2013 questions Flashcards

Question

Which reportable condition can affect cattle, but mainly causes disease in sheep? ## Footnote A - Vesicular stomatitis B - Anthrax C - Malignant Catarrhal fever D - Rinderpest E - Bluetongue

Answer 1

E-bluetongue [Bluetongue](http://www.merckmanuals.com/vet/generalized_conditions/bluetongue/overview_of_bluetongue.html?qt=&sc=&alt=)is almost exclusively a sheep disease, (but cattle and deer can get it). [Rinderpest](http://www.merckmanuals.com/vet/generalized_conditions/rinderpest_cattle_plague/overview_of_rinderpest.html?qt=&sc=&alt=)mainly affects cattle and is reported to be eliminated as of October 2010 by the the United Nation's Global Rinderpest Eradication Program. Because it is a classic severe and reportable vesicular disease, vets will likely need to keep rinderpest on their mental DDX list for years to come. Pseudorabies is basically a pig pathogen. Can affect cows, but horses (and humans) are resistant [Vesicular Stomatitis](http://www.merckmanuals.com/vet/generalized_conditions/vesicular_stomatitis/overview_of_vesicular_stomatitis.html?qt=&sc=&alt=)(VS) can occur in horses, pigs, cows. Remember the big 8 vesicular diseases: BVD, IBR, BPS, MCF, Bluetongue, VS, FMD, Rinderpest)

Answer 2

B-years The exact amount of time you must preserve medical records varies by state and provincial law, but it is measured in YEARS, usually 4-6 years or so. The number of years is typically based on the statue of limitations in your state or province for bringing certain claims against veterinarians. In the state of Michigan for example, claims include general professional malpractice (2 years), negligence (3 years), property damage (3 years) and breach of contract (6 years). See the [AVMA's Principles of Veterinary Medical Ethics](https://www.avma.org/KB/Policies/Pages/Principles-of-Veterinary-Medical-Ethics-of-the-AVMA.aspx) (2008 revision), form the last word on vet ethics. Section VIII covers medical records handling.

Answer 3

A - Hyperkalemic periodic paralysis This is likely to be [Hyperkalemic periodic paralysis](http://www.merckmanuals.com/vet/musculoskeletal_system/congenital_and_inherited_anomalies_of_the_musculoskeletal_system/congenital_and_inherited_anomalies_of_the_musculoskeletal_system_in_horses.html#v3282879?qt=&sc=&alt=) (HyPP), an autosomal dominant trait found in ~ 4% of Quarter horses. Heterozygotes often have periodic episodes 15-90 min: prolapse 3rd eyelid, muscle fasiculations, collapse. 25% cases traced back to one stallion named "Impressive". Onset of signs unpredictable, and many triggers: diets high in POTASSIUM (\>1.1%, ie: alfalfa hay, molasses, electrolyte supplements, kelp-based supplements). Fasting, anesthesia, heavy sedation, trailer rides, and stress can precipitate clinical signs. Grass staggers think "goose-stepping" (overstepping) from ergot on grass. EDM think ataxia in foals 6-8 mos. Epilepsy poorly documented in horses. Myasth. Gravis basically a dog disease.

Answer 4

D - Treat the other calves with vitamin E/Selenium Treat the other calves with vitamin E/Selenium. Think of [white muscle disease](http://www.merckmanuals.com/vet/musculoskeletal_system/myopathies_in_ruminants_and_pigs/nutritional_myopathies_in_ruminants_and_pigs.html?qt=&sc=&alt=) when you see SUDDEN DEATH and endocardial PLAQUES in a young calf, lamb or kid with a history of recent VIGOROUS EXERCISE. Follow this link to a Merck image of [pale ventricular myocardium](http://www.merckmanuals.com/vet/multimedia/v4738984.html?Ref=n&ItemId=v4738984&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). Typically seen in young, fast-growing animals (ie: calves 2 weeks-6 mos) Clinical signs may include dyspnea (due to myocardial disease), stiff gait, arched back, weakness, recumbent but BAR (bright, alert, responsive). Sudden death may resemble [enterotoxemia](http://www.merckmanuals.com/vet/management_and_nutrition/nutrition_goats/nutritional_diseases_of_goats.html?qt=&sc=&alt=), should see acute bloody diarrhea, convulsions, opisthotonos in first days of life with enterotoxemia.

Answer 5

E - Rumenal infusion 2-8 liters vinegar,3-10 gallons cold water Treat [Urea/non-protein nitrogen](http://www.merckmanuals.com/vet/toxicology/nonprotein_nitrogen_poisoning_ammonia_toxicosis/overview_of_nonprotein_nitrogen_poisoning.html?qt=&sc=&alt=) (NPN) toxicity with a rumenal infusion 2-8 liters 5% acetic acid (vinegar) and 3-10 gallons of cold water. The vinegar decreases rumenal pH which slows absorption of un-ionized ammonia. Repeat Q 6 hours up to 48 hours. Best results if animal is still ambulatory. It is often impossible to treat these cases before they die because of rapid progression to death. If possible, Rx with IV fluids. If necessary, relieve bloat. Urea/NPN toxicity is related to ammoniated feed toxicity which causes so-called "Bovine bonkers". Manage ammoniated feed toxicity by removing the ammoniated feed and treating severe cases with anticonvulsants like diazepam, pentobarbital.

Answer 6

B - Polioencephalomalacia The two most common causes of [polioencephalomalacia](http://www.merckmanuals.com/vet/nervous_system/polioencephalomalacia_cerebrocortical_necrosis/overview_of_polioencephalomalacia.html?qt=&sc=&alt=)(PEM) are low thiamine (due to thiaminase activity from plants like bracken fern or low thiamine diets) and high sulfur in the diet (which can come from a high molasses-urea diet, corn or sugar cane byproducts, water, or other plants, including alfalfa, Canada thistle (Cirsium arvense), kochia, (Kocchia scoparia), and lambsquarter (Chenopodium spp).

Answer 7

A - Deworm cows post-calving, calves by midsummer, all stock in fall Treatment includes deworming cows post-calving, calves by midsummer, all stock in fall. An abomasum with a cobblestone or "Moroccan leather" appearance is pathognomonic for [Ostertagia](http://www.merckmanuals.com/vet/digestive_system/gastrointestinal_parasites_of_ruminants/gastrointestinal_parasites_of_cattle.html#v3264456?qt=&sc=&alt=), one of the three stomach worms of cattle. Follow this link to see a Merck image of Ostertagia in an abomasum. These worms remain dormant in the gastric glands of the abomasum, emerging in the spring. Rx is based on regular deworming of whole herd (2-4 times/year). Ivermectin or high dose Albendazole/Fenbendazole, given repeatedly can help treat the dormant ("hypobiotic") Ostertagia in the gastric glands. Amprolium is your treatment of choices for calves and cows with [Coccidiosis](http://www.merckmanuals.com/vet/digestive_system/coccidiosis/coccidiosis_of_cattle.html?qt=&sc=&alt=). Refs: Pasquini's Guide to Bovine Clinics, 4th ed. pp. 21, 55 and the Merck Veterinary Manual online edition.

Answer 8

D - Senecio spp (ragwort) ## Footnote Common plants containing [pyrrolizidine alkaloids](http://www.merckmanuals.com/vet/toxicology/pyrrolizidine_alkaloidosis_seneciosis_senecio_poisoning_ragwort_toxicity/overview_of_pyrrolizidine_alkaloidosis.html?qt=&sc=&alt=) (PA) are: Senecio vulgaris, S. jacobea, Amsinckia intermedius, Heliotropium europaeum, Crotolaria spectabilis. Although generally not palatable, livestock will eat these plants when baled in hay or on pasture when forage is scarce. Chronic ingestion allows accumulation of toxic levels of PA, resulting in hepatic fibrosis. Poisoning is most common in horses and cattle, sheep and goats are more resistant to toxic effects. [Persea spp](http://www.merckmanuals.com/vet/toxicology/food_hazards/avocado.html?qt=&sc=&alt=)(avocado leaves) contain persin. Signs of toxicity are: noninfectious mastitis, abrupt cessation of milkflow, heart failure. [Nerium](http://www.merckmanuals.com/vet/multimedia/v4741277.html?Ref=n&ItemId=v4741277&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=)spp (oleander) contain cardiac glycosides. Signs of toxicity are: sudden death, weakness, diarrhea, cardiac arrhythmias. [Lupinus](http://www.merckmanuals.com/vet/toxicology/mycotoxicoses/mycotoxic_lupinosis.html?qt=&sc=&alt=)spp (lupine) contain alkaloids. Signs of toxicity are: birth defects (ingestion at 40-70 days in cattle), abortion, tremors, incoordination, head pressing, seizures. [Astragalus](http://www.merckmanuals.com/vet/multimedia/v4741709.html?Ref=n&ItemId=v4741709&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=)and [Oxytropis](http://www.merckmanuals.com/vet/multimedia/v4741682.html?Ref=n&ItemId=v4741682&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=)spp (locoweed) contain alkaloids (swainsonine). Signs of toxicity are: excitability, incoordination, difficulty eating, exaggerated mouth movements, depression. Follow this link to a Merck table with images of [Poisonous RANGE plants](http://www.merckmanuals.com/vet/toxicology/plants_poisonous_to_animals/range_plants_of_temperate_north_america.html). Follow this link to a Merck table with images of [Poisonous HOUSE plants](http://www.merckmanuals.com/vet/toxicology/plants_poisonous_to_animals/houseplants_and_ornamentals.html) Refs: Knight and Walter's A Guide to Plant Poisoning, 1st ed, pp. 144-6, 155-9, Pasquini's Guide to Bovine Clinics 4th ed., p. 233, Forero, Livestock-Poison Plants of CA, U of CA, Davis, ANR, pp. 7, 23, and the Merck Veterinary Manual online edition.

Answer 9

E - Inability to close the mouth [Idiopathic trigeminal neuritis](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_peripheral_nerve_and_neuromuscular_junction/inflammatory_disorders_of_the_peripheral_nerve_and_neuromuscular_junction.html?qt=&sc=&alt=), cranial nerve 5, (CN 5) is characterized by acute onset of flaccid jaw paralysis. Affected animals cannot close their mouth and have difficulty eating and drinking. Seen occasionally in dogs, rare in cats. Cause is unknown. [Idiopathic facial nerve paralysi](http://www.merckmanuals.com/vet/nervous_system/facial_paralysis/overview_of_facial_paralysis.html?qt=&sc=&alt=)s, cranial nerve 7, (CN 7) results in the inability to move the eyelid, lip, or ear and dryness of the eyes and mouth. [Masticatory myositi](http://www.merckmanuals.com/vet/musculoskeletal_system/myopathies_in_small_animals/masticatory_myositis_in_small_animals.html?qt=&sc=&alt=)s is characterized by pain on opening the mouth and swelling of the muscles of mastication (acute) or atrophy of the temporalis and masseter muscles with the inability to open the mouth due to fibrosis (chronic). Dysphagia, dyphonia, and stridor are most often associated with dysfunction of the vagus nerve, cranial nerve 10 (CN 10). Circling and head tilt toward the side of the lesion with no other signs is a common presentation of vestibulocochlear nerve, cranial nerve 8 (CN 8) lesions. Concurrent CN 7 paralysis and Horner's syndrome (ptosis, miosis, enophthalmis) may be present with middle- and inner-ear infections. Refs: Chrisman's Neurology for the Small Animal Practitioner, 2003 p.159, Cote's Clin Vet Advisor-Dog and Cat 1st ed., pp. 374-5, 687, 1105-6, Pasquini's Guide to Small Animal Clinics 3rd ed., p. 562-3, 590, and the Merck Veterinary Manual online edition.

Answer 10

B - Strong chance of lifelong FeLV infection 97% of cats positive for [feline leukemia virus](http://www.merckmanuals.com/vet/generalized_conditions/feline_leukemia_virus_and_related_diseases_feline_lymphoma_and_leukemia_lymphosarcoma/overview_of_feline_leukemia_virus_and_related_diseases.html?qt=&sc=&alt=) (FeLV) by IFA remain persistently infected and viremic for life. The FeLV ELISA is more [seNsitive](http://zukureview.com/images/question-images/Epi/High_Sensitivity_means_low_FalseNEGs.JPG)than the IFA (fewer false Negs, so trust a NEG test more), so it is a better general screening test with which to start. Click here for a diagram. The FeLV IFA is more sPecific than the ELISA, (fewer false Pos, so trust a POS test more) so it is a better confirmatory test for any cats with a positive FeLV ELISA. [Click here for a diagram.](http://zukureview.com/images/question-images/Epi/High_Specificity_means_low_FalsePos.JPG) THREE things to remember about FeLV and vaccinations: 1. FeLV ELISA and IFA tests measure ANTIGEN, not antibody, so FeLV vaccination does NOT interfere with testing. 2. Vaccinate FeLV-positive cats yearly against respiratory, enteric viruses with inactivated vaccines. 3. FeLV vaccination for FeLV-negative cats has been associated with sarcomas. Vaccinate LOW on the LEFT hind. Refs: Blackwell's 5-Min. Vet Consult Canine-Feline, 4th ed. pp. 490-1, Cote, Clin Vet Advisor-Dog and Cat, 1st ed. pp. 380-2 and the Merck Veterinary Manual online edition.

Answer 11

E. after 28 days After 28 days. According to the [Compendium for Rabies Control](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6006a1.htm), a [peak rabies virus](http://www.merckmanuals.com/vet/nervous_system/rabies/overview_of_rabies.html?qt=&sc=&alt=) antibody titer is reached 28 days after initial vaccination and immediately after booster vaccination. Here are some thoughts on rabies: When in doubt, it is never wrong to check with your local health department. Basically all potential rabies exposures boil down to 2 questions: 1. Who is involved? Animal-Animal exposure (less alarm bells) Animal bites/exposes human (more alarm bells) 2. Was animal vaccinated/up to date on vaccination? Up to date on vaccs (less alarm bells, shorter observation) Vaccinated, but not up to date (Handle on case-by-case basis) Un-vaccinated pet (more alarm bells, euthanize or long observation period) Wild animal, esp. bats, raccoon, skunk (euthanize, send head to state lab) When dealing with rabies questions, ask yourself if this seems like a HIGH-risk exposure (ie: wild raccoon bites a child) or a LOWER risk exposure (ie: Up-to-date vaccinated dog messes with woodchuck but no bite wounds on dog). For high risk lean towards euthanasia/testing or long quarantine. For low risk lean towards short observation period (10 days) and a rabies booster. Refs: The SINGLE BEST REF on rabies is the Compendium for Rabies Prevention and Control, 2011; Nov 4, 2011 / 60(RR06);1-14. For info on post-exposure prophylaxis for people see: [Human Rabies Prevention-](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm)US, 2008 ACIP Reccs: May 23, 2008 / 57(RR03);1-26,28 and, as always, the Merck Veterinary Manual online edition.

Answer 12

D - Pasteurella multocida Pasteurella multocida is the causative agent of [Fowl Cholera.](http://www.merckmanuals.com/vet/poultry/fowl_cholera/overview_of_fowl_cholera.html) Older chickens are more vulnerable than are younger chickens. The description above is of chronic fowl cholera. In acute fowl cholera, there are usually no clinical signs before a large number of birds die. Classic lesions of [Marek's disease](http://www.merckmanuals.com/vet/poultry/neoplasms/mareks_disease_in_poultry.html)are enlarged sciatic nerves and lymphoid tumors. It is a highly contagious disease, but may be subclinical in many cases. Refs:The Merck Veterinary Manual online edition. Image courtesy, The Poultry Site.

Answer 13

Test for acetylcholine receptor antibodies, to ruleout [myasthenia gravis](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_peripheral_nerve_and_neuromuscular_junction/inflammatory_disorders_of_the_peripheral_nerve_and_neuromuscular_junction.html), which is a frequent finding in older dogs with acquired [megaesophagus](http://www.merckmanuals.com/vet/digestive_system/diseases_of_the_esophagus_in_small_animals/dilatation_of_the_esophagus_in_small_animals.html?qt=megaesophagus&alt=sh), outlined in the image below. Edrophonium (Tensilon) can be given as a clinical test for myasthenia gravis. However, since this dog is not weak it would not be useful. Megaesophagus can be idiopathic or secondary to several disorders. Other causes include megaesophagus are heavy metal toxicity, polymyositis, lupus, and possibly hypothyroidism. Refs: Cote, Clin Vet Advisor 2nd ed. pp. 709-11, Merck Vet Manual 10th ed. online, Dilation of the Esophagus in Small Animals, Image courtesy, Dr Kalumet and Wikimedia Commons.

Answer 14

[Circovirus](http://www.merckmanuals.com/vet/generalized_conditions/porcine_circovirus_diseases/overview_of_porcine_circovirus_diseases.html), a nonenveloped DNA virus was first described in Canada in 1991 and causes Postweaning multisystemic wasting syndrome (PMWS). The virus is also associated with porcine dermatitis and nephropathy syndrome caused by necrotizing vasculitis, which is more prominent in the skin, renal pelvis, mesentery, and spleen. Refs: Handbook of Pig Medicine, Jackson & Cockcroft, pp. 188-190, Merck Vet Manual 10th ed. online, Images courtesy, The Pig Site.

Answer 15

A-Newcastle disease The symptoms above are compatible with the viscerotropic velogenic strain of [Newcastle Disease](http://www.merckmanuals.com/vet/poultry/newcastle_disease_and_other_paramyxovirus_infections/newcastle_disease_in_poultry.html). Hemorrhage and edema in the proventriculus is a very common post mortem finding. Also, multifocal necrosis and hemorrhage of the intestinal mucosa at lymphoid foci (eg cecal tonsils) is almost pathognomomic. [Infectious bronchitis](http://www.merckmanuals.com/vet/poultry/infectious_bronchitis/overview_of_infectious_bronchitis_in_poultry.html) predominantly has respiratory symptoms and is negative onhemagglutination. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases [Newcastle Disease](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/507)and the Merck Vet Manual 10th ed. online. Images courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 16

D-vitamin E deficiency [Vitamin E deficiency](http://www.merckmanuals.com/vet/poultry/nutrition_and_management_poultry/vitamin_deficiencies_in_poultry.html)causes 3 syndromes in birds: 1) encephalomalacia, 2) exudative diathesis, and 3) muscular dystrophy. With exudative diathesis to occur, the diet is deficient in both vitamin E and selenium. With muscular dystrophy, the diet is deficient in both vitamin E and sulfur amino acids. [Avian encephalomyelitis](http://www.merckmanuals.com/vet/poultry/avian_encephalomyelitis_epidemic_tremor/overview_of_avian_encephalomyelitis.html)has no gross necropsy lesions. It is caused by a picornavirus that is shed primarily in the feces. Refs: [Vitamin E and Selenium Deficiency,](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/521) Cornell University College of Veterinary Medicine Atlas of Avian Diseases and the Merck Vet Manual 10th ed. online. Images courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 17

B- cauda equina syndrome This is a common presentation of [Cauda equina syndrome](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_spinal_column_and_cord/degenerative_diseases_of_the_spinal_column_and_cord.html?qt=&sc=&alt=). Look for PAIN in the lumbosacral area (elicited by tail raise, hindlimb extension), LMN hindlimbs, especially Sciatic nerve damage at L7-S1 (lack withdrawal), +/- urinary/fecal incontinence, +/- SELF-MUTILATION of tail, perineum, pelvic limb. Lesion due to compression of cauda equina at L7-S1 (lumbosacral stenosis). Can be congenital (abn development dorsal arch L7-S1, small dogs, Border Collies) or acquired (degenerative changes, big dogs, especially German Shepard, Rottweiler, Boxer). [Wobbler syndrome](http://www.merckmanuals.com/vet/nervous_system/congenital_and_inherited_anomalies_of_the_nervous_system/congenital_and_inherited_spinal_cord_disorders.html#v3287289?qt=&sc=&alt=)is a cervical spinal cord disease (also called cervical vertebral instability/ caudal cervical spondylomyelopathy). In adult form it is an intervertebral disc disease, usually seen at C5-C6 or C6-C7 in Dobies\> 5 yrs, Great Danes\> 2 years. [Diskospondylitis](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_spinal_column_and_cord/inflammatory_and_infectious_diseases_of_the_spinal_column_and_cord.html#v3287958?qt=&sc=&alt=)is a good second choice on your DDX of a large middle aged dog presenting with lumbosacral pain. Due to bacterial/fungal infection of intervertebral disk and adjacent vertebral bodies. Look for systemic signs like fever (1/3 of patients), weight loss, anorexia. Follow this [link](http://www.merckmanuals.com/vet/multimedia/v4739344.html?Ref=n&ItemId=v4739344&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=)to see a Merck image of diskospondylitis. Refs: De Lahunta, Vet Neuroanatomy and Clin Neurology, 2nd ed. p. 74, Pasquini's, Tschauner's Guide to Small Animal Clinics, vol 1, 2nd ed. pp. 529, 533, and the Merck Veterinary Manual online edition.

Answer 18

E- Mycoplasma gallisepticum [Mycoplasma gallisepticum](http://www.merckmanuals.com/vet/poultry/mycoplasmosis/mycoplasma_gallisepticum_infection_in_poultry.html) causes these diseases. It is the most pathogenic avian mycoplasma. Morbidity is high and mortality low in chickens. Symptoms include respiratory distress, sneezing, nasal discharge, and frothiness about the eyes. Refs: [Mycoplasma gallisepticum](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/504), Cornell University College of Veterinary Medicine Atlas of Avian Diseases and the Merck Vet Manual 10th edition online. Image courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 19

A- Marek's Disease [Marek's disease](http://www.merckmanuals.com/vet/poultry/neoplasms/mareks_disease_in_poultry.html) usually causes a lymphoproliferative syndrome. Infiltrates develop in peripheral nerves, irises, feather follicles, and other organs. It can also be subclinical and still cause decreased growth rates and a drop in egg production. Vaccination has a greater than 90% efficacy. [Newcastle disease](http://www.merckmanuals.com/vet/poultry/newcastle_disease_and_other_paramyxovirus_infections/newcastle_disease_in_poultry.html) can cause neurologic symptoms, but usually they are in conjunction with, or following, respiratory symptoms. Refs:[Marek's Disease](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/502) Cornell University College of Veterinary Medicine Atlas of Avian Diseases, and the Merck Vet Manual 10th ed. online. Images courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 20

D- Avibacterium gallinarum Avibacterium gallinarum. [Infectious Coryza](http://www.merckmanuals.com/vet/poultry/infectious_coryza/overview_of_infectious_coryza_in_poultry.html) causes acute respiratory disease and primarily affects chickens. The severe form is most often seen in young adults. Clinical signs include nasal discharge, sneezing, swelling of the infraorbital sinuses, facial edema with eyelids so swollen they cannot open, swollen wattles, and conjunctivitis. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases [Infectious Coryza](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/480), and the Merck Vet Manual 10th ed. online. Image courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 21

B-infectious laryngotracheitis The hemorrhagic expectorations are highly suspicious of I[nfectious Laryngotracheitis](http://www.merckmanuals.com/vet/poultry/infectious_laryngotracheitis/overview_of_infectious_laryngotracheitis_in_poultry.html). This disease is highly contagious and recovered birds become carriers and are the most important vector. During an outbreak, adults should be immediately vaccinated. [Infectious bronchitis](http://www.merckmanuals.com/vet/poultry/infectious_bronchitis/overview_of_infectious_bronchitis_in_poultry.html)lesions are generally not hemorrhagic and mortality is not as high. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases [Infectious Laryngotracheitis](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/499); Merck Vet Manual 10th ed. online. Images courtesy, Cornell University College of Veterinary Medicine.

Answer 22

D-infectious bronchitis Think 3 Rs with [Infectious bronchitis](http://www.merckmanuals.com/vet/poultry/infectious_bronchitis/overview_of_infectious_bronchitis_in_poultry.html): respiratory, renal, reproductive. Nephropathogenic strains of infectious bronchitis virus (IBV) cause diarrhea and possibly fatal secondary urolithiasis. [Newcastle disease](http://www.merckmanuals.com/vet/poultry/newcastle_disease_and_other_paramyxovirus_infections/newcastle_disease_in_poultry.html) and [avian influenza](http://www.merckmanuals.com/vet/poultry/avian_influenza_fowl_plague/overview_of_avian_influenza.html) have positive hemagglutination reactions with chicken RBCs. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases [Infectious Bronchitis](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/497)and the Merck Vet Manual 10th ed. online. Images courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 23

C-Pasteurella multocida [Fowl Cholera](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/494)is a highly contagious disease caused by P multocida. Acutely, there may be fever, ruffled feathers, anorexia, and cyanosis of the comb and wattles. The chronic form of [Fowl Cholera](http://www.merckmanuals.com/vet/poultry/fowl_cholera/overview_of_fowl_cholera.html) is characterized by localized infections of the wattles, sinuses, foot pads, sternal bursa and joints. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases, and the Merck Vet Manual 10th ed. online; Image courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 24

A-Doxycycline Doxycycline. [Chlamydophila psittaci](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/488)causes clinical disease in hundreds of bird species. Clinical signs vary from asymptomatic to diarrhea and respiratory symptoms. [Chlamydiosis](http://www.merckmanuals.com/vet/exotic_and_laboratory_animals/pet_birds/bacterial_diseases_of_pet_birds.html)is a REPORTABLE disease and poses a significant public health concern for humans. Refs: Merck Vet Manual 10th ed. online; Image courtesy Atlas of Avian Diseases, Cornell University College of Veterinary Medicine.

Answer 25

B Avian Pox Avian pox, also known as [Fowlpox](http://www.merckmanuals.com/vet/poultry/fowlpox/fowlpox_in_chickens_and_turkeys.html). This disease is not contagious to humans. There are two forms of the disease - 1) cutaneous or dry pox has low mortality, with proliferative lesions on comb, wattles, etc, and 2) diphtheritic or wet pox that causes yellow canker lesions on mucous membranes, tongue, esophagus, or trachea. [Fowl cholera](http://www.merckmanuals.com/vet/poultry/fowl_cholera/overview_of_fowl_cholera.html) causes swellings and abscesses in the comb and wattles, but also affects the respiratory tract. The mortality can be high. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases, [Avian Pox](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/510), and the Merck Vet Manual 10th ed. online; Image courtesy of Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 26

C-Avian Influenza [Avian Influenza,](http://www.merckmanuals.com/vet/poultry/avian_influenza_fowl_plague/overview_of_avian_influenza.html) also called fowl plague, is the most likely diagnosis. This virus can either be of low pathogenicity (most common) or highly pathogenic. Viruses of low pathogenicity typically cause subclinical or mild respiratory disease. The case above is due to a highly pathogenic strain of avian influenza. [Infectious bronchitis](http://www.merckmanuals.com/vet/poultry/infectious_bronchitis/overview_of_infectious_bronchitis_in_poultry.html) is characterized by respiratory symptoms and is a differential for infection with an avian influenza strain of low pathogenicity. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases: [Avian Influenza](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/565) and the Merck Vet Manual 10th ed. online; Image courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 27

B. Avian Encephalomyelitis [Avian Encephalomyelitis](http://www.merckmanuals.com/vet/poultry/avian_encephalomyelitis_epidemic_tremor/overview_of_avian_encephalomyelitis.html), also called epidemic tremor, is the most likely diagnosis. This disease has about 60% morbidity and 25% mortality. Other differentials would include vitamin E deficiency, thiamine deficiency, Newcastle disease, and Marek's disease, however, these do not typically cause cataracts. [M gallisepticum](http://www.merckmanuals.com/vet/poultry/mycoplasmosis/mycoplasma_gallisepticum_infection_in_poultry.html) typically causes a chronic respiratory disease in chickens and infectious sinusitis in turkeys. Refs: Cornell University College of Veterinary Medicine Atlas of Avian Diseases: [Avian Encephalomyelitis](http://partnersah.vet.cornell.edu/avian-atlas/search/disease/481) and the Merck Vet Manual 10th ed. online; Images courtesy Cornell University College of Veterinary Medicine Atlas of Avian Diseases.

Answer 28

E-Antibodies against P2-myelin protein Antibodies against P2-myelin protein. Horses with [polyneuritis equi](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_peripheral_nerve_and_neuromuscular_junction/inflammatory_disorders_of_the_peripheral_nerve_and_neuromuscular_junction.html) have circulating antibodies against P2-myelin protein. Other diseases to rule out in this case would be [equine herpesvirus-1](http://www.merckmanuals.com/vet/respiratory_system/respiratory_diseases_of_horses/equine_herpesvirus_infection.html) and [equine protozoal encephalomyelitis.](http://www.merckmanuals.com/vet/nervous_system/equine_protozoal_myeloencephalitis/overview_of_equine_protozoal_myeloencephalitis.html) Refs: Mayhew, Large Animal Neurology, 2nd ed. pp. 274-276, 255-257, 260-267 and the Merck Veterinary Manual online edition.

Answer 29

B-left cerebrum Left cerebrum. Remember that conscious proprioception and visual perception are affected by lesions in the [contralateral cerebral hemisphere](http://www.merckmanuals.com/vet/nervous_system/nervous_system_introduction/overview_of_nervous_system.html). Circling direction is generally toward the side of the lesion. Refs: Curtis Dewey, A Practical Guide to Canine and Feline Neurology, 2nd ed. pp. 17-22 and the Merck Veterinary Manual online edition.

Answer 30

E-Granulomatous meningoencephalitis Granulomatous meningoencephalitis. The lesion in this case localizes to the left cerebellum causing the left hypermetria and a right paradoxical head tilt. [Granulomatous meningoencephalitis](http://www.merckmanuals.com/vet/nervous_system/meningitis_encephalitis_and_encephalomyelitis/overview_of_meningitis_encephalitis_and_encephalomyelitis.html)often affects this area. Another top differential would be a cerebellar neoplasm. Refs: De Lahunta, Vet Neuroanatomy and Clin Neurology, 3rd ed. p. 333 and the Merck Veterinary Manual online edition.

Answer 31

Hypokalemic myopathy. The posture is classic for [hypokalemia](http://www.merckmanuals.com/vet/musculoskeletal_system/myopathies_in_small_animals/feline_hypokalemic_polymyopathy.html)and other neuromyopathies (e.g., myasthenia gravis, organophosphate intoxication) in cats. Hyperkalemic periodic paralysis has not been reported in cats. Refs: Dewey, A Practical Guide to Canine and Feline Neurology, 2 nd ed. pp. 497-500 and the Merck Veterinary Manual online edition. Image courtesy of Dr. Shirley Scott.

Answer 32

A-Bone spavin This is [bone spavin,](http://www.merckmanuals.com/vet/musculoskeletal_system/lameness_in_horses/bone_spavin_in_horses.htmlhttp://www.merckmanuals.com/vet/musculoskeletal_system/lameness_in_horses/bone_spavin_in_horses.html) the number one hock problem (tarsus) in horses, an osteoarthritis of the lower hock joints, usually affecting the distal intertarsal and tarsometatarsal articulations. Etiology not clear (several theories)-seen most in Standardbreds, Quarter Horses. If horse is lame, tends to drag toe. [Tarsal hydrarthrosis](http://www.merckmanuals.com/vet/musculoskeletal_system/lameness_in_horses/bog_spavin_in_horses.html) (bog spavin) is a chronic synovitis of the tibiotarsal joint- look for swelling and distention of the joint capsule. Follow this link to see a photo of bog spavin (lateral swelling, left tarsus). Refs: Pasquini & Spurgeon's Anatomy Dom An 11th ed. pp. 100-1, 645b and the Merck Veterinary Manual online edition.

Answer 33

E-Facial nerve Think of f[acial nerve paralysis](http://www.merckmanuals.com/vet/nervous_system/facial_paralysis/overview_of_facial_paralysis.html?qt=&sc=&alt=) (CN 7) with a unilaterally droopy face. Remember the [facial nerve](http://www.merckmanuals.com/vet/nervous_system/nervous_system_introduction/physical_and_neurologic_examinations.html#v3286756?qt=&sc=&alt=) is motor to the muscles of facial expression (explaining the right side drooped ear, lip and eyelid) and innervates the lacrimal and salivary glands. Loss of innervations can lead to a dry eye, and possibly to exposure keratitis if animal losses ability to close eyelid from damage to facial nerve innervation of the orbicularis oculi muscle. Idiopathic in 75% of canine cases (25% of cats). Can also see these signs with middle ear damage (from [otitis media](http://www.merckmanuals.com/vet/eye_and_ear/otitis_media_and_interna/overview_of_otitis_media_and_interna.html?qt=&sc=&alt=)), from facial nerve trauma (ear surgery in dogs, or pressure from halter buckles in anesthetized horse), or neoplasia. F[ollow this link to see a horse with facial nerve damage](http://www.merckmanuals.com/vet/multimedia/v4739308.html?Ref=n&ItemId=v4739308&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=): note the nose pulled to horse's left. (means facial nerve damaged on right). Think more of a dropped jaw with [trigeminal nerve](http://www.merckmanuals.com/vet/nervous_system/nervous_system_introduction/physical_and_neurologic_examinations.html#v3286756?qt=&sc=&alt=)neuropathy (CN 5-dogs, horses). Refs: Pasquini & Spurgeon's Anatomy Dom An 11th ed. pp., 552-4, 579 , Pasquini's, Tschauner's Guide to Sm An Clin, vol 1, 2nd ed. p. 563 and the Merck Vet Manual online edition.

Answer 34

B-normal age-related change These are normal age related changes. Rats normally live two to three years, though some may live to five years of age. With age, the hair coat of white rats normally develop yellowing fur. They may also show a brownish, granular sebaceous secretion at the base of affected hair shafts which an owner may mistake for a skin parasite. Refs: Quesenberry and Carpenter, Clin Med and Surg of Ferrets, Rabbits and Rodents, 3rd ed. p. 342.

Answer 35

D-Vomit and diarrhea Ongoing losses are typically vomiting, diarrhea or other losses into a third compartment (pleura, abdomen etc). These are sometimes called "contemporary" losses. A classic example of a disease with significant ongoing losses is a p[uppy with parvovirus](http://www.merckmanuals.com/vet/digestive_system/diseases_of_the_stomach_and_intestines_in_small_animals/canine_parvovirus.html?qt=&sc=&alt=) who has both diarrhea and vomiting. Sensible losses are easily measured, like the fluids the animal loses by urination. Insensible losses are the fluids an animal loses that are hard to measure, through breathing and via the skin. In humans and animals that sweat (like horses) sweating is part of insensible losses. Remember that all three types of loss must be accounted for (or at least estimated) when calculating fluids needed to [rehydrate a dehydrated animal](http://www.merckmanuals.com/vet/emergency_medicine_and_critical_care/fluid_therapy/the_fluid_resuscitation_plan.html?qt=&sc=&alt=). Refs: Cote, Clin Vet Advisor-Dog and Cat, 2nd ed. pp. 287-9, McCurnin and Bassert, Clin Textbook for Vet Technicians, 7th ed. pp. 683-4 and the Merck Veterinary Manual online edition.

Answer 36

B-*Stephanurus dentatus* This is [*Stephanurus dentatus*](http://www.merckmanuals.com/vet/urinary_system/infectious_diseases_of_the_urinary_system_in_large_animals/swine_kidney_worm_infection.html), the swine kidney worm. Found worldwide, particularly in tropical and subtropical areas. Seen in the U.S. as a parasite of pigs raised outside in the southeastern and southcentral states. [Click here](http://cal.vet.upenn.edu/projects/merial/Strongls/strong_3.html)to see these large worms (2-4.5 cm long) encysted in pairs along the ureters from the kidney to the bladder (courtesy of the UPenn CAL site). Refs: The Merck Veterinary Manual online edition.

Answer 37

D-born post-term but small [Dysmature foals](http://www.merckmanuals.com/vet/emergency_medicine_and_critical_care/equine_emergency_medicine/neonatal_intensive_care_and_emergencies_in_foals.html#v3300673?qt=&sc=&alt=) are born post-term but small. Also called "small for gestational age", these foals are thought to have suffered placental insufficiency in-utero. A postmature foal is a post-term foal that with normal axial skeletal size but is thin to emaciated. Most commonly born to mares ingesting e[ndophyte-infested fescue](http://www.merckmanuals.com/vet/toxicology/mycotoxicoses/fescue_poisoning.html#v3352092?qt=&sc=&alt=). Gestation length in mares ranges from 310 days to more than 370 days. Refs:Pasquini's Guide to Eq Clin, 3rd ed. pp. 121 and the Merck Veterinary Manual online edition.

Answer 38

C-hip dysplasia A positive Ortolani sign indicates joint laxity, typically associated with [hip dysplasia](http://www.merckmanuals.com/vet/musculoskeletal_system/arthropathies_and_related_disorders_in_small_animals/hip_dysplasia_in_small_animals.html?qt=&sc=&alt=). A click/pop heard or felt by one hand pressed over coxofemoal joint while other hand presses upward and abducts knee. Think LARGE, hindlimb-LAME dogs, especially German shepherds. Follow these links to see radiographs of: e[arly hip dysplasia,](http://en.wikipedia.org/wiki/File:Bilateral_hip_dysplasia.JPG)(no DJD yet), [severe hip dysplasia](http://www.merckmanuals.com/vet/multimedia/v4739047.html?Ref=n&ItemId=v4739047&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=)(Note flattened, angular femoral head, poor congruence (parallel line) with acetabulum) and in contrast [normal canine hips](http://en.wikipedia.org/wiki/File:Normal_canine_hips.JPG) with deeply seated femoral heads and good congruence with acetabulae. Do a "Thumb test" for [coxofemoral luxation](http://www.merckmanuals.com/vet/multimedia/v4739092.html?Ref=n&ItemId=v4739092&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=) (dislocated hip)- place thumb in the groove between greater trochanter & ischial tuberosity, externally rotate femur: thumb is pushed OUT of groove with normal hip, but stays in groove with luxated hip or fractured femoral head. A positive drawer sign indicates [cranial cruciate rupture](http://www.merckmanuals.com/vet/musculoskeletal_system/arthropathies_and_related_disorders_in_small_animals/joint_trauma_in_small_animals.html#v3286326?qt=&sc=&alt=). [Panosteitis](http://www.merckmanuals.com/vet/musculoskeletal_system/osteopathies_in_small_animals/developmental_osteopathies_in_small_animals.html#v3286553?qt=&sc=&alt=) characterized by long bone pain on palpation and Hx of a shifting leg lameness in young, large dogs. Refs: Pasquini's, Tschauner's Guide to Sm An Clin, vol 1, 2nd ed. pp. 638-40; Blackwell's 5-Min. Vet Consult Canine-Feline, 4th ed. pp. 624-5 and the Merck Veterinary Manual online edition.

Answer 39

A-heel block A heel block (also called the palmar digital block) will anesthetize the bulbs of the heel, mimicking the effect of a palmar digital neurectomy, the last-ditch treatment to lengthen the athletic life of a horse with [caudal heel pain](http://www.merckmanuals.com/vet/musculoskeletal_system/lameness_in_horses/navicular_disease_in_horses.html) (navicular disease). Remember that neurectomy will eliminate pain, but not disease- you do it when there has been no improvement from medical Rx after 6-12 weeks. [Follow this link to see a radiograph of navicular disease.](http://www.merckmanuals.com/vet/multimedia/v4738165.html?Ref=t&ItemId=v4738165&RefId=musculoskeletal_system/lameness_in_horses/navicular_disease_in_horses&Speed=256&Plugin=WMP&Error=) Refs: Pasquini, Jahn and Bahr, Guide to Eq Clin: LAMENESS vol. II, pp. 62-4 and X8 and the Merck Veterinary Manual online edition.

Answer 40

B-Feminization syndrome Feminization syndrome. Nonpainful unilateral testicular swelling in an old dog should make you think of neoplasia, especially an estrogen-secreting sertoli cell tumor, which can cause feminization syndrome. See gynecomastia, penile atrophy, pendulous prepuce, attraction of other males, blood dyscrasias, +/-bone marrow depression (via high estrogen), bilateral alopecia. Remember that [cryptorchidism](http://www.merckmanuals.com/vet/reproductive_system/congenital_and_inherited_anomalies_of_the_reproductive_system/overview_of_congenital_and_inherited_anomalies_of_the_reproductive_system.html?qt=&sc=&alt=)increases risk of sertoli cell tumor: About 25-29% of sertolis develop feminization syndrome and ~ 70% of intra-abdominal testicular tumors, regardless of type, cause feminization syndrome. May see prostate hypertrophy with sertoli, but it is due to squamous metaplasia, not the classic (and common) [benign prostatic hypertrophy](http://www.merckmanuals.com/vet/reproductive_system/prostatic_diseases/benign_prostatic_hyperplasia_in_small_animals.html?qt=&sc=&alt=) (BPH). [Hypothyroidism](http://www.merckmanuals.com/vet/endocrine_system/the_thyroid_gland/hypothyroidism.html?qt=&sc=&alt=)and BPH are common older dog conditions, but not associated with unilateral testicular hypertrophy. Remember that sex hormones are also secreted by the zona reticularis of adrenal cortex and can see [feminization](http://www.merckmanuals.com/vet/endocrine_system/the_adrenal_glands/adrenal_cortex.html?qt=&sc=&alt=)or virilism with excess secretion. Refs: Pasquini's, Tschauner's Guide to Sm An Clin, vol 1, 2nd ed. p. 458, Blackwell's 5-Minute Vet Consult Canine Feline, 4th ed. pp. 318, 1242-3 and the Merck Veterinary Manual online edition.

Answer 41

E-*Pasteurella multocida* *Pasteurella multocida* infection in conjunction with *Mycoplasma hyopneumoniae* causes exudative bronchopneumonia, polyarthritis, and chronic lung lesions. [*Mycoplasma hyopneumoniae*](http://www.merckmanuals.com/vet/respiratory_system/respiratory_diseases_of_pigs/mycoplasmal_pneumonia_in_pigs.html?qt=&sc=&alt=), (also called "Enzootic pneumonia") is a common, smoldering low-level illness. Stressors (parasites, other infections, even weather) can result in severe pneumonia. Best managed by decreasing stressors with improved ventilation and decreased overcrowding. In endemic herds, ABX for sick individuals (ie: lincomycin, tylosin, tiamulin, or a tetracycline) helps control illness, most likely by preventing secondary bacterial infection (like *Pasteurella*). Bacterin vaccines give good protection, decrease signs (coughing). Pre-farrowing vaccination of sows decreases colonization in suckling piglets. Ref: The Merck Veterinary Manual online edition.

Answer 42

B-Due to colostrum absoprtion Very high GGT levels are seen with colostrum absorption In newborn pups, lambs, and calves, an [increase in GGT up to 1000 times](http://www.merckmanuals.com/vet/digestive_system/hepatic_disease_in_small_animals/enzyme_activity_in_hepatic_disease_in_small_animals.html)is normal when they receive high levels of colostrum from the dam. High levels of GGT are produced in the mammary epithelium during lactation. When evaluating bloodwork, reference ranges specific for the age of the patient should be utilized. Refs: Latimer, Mahaffey, Prasse, Duncan and Prasse's: Veterinary Laboratory Medicine 4th ed. pp. 193-214 and the Merck Veterinary Manual online edition.

Answer 43

D-*Conium maculatum* (Poison Hemlock) Poisoning with *Conium maculatum* (Poison hemlock) is responsible for the death of this cow. At least 8 toxic piperidine alkaloids have been isolated from poison hemlock . Coniine is found in seeds and the mature plants; g-coniceine is found in young growing plants. Poison hemlock is toxic to all livestock and humans. Signs of toxicity develop 1-2 hours after ingestion and are usually fatal. Signs include nervousness, trembling, weakness especially of the hind limbs, weak pulse, irregular heart rate, recumbency, coma and death. A mousy odor exuding from the urine and breath is pathognomonic. Ingestion of poison hemlock during gestation causes arthrogryposis and other congenital defects in cattle, goats, and pigs. [Click here to see an image of *Conium maculatum* (Poison hemlock).](http://www.merckmanuals.com/vet/multimedia/v4741241.html) [Click Here to see a Merck table of Poisonous Range Plants of Temperate North America.](http://www.merckmanuals.com/vet/toxicology/plants_poisonous_to_animals/range_plants_of_temperate_north_america.html) Refs: Forero, Livestock-Poison Plants of CA, U of CA, Davis, ANR, p. 39, Knight and Walter's A Guide to Plant Poisoning of Animals in NA, pp. 38-40, 282, and the Merck Veterinary Manual online edition.

Answer 44

E-Premature ventricular contractions Three premature ventricular contractions are present on this ECG strip. Usual characteristics of PVCs - No p wave present that is associated with the QRS wave, the QRS is wider than normal and bizarre in shape compared to normal, often the QRS is oriented opposite to that of the sinus beats. The orientation of the QRS is the same (both negative) in both the normal and ectopic beats in this case. Don't be fooled by the presence of the small waveform just before the PVC, these are the T waves from the prior beat. Cardiac arrhythmias that occur under anesthesia can be caused by hypercarbia, hypoxemia, hypotension, hypothermia, anesthetic drugs, sympathetic stimulation, electrolyte disturbances, and myocardial disease. This foal had just been induced with isoflurane, was likely hypoventilating, and a little deeper than necessary. The isoflurane was decreased, she was put on a ventilator - the PVCs disappeared and did not return. Refs: Muir and Hubbell's Equine Anesthesia, 2nd ed. pp. 85-88, Grimm, Tranquilli, and Lamont's Essentials of Anes and Analgesia in SA, 2nd ed. p. 230. ECG image courtesy of Dr JG Adams.

Answer 45

B-cattle Cattle. This is a circumscribed dermatitis along the ventral midline of a cow with [cutaneous stephanofilariasis](http://www.merckmanuals.com/vet/integumentary_system/helminths_of_the_skin/stephanofilariasis.html?qt=&sc=&alt=), caused by *Stephanofilaria stilesi* a filarial parasite of cattle. Cutaneous stephanofilariasis has been reported throughout the North AMerica but is more common in the western and southwestern U.S. The intermediate host is the horn fly, *Haematobia irritans* which ingests filarial larvae when it feeds on skin lesions. Refs:Pasquini's Guide to Bovine Clinics, 4th ed. p.180 and the Merck Veterinary Manual online edition.

Answer 46

C-*Toxoplasma gondii* [*T. gondii* i](http://www.merckmanuals.com/vet/reproductive_system/abortion_in_large_animals/abortion_in_sheep.html?qt=&sc=&alt=)nfection can cause severe abortion storms in sheep. Clinical signs pathognomonic of *T. gondii* are bright to dark red cotyledons with white foci of necrosis; the intercotyledonary areas of placenta are normal. With *Brucella* and *Histophilus ovis* the abortion rate is much lower. Abortion caused by *Listeria* spp is associated with the feeding of silage. Refs: Youngquist and Threlfall, Current Therapy in Large Animal Theriogenology 2nd ed. pp. 667-80, Pugh and Baird's Sheep and Goat Medicine 2nd ed. pp. 220-1 and the Merck Veterinary Manual online edition.

Answer 47

B-Granulosa cell tumor Granulosa cell tumors (GCTs) secrete reproductive hormones such as testosterone, inhibin, and estrogen. Testosterone causes the mare to show stallion-like behavior, while estrogen causes persistent estrus Approximately 50-90% of mares with GCTs have elevated testosterone and over 85% of mares with GCTs have high inhibin. With GCTs the contralateral ovary tends to stop producing follicles and resembles an ovary during anestrus. [Click here to see GCT from a mare](http://www.merckmanuals.com/vet/multimedia/v4740278.html?Ref=n&ItemId=v4740278&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). Refs: Youngquist and Threlfall, Current Therapy in Large Animal Theriogenology 2nd ed. pp. 144-152, Pasquini's Guide to Equine Clinics, 3rd ed. p. 188 and the Merck Veterinary Manual online edition.

Answer 48

D-Seasonal anestrus [Anestrus](http://www.merckmanuals.com/vet/management_and_nutrition/management_of_reproduction_horses/reproductive_cycle_in_horses.html?qt=&sc=&alt=) Mares are seasonal breeders and enter anestrus in the short day months, late fall and winter. In anestrus the ovaries are inactive with small follicles and no corpus lutea. During estrus, the uterus softens and multiple follicles form on the ovaries. During pregnancy the uterus has good tone. Refs: Youngquist and Threlfall, Current Therapy in Large Animal Theriogenology 2nd ed. pp. 144-152, Pasquini's Guide to Equine Clinics, 3rd ed. pp. 160-1 and the Merck Veterinary Manual online edition.

Answer 49

B-Fescue toxicity [Fescue toxicity](http://www.merckmanuals.com/vet/toxicology/mycotoxicoses/fescue_poisoning.html#v3352092?qt=&sc=&alt=). Ingestion of fescue grass contaminated with the endophyte fungus Acremonium coenophialum causes agalactia, thickened placentas, and prolonged pregnancy in mares by suppressing prolactin release. Toxicity is most significant in the last 90 days of gestation Mares should be removed from fescue pastures (and not fed fescue hay) for the last 90 days of gestation to reduce the incidence of fescue-associated problems. Treatment with domperidone can help affected mares produce milk. Mares with malnutrition are more likely to abort than carry a pregnancy over term. Refs: Youngquist and Threlfall, Current Therapy in Large Animal Theriogenology 2nd ed. pp. 131-4, Pasquini's Guide to Equine Clinics, 3rd ed. pp. 218, 241 and the Merck Veterinary Manual online edition.

Answer 50

D-mare will need an episiotomy before foaling The mare will need an episiotomy (a surgically planned incision on the perineum and the posterior vaginal wall) prior to foaling. Sometimes an episiotomy may be needed prior to breeding by stallion if the remaining vulvar cleft is too small to permit intromission. A Caslick's operation (vulvoplasty, a superficial form of the episioplasty) is used to treat [pneumovagina](http://www.merckmanuals.com/vet/management_and_nutrition/management_of_reproduction_horses/abortion_in_horses.html?qt=&sc=&alt=)in horses to prevent genital infections and infertility. Refs: McKinnon and Voss, Equine Reproduction, 1st ed. pp. 418-20, Pasquini's Guide to Equine Clinics, 3 rd ed. p. 177 and the Merck Veterinary Manual online edition.

Answer 51

E-Interruption of inhibitory neuron input from lumbar spinal cord With severe trauma between T2-T13, inhibitory pathways (esp. around L2-L4) are interrupted and cervical intumescence neurons (C6-T2) are "released", causing extensor hypertonia in the forelimbs. Think of [Schiff-Sherrington syndrome](http://www.merckmanuals.com/vet/nervous_system/nervous_system_introduction/physical_and_neurologic_examinations.html#v3286942?qt=&sc=&alt=) when you see a combination of forelimb extensor rigidity and hind limb flaccid paralysis, in an animal that has just had major spinal trauma, like being hit by a car. Refs: de Lahunta and Glass, Vet Neuroanatomy & Clin Neurology, 3rd ed. p. 248-50, Pasquini's, Tschauner's Guide to Small Animal Clinics, vol 1, 2nd ed. p. 529 and the Merck Veterinary Manual online edition.

Answer 52

D-Lesions usually persist for life [Equine aural plaques](http://www.merckmanuals.com/vet/eye_and_ear/diseases_of_the_pinna/equine_aural_plaques.html)(papillary acanthoma, ear papilloma) typically persist for life. Equine aural plaques are caused by a papillomavirus and thought to be transmitted through mechanical transmission by biting [Black flies](http://www.merckmanuals.com/vet/integumentary_system/flies/black_flies.html?qt=&sc=&alt=) (*Simulium* spp.) There is no specific treatment. Prevention includes application of fly repellent and stabling the horse during the Black fly's feeding times (dusk and dawn). Refs: Pasquini's Guide to Eq Clin, 3rd ed. pp. 292 and the Merck Vet Manual online.

Answer 53

A-Foothill abortion agent This is a typical case of f[oothill abortion](http://www.merckmanuals.com/vet/reproductive_system/abortion_in_large_animals/abortion_in_cattle.html), also called Epizootic Bovine Abortion. The condition is common in the coastal and Sierra Nevada foothills, and throughout much of the western United States. It is the most common cause of abortion in California beef cattle. The etiologic agent has not been identified with certainty. Research suggests that it is a delta protobacteria with DNA homology to bacteria of the vibrio genus. Pregnant cattle exposed to thymic tissues from aborted fetuses can be protected from abortion by feeding tetracycline through the early stages of pregnancy. The agent is transmitted by the soft shelled Pajahuello tick (*Ornithodorus coriaceus*). The disease occurs predominantly in heifers. Infection develops during the first trimester of pregnancy while abortions occur later around the 5th to 9th month. Exposed cattle develop immunity, but it is not known how long protection lasts. However, abortion does not often recur in these animals. The presence of petechial hemorrhages and lymphadenopathy in a late-term aborted fetus is suggestive of foothill abortion. Neospora is another common abortifacient of beef cattle, but does not produce lymhadenopathy or petechiae in the fetus. Leptospirosis, brucellosis, and pine needles also do not produce the same pathologic lesions as the foothill agent. Ref: Pasquini's Guide to Bovine Clinics 4th ed., p. 123, Divers and Peek, Rebhun's Diseases of Dairy Cattle, 2nd ed., pp. 430 -1, Image courtesy Dr. Lisle George copyright 2012 and the Merck Veterinary Manual online edition.

Answer 54

E-Congenital hypotrichosis This calf has [congenital hypotrichosis](http://www.merckmanuals.com/vet/integumentary_system/congenital_and_inherited_anomalies_of_the_integumentary_system/hereditary_alopecia_and_hypotrichosis.html?qt=&sc=&alt=) of Herefords, an autosomal recessive genetic problem. Hereditary hypotrichosis can be differentiated from the other disease choices because the dermis of the calf is normal in appearance. [Baldy calf disease](http://www.merckmanuals.com/vet/integumentary_system/congenital_and_inherited_anomalies_of_the_integumentary_system/cutaneous_manifestations_of_multisystemic_and_metabolic_defects.html?qt=&sc=&alt=) is an inherited problem of Holsteins. The calves may lose hair, have thickened skin and metabolic illnesses. Refs: Smith, Large Animal Internal Medicine, 3rd ed., p. 1849 and the Merck Veterinary Manual online edition, Images courtesy Dr. Lisle George copyright 20112.

Answer 55

A-northern fowl mite The [Northern fowl mite](http://www.merckmanuals.com/vet/poultry/ectoparasites/mites_of_poultry.html#v3343274?qt=&sc=&alt=)(*Ornithonyssus sylviarum*) is the only poultry mite that normally spends its entire life cycle on the host. *O. sylviarum* is the most important parasite of caged layers and breeding chickens in the U.S.. [Click here to see northern fowl mites on a hen](http://www.merckmanuals.com/vet/multimedia/v4739765.html?Ref=n&ItemId=v4739765&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). [MOST chicken mites](http://www.merckmanuals.com/vet/poultry/ectoparasites/mites_of_poultry.html#v3343223?qt=&sc=&alt=) are nocturnal feeders that are only on the birds at night. They hide during the day away from the chicken, under manure and in crevices of the chicken house, where they lay eggs. Click here to see a photo of [*Dermanyssus gallinae*](http://www.merckmanuals.com/vet/multimedia/v4739756.html?Ref=n&ItemId=v4739756&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). Click here to see a chicken with [*D. gallinae* mites](http://www.merckmanuals.com/vet/multimedia/v4739747.html?Ref=n&ItemId=v4739747&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=) Ref: The Merck Veterinary Manual online edition.

Answer 56

B- II and VII The [menace response](http://www.merckmanuals.com/vet/nervous_system/nervous_system_introduction/physical_and_neurologic_examinations.html) is used to test visual input (cranial nerve II – optic) and blink response (cranial nerve VII – facial). Take care not to induce air movement which would elicit a tactile response (cranial nerve V – trigeminal) instead of visual. There are many mnemonics to help memorize the cranial nerves. [Click here](http://www.neuromonkey.com/index.php?option=com_zoo&view=item&Itemid=143) for mnemonics courtesy of Neuromonkey. Refs: Curtis Dewey, A Practical Guide to Canine and Feline Neurology, 2nd ed. pp. 57,63 and the Merck Veterinary Manual online edition.

Answer 57

E- Penicillin IM for all rabbits, 5-7 days Treat ALL rabbits with parenteral (IM) penicillin when there is an outbreak of [*Treponema cuniculi*](http://www.merckmanuals.com/vet/exotic_and_laboratory_animals/rabbits/bacterial_and_mycotic_diseases_of_rabbits.html)(tremponematosis). Tetracycline or chloramphenicol are also effective AVOID oral antibiotics in rabbits, which can upset normal gram-positive gut flora. Particularly avoid lincosamide antibiotics like Clindamycin and Lincomycin, which target gram-postive bacteria and are specifically contraindicated in rabbits and rodents Refs: Quesenberry and Carpenter, Clin Med and Surg of Ferrets, Rabbits and Rodents, 3rd ed. pp. 235-6, Plumb's Vet Drug Handbook, 7th ed. pp. 309-13,1056-1059 and the Merck Veterinary Manual online edition.

Answer 58

C- Cerviothoracic: C6-T2 Cervicothoracic: C6-T2. Weak, hypotonic (Lower motor neuron-LMN) forelimbs and spastic paresis (Upper motor neuron-UMN) hindlimbs are signs of a cervicothoracic (C6-T2) lesion. May see worse signs in fores then hinds. NOTE: This is the OPPOSITE presentation as [Schiff-Sherrington syndrome](http://www.merckmanuals.com/vet/nervous_system/nervous_system_introduction/physical_and_neurologic_examinations.html)ie: severe spinal cord trauma T3-L3, with thoracic limb extensor rigidity (UMN) and hind limb flaccid paralysis (LMN). Lesion is caudal to T2, typically see animal soon (hours) after a bad trauma, like hit by car. Can localize T3-L3 lesion by checking cutaneous trunci reflex -The lesion is usually 1-2 vertebrae cranial to the line of analgesia (where dog does not feel pinching skin). With C1-C5 would expect UMN signs in all 4 limbs, usually worse in hinds. With a T3-L3, would see UMN hind limb signs and normal forelimbs. Refs: De Lahunta, Vet Neuroanatomy & Clin Neurology, 2nd ed. pp. 180-190, Pasquini's, Tschauner's Guide to Small Animal Clinics, vol 1, 2nd ed. pp. 529, 542, and the Merck Veterinary Manual online edition.

Answer 59

B- Cornual Typically a cornual nerve block (branch of the trigeminal- midway between eye and base of horn, just below temporal line) will anesthetize most cows for dehorning. If that is not enough, do a ring block around the base of the horn. In contrast, for goats you need to block BOTH the cornual nerve (caudal ridge, root of zygomatic arch of frontal bone) and infratrochlear nerve (dorsomedial to eye, close to edge of bony orbit) before dehorning. This is because the [goat horns lie more rostral](http://commons.wikimedia.org/wiki/File:Goat_anatomy_head.jpg)on the skull and closer to the bony orbits than the [horns of a cow.](http://upload.wikimedia.org/wikipedia/commons/7/71/Cow_anatomy.jpg) Refs: Pasquini and Spurgeon's Anatomy Dom An 11th ed. p. 545 and the Wikimedia Commons image library.

Answer 60

B Oxytetracycline Oxytetracycline is an extremely effective treatment for [Equine granulocytic ehrlichiosis](http://www.merckmanuals.com/vet/generalized_conditions/equine_granulocytic_ehrlichiosis/overview_of_equine_granulocytic_ehrlichiosis.html?qt=&sc=&alt=) (*Anaplasma phagocytophilum*), most commonly seen in California in the United States. Dexamethsone may help horses with severe ataxia and edema (20 mg, sid for 2-3 days). Penicillin, chloramphenicol, and streptomycin are not effective. Refs: Smith, Large Animal Internal Medicine, 3rd ed. pp. 1073-4 and the Merck Veterinary Manual online edition.

Answer 61

A- Acute bovine pulmonary emphysema and edema [Acute bovine pulmonary emphysema and edema(ABPEE)](http://www.merckmanuals.com/vet/respiratory_system/respiratory_diseases_of_cattle/acute_bovine_pulmonary_emphysema_and_edema.html?qt=&sc=&alt=) is associated with Fall onset, occurring 5-10 days after changing cattle from poorer to better, often lush, pasture. Toxicity occurs because rumen micro-organisms convert L-tryptophan in lush pasture grasses to pneumotoxic 3-methylindole, which damages respiratory epithelial cells. Refs: Pasquini, Guide to Bovine Clinics 4th ed. p. 67 and the Merck Veterinary Manual online edition.

Answer 62

B- Proximal enteritis [Proximal enteritis](http://www.merckmanuals.com/vet/digestive_system/colic_in_horses/diseases_associated_with_colic_by_anatomic_location.html#v3262795?qt=&sc=&alt=), or duodenitis-proximal jejunitis, is a clinical syndrome characterized by large volumes of gastric reflux resulting from excessive fluid and electrolyte secretion into the small intestine and small intestinal inflammation and edema. [Laminitis](http://www.merckmanuals.com/vet/musculoskeletal_system/lameness_in_horses/laminitis_in_horses.html?qt=&sc=&alt=)is an important potential sequela. The cause is unknown but several bacteria and toxins including *Clostridium difficile,* *Clostridium perfringens*, Salmonella, and fumonosin B1 mycotoxins have been implicated. Ulcerative duodenitis is a disorder of foals resulting in fever, colic, diarrhea, and delayed gastric emptying. *Lawsonia intracellularis* causes [proliferative enteropathy](http://www.merckmanuals.com/vet/digestive_system/intestinal_diseases_in_horses_and_foals/foal_heat_diarrhea.html?qt=&sc=&alt=) in foals and weanlings, a disease characterized by hypoproteinemia, diarrhea, chronic ill thrift, and ventral edema. [Right dorsal colitis](http://www.merckmanuals.com/vet/digestive_system/intestinal_diseases_in_horses_and_foals/nsaid_toxicosis_in_horses.html?qt=&sc=&alt=) is typically a result of non-steroidal anti-inflammatory drug toxicity and results in hypoproteinemia and colic. [Cantharidin toxicity](http://www.merckmanuals.com/vet/toxicology/cantharidin_poisoning_blister_beetle_poisoning/overview_of_cantharidin_poisoning.html?qt=&sc=&alt=)(blister beetles, *Epicauta* spp.) causes a wide range of clinical signs predominated by profuse diarrhea, stranguria and pollakiuria, and colic. Refs: Smith, Large Animal Internal Medicine, 4th ed., pp. 725-28 and the Merck Veterinary Manual online edition.

Answer 63

A- Diphenhydramine hydrocloride Diphenhydramine hydrochloride. [Metoclopramide](http://www.merckmanuals.com/vet/pharmacology/systemic_pharmacotherapeutics_of_the_digestive_system/gastrointestinal_prokinetic_drugs_monogastric.html?qt=&sc=&alt=)crosses the blood-brain barrier, where dopamine antagonism at the medullary chemoreceptor trigger zone (CTZ) causes an antiemetic effect. This dopamine antagonism can also cause adverse extrapyramidal signs, like involuntary muscle spasms, motor restlessness and inappropriate aggression. If recognized in time, extrapyramidal signs can be reversed by restoring the dopamine:acetylcholine balance with the anticholinergic action of an antihistamine like diphenhydramine hydrochloride. The pyramidal and extrapyramidal systems are a complex series of upper motor neurons (UMN) that connect the cerebral cortex to distant body parts and influence muscular tone and control. The pyramidal system controls skilled muscle movement. The extrapyramidal system helps support the body against gravity (posture) and recruits spinal reflexes to initiate voluntary movement. Refs: De Lahunta, Vet Neuroanat & Clin Neuro, 3rd ed. pp. 192, 195-200, Plumb's Vet Drug Handbook, 7th ed. pp. 909-2 and the Merck Veterinary Manual online.

Answer 64

C-Flip over disease This is the clinical picture of [flip-over disease](http://www.merckmanuals.com/vet/poultry/sudden_death_syndrome_of_broiler_chickens_flip-over_disease_acute_death_syndrome_dead_in_good_condition/overview_of_sudden_death_syndrome_of_broiler_chickens.html?qt=&sc=&alt=), a production-related disease associated with intensive husbandry. The cause is not known but thought to be related to high carbohydrate intake. Ventricular fibrillation may be the cause of sudden death, and a lack of gross pathology is common. Because broilers affected with flip over disease frequently die on their backs, differential diagnosis includes [ascites syndrome](http://www.merckmanuals.com/vet/poultry/miscellaneous_conditions_of_poultry/ascites_syndrome_in_poultry.html?qt=&sc=&alt=)(waterbelly). Sick birds with ascites syndrome typically show clinical signs like cyanosis, panting and abdomens distended by fluid. Essentially a form of right ventricular heart failure secondary to pulmonary hypertension or more rarely, hepatic failure. [Dissecting aneurysm](http://www.merckmanuals.com/vet/poultry/dissecting_aneurysm_aortic_rupture_internal_hemorrhage/overview_of_dissecting_aneurysm_in_poultry.html?qt=&sc=&alt=) is another cause of sudden death, but animals display severe hemorrhage on necropsy. [Click here](http://www.merckmanuals.com/vet/multimedia/v4739666.html?Ref=n&ItemId=v4739666&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=) to see a necropsied chicken with frank abdominal hemorrhage and a [ruptured aorta](http://www.merckmanuals.com/vet/multimedia/v4739675.html?Ref=n&ItemId=v4739675&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=) Ref: The Merck Veterinary Manual online edition.

Answer 65

D- 128/191 ## Footnote Sensitivity=128/191 (67%) a/(a+c) This is a classic example of a 2x2 table in epidemiology, used to compare a new test (the immunochromatographic test kit) to a gold standard test (the CPV test). Draw a 2x2 table, and label the boxes a,b,c,d. Sensitivity = a/(a+c). Click here to see a [Basic 2X2 table](http://zukureview.com/images/question-images/Epi/2by2_shell_SENS_SPEC.GIF). [Feline panleukopenia virus(FPV)](http://www.merckmanuals.com/vet/generalized_conditions/feline_panleukopenia_feline_infectious_enteritis_feline_parvoviral_enteritis/overview_of_feline_panleukopenia.html?qt=&sc=&alt=) is closely related to [type 2 canine parvoviruses](http://www.merckmanuals.com/vet/digestive_system/diseases_of_the_stomach_and_intestines_in_small_animals/canine_parvovirus.html?qt=&sc=&alt=)(CPV-2, CPV-2a, CPV-2b). CPV-2a and CPV-2b have been shown to cause a panleukopenia-like illness in domestic cats. Click here for a PDF summary on [Canine and Feline Parvovirus in Animal Shelters (](http://www.merckmanuals.com/vet/digestive_system/diseases_of_the_stomach_and_intestines_in_small_animals/canine_parvovirus.html?qt=&sc=&alt=)may take a half minute to load) by Dr. Cynda Crawford, Maddie's Shelter Medicine Program, Univ. Florida College Vet Med. Refs: Decaro et al, [Characterisation of canine parvovirus strains isolated from cats with feline panleukopenia,](http://www.ncbi.nlm.nih.gov/pubmed/20334885) Res Vet Sci. 2010 Mar 22, Hennekens and Buring, Epidemiology in Medicine 5th ed. pp. 332-39

Answer 66

A-Long acting oxytetracycline for entire herd Long-acting oxytetracycline for entire herd. [Anaplasmosis](http://www.merckmanuals.com/vet/circulatory_system/blood_parasites/anaplasmosis.html?qt=&sc=&alt=)is transmitted through tick vectors. Theoretically, tick control should eliminate the agent. Unfortunately, there is no effective method for controlling ticks on a range pasture. Affected cattle are long term carriers, so effective control must be based upon minimizing the number of inapparently infected cattle within the herd. This is best accomplished with 2 to 4 weekly injections of long-acting oxytetracycline. Imidocarb has been used for treating carrier cows in some countries, but the drug is not currently approved for use in the United States in cattle. Modified live vaccines exist, but have variable efficacy, availability and adverse effects. Refs: Smith's Large An Med 3rd ed. pp. 1049-55, Pasquini's Guide to Bov Clin, 4th ed. p. 92 and Merck Veterinary Manual online edition.

Answer 67

B- At least 60% of treated horses improve The prognosis is guarded to fair for treatment of [Equine protozoal myeloencephalitis](http://www.merckmanuals.com/vet/nervous_system/equine_protozoal_myeloencephalitis/overview_of_equine_protozoal_myeloencephalitis.html?qt=&sc=&alt=)(EPM). Less than 25% recover completely, but at least 60% of treated horses improve. Horses that remain positive by immunoblot testing commonly relapse, but horses who become negative by immunoblot testing rarely relapse. Refs: Plumb's Vet Drug Handbook, 7th ed. pp. 1190-2, 1271-6, Pasquini's Guide to Eq Clin, 3rd ed. pp. 250, 266-7, and the Merck Veterinary Manual online edition.

Answer 68

C- Histoplasmosis Think of [Histoplasmosis](http://www.merckmanuals.com/vet/generalized_conditions/fungal_infections_mycoses/histoplasmosis.html?qt=&sc=&alt=)in a dog with these findings (possible respiratory and diarrheal fungal disease, with tiny organisms in macrophages). Histoplasmosis is seen in the river valleys of the central United States, associated with bird and bat droppings in soil. The big DDX is [blastomycosis](http://www.merckmanuals.com/vet/generalized_conditions/fungal_infections_mycoses/blastomycosis.html?qt=&sc=&alt=), also seen in the same area, with a respiratory presentation. Histo is more a chronic diarrheal and respiratory disease in dogs and a respiratory disease in cats. Note that histoplasma organisms are much smaller (1-4 micrometer for histo vs. 8-25 micrometers for blasto), and UNLIKE blasto, histoplasma organisms are difficult to detect with routine H&E stain. Use PAS, Gomoris methenamine silver or Gridley's fungal stains to see yeast forms in macrophages and giant cells (round to ovoid structures(1-4 micrometers), thin cell wall, thin, clear zone between cell wall and cytoplasm. [Coccidioidomycosis](http://www.merckmanuals.com/vet/generalized_conditions/fungal_infections_mycoses/coccidioidomycosis.html?qt=&sc=&alt=)is seen in the arid and semiarid Southwestern U.S., Mexico and Central America. Organisms vary in size (20-80 micrometers to 200 micrometers) spherules with a double-contoured wall. Mature spherules (sporangia) contain tiny endospores (sporangiospores) 2-5 micrometers in diameter. THINK DUSTY DESERT. Spores are carried on dust and inhaled. Epidemics may occur after dust storms or excavation. Because it is ubiquitous, positive culture results for [*aspergillus*](http://www.merckmanuals.com/vet/generalized_conditions/fungal_infections_mycoses/aspergillosis.html?qt=&sc=&alt=)should be supported by demonstration of [narrow, hyaline, septate, branching hyphae](http://www.merckmanuals.com/vet/multimedia/v4736114.html?Ref=n&ItemId=v4736114&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). Usually a [nasal presentation in dogs](http://www.merckmanuals.com/vet/multimedia/v4736123.html?Ref=n&ItemId=v4736123&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). Think of [Cryptococcus](http://www.merckmanuals.com/vet/generalized_conditions/fungal_infections_mycoses/cryptococcosis.html?qt=&sc=&alt=)in cats with a granulomatous rhinitis and sinusitis. This nasal cavity disease in cats sometimes causes a swollen "roman nose" appearance. Seen in other species as well (cows, dogs) but with varying presentations. Refs: Pasquini's, Tschauner's Guide to Sm An Clin, vol 1, 2nd ed. pp. 702-5 and the Merck Veterinary Manual online edition.

Answer 69

D- *Ancylostoma* spp [Hookworms](http://www.merckmanuals.com/vet/digestive_system/gastrointestinal_parasites_of_small_animals/hookworms_in_small_animals.html?qt=&sc=&alt=)(*Ancylostoma* spp) may cause cutaneous larva migrans in people. Note that [Roundworms](http://www.merckmanuals.com/vet/digestive_system/gastrointestinal_parasites_of_small_animals/roundworms_in_small_animals.html?qt=&sc=&alt=)(*Toxocara* spp, *Toxasacaris* spp) are also zoonotic, causing visceral and ocular larva migrans in people. In dogs, [Whipworms](http://www.merckmanuals.com/vet/digestive_system/gastrointestinal_parasites_of_small_animals/whipworms_in_small_animals.html?qt=&sc=&alt=), *Trichuris* spp are associated with a [hypoadrenocorticism](http://www.merckmanuals.com/vet/endocrine_system/the_adrenal_glands/hypoadrenocorticism.html?qt=&sc=&alt=)-like syndrome (hyponatremia, hyperkalemia, azotemia, metabolic acidosis). Whipworm infection has been suggested as one cause of cecocolic [intussusception](http://www.merckmanuals.com/vet/digestive_system/diseases_of_the_stomach_and_intestines_in_small_animals/gastrointestinal_obstruction_in_small_animals.html?qt=&sc=&alt=). [*Habronema*](http://www.merckmanuals.com/vet/digestive_system/gastrointestinal_parasites_of_horses/habronema_spp_in_horses.html?qt=&sc=&alt=)spp in horses can cause [tumorlike stomach nodules](http://www.merckmanuals.com/vet/multimedia/v4732262.html?Ref=n&ItemId=v4732262&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=) and sometimes [cutaneous lesions](http://www.merckmanuals.com/vet/integumentary_system/helminths_of_the_skin/cutaneous_habronemiasis.html?qt=&sc=&alt=). Refs: Cote', Clin Vet Advisor-Dog and Cat, 1st ed. pp. 529-30, 979-80, 1165-6 and the Merck Vet Manual online edition

Answer 70

C. *Mycoplasma haemofelis* When you see regenerative anemia (polychromasia, reticulocytosis, anisocytosis) in a FeLV-positive cat, suspect coinfection with *Mycoplasma haemofelis* (or Mycoplasma haemominutum). Typically, the anemia of [feline leukemia virus](http://www.merckmanuals.com/vet/generalized_conditions/feline_leukemia_virus_and_related_diseases_feline_lymphoma_and_leukemia_lymphosarcoma/overview_of_feline_leukemia_virus_and_related_diseases.html?qt=&sc=&alt=) (FeLV) alone is NON-regenerative. *Mycoplasma haemofelis* (formerly called *Hemobartonella felis*) causes f[eline infectious anemia](http://www.merckmanuals.com/vet/circulatory_system/blood_parasites/hemotropic_mycoplasmas.html#v3257839?qt=&sc=&alt=), and is treated with tetracyclines. Click here to see [regenerative anemia](http://www.merckmanuals.com/vet/multimedia/v4730297.html?Ref=n&ItemId=v4730297&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=)on a blood smear. In the SE USA, [*Cytauxzoon felis*](http://www.merckmanuals.com/vet/circulatory_system/blood_parasites/cytauxzoonosis.html?qt=&sc=&alt=) must be differentiated from Mycoplasma felis in cats with regenerative anemias. Think of [*Toxoplasma gondii*](http://www.merckmanuals.com/vet/generalized_conditions/toxoplasmosis/overview_of_toxoplasmosis.html?qt=&sc=&alt=)(with neurologic and ocular manifestations) more in association with f[eline immunodeficiency virus (](http://www.merckmanuals.com/vet/immune_system/immunologic_diseases/secondary_immunodeficiencies.html#v3277182?qt=&sc=&alt=)FIV). Refs: Blackwell's 5-Min. Vet Consult Canine-Feline, 4th ed. pp. 490-1, Cote, Clin Vet Advisor-Dog and Cat, 1st ed. pp. 380-2, Wikimedia Commons and the Merck Veterinary Manual online edition.

Answer 71

E- idiopathic thrombocytopenia The history, plus a lab pattern of low platelets, increased bleeding time and normal aPTT, PT and TT tests suggests [thrombocytopenia](http://www.merckmanuals.com/vet/circulatory_system/hemostatic_disorders/platelet_disorders.html#v3258438?qt=&sc=&alt=). Idiopathic thrombocytopenia (often immune-mediated) is the most common cause of spontaneous bleeding in dogs. Twice as common in females; cockers, poodles and old English sheepdogs are predilected, but can occur in any breed. Of the common causes of coagulation disorders, only [disseminated intravascular coagulation](http://www.merckmanuals.com/vet/circulatory_system/hemostatic_disorders/coagulation_protein_disorders.html#v3258585?qt=&sc=&alt=)(DIC) also presents with thrombocytopenia. Follow this link to see a table of the four [most important coagulation disorder patterns](http://zukureview.com/images/question-images/misc-tables/Zuku_Coag_table.JPG) Refs: Blackwell's 5-Min. Vet Consult Canine-Feline, 4th ed. pp.1335-7, Pasquini's, Tschauner's Guide to Sm An Clin, vol 1, 2nd ed. pp. 290-3 and the Merck Veterinary Manual online edition.

Answer 72

B- Glomerulonephritis [Glomerulonephritis](http://www.merckmanuals.com/vet/urinary_system/noninfectious_diseases_of_the_urinary_system%C2%A0in_small_animals/glomerular_disease_in_small_animals.html?qt=&sc=&alt=)is a top rule out here for a middle-aged dog with low albumin, ascites and proteinuria without evidence of urinary infection (no RBC or WBC in urine sediment). This is a [type III immune reaction](http://www.merckmanuals.com/vet/immune_system/immunologic_diseases/excessive_acquired_responses.html#v3277380?qt=&sc=&alt=)in which antigen-antibody complexes deposited on glomeruli or capillary walls of glomeruli, stimulate complement and cause damage via a neutrophilic inflammatory response. Another big rule out for a canine protein-losing nephropathy is [renal amyloidosis](http://www.merckmanuals.com/vet/generalized_conditions/amyloidosis/overview_of_amyloidosis.html?qt=&sc=&alt=). Renal biopsy is the best way to distinguish between glomerulonephritis and amyloidosis Refs: Blackwell's 5-Min. Vet Consult Canine-Feline, 4th ed. pp. 548-9, Pasquini's, Tschauner's Guide to Sm An Clin, vol 1, 2nd ed. pp. 360-1 and the Merck Veterinary Manual online edition.

Answer 73

E- Listeriosis [Listeriosis](http://www.merckmanuals.com/vet/generalized_conditions/listeriosis_listerellosis_circling_disease/overview_of_listeriosis.html?qt=&sc=&alt=)is most likely in this bull. Infection with *Listeria monocytogenes* usually presents with MULTIFOCAL brainstem signs as seen by dysfunction of multiple cranial nerves, most often V, VII-X, and XII. Circling is thought to be more than just CN VIII damage because of the intensity associated - affected animals will sometimes continuously circle till they collapse. This suggests that other areas of the brain such as the basal ganglia and the descending reticular formation are also affected. [Thromboembolic meningoencephalitis](http://www.merckmanuals.com/vet/generalized_conditions/histophilosis/overview_of_histophilosis.html?qt=&sc=&alt=) (TEME) causes brainstem and cerebellar signs but the CSF would be neutrophilic and xanthochromic. The xanthrochromia is due to vasculitis/thrombosis in the CNS. TEME is more common in feedlot calves; respiratory disease, septicemia, and joint disease may also be seen. Animals with [otitis media/interna](http://www.merckmanuals.com/vet/eye_and_ear/otitis_media_and_interna/overview_of_otitis_media_and_interna.html?qt=&sc=&alt=) are alert and responsive, and have signs of vestibular dysfunction, but are not paretic. The bull could have [rabies](http://www.merckmanuals.com/vet/nervous_system/rabies/overview_of_rabies.html?qt=&sc=&alt=), but the multifocal nature of this bull's problem and the localization of lesions to the brainstem favor a diagnosis of listeriosis. Patients with [nervous coccidiosis](http://www.merckmanuals.com/vet/digestive_system/coccidiosis/coccidiosis_of_cattle.html?qt=&sc=&alt=) are usually centrally blind, and have cerebral rather than brainstem signs. It is most often seen in calves soon after the development of diarrhea. Refs: Pasquini's Guide to Bovine Clinics 4th ed., p 141-4, 150, Divers and Peek, Rebhun's Diseases of Dairy Cattle, pp. 512-8, 520, 530, 551-3, and the Merck Veterinary Manual online edition. Image courtesy Dr. Lisle George copyright 2012

Answer 74

E-Potassium Potassium. This is a classic presentation of a cat with [hypokalemic myopathy](http://www.merckmanuals.com/vet/musculoskeletal_system/myopathies_in_small_animals/feline_hypokalemic_polymyopathy.html) which is often due to potassium loss from renal disease. Other causes of generalized weakness and neck ventroflexion include polymyositis, organophosphate toxicity, myasthenia gravis. Refs: Curtis Dewey, A Practical Guide to Canine and Feline Neurology, 2nd ed. pp. 458-9 and the Merck Veterinary Manual online edition. Image courtesy Dr. Shirley Scott.

Answer 75

D- Cauda equina syndrome This is a common presentation of [Cauda equina syndrome](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_spinal_column_and_cord/degenerative_diseases_of_the_spinal_column_and_cord.html?qt=&sc=&alt=). Look for PAIN in the lumbosacral area (elicited by tail raise, hindlimb extension), LMN hindlimbs, especially Sciatic nerve damage at L7-S1 (lack withdrawal), +/- urinary/fecal incontinence, +/- SELF-MUTILATION of tail, perineum, pelvic limb. Lesion due to compression of cauda equina at L7-S1 (lumbosacral stenosis). Can be congenital (abn development dorsal arch L7-S1, small dogs, Border Collies) or acquired (degenerative changes, big dogs, especially German Shepard, Rottweiler, Boxer). [Wobbler syndrome](http://www.merckmanuals.com/vet/nervous_system/congenital_and_inherited_anomalies_of_the_nervous_system/congenital_and_inherited_spinal_cord_disorders.html#v3287289?qt=&sc=&alt=)is a cervical spinal cord disease (also called cervical vertebral instability/ caudal cervical spondylomyelopathy). In adult form it is an intervertebral disc disease, usually seen at C5-C6 or C6-C7 in Dobies\> 5 yrs, Great Danes\> 2 years. [Diskospondylitis](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_spinal_column_and_cord/inflammatory_and_infectious_diseases_of_the_spinal_column_and_cord.html#v3287958?qt=&sc=&alt=) is a good second choice on your DDX of a large middle aged dog presenting with lumbosacral pain. Due to bacterial/fungal infection of intervertebral disk and adjacent vertebral bodies. Look for systemic signs like fever (1/3 of patients), weight loss, anorexia. Follow this link to see a Merck image of [diskospondylitis](http://www.merckmanuals.com/vet/multimedia/v4739344.html?Ref=n&ItemId=v4739344&RefId=x&Speed=256&Plugin=WMP&Error=?qt=&sc=&alt=). Refs: De Lahunta, Vet Neuroanatomy and Clin Neurology, 2nd ed. p. 74, Pasquini's, Tschauner's Guide to Small Animal Clinics, vol 1, 2nd ed. pp. 529, 533, and the Merck Veterinary Manual online edition.

Answer 76

A-Acromegaly his complicated mix of [diabetes mellitus](http://www.merckmanuals.com/vet/endocrine_system/the_pancreas/diabetes_mellitus.html) , [renal disease](http://www.merckmanuals.com/vet/urinary_system/noninfectious_diseases_of_the_urinary_system%C2%A0in_small_animals/renal_dysfunction_in_small_animals.html)and [heart failure/cardiomyopathy](http://www.merckmanuals.com/vet/circulatory_system/heart_disease_and_heart_failure/specific_cardiac_diseases.html)in an OLDER MALE cat suggests [feline acromegal](http://www.merckmanuals.com/vet/endocrine_system/the_pituitary_gland/feline_acromegaly.html)y. First presenting sign may be PU/PD, polyphagia of diabetes. WEIGHT GAIN in an unregulated diabetic cat STRONGLY SUGGESTS acromegaly, (but they may LOSE weight at first). Follow this link to see [pulmonary edema and a large heart](http://zukureview.com/images/question-images/Lat_Pulm_Ed_Terri_DeFran_sm.jpg). May see [prognathism](http://www.merckmanuals.com/vet/digestive_system/dentistry/developmental_abnormalities_of_the_mouth_and_dentition_in_small_animals.html)(long mandible), lameness (esp. cats), marked vertebral spondylosis, thickened skin, large head, wide interdental spaces and a [Stress leukogram](http://www.merckmanuals.com/vet/circulatory_system/leukocyte_disorders/leukogram_abnormalities.html) (High neuts, low lymphs/Eos) Refs: Blackwell's 5-Minute Vet Consult Canine Feline, 5th ed. p. 17, Tschauner/Pasquini's Guide to Sm An Clinics, 3rd ed. p. 683 and the Merck Veterinary Manual online edition.

Answer 77

E-Bluetongue [Bluetongue](http://www.merckmanuals.com/vet/generalized_conditions/bluetongue/overview_of_bluetongue.html)is an infectious, noncontagious viral disease of ruminants. Some affected sheep will have swollen, cyanotic tongues. It is transmitted via bites from the vector - Culicoides spp biting midges. [Sheeppox](http://www.merckmanuals.com/vet/integumentary_system/pox_diseases/sheeppox_and_goatpox.html)can cause crusty, scabby lesions on the nose, but not lameness or the changes at the coronary band. Refs: Merck Vet Manual 10th ed. online. Images courtesy Dr Jerry J Callis, Dr Brian WJ Mahy and the CDC.

Answer 78

C-African Horse Sickness [African Horse Sickness](http://www.merckmanuals.com/vet/generalized_conditions/african_horse_sickness/overview_of_african_horse_sickness.html) (AHS) presents with fever, respiratory signs, and edema. Those with respiratory signs die within about a week; death occurs after 1-2 weeks in the "cardiac" form of the disease. Caused by an orbivirus, AHS is transmitted via bites of infected Culicoides spp. most often during warm, humid, seasons. AHS is very lethal, especially in naive populations where mortality approaches 90%. No specific treatment is effective, but attenuated-live virus vaccines are available that are protective. Edema is a prominent clinical sign, especially of the head and neck. Pulmonary edema and hydropericardium are a common necropsy findings. The disease is endemic in southern Egypt and occurs sporadically in many parts of Africa. AHS has never occurred in the United States and is a REPORTABLE disease. Other differentials include anaplasmosis, piroplasmosis, equine viral arteritis, and [Equine infectious anemia](http://www.merckmanuals.com/vet/generalized_conditions/equine_infectious_anemia/overview_of_equine_infectious_anemia.html) Refs: Blackwell's 5 Minute Consult: Equine 2nd ed., p. 41, and the Merck Vet Manual 10th edition online, Image courtesy, Dr Jerry J Callis, Dr Brian WJ Mahy and the CDC.

Answer 79

E-Right middle/inner ear A lesion of the right middle/inner ear could cause ipsilateral Horner's syndrome (miosis, ptosis, enophthalmos), facial nerve paralysis, and vestibulopathy. [Otitis Media and Interna](http://www.merckmanuals.com/vet/eye_and_ear/otitis_media_and_interna/overview_of_otitis_media_and_interna.html) is the most common cause of disease in this area, but neoplasia can also occur in the middle/inner ear. A [brachial plexus avulsion](http://www.merckmanuals.com/vet/nervous_system/diseases_of_the_peripheral_nerve_and_neuromuscular_junction/trauma_of_the_peripheral_nerve_and_neuromuscular_junction.html) can also cause an ipsilateral Horner's syndrome, but not facial nerve paralysis or vestibulopathy. Refs: Cote, Clin Vet Advisor 2nd ed. pp. 543-5 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 80

D- All of these A unilateral thyroidectomy could allow for recurrent [Hyperthyroidism](http://www.merckmanuals.com/vet/endocrine_system/the_thyroid_gland/hyperthyroidism.html), by way of hyperplasia or adenoma, of the contralateral thyroid gland. The cat should be treated medically for several weeks before surgery. Refs: Cote, Clin Vet Advisor 2nd ed. pp 562-5 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School

Answer 81

C-Serum T4. The signalment and clinical signs are highly compatible with hyperthyroidism. Canned food diet, ectoparasiticide exposure, and mixed breed origin are probable risk factors for [Hyperthyroidism](http://www.merckmanuals.com/vet/endocrine_system/the_thyroid_gland/hyperthyroidism.html). The three treatment options are antithyroid medication, radioactive iodine therapy, and surgical thyroidectomy. Refs: Cote, Clin Vet Advisor 2nd ed. pp. 562-5 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 82

B-[Bacterial contamination](http://www.merckmanuals.com/vet/clinical_pathology_and_procedures/diagnostic_procedures_for_the_private_practice_laboratory/cytology.html) Simonsiella are bacteria that normally inhabit the pharynx and have a large, ladder-like appearance. Their presence indicates contamination from the oropharynx. Bacteria, if present within neutrophils or macrophages, would be a significant finding. Refs: Cote, Clin Vet Advisor 2nd ed. pp 160-2 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 83

C-Incisional drainage This is an [aural hematoma](http://www.merckmanuals.com/vet/eye_and_ear/diseases_of_the_pinna/auricular_hematomas.html), a commonly seen condition in practice. Following incisional drainage, mattress sutures are applied to prevent deformation and the ear is bandaged to the head. It is important to determine the underlying cause of aural hematomas with a thorough aural exam, cytology, thyroid profile, food trial, or allergy skin testing. Refs: Cote, Clin Vet Advisor 2nd ed. pp. 120-2 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 84

A-Left peripheral vestibular Peripheral vestibular disease in a geriatric dog has a high likelihood of being idiopathic geriatric vestibular syndrome – a self-limiting syndrome. [Otitis Media and Interna](http://www.merckmanuals.com/vet/eye_and_ear/otitis_media_and_interna/overview_of_otitis_media_and_interna.html) or hypothyroidism would be other possibilities. Refs: Cote, Clin Vet Advisor 2nd ed. pp. 1170-1 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 85

E-Mast cell tumor This cytology slide shows mast cells full of purple histamine granules, suggesting a [mast cell tumor](http://www.merckmanuals.com/vet/integumentary_system/tumors_of_the_skin_and_soft_tissues/lymphocytic_histiocytic_and_related_cutaneous_tumors.html). Follow this link to see another slide of [mast cell cytology](http://commons.wikimedia.org/wiki/File:Mast_cell_tumor_cytology_2.JPG). Grossly, appearances are highly variable and mast cell tumors can be mistaken for skin tags or lipomas. Skin and subcutaneous masses should always be examined cytologically. These tumors can range from low grade to highly aggressive with local recurrence or lymph node metastasis. [Transmissible venereal tumors](http://www.merckmanuals.com/vet/reproductive_system/canine_transmissible_venereal_tumor/overview_of_canine_transmissible_venereal_tumor.html) are often papillary or nodular in appearance. Cytologically they are a round cell tumor with large, central nucleoli. Refs: Cote, Clin Vet Advisor 2nd ed. pp 701-3 and the Merck Veterinary Manual online edition. Images courtesy, Nottingham Veterinary School and Wikimedia commons.

Answer 86

A-[Sick sinus syndrome.](http://www.merckmanuals.com/vet/circulatory_system/cardiovascular_system_introduction/abnormalities_of_the_cardiovascular_system.html) The "seizure-like" episodes, after questioning the owner further, were actually syncopal episodes. Syncope lacks muscle activity and post-ictal behavior. Older female Miniature Schnauzers tend to be overrepresented with sick sinus syndrome. The ECG here shows sinus arrest with bradycardia and tachycardia. First degree [AV block](http://www.merckmanuals.com/vet/circulatory_system/heart_disease_and_heart_failure/diagnosis_of_heart_disease.html) is characterized by an increased PR interval. Second degree AV block consists of occasional P waves not followed by QRS complexes. Refs: Cote, Clin Vet Advisor 2nd ed. pp.1022-4 and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 87

D-ST segment depression or elevation is consistent with [myocardial hypoxia](http://www.merckmanuals.com/vet/circulatory_system/heart_disease_and_heart_failure/diagnosis_of_heart_disease.html). Tall T waves are commonly normal in cats and dogs, however, if the onset of tall waves is noted during ECG monitoring over time it could indicate hypoxia or movement artifact. Alternating bradycardia and tachycardia is seen with [sick sinus syndrome](http://www.merckmanuals.com/vet/circulatory_system/cardiovascular_system_introduction/abnormalities_of_the_cardiovascular_system.html#v3259022)(SSS). In SSS, the sinoatrial node is unable to generate an impulse. Older female miniature schnauzers are predisposed. Look for signs of fainting, weakness, confusion. Rx is a pacemaker. Refs: Cote, Clin Vet Advisor 2nd ed. web only and the Merck Veterinary Manual online edition. Image courtesy, Nottingham Vet School.

Answer 88

D- [Hypoinflation of lungs](http://www.merckmanuals.com/vet/respiratory_system/laryngeal_disorders/laryngeal_paralysis.html). Within the thorax, there is poor inflation with the diaphragm remaining in a relatively vertical position and contacting the entire caudal border of the heart. There is increased opacity throughout the lungs, with a bronchointerstitial pattern. The cranial mediastinum is uniformly widened on the d/v projections with no evidence of a mass on the lateral projection. The heart and vessels appear normal. The pulmonary changes are probably due to hypoinflation secondary to upper airway obstruction, however, additional airway or parenchymal disease cannot be ruled out. In this case, the dog had bilateral laryngeal paralysis. [Emphysema](http://www.merckmanuals.com/vet/respiratory_system/pulmonary_emphysema/overview_of_pulmonary_emphysema.html)can be either alveolar or interstitial. Pekingese can have congenital lobar emphysema due to poor development of bronchiolar cartilage resulting in air trapping during expiration. Refs: Thrall, Textbook of Veterinary Diagnostic Radiology 6th ed. pp. 608-31 and the Merck Veterinary Manual online edition., Radiographic interpretation and images courtesy, Dr A. Zwingenberger and Veterinary Radiology.

Answer 89

C-Left ilium There is a mixed lytic and productive bone lesion on the wing of the [left ilium,](http://www.merckmanuals.com/vet/musculoskeletal_system/osteopathies_in_small_animals/osteomyelitis_in_small_animals.html) extending to the cranial acetabulum. The femoral head is not involved. The lesion is seen best on the v/d projection.The differentials would include neoplasia or osteomyelitis. The diagnosis in this case is osteomyelitis secondary to coccidiomycosis. Refs: Cote Clin Vet Advisor 2nd ed. pp. 800-1 and the Merck Veterinary Manual online edition. Images courtesy, Dr A Zwingenberger and Veterinary Radiology.

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