medicine Flashcards
An owner presents her pregnant newfoundland bitch, she is concerned that whelping is not progressing as it has done for previous litters. A)what are the clinical signs of dystocia in the bitch,
B)give two diagnostic tests that can be used to assess a whelping bitch with dystocia, how do the help guide treatment,
C) what is the main option for medical management, what considerations should be taken (Ie when should medical management not be attempted) and what further investigation should be attempted prior to medical treatment and how successful is it likely to be
D) describe an anaesthetic and analgesic plan for a bitch requiring c-section (do not cover resuss in puppies) (6,6,6,12)
Dystocia- excessive unproductive straining, malodorous or discoloured discharge, over two hours with no sign of an expected puppy, exhaustion and collapse of the bitch, excessive pain (panting, heart rate, irritation of vulva), restlessness
Tests- radiography- visualisation of puppy skeleton allows you to check there are more puppies, location of those puppies and to check for certain foetal monsters (malpresentation, malposition and malposture)
-ultrasonography- foetal heart beat, myometrial contractions, malposition, malposture, malpresentation, composition of the amniotic and allantoic fluids and assess placental thickness and regularity
medical management- oxytocin administration, not if puppy stuck in pelvic canal or unlikely to be able to be delivered naturally as increasing contractility will worsen an obstruction. Vaginal examination (+/-radiography/ultrasound). Unlikely to succeed as most causes of dystocia in the bitch are foetal pelvic disproportion and are not related to failure of myometrial contractions.
Anaesthesia- time is of the essence, pre clip before induction if possible, fluid therapy (hartmanns 10ml/kg/hr increased if clinical signs of dehydration pre anaesthetic), propafol to induce titrate to effect, no acepromazine or alpha 2 agonist premed or opiod pain relief if possible. If calm and quiet, catheterise without sedation (always have a catherter for IV access), induce anaesthesia with propofol to effect, iso or sevo to maintain, light plane of anaesthesia, epidural for pain management (local anesthetic- bupivicaine- with caution if cardiovascularly unstable), once neonates delivered give methadone for pain relief. If bitch fractious/difficult to catheterise could use fentanyl and diazepam for premed. Line block possible if epidural not for some reason.
An owner presents her pregnant newfoundland bitch, she is concerned that whelping is not progressing as it has done for previous litters. A)what are the clinical signs of dystocia in the bitch,
B)give two diagnostic tests that can be used to assess a whelping bitch with dystocia, how do the help guide treatment,
C) what is the main option for medical management, what considerations should be taken (Ie when should medical management not be attempted) and what further investigation should be attempted prior to medical treatment and how successful is it likely to be
D) describe an anaesthetic and analgesic plan for a bitch requiring c-section (do not cover resuss in puppies) (6,6,6,12)
Dystocia- excessive unproductive straining, malodorous or discoloured discharge, over two hours with no sign of an expected puppy, exhaustion and collapse of the bitch, excessive pain (panting, heart rate, irritation of vulva), restlessness
Tests- radiography- visualisation of puppy skeleton allows you to check there are more puppies, location of those puppies and to check for certain foetal monsters (malpresentation, malposition and malposture)
-ultrasonography- foetal heart beat, myometrial contractions, malposition, malposture, malpresentation, composition of the amniotic and allantoic fluids and assess placental thickness and regularity
medical management- oxytocin administration, not if puppy stuck in pelvic canal or unlikely to be able to be delivered naturally as increasing contractility will worsen an obstruction. Vaginal examination (+/-radiography/ultrasound). Unlikely to succeed as most causes of dystocia in the bitch are foetal pelvic disproportion and are not related to failure of myometrial contractions.
Anaesthesia- time is of the essence, pre clip before induction if possible, fluid therapy (hartmanns 10ml/kg/hr increased if clinical signs of dehydration pre anaesthetic), propafol to induce titrate to effect, no acepromazine or alpha 2 agonist premed or opiod pain relief if possible. If calm and quiet, catheterise without sedation (always have a catherter for IV access), induce anaesthesia with propofol to effect, iso or sevo to maintain, light plane of anaesthesia, epidural for pain management (local anesthetic- bupivicaine- with caution if cardiovascularly unstable), once neonates delivered give methadone for pain relief. If bitch fractious/difficult to catheterise could use fentanyl and diazepam for premed. Line block possible if epidural not for some reason.
You suspect that a canine patient you are treating is suffering from leptospirosis, the dog has azotemia and raised liver enzymes. the owners are upset that they have vaccinated their dog yearly for this disease and don’t understand how it could have acquired infection in spite of that.
A) what will you say to the owners to say how their dog might develop lepto in spite of vaccination
B) what precautions should the owner take
C) name two tests to confirm an infection with lepto
D) how are you going to treat your patient? (4,2,2,4)
It could be a different serovar to the infection (ictoheamorrhagica and canicola in most vaccines, pomona and grippotyphosa are reemerging strains associated with liver disease and renal failure). Overwhelming challenge a possibility. Vaccination doesn’t prevent infection and formation of a carrier state (question does not state dog is clinically sick). May not be leptospirosis! Immunity may not last a full 12 months
Some of the strains are zoonotic, avoid the dogs urine (gloves/face shield) and take special precautions if bitten. Quarantine from other dogs/ animals for at least 3 months after active infection.
Blood/urine culture/ PCR, rising antibody titre (ELISA) with signs, dark field microscopy of urine, microscopic/microcapsular agglutination tests
Antibiotics- doxycycline is best choice as it also targets the renal carrier phase, preventing transmission. Fluroquinolones or penicillin are other options in initial stage, but should be followed by 2-4 weeks of doxy. IVFT as renal and liver failure, possibility of decreased clotting factors or hypoproteineamia- may need plasma/blood transfusion. Prognosis good, less than 10% fatality.
You are presented with a dachshund off his legs. The dog appears painful in the middle of his back. He has normal voluntary movements on the FLs but has no volnttary movement of his hindlimbs. His knuckling response is normal in the FLs, absent in HLs.
A) how would you describe the gait of this dog in one word
B) In terms of between which spinal cord segments this lesion could be lying, what are the two broad regions of localisation within the spinal cord that could explain this neurological syndrome and how might your neurological exam differ for these two regions? (1,2,9)
Paraplegia
T3-L3, L4-S3
Cutaneous trunci reflex - Intact L4-S3, impaired to approximately two segments caudal to the lesion in T3-L3.
Patellar reflex - Intact T3-L3, impaired/reduced L4-S3 - can loclise further to L4-L6.
Withdrawal reflex - Intact
Knuckling - Impaired or reduced in both
Perineal reflex - Intact T3-L3, impaired or reduced in L4-S3.
Tail tone - Intact T3-L3, impaired or reduced in L4-S3
Cranial nerves and mentation normal in both.
Schiff-Sherrington phenomenon can mean forelimbs held in rigid extension with a T3-L3 lesion, normal in L4-S3.
Due to spinal shock, localisation can be confused as a lesion in L4-S3 can present as a T3-L3 lesion, in addition multiple lesions are a possibility.
You are presented with a 9 year old female neutered dog that has been lethargic and anorexic for the past week. On physical examination you find the dog to be depressed, pyrexic (40C) and note pallor of the mucous membrane.You take a blood sample for haematology and find the dog to be pancytopenic: neutrophils 0.7 x 109/l (norm - 3-11), RBC 1.8 x 1012/l (nom - 5.5-8.5), and platelets 34 x 109/l (norm - 175-500).
A) What further investigation would you advise and why?
B) List the possible causes of bone marrow suppression in this dog.
C) Explain the difference between acute and chronic forms of leukaemia. (2,4,4)
Bone marrow biopsy to try to discern a cause within the bone marrow for the pancytopaenia.
reduced production
- myelofibrosis- idiopathic
- aplastic anaemia
neoplastic proliferation of other cells
- acute lymphoid/myeloid leukaemia
- chronic lymphocytic leukaemia
- multiple myeloma
- lymphoma
Infectious
- erhlichiosis, parvovirus
drug induced
- hyperoestrogenism (iatrogenic/sertoli cell tumour)
- irradiation/toxins/drugs (esp chemotherapeutic)
other
-primary myelodysplasia, immune mediat-prolonged stimulation (eg chronic IM anaemia)ed or neoplastic
acute-aggressive, rapid progression, myelosuppression, increased risk of infection, organ failure due to infiltration, DIC. Proliferation of early lymphoblastic precurors which arrests normal cell production- blast cells predominate. Poor prognosis and treatment tends to be unrewarding
chronic- slow progression, mild signs, proliferation of late precurors or mature lymphoid/erythroid cells. normally see lymphocytosis of one line. Can use chemotherpaeutic regimes to good effect. Chronic myeloid can enter blast cell crisis and see acute signs.
You are presented with a 9 year old female neutered dog that has been lethargic and anorexic for the past week. On physical examination you find the dog to be depressed, pyrexic (40C) and note pallor of the mucous membrane.You take a blood sample for haematology and find the dog to be pancytopenic: neutrophils 0.7 x 109/l (norm - 3-11), RBC 1.8 x 1012/l (nom - 5.5-8.5), and platelets 34 x 109/l (norm - 175-500).
A) What further investigation would you advise and why?
B) List the possible causes of bone marrow suppression in this dog.
C) Explain the difference between acute and chronic forms of leukaemia. (2,4,4)
Bone marrow biopsy to try to discern a cause within the bone marrow for the pancytopaenia.
A 3 year old rabbit is presented to you with copious white discharge from one eye, this having been present for several weeks but not seeming to cause the animal discomfort.
A) What might be the cause of this discharge?
B)What steps would yo take to come to a diagnosis?
C) How might you seek to treat the condition and what prognosis would you give to the owner?
D) How might you assess pain in this species? (2,4,3,3)
Please fill in
- How can you try to differentiate primary and secondary seizures based on history, clinical signs and basic diagnostic tests? Give 6 major differences (2 marks for each difference).
History
- signalment- age (more likely to be 1o if 6m-6y), breed (some breeds eg GSD,boxer 1o more likely), species (cats more likely to be 2o),
- familial history- genetic hereditability in suspect breeds for 1o
- previous seizures (more likely to be 1o)
- progression of seizures (rapid more likely to be 2o)
- toxic exposure (secondary)
- timing of siezures (2o more likely to be assoicated with eating or activity)
- trauma
- endocrine diseases (diabetic ketoacidosis, addisons)
Clinical signs
- partial vs generalised vs status (partial more likely o be secondary as is first presentation in status)
- inter-ictal signs mean more likely to be secondary
- systemic health (good more likely to be 1o)
Basic diagnostics
- bloods (liver enzymes, hypoglycaemia, hypokalaemia, t4 abnormal if 2o)
- therapeutic trial- 1o well controlled, 2o not
- CSF tap- normal for 1o, increase in protein, wbc, positive serology for toxoplasma
- An 8-year-old entire male Doberman pinscher is presented to you for the investigation of sudden onset exercise intolerance with tachypnoea,
irregular tachycardia, cyanosis and frequent coughing. The dog has no significant previous disease history. List your differential diagnoses. (6 marks)
What emergency treatment options would be appropriate for this dog? (6 marks)
heart muscle disorders
- DCM
- mitral valve disease
- restrictive cardiomyopathy
- congestive heart failure
heart rhythm disorders
- atrial fibrillation
- ventricular tachycardia
- ventricular fibrillation
- electryolyte abnormalities (potassium, calcium)
restriction of heart
- pericardial effusion- haemangiosarcoma rupture
- pericarditis
obstruction to ventricular outflow
- pulmonary stenosis
- aortic stenosis
hypoxaemia-
- pleural effusion
- pulmonary oedema
- pulmonary fibrosis
- pulmonary embolism
- pulmonary contusions
other
- sepsis
- shock (trauma, GDV)
- endocrine collapse
- anaemia (haemorrhage)
provide oxygen- nasal prongs, mask, oxygen tent
IV access, fluids containdicated if in pulmonary oedema but necessary if in hypovolaemic shock, or electrolyte abnormalities
frusemide- diuretic used to reduce preload, contrindicated if cardiac tympany, can help reduce pulmonary oedema
pimobendan- positive inotrope, calcium sensitiser, prolongs life with DCM
ace inhibitors (benazepril)- inhibits RAAS, improves survival with DCM
digoxin if in AF,- positive inotrope, risk of causing other arrhythmias
ECG to monitor
- Write short notes on:
a) The treatment of pemphigus foliaceus in cats (3 marks)
b) Treatment of parasitic skin disease in guinea pigs (3 marks)
c) The treatment of a dog with confirmed atopic dermatitis (3 marks)
d) Treatment of canine cheyletiellosis (3 marks)
pemphigus foliaceus
- immune mediated, so immunosupression useful
- topical corticosteroids may be suitable for mild lesions
- systemic glucocorticoids provide rapid relief assuming not contraindicated by other systemic disease
- azathioprine purine analogue interfereing with nuclear synthesis is often used in dogs refractory to glucocorticoids, but not in cats as high risk of immunosuppression
- chlorambucil often used in cats refractory alkylating agent cross linking cellular DNA
- cyclosporine is a useful adjunct but slow to work on its own due to action on T lymphocytes rather than directly
parasitic skin disease in guinea pigs
- topical spot on ivermectin (designed for small animals)
- follow with bathing after 48 hours
- special shampoos availiable to kill lice
atopic dermatitis
- glucocorticoids cheap but may see side effects long term
- cyclosporin good alternative, less side effects, more expensive
- immune modulation therapy especially if identified a low number of allergic components that can be vaccinated for
- apoquel (oclacitinib)- janus kinase inhibitor, hard to get hold of but very effective and less side effects.
- omega 3 fatty acids- adjunctive, reduce inflammation
- anti histamines often an adjunct to reduce dose
Cheyletiella
- weekly bathing in pyrethrin shampoo,
- lime sulfur dips every five to seven days for three weeks
- fipronil spray one spritz/lb body weight repeated again in three weeks
- selamectin topically one dose every 15 days for a total of three doses
- ivermectin 200 micrograms/kg every week for three weeks (must be heartworm negative first and not used in herding breeds or crosses thereof)
- milbemycin 2 mg/kg once weekly for three weeks
- The environment must be treated with a house and carpet spray such as those that are used for fleas. Remember to treat any pet exposed to the affected animal and not just the affected animal.
- The following three drugs are all licensed as anti-emetics in dogs. For each drug, explain the mode of action including whether it works peripherally or centrally; any potential side-effects and give examples of when you might use the drug.
a) Metoclopramide (4 marks)
b) Maropitant (4 marks)
c) Cimetidine (4 marks)
metaclopramide- mixed peripheral and central actions. peripherally to improve coordination of gastric motility and gastric emptying. central blockade of chemoreceptor trigger zone. Used in radiation sickness, chemotherapy, pylorospasm, peritonitis, pancreatitis (abnormal GI motility), drug/toxin induced. side effects- sedation, seizures, abdominal pain, diarrhoea, constipation, hyperactivity
maropitant- NK1 receptor blocker, central action. chemotherapy and radiation induced vomiting (especially delayed), post op vomiting, motion sickness prevention. side effects- drooling, diarrhoea, inappetance, sedation.
cimetidine- h2 receptor antagonist acting peripherally, to reduce stomach acid, often used in cases of gastric ulceration or prophylactically in patients at risk of regurgitation during anaesthesia where vomiting is associated with increased gastric acidity. Side effects- may react with other antiemetics, heart rhythm abnormalities, drowsiness.
- You are presented with a 2-year-old bichon frise that had puppies 2 weeks ago and is now restless, whining and panting with visible muscle tremors and an elevated rectal temperature.
a) Name two possible differential diagnoses (2 marks)
b) What diagnostic tests would you choose to help you make your diagnosis?
(5 marks)
c) For one of the possible diagnoses, describe briefly how you would manage the condition (5 marks)
- metritis
- eclampsia
- history
- clinical examination
- bloods- CBC for systemic infection, Biochem for electrolytes (especially calcium)
- abdominal ultrasound, particularly for fliud in the uterus and possible FNA and cytology for analysis, culture and sensitivity.
- ECG for calcium effects on heart
eclampsia- slow IV calcium gluconate to clinical effect while monitoring heart rate. once seizures subside, subcutaneous and then oral calcium. Neonates fed milk replacer and gradually returned to suckling with continuous supplementation with milk replacers to decrease lactational pressure.
metritis- IVFT, antibiosis (systemic), possible spay.
- How can you try to differentiate primary and secondary seizures based on history, clinical signs and basic diagnostic tests? Give 6 major differences (2 marks for each difference).
History
- signalment- age (more likely to be 1o if 6m-6y), breed (some breeds eg GSD,boxer 1o more likely), species (cats more likely to be 2o),
- familial history- genetic hereditability in suspect breeds for 1o
- previous seizures (more likely to be 1o)
- progression of seizures (rapid more likely to be 2o)
- toxic exposure (secondary)
Clinical signs
- partial vs generalised vs status (partial more likely o be secondary as is first presentation in status)
- inter-ictal signs mean more likely to be secondary
Basic diagnostics
-bloods (liver enzymes, hypoglycaemia
- An eight-year-old miniature poodle, blinded by cataracts for three years, is presented to you as the owner has just won three thousand pounds on the lottery and wants referral of her dog for cataract surgery. What causes might there be for the opacity in the dog’s lenses? (3 marks)
What tests would you undertake and what signs would you look for, to assess whether cataract surgery if likely to be successful? (3 marks)
Describe briefly to the owner what sort of surgery is involved in removing the cataract. (3 marks)
What pre- and post-operative medications are likely to be needed to ensure long-term success of surgery? (3 marks)
- diabetic cataracts- increased lens glucose converted to sorbitol to increase of osmotic pull of water into lens
-post PRA metabolic cataract- secondary to retinal atrophy due to toxic metabolites from liquid peroxidation in degenerate retina
-inherited non congenital cataract- progressive in poodle starting from equator
(-traumatic cataracts possible) - associated ocular condition that may complicate surgery- opthalmoscopy, especially lens induced uveitis
- associated systemic condition that may complicate- especially diabetics- check blood glucose well controlled
- associated condition that woudl preclude a return of vision.- PRA as retinal pathology- if cant be visualised use electroretinogram as PLR not adequate. Also retinal detachment.
phacoemulsification is the preferred surgery. Ultrasonic frequences of pulsating fluid to break up lens, small incision in cornea to minimise fluid loss. Posterior capsule polished to remove last bits of lens. Suture closed. Can place an artificial lens but many feel unnecessary as extra point of inflammation.
Risk of uveitis, glaucoma, posteror capsule opacification, corneal oedema.
preoperatve antiflammatory mediacation with topical steroid (pred forte) and NSAID (acular). Possibly a single dose of atropine preoperatively to induce mydriasis if not present due to acular. Possible antibiosis post op (chloramphenicol), as well as post op steroid continuing and NSAID.
Write short notes on the acute treatment and long term management of non-obstructive feline idiopathic (interstitial) cystitis.
? need to treat- will recover in 2-3 days, though repeat bouts become more severe and frequent
Acute-
-Pain relief - NSAIDs possible buprenorphine.
-Enhance water uptake- possibly add salt to diet, tempt more. Change to moist food.
-Pheromones
Feliway- shows a positive correlation with improvement
-Tricyclic antidepressants- amitriptyline (2.5-10mg/cat SID).- anticholinergic, anti-inflammatory, anti alpha adrenergic, analgesic, antidepressant
-Antibiotics? only if infection present
-Antispasmodics? if urethral spasm and functional blockage
Long term-
Causal link with cats perception of stress, can be reduced by:
-Multimodal environmental modification (MEMO)
-Clean up urinary soiling
-Enhance litter tray management
-Consider altering diet- waltham PH/other diets aimed at this, acidification not appropriate unless struvite stones
-Replacing the protective GAG layer (Cystaid)
binding to the urothelium and decreasing bladder wall permeability.
- How can you try to differentiate primary and secondary seizures based on history, clinical signs and basic diagnostic tests? Give 6 major differences (2 marks for each difference).
History
- signalment- age (more likely to be 1o if 6m-6y), breed (some breeds eg GSD,boxer 1o more likely), species (cats more likely to be 2o),
- familial history- genetic hereditability in suspect breeds for 1o
- previous seizures (more likely to be 1o)
- progression of seizures (rapid more likely to be 2o)
- toxic exposure (secondary)
- timing of siezures (2o more likely to be assoicated with eating or activity)
- trauma
- endocrine diseases (diabetic ketoacidosis, addisons)
Clinical signs
- partial vs generalised vs status (partial more likely o be secondary as is first presentation in status)
- inter-ictal signs mean more likely to be secondary
- systemic health (good more likely to be 1o)
Basic diagnostics
- bloods (liver enzymes, hypoglycaemia, hypokalaemia, t4 abnormal if 2o)
- therapeutic trial- 1o well controlled, 2o not
- CSF tap- normal for 1o, increase in protein, wbc, positive serology for toxoplasma
- An 8-year-old entire male Doberman pinscher is presented to you for the investigation of sudden onset exercise intolerance with tachypnoea,
irregular tachycardia, cyanosis and frequent coughing. The dog has no significant previous disease history. List your differential diagnoses. (6 marks)
What emergency treatment options would be appropriate for this dog? (6 marks)
heart muscle disorders
- DCM
- mitral valve disease
- restrictive cardiomyopathy
- congestive heart failure
heart rhythm disorders
- atrial fibrillation
- ventricular tachycardia
- ventricular fibrillation
- electryolyte abnormalities (potassium, calcium)
restriction of heart
- pericardial effusion- haemangiosarcoma rupture
- pericarditis
obstruction to ventricular outflow
- pulmonary stenosis
- aortic stenosis
hypoxaemia-
- pleural effusion
- pulmonary oedema
- pulmonary fibrosis
- pulmonary embolism
- pulmonary contusions
other
- sepsis
- shock (trauma, GDV)
- endocrine collapse
- anaemia (haemorrhage)
provide oxygen- nasal prongs, mask, oxygen tent
IV access, fluids containdicated if in pulmonary oedema but necessary if in hypovolaemic shock, or electrolyte abnormalities
frusemide- diuretic used to reduce preload, contrindicated if cardiac tympany, can help reduce pulmonary oedema
pimobendan- positive inotrope, calcium sensitiser, prolongs life with DCM
ace inhibitors (benazepril)- inhibits RAAS, improves survival with DCM
digoxin if in AF,- positive inotrope, risk of causing other arrhythmias
ECG to monitor
List the causes of hypercalcaemia in the dog (8 marks).
A good laboratory can give you two values for serum calcium concentrations: what are these and how is it helpful to measure calcium in two ways? (2 marks) What other electrolyte is it important to measure in the blood and why? (2 marks
hypercalcaemia of malignancy
-osteosarcoma through bone destruction and lysis
-lymphoma, multiple myeloma and anal sac adenocarcinoma through production of parathyroid-like protein
primary hyperprathyroidism
nutritional secondary hyperparathyroidism
renal secondary hyperparathyroidism
hypoadrenocorticism
vitamin D toxicity
vitamin A toxicity
chronic kidney disease/acute renal failure
granulomatous disease
physiological (young/post prandial)
ionised calcium and total calcium because the vast majority of calcium is bound to plasma proteins but active calcium must be ionised (free), and so ionised calcium is probably more accurate but harder for laboratories to perform accurately
phosphate because it binds calcium and is affected by parathyroid hormone secretion- likely to be hypophosphatemic
List six clinical signs used to monitor fluid resuscitation in a dog suffering from septic shock (6 marks). State briefly 3 ways in which monitoring equipment may be used to assist you (6 marks)
Heart rate CRT Pulse quality/rhythm BP mucus membranes Respiratory rate
An ECG allows quick and accurate measurement of the heart rate and rhythm so you can see the heart rate coming down and assists in knowing the accuracy of other pieces of monitoring equipment.
A direct arterial blood pressure is the most accurate method of reading blood pressure but is invasive and difficult to maintain. Blood pressure is very important as avoiding hypotension avoids ischaemic damage to organs. It allows a real time measure of the hypovolaemia and adds to the ECG data about heart rate as neither can tell stroke volume. Other methods of reading blood pressure include oscillometry and Doppler.
Pulse oximetry gives an idea of pulse quality and shape as well as potential hypoxaemia. It gives you an idea of how peripheral tissues are coping.
List two drugs that may be used to control hypertension in small animal practice (2 marks). For both of these drugs indicate:
a) The mode of action (4 marks) b) Indications for use (4 marks) c) Possible side effects (2 marks)
ACE inhibitors - benazepril
MOA - inhibits breakdown of angiotensin 1 into angiotensin 2 and inhibits the breakdown if bradykinin. Therefore reduces preload and afterload via venodilation and arteriodilation, decreased sodium chloride and water retention via decreased aldosterone production and inhibiting angiotensin-aldosterone mediated cardiac and vascular remodelling.
Indications for use - treatment of CHF in dogs and cats. Chronic renal insufficiency in cats. Protein losing nephropathies. Reduces blood pressure in hypertension. Hepatic metabolism, no renal, exacerbate prerenal azotemia in hypotension animals and those with poor renal perfusion.
Side effects - hypotension, hyperkalaemia and azotemia, causes azotemia in rabbits.
Amlodipine - not licensed.
MOA - dihydropyridine calcium channel blocker with predominant action at the peripheral arteriolar vasculature resulting in a decrease in afterload. Mild negative inotropic and chronotropic effects that are negligible at low doses.
Indications - systemic hypertension in cats and appears to be safe even when there is concurrent renal failure. Used in dogs for treatment of systemic hypertension and in normotensive dogs as adjunctive therapy for refractory heart failure due to mitral regurg. Decreases proteinuria in cats with systemic hypertension, metabolised in the liver.
Side effects - lethargy, hypotension, inappetence rarely, avoid in cardio genie shock and pregnancy.
A thirteen year old domestic short haired cat is presented to you with one eye filled with blood. What other ophthalmic and systemic signs might you see on a clinical examination and what diagnoses might you reach? What ancillary tests might be appropriate and what treatment might you use? (12)
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You are presented with an acutely paraplegic Dachshund with a normal cranial nerve examination and normal forelimb examination. In terms of between which vertebrae this spinal lesion could be lying, what are the two broad regions of localisation that could explain this paraplegia (2 marks) and how would your neurological examination differ for these two regions? (9 marks) What important test should be performed last to give an indication of potential prognosis for recovery of ambulation in this dog? (1 mark)
T3-L3, L4-S3 last test - deep pain sensation
Schiff-Sherrington phenomenon possible.
Paniculus reflex - cuts out at dermatome just caudal to the extrusion.
Spinal reflexes in hindlimbs - patellar reflex - femoral nerve, not working lesion in L4-L6.
Withdrawal reflex - potentially hyper reflexive if T3-L3, absent on other.
Perineal reflex - absent if lesion is L4-S3.
Urinary retention if T3-L3, urinary incontinence otherwise as upper motor neuron and lower motor neuron bladder.
This can all be contraindicated as spinal shock can occur whereby a lesion in the L4-S3 region can also have T3-L3 signs.
A two year old neutered male Labrador retriever presents for the investigation of chronic intermittent diarrhoea of 2 months’ duration. The owner reports that there are flecks of fresh blood and mucus in the faeces, but that the dog’s appetite is normal and there is no weight loss.
a) List your differential diagnoses for this dog’s problem in order of likelihood (6 marks)
b) How would you investigate this diarrhoea? (6 marks)
Likely large intestinal as no weight loss and fresh blood and mucus present. Therefore localises differentials:
Constipation
Dietary indiscretion/abrasion but usually acute.
1 - Chronic inflammatory colitis - lymphocytic-plasmocytic, eosinophilic, granulomatous, histiocytic.
Infections - campylobacter, salmonella, Clostridia, E. coli, giardia, trichuris.
Uraemia colitis.
Secondary to is fat maldigestion/malabsorption so EPI, sibo, IBD, chronic pancreatitis, bile salt deficiency.
Secondary to local irritation - peritonitis, extracolonic mass
Colonic neoplasia or polyps.
2- Colonic motility disorder: irritable bowel syndrome
Investigation:
History and clinical exam - is it SI? Constipation or colitis? Abdominal palpation, rectal palpation.
Faecal sample - gross appearance, culture, flotation for giardia, nematodes, undigested fat, cytology.
Blood samples - rule out renal, hepatic, pancreatic, metabolic, endocrine disease. TLI and folate and B12 if fat suspected.
Radiography - rule out neoplasia, FBs, mega colon, contrast more helpful.
Ultrasound - colonic masses
Proctoscopy and biopsy
Biopsy at laparoscopy
- You suspect that a Basset hound may have a cutaneous intertriginous Malassezia overgrowth. Briefly describe the optimal method by which you would seek to confirm your clinical suspicion. (6) List four treatments that you would expect to be helpful in decreasing Malssezial colonisation of this dog. (6)
History, when did it come about, how long have the owners noticed it, have they been itchy at all etc.
Clinical exam, where is the lesion? What does it look like, how does it smell, is it greasy, is it pruritic usually not but can be on the face, is it painful. Is there hyper pigmentation, is it erythematous.
Investigations - adhesive tape to the area and removed, stained in diff quik and looked at under the microscope, appear as black ovals. Can also take a swab and grow the yeast on Sebrourauds medium. Want to rule out other cause, check for fleas, skin scrapes for parasitic infection with demodex canis or sarcoptes but clinical signs likely to be different. Hair pluck for dermatophytosis. Swab for bacterial infection, maybe secondary to malassezia pachydermatitis.
Treatment - antifungals medicated shampoo with miconazole and chlorhexidine to reduce yeast population.
Systemic antifungal drugs can be used such as ketoconazole.
Topical antibiotic cream for secondary infections.
Surgical resection of tissue resulting in humid conditions for mallassezia growth to allow better ventilation.
- For each of the following immunosuppressive drugs, outline their mechanisms of action and potential side-effects. Also indicate for each drug whether it is safe for dogs and cats and whether it is licensed for use in small animals.
a) Prednisolone (6)
b) Azathioprine (4)
c) Cyclosporine (4)
Prednisolone - binds to cytoplasmic receptors and then enters the nucleus to alter DNA transcription. Cellular metabolism alters resulting in antiinflammatory, immunosuppressive and antifibrotic effects. In dogs acts as an adh antagonist.
Side effects - suppresses the hpa axis resulting in adrenal atrophy and can cause protein urea and glomerular changes in the dog leading to being pupd. Weight loss and cutaneous atrophy due to catabolic effects leading to pot belly and poor wound healing and polyphagia. Vomiting, diarrhoea and GI ulceration possible.
Ophthalmic, topical and oral formulations licensed.
Azathioprine - purine analogue that inhibits purine synthesis that is necessary for cell proliferation, especially leukocytes and lymphocytes. Suppresses cell mediated immunity, alters antibody production and inhibits cell growth.
Side effects - bone marrow suppression and is genetically influenced, GI upset/anorexia, poor hair growth, acute pancreatitis and hepatotoxicity. Do not use in cats as develop a severe non responsive fatal leucopaenia and thrombocytopenia. Avoid rapid withdrawal. Off license use in both dogs and cats.
Cyclosporine - licensed as topical ophthalmic preparation for immune mediated keratoconjunctivitis sicca and oral preparation for atopic dermatitis in dogs.
Side effects - hypertrichosis, vomiting and diarrhoea but usually mild and do not need to stop treatment, increased risk of malignancy, care in diabetic and renal failure patients.
- A 1-year-old Bernese Mountain is suspected of having steroid-responsive meningitis.
a) What are the 2 main clinical signs? (2)
b) Which 2 diagnostic tests would you advise and what would the most likely findings on these tests be in this case? (4)
c) Describe the appropriate treatment including duration of treatment and long term prognosis. (6)
a) Profound spinal pain, especially the neck, depression, fever, hyperaesthesia and stiff gait.
b) CSF tap - Rule out any underlying conditions that show steroids to be contraindicated.
Advanced imaging of the cervical region to rule out disc protrusion.
c)Treatment with immunosuppressive dose of corticosteroids in cases of SRMA usually results in rapid improvement, although there are refractory or chronic cases that require a second immunosuppressive drug. Usually see a response in 48 hours. The treatment is long term and once the clinical signs are controlled, the dose of medication is decreased over months (usually a minimum of four months). The immunosuppressive treatment requires close monitoring by a veterinary surgeon, who decides, based on different examinations and diagnostic tests, when the medication can be decreased and finally discontinued. The prognosis for recovery is good but the potential for relapse exists.
- Describe the treatment of mitral valve disease in:
a) A 2 year-old Cavalier King Charles Spaniel with a grade III/VI murmur and enlarged left atrium but no other clinical signs recognised by the owner. (4)
b) A 12 year-old Cavalier King Charles Spaniel with a grade V/VI murmur and acute onset dyspnoea and collapse. (8)
A) Leave and monitor at regular intervals if the owner wishes but would advise starting treatment.
Do good radiography and ultrasound for baseline measurements.
Pimobendan is a calcium sensitiser and phosphdiesterase inhibitor so increase cyclic AMP in myocardial cells causing increased force of contraction and decreases preload and afterload through direct inhibition of smooth muscle. Shown to improve life expectancy.
ACE inhibitors are used to promote bradykinin activity and has no vasopressin activity. Lead to decreased arterial resistance, decreased venous tension, decreased aldosterone so less sodium retention, and prolongs life but unknown why. Decreases preload and afterload.
Potentially introduce a beta blocker at the lowest effective dose an observe change in heart.
Otherwise use a cardiac diet - mild sodium restriction and high palatability with good protein source to maintain body condition, restrict excessive exercise.
B) initial triage and quick history off the owner.
Oxygen supplementation with as little stress as possible, IV access is paramount, furosemide to reduce pleural effusion (allow free access to water but care with IVFT, leave until stable and only if the animal is not drinking) and allow for stabilisation,
pimobendan, preferably the IV formulation.
Thoracocentesis may be warranted.
Appropriate nursing care, in sternal, temperature controlled, stress free.
May need to sedate but try to use a drug that has few cardiovascular effects as possible.
Potentially give an IV CRI of nitroprusside.
Monitor blood pressure, oxygenation status and start ace inhibitors, spironolactone, beta blocker, potentially cardiac glycosides if animal is still in cardiac failure. Nitroglycerin after acute phase is over.
- An unvaccinated 8 week-old mixed-breed puppy has developed a ‘cloudy eye’ according to the owner.
a) Describe how you would examine the eye (3) and what ancillary tests might be appropriate.(2)
b) What pathological changes could be the basis for ‘a cloudy eye’ and what might your list of differential diagnoses be? (5)
c) Describe the treatments you would give for two of the conditions in your list (2).
Pen torch external examination in light then moderately darkened room, tests PLRs and eye movements. Distant direct ophthalmoscopy to see tapetal reflex and at 0 dioptres, it allows assessment of any opacities in the ocular media such as cataracts that reduce the reflex. Then direct ophthalmoscopy, fundus, then optic disc, +10dioptres for the lens and structures in the anterior segment including the iris. Then examine the cornea and adnexa with 20-30dioptres. Can use indirect ophthalmoscopy, slit lamp examination. Ancillary tests - schirmer tear test, fluorescin dye for corneal ulceration, tropicamide for myriad is if pupil constricted.
Pathological basis - cloudiness of the cornea due to infections, scarring, oedema, fatty infiltration or infiltration inflammatory diseases.
Cloudiness of the aqueous humour due to white blood cells, proteins, fatty lipids or blood.
Opacification or whitening of the lens from cataracts.
Disorders if the vitreous body which can be congenital defects, haemorrhage or inflammation.
Ulcerative keratitis, CAV-1, vascular keratitis, nuclear sclerosis, cataracts, CDV, diabetes mellitus, GME, toxoplasma, corneal ulcer.
DM, cataract surgery, insulin etc
Corneal ulcer - chloramphenicol eye ointment, NSAID eye ointment, atropine if painful.
- Explain the current use of the following blood tests as part of the work up /diagnosis of acute and chronic pancreatitis in dogs and cats:
Serum amylase, lipase, TLI , cPLI and fPLI (12)
Amylase and lipase are of no use in the cat, in dogs they are only 50 percent specific but allow for a good general evaluation. Use in conjunction with the clinical signs. Lipase is more sensitive than amylase, both excreted renally, steroids increase both, and lipase if very high is associated with tumours.
TLI - in canine it is poorly sensitive, better for EPI. Feline version has variable specificity and sensitivity so should not be relied on solely for cats.
PLI - in dogs it is the most sensitive and specific, around 60% but not sure, can do as Elisa snap test in practice so useful for frontline testing. In cats it is a relatively new test and e specific figures are not yet known, it will probably be better than the test we have so far for cats though…
Chronic cases can be harder to tell as the enzymes may be normal due to compensation to the disease. All these blood tests should be done in view of the clinical signs and abdominal ultrasound.
Outline how you would establish the diagnosis and instigate a treatment protocol for a 2 year old Border Collie suspected of having idiopathic epilepsy. (10 marks)
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Write short notes on the clinical signs, diagnosis and treatment of (a third of 10 marks for each):
• Flea allergic dermatitis in a domestic shorthaired cat
• Atopic skin disease in a West Highland white terrier
• Dermatophytosis (ringworm) in a Persian cat
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A 12 year old entire Poodle bitch has diabetes mellitus which has been stable for several months on twice daily doses of Lente insulin. The owner has now noticed that the dog is drinking and urinating a lot and has documented a steadily increasing blood glucose concentration on home monitoring despite increasing daily doses of an intermediate acting insulin. List the possible reasons for this diabetic dog’s apparent lack of response to insulin (5 marks) and discuss your approach to this case (5 marks).
Lack of owner compliance - storage/rolling, technique, dosing, feeding issues and consistency.
Insulin resistance - progesterones, infections - pyometra, UTI, dental, Cushings, pancreatitis, hypothyroidism?
Increased metabolism of insulin.
Somogyi overswing.
Approach - bring in for clinical exam, ask history, observe giving insulin, check bottle and syringes, clinical exam for pyo, systemic illness, bloods, endocrine tests, glucose curve, urinalysis, ultrasound, radiography.
Anaemia is a common finding in animals with neoplasia. List 5 mechanisms whereby neoplasia might cause anaemia ad provide one example for each heading. (2 marks for each mechanism and example.)
Haemorrhage- rupture or necrosis around vessels in vascular tumours
Sequestration of red blood cells- tumours with abnormal vascualture may cause damage to rbcs- see increased schistocytes
Reduced production- tumours of cells in the bone marrow may out compete rbcs for space causing reduced production
You are presented with a 6 y.o. Boxer dog with generalised lymph node enlargement. Describe your diagnostic approach to this problem (6 marks) and discuss what factors you would take into account when considering the management of this case (4 marks).
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List the clinico-pathological findings you would expect to see in a haematology and biochemistry screen and urine sample of a dog with hyperadrenocorticism. (6 marks)
Outline two clinicopathological diagnostic tests you could use to try to confirm your diagnosis. (4 marks)
Biochemistry - hypercholesteraemia, markedly increased ALP, mildly raised other liver enzymes ALT, AST and GGT.
Haematology - right-shifted neutrophilia, eosinopaenia, monocytosis, leukopaenia.
Urinalysis - dilute, proteinuria can have UPC of 4,5,6; sometimes glucosuria, silent infection commonly present, look for struvite on sedimentation and culture and sensitivity. Urine creatinine to cortisol ratio shows high cortisol.
ACTH stimulation test - specificity 80-85, sensitivity 60-85, draw graph.
Low dose dexamethasone suppression test - specificity 70-80, sensitivity 85-90. Draw graph.
A 16 month old male entire Persian cat presents with a three week history of inappetance, pyrexia, weight loss and abdominal swelling. Physical examination reveals the presence of ascites with a palpable fluid wave and ultrasound examination confirms this is free fluid.
a. List the types of free abdominal fluid which might be found and the possible causes of each. (10 marks)
b. Outline how you would take a sample of abdominal fluid from this cat for analysis and list the tests you would ask the laboratory to perform on the sample. (5 marks)
c. An abdominal paracentesis sample shows a yellow fluid which is identified in the laboratory as an exudate. What differential diagnoses would you now consider for this case, putting them in order of likelihood? (5 marks)
d. How would you investigate this case further to reach a diagnosis? (10 marks)
Haemoabdomen - trauma, splenic rupture, aortic rupture.
Chyloabdomen - erosion of lymphatics by a neoplasia, lymphangiectasia.
Exudate - septic peritonitis from penetrating wound to abdomen, intestinal rupture, infected uterine rupture, infected urinary tract rupture
Chemical peritonitis due to urine or bile presence, changes modified transudate into exudate, looks green if bile.
Acute necrotising pancreatitis, neoplasias if necrotic, FIP.
Transudate - hypoalbuminaemia, increased hydrostatic pressure but more commonly modified transudate
modified transudate - FIP, neoplasia, abdominal organ strangulation, increased vascular hypertension.
Peritoneal fluid - some fluid is produced normally by mesothelial cells, not enough to cause ascites though.
Abdominocentesis - ultrasound guided is best, if not available put patient in lateral recumbency, insert needle near umbilicus. If no fluid obtained, four quadrant abdominocentesis.
FIP, septic peritonitis from uroabdomen, penetrating wound, intestinal perforation.
Investigate as per usual - cats with FIP have hyperglobinaemia, low albumin to globulin ration, alpha 1 acid glycoproteins often elevated. Lymphopenia, +- neutrophilia +- anaemia. Effusion, straw coloured, total protein more than 35, albumin to globulin less than 0.4, less than 5000 cells, most neuts and macrophages.
Ultrasound abdomen etc to rule out other causes, look under tongue.
Serology - for FCoV, not FIP, 25-40 percent cats exposed, 80-100 percent of multicast households, suggestive but not diagnostic. Can do RT-PCR but no consistent mutation responsible for the different strains but likely to be diagnostic for effusions. Histopathology shows granulomatous lesions on serosal surfaces as white fibrin out plaques, histology and immunohistochemistry can be used.
A 16-year-old castrated male cat is presented with a history of polydipsia and weight loss for the last 2 months. On clinical examination, the cat is fractious and in poor body condition. You auscultate a grade 2/4 left-sided systolic heart murmur and a gallop rhythm but no adventitious respiratory noises. Abdominal palpation reveals small, irregularly shaped kidneys. The cat has a normal body temperature and also has gingivitis and dental tartar.
a) List your differential diagnoses in this case in order of likelihood. (6 marks)
b) How would you investigate this case further? (12 marks)
c) Name one of the most likely diseases this cat may have from your list of differentials in section a). If the cat has this disease and requires dental extractions, what treatment would you implement prior to anaesthesia and how would you provide multimodal analgesia? (12 marks)
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. Write short notes on the clinical indications for AND the potential side effects of:
a) Cyclosporine in canine dermatology
b) Potassium bromide in canine neurology
c) Doxycycline in feline medicine (10)
Clinical indications - used as an adjunct in treatment of atopic dermatitis as licensed product atopica. If want to reduce use of preds can use ciclosporine, has some efficacy. Side effects - has anti insulin effects so care in diabetic patients, has shown renal problems in humans but not yet in dogs, hypertrichosis, vomiting and diarrhoea that is self limiting, anorexia, muscle weakness and cramps. Increased malignancy chance?
Potassium bromide - control of seizures in dogs in which the seizures are refractory to treatment with phenobarbital or where use of phenobarbital or imepitoin in is contraindicated. Usually used in conjunction, can take 3-4 months to reach peak plasma levels. Do not use in cats due to severe coughing development due to eosinophilic bronchitis, or in dogs at risk of pancreatitis, plus care with renal disease.
Doxycycline - bacteriostatic agent that inhibits protein synthesis at initiating step by interacting with 30S ribosome. Drug of choice for feline chlamydophilosis such as chlamydophila felis that is a contributor to cat flu complex, especially with eye lesions. When tetracycline is needed but renal impairment as faecally excreted. Can cause nausea, vomiting and diarrhoea, oesophagitis and oesophageal ulceration, water bolus to reduce risk.
Discuss how you would manage pseudopregnancy in the bitch. (10)
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Briefly describe 4 laboratory tests available for the diagnosis of pancreatitis in small animals, outlining the advantages, disadvantages and potential usefulness in dogs and cats. (10)
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a) List your differential diagnoses for unilateral epistaxis in a six year old ME Bassett hound.
b) Outline how you would further investigate the case.
(10)
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Hypercalcaemia is the most common paraneoplastic syndrome encountered in the dog.
a) List three tumours associated with hypercalcaemia of malignancy in the dog
b) List three clinical signs of hypercalcaemia in the dog,outlining the pathophysiology of each clinical sign.
(10)
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A six year old male neutered boxer is brought to your clinic with a superficial corneal ulcer. Outline the pathogenesis of these types of ulcer. Briefly describe your approach to the case and possible therapeutic options. (10)
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You are presented with a ten year old German shepherd dog in status epilepticus. It has no prior history of seizures and has been fitting for the last hour.
a) List your differential diagnosis, indicating the most likely ones.
b) Outline the immediate steps you would you take to stop the seizures
c) Assuming the dog recovers, what long term treatment could you use prevent more seizures occurring? (10)
Brain tumour
Toxic- heavy metal
Metabolic- acquired shunts etc
Idiopathic epilepsy v v unlikely
Immediately minimize stimuli (lights down, pad ears) check time and give rectal diazepam assuming no IV.
Attempt to get an IV ASAP possibly using retropulsion of eyeballs.
After 10 mins give phenobarbital IV. After 20 mins more diazepam.
After 30 mins give some propofol IV
Repeat phenobarbital and increase dose of propofol until seizure activity ceases, if necessary can use emg to assess activity.
Long term look for diagnosis- use MRI/ct for brain tumour. Thorough history to rule out toxic exposure. Abdominal ultrasound for shunts. Bloods to assess. Full neuro exam for post ictal signs. Treat cause if possible (RT for tumour, surgical removal)
If repeat seizure risk can use any of potassium bromide (takes a very long time to equilabrate often used as an adjunct), phenobarbital (not if liver disease but generally less toxic), imepitoin (like phenobarbital but better).
