ICVA NAVLE Exam Questions

Correct answer: The right side of the thorax in the third-fourth intercostal spaces

A murmur's Point of Maximum Intensity (PMI) can help localize the murmur to a specific or more than one valve.

The mitral valve PMI is usually directly over the valve on the left side of the chest. Still, it can also radiate dorsally towards the heart apex/base.

In horses, the tricuspid PMI is located on the right side of the chest between the third and fourth intercostal spaces, while in cattle, the tricuspid PMI is on the right between the second and third intercostal spaces. Though rare, a tricuspid murmur may be ausculted on the left cranial to the pulmonic valve in the second intercostal space.

In horses, aortic valve murmurs will produce a PMI at the left heart base in the fourth intercostal space, while pulmonic valvular lesions will be at the left heart base in the third intercostal space.

Correct answer: Mycoplasma mycoides sub. mycoides; Yes

Mycoplasma mycoides subspecies mycoides, AKA contagious bovine pleuropneumonia, is a nationally and globally notifiable disease. It is one of over 115 diseases the World Animal Health Organization (OIE) listed as reportable. It has been eradicated from the U.S. since 1892, the U.K. since 1898, Australia in 1973, Europe in 1999, and China in 1996. However, the disease still commonly occurs in sub-Saharan Africa and some areas of Asia, including the Middle East (most likely via the exportation of infected cattle from Africa).

Infection occurs via inhalation of aerosolized droplets from coughing animals. Animals who recover serve as a constant source of infection, remaining chronic carriers. The organism sequesters itself in the lung tissue. Infected organisms can be identified in uterine discharges, placentas, urine, and saliva. Transmission can occur vertically as well.

Clinical signs include fever, dyspnea, coughing, weight loss, decreased milk production, nasal discharge, and tachypnea. Some animals that are only mildly affected may only show cough, or a slight increase in respiratory rate with exercise. Uncommonly, we can see epistaxis, diarrhea, and throat and dewlap swelling. Abortion or stillborn calves may result in subclinical animals. Death is often within three weeks in the most severe. With animals younger than six months, we tend to see signs consistent with polyarthritis and not respiratory signs. They will have joint pain, swelling, and hesitancy to walk/move. 

Treatment is not recommended. This can lead to persistently subclinically infected carriers, perpetuating disease spread. However, the use of some antibiotics has the potential to limit outbreak spread.

Strict animal movement restrictions and rapid-in-place quarantine must be instituted. This includes those infected and those most likely to be carriers. Culling is ideal. Thankfully, the organism isn't very hardy in the environment.

Contact tracing and source identification is also crucial to prevent further outbreaks.

Endemic areas do make use of vaccinations to lessen the risk of outbreaks. But this must be herd-wide and annually to ensure success.

Mycoplasma bovis, on the other hand, is a known entity globally and one of the main bacterial players in the bovine respiratory disease syndrome (in addition to the bacterial etiologies of Mannheimia haemolytica, Pasteurella multocida, and Histophilus somni and viral players such as bovine viral diarrhea virus, bovine herpesvirus-1, bovine parainfluenza-3 virus, and bovine respiratory syncytial virus. This is a common entity not reportable in the U.S., or to the OIE. 

Correct answer: Poor perfusion

Lactate results from normal glucose metabolism regardless of whether it occurs aerobically or anaerobically. In the absence of oxygen, however, this level dramatically increased. In states of poor perfusion, we have inherently low oxygen delivery. This can occur for various reasons, including toxins, hypovolemia, ischemia, thromboembolic disease, heart disease, and anything that causes vasodilation, sepsis, and moderate to severe anemias.

When severe, kidney or liver disease may affect the body’s ability to clear or metabolize lactate; therefore, even if not overtly hypoperfusion, a pet may have elevated lactate.

Finding an elevated lactate doesn’t automatically mean that the entire animal is not properly perfusing, as local damage and local changes can also raise total lactate.

Dehydration, on the other hand, involves the loss of water from the interstitial and intracellular spaces. Unless severe, this doesn’t lead to a change in oxygen delivery status.

Hypovolemia refers to the volume lost in the intravascular space. In other words, our circulating volume isn't sufficient either because of dehydration or blood loss, or other conditions. 

A decreased glomerular filtration rate may occur with shock and in conjunction with hyperlactatemia. Still, it doesn’t reflect what occurs when lactate rises.

Hyperlactemia helps provide a marker for shock in our veterinary patients. While not the sole determinant of shock, in combination with mentation, heart rate, blood pressure, respiratory rate, and underlying condition, it can help determine the degree of debilitation and help guide fluid therapy and other therapies for our patients.

Correct answer: Dysmaturity

The normal gestational range for the horse is long and very variable. It may be as short as 305 to 380 days, with averages between 320 and 380 days.

Premature animals are considered when gestation is less than 320 days. However, this is a bit arbitrary, given the variation in gestational lengths seen with equine species. But, less than 320 days, tend to lead to low birth weights and poor outcomes for foals. Thus, the established preset prematurity level.

Dysmaturity refers to foals with incomplete uterine maturation. Their gestational duration can be normal, prolonged, or, less commonly, too short. Regardless, they seem to lack a readiness of birth, partly related to the proper development of the Hypothalamic-Pituitary-Adrenal Axis (HPA).  

Signs of prematurity and dysmaturity may overlap. The reason that this foal would be considered dysmature is simply that a normal gestational duration occurred rather than a premature delivery. Signs may include low birth weights, short haircoats, rounded heads, laxity, and droopy ears. They often have decreased muscle development and weakness and may be unable to stand or have difficulty doing so. Premature foals may also have trouble regulating temperature, glucose, and blood pressure. Respiratory signs may occur if a premature neonate doesn't yet have full maturation of the pulmonary system. 

The average birthweight of a term-appropriate foal is about 10% of the dam’s weight/size. Dysmature foals are usually small for their age.

Postmature foals have extra long gestational periods and often have normal/appropriate birth weights but a very large frame despite poor muscle development. Contracture (especially of the fetlock) is common in postmature foals, while laxity is seen in premature animals. These animals often have incisors erupted already at birth (normally erupting in the first five to seven days post foaling) and long hair coats.

This foal does have a Failure of Passive Transfer (FPT) or will if colostral ingestion doesn’t occur immediately, ideally within the first two to six hours of birth. However, a physical exam doesn’t diagnose FPT. This is identified by a lack of nursing or of a suckle and IgG levels < 400 mg/dL. So, while it is presumed to be a problem for this foal, it isn’t something you can diagnose on a physical exam.

Correct answer: Intranasal Live Attenuated Influenza Virus Vaccine (LAIV)

Influenza A virus, IAV, the causative agent of swine flu, is a highly contagious flu virus that affects pigs (and rarely humans), causing acute fever (104–106°F; 40–41.11°C), ocular and or nasal discharge, weakness, recumbency, anorexia, conjunctivitis, then paroxysmal coughing lasting about five to seven days, though mortality is usually low. IAV does not age discriminate. When uncomplicated, infections may cause body condition changes and weight loss but are rarely lethal. If concurrent infections are present, then this can increase mortality. Like many porcine diseases, reproductive issues such as abortion, small neonates, or weak litters can also occur.

The swine flu subtype is H1N1, and it induced a major pandemic in 1918, with approximately 20 million deaths globally. Thus, it remains a significant viral threat to the swine industry and human populations. Further, interspecies transmission occurs between swine, poultry, wild birds, and people. The ability of pigs to act as mixing vats permits genetic shift. If an avian strain and a poultry strain combine with two or more strains, it can lead to significant genetic changes and the potential for a highly virulent, highly transmissible virus that crosses multiple species.

Swine Influenza falls in the type A viruses (orthomyxoviridae). Glycoproteins create spikes on the virus's outer surface, which act as antigens. The glycoproteins are either Hemagglutinin (H), of which there are 16, or Neuraminidase (N), of which there are nine. Antigenic shift and drift can alter the gene reassortment, creating various different strains and virulences and cross-species transmission. Classically, swine flu is the H1N1 of the 1918 pandemic. However, additional combos have triggered concern and include H3N2 and H1N2.

Using a variety of diagnostics means, IAV can be identified. However, because there can be many subtypes, once IAV has been identified, it should be subtyped by the laboratories. Serology is not reliable because that could be a previous exposure.

Therapy is supportive using NSAIDs and antimicrobials if secondary pathogens are identified. Free access to food and water is key. Prevention is through all-in/all-out herd practices; in some areas, inactivated vaccines can be used.

The LAIV is preferred, however, because it aids (IgG A inducing) in inducing respiratory mucosal antibodies and helps reduce overall transmission. These are also labeled for pigs one day or older and can be used to grow pigs. Less maternal antibody interference was demonstrated in studies for this type of vaccine, permitting it to be used in pigs prior to weaning.

Experimentally, studies have been ongoing on other types of vaccine options, including viral vectors, DNA vaccines, and recombinant protein vaccines.

Finally, in the U.S., a newly licensed vaccine, the RNA replicon particle vaccine expressing HA, provides farm strain-specific options for those against H3N2.

Inactivate whole virus vaccines hope to induce serum antibodies to the viral HA (Hemagglutinin (HA) surface antigen). Most of the commercially available IAV swine vaccines are this type with an adjuvant added. The initial vaccine is a two-series injection two to four weeks apart, and then boosters are recommended two times per year for sows. Further, boostering pre-farrowing aids in improved and longer-lasting maternal antibodies, which may translate to more extended protection for nursing piglets. These inactivated vaccines hope to protect the individual pig from clinical disease, and they limits lung viral titers (much more so than in nasal secretions).

However, because there are a variety of IAV strains in pigs, the overall efficacy of inactivated vaccines can be challenging to assess readily. Bivalent options exist in some areas against two different subtypes. For example, an H1N1/H3N2 vaccine in Europe, but cross-protection to other subtypes hasn't been readily apparent. There are some polyvalent options in the U.S. with some crossprotection. Oil-based adjuvants may help improve overall protection versus unadjuvanted ones, as in human vaccines. 

Correct answer: Bronchopneumonia

About 5-10% of neonatal foals commonly have rib fractures at birth. This can occur in explosive births, with dystocias, or secondary to trauma. Most animals are asymptomatic but may be painful over the fractured areas. In foals, the fractures usually occur at the costochondral junctions and can be up to one through five ribs. Complications from rib fractures can include lung lacerations, pneumo or hemothorax, diaphragmatic hernias, flail chest, less commonly pulmonary contusions, cardiac/pericardial lacerations, or sudden death.

Palpating the foal while standing may demonstrate thoracic wall asymmetry, and you may palpate the fractures themselves or crepitus. The asymmetry is best evident when the foal lays in dorsal recumbency.

If fractures aren't evident on radiography (unless displaced), ultrasound is actually more diagnostic, and most foals have fewer than one (two to seven most commonly) ribs fractured, with the fourth the most common (ribs three through eight). Ultrasound can permit evaluation of the pleura, heart, and vessels for damage.

Supportive care with oxygen (dyspneic), strict rest, nutritional support, pain management, NSAIDs, and careful handling are key. Surgery may be warranted if fractures are significantly displaced, but ideally, avoid anesthesia if feasible.

While aspiration pneumonia is always possible in nursing foals, given the known rib trauma, damage from the ribs is the more likely cause of clinical deterioration.

Correct answer: Autosomal dominant

Polycystic kidney disease is rare in dogs and cats. It is an autosomal dominant inheritance pattern in domestic long-hairs and Persians. It is familial in beagles, bull terriers, Cairn terriers, and West Highland White Terriers. Some animals have no clinical signs, while others may have signs consistent and typical of progressive kidney failure. They may be at a higher risk of pyelonephritis.

Correct answer: Section 179

Section 179 of the tax code speaks to property depreciation (such as medical equipment as well as real estate) and how businesses can deduct the purchase cost.

Section 174 of the tax code permits businesses to amortize or deduct some research and development expenses.

Section 170 of the tax code concerns charitable contributions and gifts, not business-related purchase expenses.

Section 172 of the tax code involves various deductible allowances in the face of a net operating loss. 

Correct answer: Ventricular ectopy; dilated cardiomyopathy

Large breed dogs such as Dobermans, Great Danes, Boxers, German shepherds, Irish wolfhounds, Newfies, and labs commonly develop DCM (Dilated Cardiomyopathy) as their heart disease vs. small breed dogs who are more prone to endocardiosis (valvular disease).

DCM is a myocardial disease that leads to dilation. Further, it creates systolic dysfunction of the left or both ventricles without valvular, coronary artery, congenital, or hypertensive heart-related disease.

DCM causes progress in myocyte loss in number/function and decreased cardiac contractility over time. It is most common in male, middle-aged, to older dogs. It can occur secondary to medications like doxorubicin, viruses such as parvo, infections such as due to Lyme, toxoplasmosis, or fungal agents, taurine deficiency, and genetics (Dobermans & Boxers), or is idiopathic in nature.

DCM often has a long subclinical phase and then acute short clinical onset. Once the renin-angiotensin system can no longer compensate for the decrease in cardiac output, fluid retention develops, leading to clinical signs. Age of onset varies, but it typically manifests between four and eight years of age. Males may be predisposed based on current scientific evidence.

Dogs may show a soft systolic, left apical murmur. They may have a gallop (though this can be clinically hard to appreciate in dogs and is more commonly ausculted in cats with DCM). Femoral pulses may be weak with pulse deficits. The most widely seen arrhythmias in Dobermans and boxers are ventricular ectopic such as PVCs or ventricular tachycardia. In contrast, we can see atrial fibrillation in giant-breed dogs more easily. Clinical signs vary depending on if left or right heart failure ensues, or global failure develops. Signs may include tachypnea, dyspnea, ascites, cough, collapse, and weakness.  

Dogs with a murmur and no clinical signs at risk for this type of disease should be referred for echocardiography and possible Holter monitoring, as arrhythmias can be intermittent in initial stages and may be missed in the clinic. Radiographs can be insensitive, especially in the earlier stages of the disease.

Treatment often includes preclinical stage B use of Pimobendan to help prolong the time until the development of CHF. If a taurine deficiency is suspected, supplementation is warranted, and once CHF develops, therapy is as for any CHF patient.

Correct answer: Bartonella species

Gingivitis refers to inflammation around the gingiva. Stomatitis refers to any inflammation associated with the lining of any oral structures. It includes gingivitis and periodontitis and may even extend to the submucosal tissues. It occurs in cats without regard to the presence of tartar. However, purebred cats have been shown to have tartar more commonly than domestic shorthairs. It can occur in cats at any age. A viral association has been established, including calicivirus and the retroviruses, FELV and FIV. The disease is complex and is both a chronic and destructive inflammatory condition. Etiology is thought to be multifactorial. It is presumed that a yet-to-be-identified antigen causes stimulation triggering the disease.

Various bacterial pathogens have been identified in cats with this condition, including Pasteurella pneumotropica, Pasteurella multocida, and Capnocytophaga canimorsus. However, Cats, with and without stomatitis, are often seropositive for Bartonella species. A direct cause-and-effect hasn’t been established with this organism.

Feline Coronavirus (FCV) also likely plays a role and is shed in most cats with chronic ulceroproliferative stomatitis.

Various etiologies are presumed to occur concurrently for this disease to establish itself. These factors include:

1. Stress
2. Genetic predisposition
3. Diet
4. Bacterial infection
5. Viral disease exposure, most commonly herpes and calicivirus
6. Retroviral disease exposure – FELV/FIV

You want to ensure to discuss medical vs. surgical management of the disease, prognosis, potential need for multiple extractions over the cat’s lifetime, and overall prognosis. You want to discuss immunomodulatory options and alternative therapies based on evidence-based medicine. If you are uncomfortable with full mouth extractions (as can be warranted in severe cases), you should offer a referral to a board-certified veterinary dentist. 

Correct answer: Euthanasia or quarantine and reevaluate; euthanasia

Inclusion Body Disease (IBD) of boid snakes, previously thought to be retroviral in origin, has been determined to be a reptarenavirus. It can produce a chronic yet multisystemic wasting disease or subclinical infection.

The typical hosts are boid snakes, and they can remain asymptomatic carriers for years with no signs or only mild signs. A snake mite is being considered as a possible vector for transmission.

Often infected adult boas show signs only once immunosuppressed. History may include unthriftiness, anorexia, dysecdysis, regurgitation, poor wound healing, secondary bacterial infections, and weight loss. Juvenile boas are more likely to show clinical disease with rapid death. Boas showing signs may also show an inability to strike, prehend food, or constrict.

IBD is a top differential in any boa and should be considered in pythons presenting with acute neurological disease.

IBD derives its name from the intracytoplasmic inclusions that form in the neurons and in various organs within the epithelial cells. The disease is thought to trigger immune suppression. Pythons are more likely to develop rapidly progressive and fatal neurological signs. These may include disequilibrium, opisthotonus, failure to right themselves, torticollis, flaccid paralysis, hyperreflexia, and regurgitation. Some may also have evidence of pneumonia or stomatitis as well as dermatological lesions of varying degrees. Some affected animals have shown evidence of round-cell tumors and lymphoproliferative conditions.

Further research is needed, but this type of virus may lead to chronic infections. The means of transmission is not fully elucidated, but cohabitation and close contact for weeks to months have led to transmission. Vertical transmission likely occurs.

Because the identification of inclusion bodies is key, diagnosis requires cytology and histology. Pythons tend to have these bodies in the CNS neurons, while in boas they are often found in glial cells and within the esophageal tonsils, liver cells, and pancreatic cells, among others. Premortem diagnosis can be made via biopsy of the esophageal tonsils, kidneys, or liver. Evidence may also be found in the peripheral blood with PCR as one of the mainstays of identification in live and dead animals. Combinations of RT-PCR, immunohistochemistry, cytological blood smear evaluation, histopathology, electron microscopy, and virus isolation have been used for diagnostic purposes.

Recommendations include not mixing boas and pythons in the future, which could increase the risk of interspecies transmission.

There is no treatment for this disease. Care would be supportive and include isolation and/or humane euthanasia of animals within collections. With asymptomatic animals, consider quarantining and rechecking at least six months later. Ideally, any animals showing signs and clinically positive animals should be removed.

Recommendations to test the boa and confirm your diagnosis should occur first. Evaluate for underlying liver and kidney issues and assess bloodwork parameters. Then, if the disease is confirmed and no other overt or underlying systemic diseases are identified, the owner can either quarantine and monitor or euthanize. However, since the boa is not actively showing clinical signs, and appears healthy upon physical examination, the owner can monitor and quarantine it. If clinical signs develop, euthanasia is recommended as no therapy for this viral disease exists. For the python, euthanasia is the only humane therapeutic option. This disease will become progressively fatal, and euthanasia should be discussed with the owner. Further, a discussion about future animals should ensue. If the owner decides to adopt other snakes, you must include information about husbandry practices, keeping boas and pythons 100% separated, and preventing aerosol exposures (since the exact means of viral transmission is not yet fully understood). 

Correct answer: Good with supportive care

Thankfully, the owner knew exactly when the bite happened, had the snake for identification purposes, and brought the dog in immediately. Snakebite clinical disease varies depending on the type of snake, and this snake is consistent with a pit viper. A snakebite assessment score has been established that helps determine the severity of the bite and can be used to assess injury significance and guide therapy.

Treatment includes neutralizing the venom and treating wounds, any systemic effects must be addressed, and any devitalized tissue may need to be reconstructed over time. Antihistamines, pain medications, and IVF therapy are warranted. Broad-spectrum antibiotics are also warranted. Immobilizing the wound and maintaining a calm patient (minimizing excitement) help stabilize the wound. Wound lavage and cleaning are warranted. Even though this patient has a very low snakebite severity score, it can take a minimum of 24 hours after being bitten for systemic progression to occur. Patients should be hospitalized and monitored for at least 24 hours. Bandages that support debridement and moist wound healing are recommended until healthy granulation tissue develops. Once that occurs, one can switch to nonadherent absorbent dressings. The wound can heal via second intention or closure, via flaps/grafts.

The use of antivenin is controversial. It is costly; exact dosing isn’t fully elucidated and may lead to adverse reactions (though uncommon). Given that this was a known bite, occurred within a short time of arrival to the hospital, and we know the type of snake, antivenin therapy wouldn’t be wrong in this patient and may improve prognosis. However, how much to give and the endpoint isn’t really clear in animals. In people, it is administered until the pain of the bite is alleviated. We cannot ascertain that as easily in our patients. But given the dog’s non-systemic signs, it may not be warranted. However, administering it wouldn’t be wrong and may or may not improve the overall outcome. It is more clear-cut in more severe cases.

Steroids are contraindicated and shouldn’t be used.

Thus, for this patient with a low snakebite severity score, known species of snake, mild injury, at least currently, no bloodwork abnormalities or systemic signs, the prognosis is good with proper wound management and care. Antivenin should be considered if the wound worsens or clinical signs worsen. 

Ultimately, the prognosis varies depending on the severity of envenomation, treatment received, and how quickly it is started. Further, the type of snake also has a bearing on the ultimate prognosis. 

Correct answer: The late majority

There are five categories of adopter strategies. You may fall into a different category when considering an electronic vs. a new surgical procedure vs. electing to carry a drug in your practice. But if you were skeptical of change and waited until the majority had already added that new drug, you would be considered a late majority adopter.

1. Innovators: These people want to be the first out of the starting gate. They want the new iPhone the minute it comes on the shelves. They will take risks but also may be the first to develop novel ideas. Advertisements, continuing education, and drug rep meetings aren't necessary for these people. 
2. Early adopters: This group often equates with opinion leaders. They embrace change, enjoy leading, recognize the need for change (increasing their drug selection availability and the available bedside tests), and remain comfortable with adopting change. They often have already decided to change or add something new but still would benefit from how-to manuals or information sheets for them to pull the trigger. 
3. Early majority: While rarely considered leaders, they still take the leap forward for new ideas, new innovations, and new meds sooner than average. They want to see the medical evidence and papers with completed trials and even data for a few months, at least, before jumping on board. Success stories, case reports, and effective evidence-based information will guide this group. 
4. Late majority: These people want to see more than just case studies. They want success stories, the number of practices using it in the area with positive results, and more data before pulling the trigger. 
5. Finally, the laggards remain stuck in the past. They practice veterinary medicine based on tradition, failing to either keep up with the current medical evidence, failing to believe it, or failing to see the benefit of adding a new medication to their selections. These folks benefit from hard facts and statistics and may require appeals from others in different adopter styles. This may mean clients asking for a specific product/medication, associates wanting to improve their pain management game requesting the new drug for their treatment arsenal, or people from other adopter groups encouraging them. 

Correct answer: Pinna amputation

Most skin cancers in dogs and cats respond the best to local surgical excision. This provides a clear-cut diagnosis, in many cases, cure, and permits grading of the disease and margin assessment if not cured. This can then help guide additional therapy if warranted.

Sometimes the location of skin tumors isn’t always amenable to surgical excision due to unacceptable disfigurement to owners, lack of sufficient tissue to permit adequate closure, or financial reasons. In these cases, radiation therapy may be used, and depending on the tumor, location, side effects, and other parameters may also be curative.

Staged or serial surgical resection is sometimes warranted for tumors (SCC or hemangiosarcoma) when they arise on glabrous skin yet are still small when triggered by sunlight exposure and carcinogenesis. Generally, the pinna is an easy location because surgical excision is feasible.

In people, they may use photodynamic therapy. The laser’s light activates photosensitizing agents and is commonly utilized in human medicine but not readily available or cost-effective in animals.

Correct answer: Avoid placing a urinary catheter as this could cause more damage to the mucosa and prevent replacement of the tissue

Though uncommon, bladder eversion or prolapse may occur secondary to conditions causing repeated abdominal straining, such as colic or dystocia. Signs may include dysuria and related signs +/- signs of urethral obstruction. The bladder mucosa may be visible at the perineum. Diagnosis is by physical exam, rectal palpation, and ultrasound, and you can pass a urinary catheter to relieve any obstruction. This will also likely aid in replacing the tissue and may manually reduce the eversion.

Before replacing the tissue, apply dextrose or saline to the mucosa to decrease edema and facilitate removal.

Placing a purse-string suture near the external urethral sphincter may lessen the chance of recurrence, though it doesn't guarantee it.

Broad-spectrum antimicrobials are warranted. At a minimum, there is an increased risk of ascending infection in the urinary tract. If the prolapse is complete or severe and or for a long duration, there is also a risk of peritonitis or pelvic abscessation.

Correct answer: 2–25% worldwide; Leptospira species

Equine Recurrent Uveitis (ERU) occurs globally, and the prevalence can range from 2–25%. 

Uveitis in horses presents as it can in other species. It is the most common cause of blindness in our equine patients. Animals will commonly show inflammation in both the anterior and posterior chambers, and it is associated with the ciliary body and iris. Additional changes can occur.

Clinical signs include iridial fibrosis, posterior synechia, phthisis bulbi, chorioretinal scarring, corneal scarring, corpora nigra atrophy, lens luxation, changes in intraocular pressure (low in acute or high if glaucoma is developing). Animals often have an aqueous flare, blepharospasm, corneal edema, and epiphora, and may have fibrin within the anterior chamber. Some may have decreased vision at the time of diagnosis.

The condition may be unilateral or bilateral, so always ensure a full exam is performed on both eyes, including the Schirmer tear test, ocular staining, and intraocular pressure evaluation. Additional diagnostics such as serology and full bloodwork or PCR may be warranted.

Non-infectious causes of uveitis include trauma, immune-mediated conditions, cancer (e.g., lymphosarcoma, most notably), or lens-induced. However, infectious etiologies are also known to induce uveitis. Some animals will only get the condition once and never again. However, others are prone to recurrent bouts.

Leptospira species are notorious for inducing uveitis syndrome, though other organisms, such as Borrelia species, and other bacterial causes, such as Rhodococcus equi, E. coli, and Salmonella species. Viral diseases less commonly contribute, including influenza, equine herpesvirus, or equine viral arteritis.

Breeds that may be predisposed include Warmbloods, draft breeds, and Appaloosas. However, it is likely a combination of genetic and environmental factors that play a role in the development of ERU.

If ERU develops, therapy may be needed for life to preserve vision and prevent common sequelae to uveitis, including corneal ulcers, cataracts, or glaucoma. 

Correct answer: Antihistamine

While antivenin reactions are uncommon, they can occur, and an antihistamine may help minimize the risk. Further, some snake envenomations have been demonstrated to cause mast cell degranulation, though H1 or H2 blockers are not routinely utilized in human medicine for snakebites. More importantly, the other answers are wrong because: 

1. Corticosteroids remain controversial in many areas of veterinary medicine use, including shock. Further, steroids may enhance venom toxicity. Additionally, due to the high side effect risks and the lack of evidence of clear benefit, they are to be avoided unless an obvious anaphylactic reaction to the antivenin were to develop.
2. NSAIDs should not be utilized until coagulopathy-related complications have resolved because of their ability to create a thrombocytopathia. Once stabilized and all coag parameters normalize, these may be used as pain management therapy as the wound heals. Further, if myoglobinuria is present, these are contraindicated. 
3. Fresh frozen plasma isn’t warranted because the type of coagulopathy induced by snakebites isn’t similar to the consumptive coagulopathies we most commonly see in veterinary medicine. Instead, coagulopathy results from defibrination, not Disseminated Coagulopathy (DIC). Getting rid of the venom in the blood is paramount to preventing this from occurring.

So, even if FFP is administered, if venom is still present, it will continue to break it down and may even exacerbate the coagulopathic state. For this reason, in patients with active coagulopathy, antivenin is likely to be beneficial.

Correct answer: Compounding of animal medications can occur if the active ingredient is a bulk drug substance

We may need to compound medications in veterinary medicine for many reasons, from the size of the patient and lack of available doses to the lack of an approved veterinary product. We may need to compound to get the medication into a more palatable format (like creating a suspension for owners who cannot pill their pets). Regardless, according to The Federal Food, Drug, and Cosmetic Act (FD&C Act), the FDA permits compounding animal drugs when the active ingredient source is a finished drug that is already FDA-approved. They do not consider it acceptable to compound from a bulk drug substance (something used to make a drug that, in the finished form, becomes active). Compounding from bulk substances is not FDA-approved.

Clopidogrel is the treatment of choice for cats at risk for thromboembolic disease. We dose cats who can be pilled at 1/4 the standard human 75 mg tablet or 18.75 mg/cat. Because we are using the FDA-approved product and changing it to a more palatable source, the FDA permits this compounding. You explain to the owner that you will be calling the script into a special compounded pharmacy, and they will contact the owner directly to arrange shipping and pricing/payment.

You review drug side effects and signs to look out for related to thromboembolic disease in cats. Additionally, you review signs of cardiac compromise (congestive heart failure). You explain to your client thatm based on the current ECHO, she has early signs of heart disease, which doesn’t warrant medication. However, because of the "smoke," she is at higher risk of throwing a clot. 

All the remaining options in the answers are correct pertaining to compounding in veterinary medicine. 

Correct answer: Amblyomma americanum

Amblyomma americanum, the lone star tick, is the present primary means of transmission for Cytauxzoon felis in the U.S. As this tick’s range expands, the disease occurs much more frequently, initially once confined to the south-central U.S. They have the disease in Brazil, where Amblyomma americium is not found. Thus, it is presumed that Amblyomma cajennense is the primary vector in that region.

Ixodes scapularis (deer tick) is adept at carrying and transmitting diseases. However, it is associated with Lyme disease most commonly. It hasn’t been reported in association with this condition. Dermacenter variabilis (American dog tick) may be a potential competent vector, as the organism has been identified in this tick with competence transfer from nymphs to adults. This hematoprotozoal organism causes a progressively febrile condition. Signs may include depression, anorexia, lethargy, nictitans elevation, tachypnea, vocalization, organomegaly including the liver, spleen, lymph nodes, icterus, pallor, and sometimes dull mentation or seizures.

Treatment is feasible with aggressive supportive care and combination drug therapies, and once described as universally fatal, it may be treatable. However, the prognosis remains guarded to poor, depending on how sick the pet is on presentation and diagnosis.

Correct answer: Improving communications

Failed communication is often the number one breakdown in any business. Communication challenges occur among colleagues, support staff, clients, and with representatives from other companies. Poor communication can lead to decreased job satisfaction and lower productivity. Poor communication increases the risk of medical errors, and having well-written, routinely reviewed, and updated SOPs can prevent some common pitfalls resulting from a lack of communication or communication breakdown. Anything crucial to day-to-day clinical practice and those things that may only happen once a year need to be documented and easily understood by all employees.

Good communication is an individual skill, but when done well within an organization, it becomes a collective one.

The following is a broad list of concrete advantages derived from well-organized, well-written, and easily understandable SOPs. SOPs help us to:

1. Improve communications by putting everyone on equal footing
2. Enforce best practices
3. Create repeatable procedures
4. Aid in onboarding employees
5. Prevent failures in routine procedures and processes (from shutting down the cash register to autoclaving the surgical instruments to cleaning isolation after a parvo puppy has been discharged)
6. Decreased errors and the need for corrective actions
7. Ensure that the practice complies with laws and regulations for the industry, the state, and the locale in which it operates
8. Add value to your company — if you sell the company and these procedural standards are already in place, this increases the worth of your practice, as you already have established what works and what doesn't