to-black nodules and are often circumscribed and compressible. They can be ulcerated and appear first as a blood blister. They are benign, but because they ulcerate and can grow large, excision is the treatment of choice. Sometimes, those tumors on a distal extremity may be difficult to remove, and radiation or cryosurgery may be warranted. Because these lesions are benign, chemotherapy isn't necessary.

Correct answer: d-Penicillamine

Cattle with acute lead toxicity may show GI signs such as drooling and bruxism and neurological signs such as blindness, eyelid twitching, muscle tremors, ataxia, or seizures. This usually occurs in younger animals, and signs occur about one to two days post-ingestion. Those with subacute poisoning, usually older cattle, will have signs of dullness, rumen stasis, anorexia, head pressing, blindness, and constipation, followed by diarrhea, bruxism, incoordination, and hyperesthesia. Chronic toxicity can manifest in various ways, including a combo of acute/subacute disease. Chronic disease swallowing reflexes may be a problem, and aspiration pneumonia may ensue. Infertility may also be a sign of chronic disease in males or females.

The presence of GI, along with neurological signs, occurs in about 60% of cattle ingestions and helps differentiate lead toxicity from other common cattle neurological diseases. 
Treatment in food-producing animals with lead toxicity is not recommended. A combination of a poor prognosis (poor response to therapy), level of clinical illness, herd management mentality (vs. individual animal), and tissue residue severity with both public health and economic ramifications for the animal/producer make it difficult to recommend treatment in cattle used in food production. For small animals, where tissue residues and human health risks aren't a concern, depending on the severity and acute vs. chronic exposure, treatment may be warranted and prove fruitful.

No approved treatment on-label exists for chelation in cattle. Of the available chelators, d-penicillamine, dimercaprol, and calcium sodium EDTA, the latter is the most effective in cattle. Treatment is given for a few days, then an off period is needed, and post-treatment, blood lead levels, and kidney function should be evaluated. Care must be made to ensure mineral deficiencies do not arise, as it will also chelate other things like zinc. Oral supplementation of zinc may be needed.

Supplementation with thiamine has been shown in small and large animals to aid in acute toxicities, lessening clinical signs.

For animals with obvious lead present in the rumen, a rumenotomy should be performed to remove the exposure. Magnesium sulfate laxatives may be used to form insoluble compounds of lead sulfides.

Some patients may require supportive care and nutritional management depending on the degree of neurologic and other abnormalities.  

Correct answer: Toxoplasma gondii DNA

In addition to proper blood typing, all cats, due to the naturally occurring alloantibodies in some blood types and the severe risk of potentially lethal reactions without typing, typing, and crossmatching, have to be built into your program. Crossmatching may be skipped in dire straights if there is no previous blood transfusion in the patient’s history or if they have had a transfusion two or more days earlier.

Which organisms should be tested in addition to the key pathogens varies with the clinical practice location. Knowledge of endemic concerns and epidemiology associated with those diseases is critical in deciding what other organisms to test for in your practice situation.

These primary pathogens should be included regardless of practice location.

1. Feline leukemia virus DNA
2. Feline Leukemia virus RNA
3. Feline immunodeficiency virus DNA
4. Bartonella species DNA
5. Mycoplasma haemofelis DNA (though inactivated during storage of whole blood for one week)

Additional screening should be based on incidence and prevalence data in your area.

1. ‘Candidatus Mycoplasma haemominutum’ (survives a week in stored blood); (low pathogenicity relative to other mycoplasma species)
2. ‘Candidatus Mycoplasma turicensis’ (low pathogenicity relative to other mycoplasma species)
3. Anaplasma phagocytophilum (If they reside in areas where Ixodes spp. ticks are of threat)
4. Anaplasma platys (If residing in areas with Rhipicephalus spp. ticks)
5. Cytauxzoon felis
6. Babesia felis
7. Ehrlichia canis
8. Leishmania infantum
9. Neorickettsia risticii

The 2021 AAFP ISFM Consensus Guidelines on the Collection and Administration of Blood Products does not recommend testing for coronavirus, Rickettsia felis, or Toxoplasma gondii, as transmission from blood products hasn’t been documented. If you look at the reference by Jane E. Sykes’ Greene’s Infectious Diseases of the Dog and Cat Fifth Edition, they list coronavirus as a primary pathogen to evaluate for, with a publication date of 2023. So, the consensus about testing for coronavirus obviously isn’t 100% across the board. However, if it isn’t transmitted through blood or is already part of a pre-established lab profile, there isn’t necessarily harm in evaluating for its presence. Care needs to be taken with the interpretation of results. But the interpretation of PCR test results is a question unto itself.

Correct answer: Urine and feces

Liquid waste such as fluid from body cavities, excretions, secretions, and irrigation solutions may be considered biomedical waste but often is permitted to be carefully placed in a drain or toilet associated with a septic tank or sewer system. Various local, state, and federal regulations may vary regarding the amount or what can be disposed of in this manner.

Sharps are considered biomedical waste and need to be disposed of as per local and state regulations. Usually, puncture-resistant sharps containers, properly labeled, can be used for items that can cause punctures or similar wounds. This would include needles, syringes, and related materials.

Nonanatomical waste covered in blood (lap sponges, gauze) is considered biomedical waste and should be disposed of appropriately as per local regulations.

Unless infected with an infectious or zoonotic disease, feces and urine is not considered biomedical waste.

Disposable equipment that comes in contact with an infectious patient, such as gloves, bandage materials, or gowns, that are not heavily contaminated with bodily fluids aren't considered biomedical waste. However, when dealing with infectious diseases such as parvovirus or zoonotic diseases such as lepto, most veterinary hospitals have policies that require disposal in biohazard labeled bags (usually red) and not placed in the regular trash as this risks exposure to other animals/people.

Double bagging potentially contaminated materials, even if not legally considered medical waste, may help protect you, your staff, and the hospital/equipment. 

Correct answer: Increased response by the thyroid gland to TSH

Clinical signs of hypothyroidism in cats with significant clinical disease may include lethargy, dullness, hypothermia, decreased appetite, bradycardia (uncommonly), non-pruritic, and seborrhea sicca. Obesity can also occur, especially in those with the iatrogenic form. Unlike dogs, who may develop bilateral focal alopecia, if cats develop alopecia, they tend to get focal areas of alopecia over the caudal hocks, craniolateral carpi, dorsal, and lateral tail bases. Many cats with iatrogenic have none or mild signs. Cats with juvenile-onset/congenital forms have significant signs, including severe lethargy, mental dullness, constipation, poor appetite, disproportionate dwarfism, and bradycardia.

Some congenital forms of hypothyroidism may develop, though rare in cats. These include dyshormonogenesis (intrathyroidal defects in thyroid hormone biosynthesis), thyroid dysgenesis, and failure of the thyroid gland to respond to TSH (not an increased response).

Iatrogenic remains the primary cause of hypothyroidism in cats. Usually, a consequence of overtreating hyperthyroid cats is either via radioiodine therapy, antithyroid drug (methimazole) administration, or thyroidectomy.

Correct answer: Keep the dog confined at home when they cannot watch the dog

Sometimes time outs may be needed. This goes for kids, parents, and even dogs. However, this should be as a last resort to keep the pet safe, not as the go-to way to limit destructive behaviors. This puppy is just that, a puppy. Age-appropriate behaviors include chewing, digging, stealing, and others. They need to be taught using positive reinforcement, not punishment, what behaviors are acceptable and what aren't, and provided with an outlet and something to do instead of those behaviors. Providing feeder toys to slow down meals and make them work for their kibble, freezing kongs with tasty treats in them, and reward-based training keep them occupied and stimulated. Regular exercise (not just sending them out in a fence in the yard, but walking on a leash for 20–30 minutes at least once per day can help). For dogs that dig, one may need to separate them from that area with a barrier and even provide them with their own safe place where you allow them to dig. For dogs that chew, redirecting that behavior to a favorite toy or another safe object may also be beneficial. With this puppy, most likely, it is just being a puppy. The breed requires a lot of exercise and mental stimulation. These owners need to find a way to encourage healthy behaviors, stimulate the dog's mind and body and permit it to still engage in normal puppy learning methods in the environment.

Often it is a combo of the owner's learning what the dog likes to do and balancing enough mental and environmental stimulation with physical exercise to enable a more peaceful co-existence. 

Correct answer: In horses with a history of prior choke or if ongoing for more than eight hours, this is a medical emergency

Choke, or an esophageal foreign, usually involves the obstruction of the esophagus via food material, e.g., hay, pellets, dried beet pulp, bedding, or wood chips. Those with increased appetites and older horses on pelleted feed are at higher risk. Fresians are prone to chronic choke and megaesophagus. Animals immediately fed after arriving at a hospital, after travel, or on the road at rest stops are at increased risk. Senior horses are at higher risk because of less salivary production and sometimes decreased mastication.

Clinical signs include hypersalivation, neck stretching, retching, dysphagia, food dripping from the nares, and coughing with saliva. In proximal obstructions, the foreign body may be palpable in the esophagus in the acute phase. Animals with an obstruction within the cervical esophagus will retch immediately upon attempting to swallow, while those more distally take ten to 12 seconds before retching after swallowing. Despite obstruction, many horses will continue eating, worsening the issue.

The management of choke, or an esophageal foreign body, includes: 

1. Provide tranquilization to relax the animal, lessen stress and anxiety, lower the head, and, hopefully, relax the esophagus. For sedation, however, do not use butorphanol, as this suppresses the cough reflex.
2. When suspected, immediately remove all hay and water.
3. Sometimes numbers one and two are sufficient to alleviate the obstruction within four to six hours.
4. If the animal has had an episode of choke before or the current issue has been ongoing for fewer than six hours, this is then considered a true medical emergency.
5. Upon arrival, after sedation, one can pass a stomach tube. This will allow a gentle water lavage (once you reach the level of obstruction) and helps to confirm your diagnosis. Keep the horse’s head down while gently ‘pushing’ the obstruction if feasible. However, this is not recommended if the foreign material is just caudal to the larynx, only if more distal. If the lesion is at this proximal region, withhold food and water, maintain sedation, wait three to four hours, and then lavage.
6. If the obstruction hasn’t passed in four to six hours, then a full lavage should be undertaken, with the animal sedated. Repeat several times to assist in breaking up the obstruction (which is usually feed material. Take care not to put too much pressure on the tube while lavaging.
7. Surgical management may be necessary if you suspect a foreign object, like rope, vs. food material.
8. Surgical management is warranted if one fails to dislodge the obstruction with medical management or strictures are suspected.
9. Always ensure the head is lowered when lavaging.
10. Re-examination within 24 hours may be warranted if a previous history of choke, choke lasted less than four hours, or animals where owners failed to remove water/hay on identifying the issue.
11. Consider butylscopolammonium bromide; this may help relax the esophageal tone.
12. Regardless of what you are doing, careful manipulation is key to minimizing the risk of esophageal stricture, tears, or other complications.
13. Ensure adequate hydration. In young, minis, or pregnant animals, IV nutrition/hydration may be warranted.
14. Take care not to feed too soon after relieving an obstruction. First, offer water and then begin with a significantly wetted and mashed gruel.
15. Consider prophylactic antimicrobials if suspicion or high risk for aspiration pneumonia exists. However, use caution and proper antimicrobial stewardship.

Correct answer: Dermatophytosis; Yes

Demodectic mange does occur in hamsters. Species of mite include Demodex criceti and D. aurati. We see it more commonly in older, often male hamsters, secondary to malnutrition and other diseases. Signs may include dry and scaly skin with alopecia on the rump and back. However, they tend not to be itchy. They are not zoonotic.

Otodectic mange or ear mites uncommonly occur in hamsters. They are transmitted by close contact. Other species, including cats, dogs, and ferrets, are susceptible. However, it is not considered contagious to people. Signs may include scratching at the head, localized fur loss, shaking the head, and ear discharge. Some will also have lesions on the face, feet, and tail because of self-grooming and shaking the head, dislodging mites on their bodies.

Dermatophytosis, or ringworm, may uncommonly occur in hamsters. Causative agents include Microsporum species and Trichophyton mentagrophytes. Often, hamsters are asymptomatic, but when signs manifest, they may have signs as described in our question. They are infected by contact with infected humans, animals, or fomites. Since these organisms can be found in the soil, and are ubiquitous, humans can be a source of infection, bringing it in on their shoes or person. It is contagious to humans as well as other hamsters. Care must be used when handling and treating the disease. Have owners wear gloves if ringworm is suspected and ensure they clean cage/bedding appropriately and regularly. Both hamsters are likely to have been exposed and should be treated. Advise the owner that if anyone in the home develops skin lesions like the hamster, they should be evaluated by a healthcare professional. 

Note that spontaneous ringworm is extremely rare in Syrian hamsters, the most commonly used species for pets. 

Correct answer: Bottle feeding with formula ASAP

First and foremost, you need to stabilize this puppy. Fading puppy syndrome includes dehydration, hypothermia, and hypoglycemia. This little girl has two of the three so far. We need to actively warm her using a Baer hugger and a warm water bath (water temp between 95–99°F) while carefully monitoring temperature, and warmed IV fluids (if IV or IO access can be obtained). If access isn't obtainable either because of collapsing veins, catheters too small to place, or lack of experience placing IO catheters, and if the patient is conscious and actively suckles from the bottle, you can use warmed water orally until the temperature normalizes for her age. You do not want to offer formula until her temperature returns to a physiologic state, or she will not be able to metabolize/absorb the food properly, and this can cause more harm than good. You can start bottle feeding once her temp has returned to normal. The sooner she returns to the mother and nurses and obtains colostrum, the better.

Education for the owner will be paramount. Advise the owner to ensure that she is weighing both puppies daily and gaining 5–10% of their birth weight daily. If they are losing weight, not gaining weight, not eating/nursing, mom doesn't seem to have enough milk, or there are other concerns, then a recheck is warranted ASAP. You need to discuss the risks of this puppy and that even though her temp improved and she took the bottle well, she developed a bout of hypoglycemia that responded to another feeding and stabilized, but if she doesn't get enough milk from mom, she will be at risk for hypothermia, hypoglycemia, and sudden death. You need to discuss ways to keep the puppies warm with safe methods. You provide them with disposable gloves to fill with warm water and put under blankets. You review other options as well. You recommend that if they are at all concerned, they should be bottle feeding her q two hours. If she seems to be nursing well, they may not have to do it at all or only a few times per day, but if she becomes aloof, shows excessive vocalization, doesn't latch on to mom/isn't nursing or her rectal temperature again drops below 96, they should seek additional care.

Neonates have no glucose reserves and cannot thermoregulate for the first seven-plus days after birth. Mom's body heat helps, but additional support is often needed.

Further education needs to include proper whelping box and means of egress/ingress for the mom, how/when the puppies need to be stimulated to go to the bathroom if the mother isn't doing it herself, and when to introduce puppy food. The mother should remain on puppy food throughout nursing, then she can be transitioned to adult dog food once they are weaned.