SMALL ANIMAL SOFT TISSUE CASE-BASED EXAMINATION

SMALL ANIMAL SOFT TISSUE CASE-BASED EXAMINATION

CASE-BASED EXAMINATION INSTRUCTIONS The case-based examination measures surgical principles in case management prior to, during, and after surgery. Information about these cases is presented in the form of images, videos, and data. Visual information will be projected on the screens. Data and text will be given in your exam binder. Information given on the screen is not shown on the question page. OBSERVE ALL INFORMATION PRESENTED ON THE SCREEN PRIOR TO ANSWERING QUESTIONS IN YOUR EXAM BINDER. On the front cover of your binder is a sticker that shows your candidate ID number. Please confirm at this time that the ID number on the cover of the binder is your ID number. If it is not your ID number, let a proctor know immediately. The examination binder consists of XX pages of questions, each related to a corresponding screen image. Each image presented on the screen will correspond with one page of the exam. The screen image will show the corresponding page number in your examination binder. For some images, particularly radiographs and ultrasounds, the lights will be dimmed for approximately one minute after you have had a chance to read the question. You will have approximately 30 seconds to read the question before the lights are dimmed. If a question asks for a specific number of responses, you will be graded on only the requested number of answers. Additional responses beyond the number requested will not be graded. For instance, if we ask you for one diagnosis, and you give us two, we will grade only the first answer. Minimize the use of abbreviations to make sure your answer is clearly understood. Commonly used medical abbreviations may be used; however, if you are concerned that the grader may not understand the abbreviation, you should define it. You will have two minutes, four minutes, six minutes or eight minutes to respond to the questions on each page. The time allotted for each page will be indicated on the top of the page, as well as the top of the corresponding screen image. A one-minute warning will be issued prior to moving to the next page. If we experience technical difficulties while showing an image, the time will be stopped and will resume after the problem has been corrected. You will still receive the full amount of time for that question. When the allotted time is up for each question, you will be instructed to turn the page in your binder to the colored plastic divider that follows. Once you turn to the plastic divider, you may NOT go further in the exam until instructed to do so. Therefore, when instructed to do so at the end of each question, you will turn the page to the plastic divider and wait for instructions before turning the plastic divider to the next test question.

UNDER NO CIRCUMSTANCES ARE YOU ALLOWED TO MOVE FORWARD IN THE EXAMINATION UNTIL INSTRUCTED. FURTHERMORE, YOU MAY NOT RETURN TO A PREVIOUS PAGE OF QUESTIONS AT ANY TIME DURING THE EXAM. FAILURE TO FOLLOW THESE INSTRUCTIONS WILL RESULT IN DISQUALIFICATION FROM THE EXAM. Scrap paper has been supplied for you to take notes during the exam. You are encouraged to use the scrap paper throughout the exam. You can refer to the notes on your scrap paper for the entire duration of the exam. Your scrap paper will not be scored. Raise your hand if you need additional pencils, have a question, or if you need to leave the room for any reason. We highly recommend that you do not leave the examination for any reason since questions cannot be revisited once they have been shown. Are there any questions before we begin the exam?

PAGE 1 (4 minutes) A 15 kg, 8 month old, male, Labrador retriever dog is presented with a history of intermittent circling, ataxia, and occasional vomiting. Physical examination reveals a thin dog with no other abnormalities noted. Laboratory work (complete blood count, chemistry profile with electrolytes, and urinalysis) is performed. Results of a complete blood count and reference ranges are listed below. Abnormal values are in bold font. The image is from the blood smear. Complete blood count Patient Values Reference Range RBC (x 10 6 /μl) 6.9 5.5-8.5 Hemoglobin (g/dl) 10.4 12-18 PCV (%) 34 37-55 MCV (fl) 49.2 60-77 MCHC (g/dl) 30.5 32-36 WBC (x 10 3 /μl) 11.1 6-17 Neutrophils (x 10 3 /μl) 5.1 3-11 Bands (x 10 3 /μl) 0.1 0-0.3 Lymphocytes (x 10 3 /μl) 3.7 1-4 Monocytes (x 10 3 /μl) 0.9 0.2-1.4 Eosinophils (x 10 3 /μl) 1.3 0.1-0.75 Platelets (x 10 3 /μl) 241 164-510 Cell morphology: see projected image 1. List three abnormalities visible on the image of the blood smear. C. 2. Interpret the results of the complete blood count.

PAGE 2 (4 minutes) Results of the chemistry profile with electrolytes and reference ranges are listed below. Abnormal values are in bold font. Chemistry profile with electrolytes Patient Values Reference Range Total protein (g/dl) 5.3 5.1-7.3 Albumin (g/dl) 3.0 2.6-3.5 Globulin (g/dl) 2.6 2.6-5.0 Alkaline phosphatase (U/L) 177 4.0-95 ALT (U/L) 363 26-200 Bilirubin (mg/dl) 0.25 0.1-0.3 CK (U/L) 211 92-357 BUN (U/L) 5 10-25 Creatinine (mg/dl) 0.7 0-1.3 Calcium (mg/dl) 9.6 9.5-11.8 Phosphorus (mg/dl) 4.5 3.3-5.8 Magnesium (mg/dl) 1.7 1.7-3.3 Glucose (mg/dl) 70 80-100 Cholesterol (mg/dl) 42 68-224 Bicarbonate (mmol/l) 18.6 13.9-30 Sodium (meq/l) 148 146-160 Potassium (meq/l) 4.8 3.5-5.9 Chloride (meq/l) 118 108-125 1. Interpret the results of the chemistry profile.

PAGE 3 (2 minutes) Results of the urinalysis are listed below. The image is from the urine sediment. Urinalysis Patient Values Color Yellow Turbidity Clear Specific Gravity 1.023 ph 8.5 Protein Negative Glucose Negative Ketones Negative Blood Negative Bilirubin 1+ Urobilinogen Trace Urine sediment exam: see projected image 1. Identify the material on the image indicated by the arrow. 2. Based on the results of the urinalysis and blood work presented, list two other clinicopathologic tests that would further characterize this dog s problem.

PAGE 4 (2 minutes) Results of serum bile acid analysis and reference ranges are listed below. Abnormal values are in bold font. Serum bile acids Patient Values Reference Range Fasting (µmol/l) 98 < 10 Post-prandial ( µmol/l ) 260 < 20 1. What do these results indicate? 2. What is the most likely clinical diagnosis? 3. Other than abdominal radiography, list two noninvasive imaging procedures that would be appropriate to perform in this dog. A. B.

PAGE 5 (4 minutes) Lateral and ventrodorsal abdominal radiographs of this dog are shown. 1. List two radiographic abnormalities visible on these radiographs. 2. What is the radiographic diagnosis? 3. List four findings on abdominal ultrasonography that would be supportive of your clinical diagnosis. A. B. C. D.

PAGE 6 (4 minutes) This image is a composite view of transcolonic scintigraphy from this dog. Cranial (Cr) and caudal (Ca) are indicated. The arrow indicates the location of the xiphoid process. 1. Describe and interpret the results. 2. List two diagnostic limitations to transcolonic scintigraphy other than radiation safety issues. A. B. 3. What is the significance of a shunt fraction of 78% in this dog?

PAGE 7 (4 minutes) Portography is performed, and the image is projected. 1. Identify the type of portography that has been performed. 2. Describe the abnormality demonstrated by this image. Be specific. 3. List three advantages of this type of portography compared to other methods of contrast portography. C.

PAGE 8 (4 minutes) The diagnosis of a right division intrahepatic portocaval shunt is confirmed. The dog is anesthetized and prepared for abdominal surgery. 1. Other than direct visualization, list three methods for intra-operatively confirming the location of the shunting vessel. A. B. C. 2. List five different procedures for attenuating this right division intrahepatic portocaval shunt at surgery. C. D.. E.

PAGE 9 (4 minutes) Partial attenuation of the shunting vessel is achieved with suture, a liver biopsy is obtained, and the dog recovers uneventfully. On the third postoperative day, the dog is normal on physical examination, except for mild abdominal distention. 1. List two complications, other than hemorrhage, hypothermia, or those due to acute portal hypertension, which have been reported as acute complications of portosystemic shunt attenuation. 2. What is the most likely mechanism for the abdominal distention in this dog? 3. Is treatment of the abdominal distention in this dog necessary? Yes No 4. If yes, list the treatment. 5. Make short-term postoperative dietary recommendations for this dog. 6. Make short-term postoperative treatment recommendations for this dog.

PAGE 10 (4 minutes) 1. List four prognostic factors relating to survival which have been identified by Papazoglou, et al. (Vet Surg 31:561-570, 2002) in dogs with intrahepatic portosystemic shunts. C. D. 2. List which hepatic lobe(s) or process(es) undergo(es) atrophy after ligation of the right branch of the portal vein as reported by Tobias, et al. (Vet Surg 33:32-39, 2004). This Concludes the Small Animal Soft Tissue Case-Based Examination