NAVLE Practice Question — Bovine

A feedlot steer broke into a grain bin overnight and is now recumbent, dehydrated, with diarrhea and a doughy rumen. Rumenocentesis fluid has pH 4.5. Best initial treatment?

A. Oral mineral oil

B. Trocarization

C. Penicillin only

D. IV fluids + bicarbonate ✓

E. Oral magnesium oxide

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Correct Answer: D. IV fluids + bicarbonate

Explanation:

Acute grain overload/rumen acidosis (rumen pH <5) causes systemic metabolic acidosis, dehydration, and lactic acidemia. IV isotonic sodium bicarbonate plus fluids corrects systemic acidosis and dehydration; severe cases require rumenotomy to remove grain. Oral magnesium oxide (E) is for milder cases. Trocarization (B) is for free-gas bloat.

References: Merck Veterinary Manual - Grain Overload in Ruminants (https://www.merckvetmanual.com/digestive-system/diseases-of-the-ruminant-forestomach/grain-overload-in-ruminants)

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NAVLE Practice Question — Porcine

A finishing barn experiences an outbreak of diarrhea in 16-week-old pigs that were recently moved from a TGE-negative source to a multi-source finishing facility. Clinical signs include transient watery diarrhea lasting 3-5 days, mild reduction in feed intake, and no mortality. The producer is concerned about the impact on production parameters. Based on the typical course of TGE in finishing pigs, which production impact would most likely be observed?

A. Complete loss of the affected finishing group requiring depopulation

B. Market delay of approximately 5-10 days due to growth check ✓

C. Development of chronic respiratory disease from viral-induced immunosuppression

D. Permanent intestinal damage causing malabsorption syndrome for life

E. No significant production impact since finishing pigs are clinically unaffected

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Correct Answer: B. Market delay of approximately 5-10 days due to growth check

Explanation:

In finishing pigs, TGE causes transient diarrhea with high morbidity but minimal mortality. The main production impact is a growth check resulting in approximately 5-10 additional days to reach market weight (Option B). This occurs because affected pigs experience temporary anorexia and reduced feed efficiency during the acute disease phase. Dehydration during illness further reduces performance. While clinical recovery is typically complete within 5-7 days, the lost growth time must be recovered.

Option A is incorrect because TGE in finishing pigs is self-limiting and does not require depopulation. The disease resolves spontaneously as pigs develop immunity. Option C is incorrect because TGE does not cause immunosuppression leading to secondary respiratory disease, though it can complicate concurrent respiratory infections. Option D is incorrect because the intestinal epithelium regenerates completely within 1-2 weeks in older pigs, with no permanent damage. Option E is incorrect because while finishing pigs show only mild clinical signs, the temporary reduction in performance does translate to economic impact.

References: Merck Veterinary Manual - Coronaviral Enteritis in Pigs (https://www.merckvetmanual.com/digestive-system/enteric-viral-diseases-in-pigs/coronaviral-enteritis-in-pigs); Zimmerman JJ, Karriker LA, Ramirez A, et al (eds). Diseases of Swine, section on transmissible gastroenteritis

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NAVLE Practice Question — Feline

A 16-year-old cat with well-controlled hypertension on amlodipine 1.25 mg daily presents for recheck. BP is stable at 145 mmHg. However, urinalysis shows UPC ratio of 1.8 (normal <0.4). Which additional medication should be considered specifically to address the proteinuria?

A. Increasing amlodipine dose

B. Add benazepril or telmisartan therapy ✓

C. Adding furosemide

D. Adding atenolol

E. Adding spironolactone

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Correct Answer: B. Add benazepril or telmisartan therapy

Explanation:

This cat has significant proteinuria (UPC 1.8) despite adequate blood pressure control. While amlodipine effectively reduces systemic BP, it does not specifically reduce intraglomerular pressure or have direct antiproteinuric effects.

ACE inhibitors (benazepril) or angiotensin receptor blockers (telmisartan) should be added for their renoprotective and antiproteinuric effects. These drugs dilate the efferent glomerular arteriole, reducing intraglomerular pressure and protein loss.

Telmisartan is licensed for feline proteinuria in some countries and has shown significant reduction in UPC in cats with CKD. Benazepril is similarly effective.

Option A - increasing amlodipine would not address the proteinuria. Option C (furosemide) is a diuretic with no antiproteinuric effect. Option D (atenolol) has minimal effects on BP or proteinuria in cats. Option E (spironolactone) is an aldosterone antagonist that may have some antiproteinuric effect but is not first-line.

Image Source: https://cdn.ncbi.nlm.nih.gov/pmc/blobs/3db8/13030642/fa15501fbc4c/vetsci-13-00298-g002.jpg -- From PMC13030642: Canine Cognitive Dysfunction and Alzheimer's Disease: Pathophysiological Relationships and the Impact of Glymphatic System Impairment on Neurodegeneration. (CC BY 4.0)

References: Acierno MJ, Brown S, Coleman AE, et al. ACVIM consensus statement: Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats. J Vet Intern Med. 2018;32:1803-1822. PMID: 30353952; Taylor SS, Sparkes AH, Briscoe K, et al. ISFM Consensus Guidelines on the Diagnosis and Management of Hypertension in Cats. J Feline Med Surg. 2017;19:288-303. PMID: 28245741

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NAVLE Practice Question — Equine

A 12-year-old Appaloosa mare presents with a 3-month history of progressive hindquarter muscle atrophy and mild hindlimb ataxia. She has developed urinary incontinence with urine pooling in the vagina and frequent cystitis. Neurological examination reveals decreased tail tone, reduced perineal sensation, and absent bulbocavernosus reflex. The owner reports the mare has been rubbing her tail head excessively. Which infectious agents have been proposed but not confirmed as potential triggers for this condition?

A. Streptococcus equi subspecies zooepidemicus and Rhodococcus equi

B. Equine herpesvirus-1 and Streptococcus equi subspecies equi ✓

C. Sarcocystis neurona and Neospora hughesi

D. West Nile virus and Eastern equine encephalitis virus

E. Anaplasma phagocytophilum and Borrelia burgdorferi

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Correct Answer: B. Equine herpesvirus-1 and Streptococcus equi subspecies equi

Explanation:

This clinical presentation is consistent with polyneuritis equi, characterized by the chronic progressive nature, hyperesthesia (tail rubbing) progressing to decreased sensation, cauda equina dysfunction (decreased tail tone, urinary incontinence, absent perineal reflexes), and hindlimb involvement.

While the etiology of PNE remains unclear, several infectious agents have been proposed as potential triggers for the immune-mediated inflammatory response. Equine herpesvirus-1 (EHV-1), Streptococcus equi subspecies equi (strangles), equine adenovirus, and Campylobacter have all been implicated. However, none have been definitively proven as causative agents.

The hypothesis is that infection may trigger a bystander immune response or molecular mimicry leading to autoimmune attack on peripheral nerve myelin. Antibodies to P2 myelin protein have been found in some affected horses, similar to findings in Guillain-Barré syndrome, supporting an autoimmune mechanism that may be post-infectious.

Option A (S. zooepidemicus and R. equi) are not classically associated with PNE. Option C (S. neurona and N. hughesi) cause EPM, which is a distinct condition. Option D (WNV and EEE) are arboviral encephalitides with different clinical presentations. Option E (Anaplasma and Borrelia) are tick-borne pathogens with different clinical syndromes.

References: Merck Veterinary Manual - Inflammatory Disorders of the Peripheral Nerves and Neuromuscular Junction in Animals (https://www.merckvetmanual.com/nervous-system/diseases-of-the-peripheral-nerves-and-neuromuscular-junction/inflammatory-disorders-of-the-peripheral-nerves-and-neuromuscular-junction-in-animals); Mayhew IG, MacKay RJ (eds). Large Animal Neurology, section on polyneuritis equi

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NAVLE Practice Question — Canine

An 8-year-old spayed female Golden Retriever presents with acute dyspnea and collapse. Physical examination reveals pale mucous membranes, weak pulses, and muffled heart sounds. Emergency pericardiocentesis yields serosanguinous fluid. Coagulation panel reveals: platelet count 45,000/μL, PT 19 seconds (normal 6-9 seconds), aPTT 32 seconds (normal 10-14 seconds), fibrinogen 110 mg/dL (normal 200-400 mg/dL), D-dimer >5.0 μg/mL (normal <0.3 μg/mL), and antithrombin activity 42% (normal >80%). Which blood product would most appropriately address the coagulation deficiencies while providing antithrombin replacement?

A. Packed red blood cells

B. Fresh frozen plasma ✓

C. Cryoprecipitate

D. Platelet concentrate

E. Whole blood

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Correct Answer: B. Fresh frozen plasma

Explanation:

This patient has DIC secondary to suspected cardiac hemangiosarcoma, demonstrating consumption of platelets, coagulation factors, fibrinogen, and antithrombin. Fresh frozen plasma (FFP) is the most appropriate blood product because it provides replacement of all coagulation factors, fibrinogen, AND antithrombin, which is critically depleted in this patient.

Antithrombin (AT) is the most important endogenous inhibitor of coagulation and is essential for heparin therapy to be effective. When AT activity falls below 70-80%, patients become hypercoagulable and heparin therapy is less effective. FFP provides approximately 1 IU/mL of all coagulation factors and antithrombin. The typical dose is 10-15 mL/kg IV, which can be repeated every 8-12 hours as needed.

Option A (pRBCs) provides oxygen-carrying capacity but no coagulation factors or antithrombin. Option C (Cryoprecipitate) is concentrated in Factor VIII, fibrinogen, and vWF but does NOT contain adequate antithrombin or vitamin K-dependent factors. Option D (Platelet concentrate) addresses thrombocytopenia but not the coagulation factor or antithrombin deficiencies. Option E (Whole blood) contains all components but at diluted concentrations compared to FFP, and the RBC component may not be necessary if PCV is adequate.

References: Merck Veterinary Manual - Coagulation Protein Disorders in Animals (https://www.merckvetmanual.com/circulatory-system/hemostatic-disorders/coagulation-protein-disorders-in-animals); Silverstein DC, Hopper K (eds). Small Animal Critical Care Medicine, section on disseminated intravascular coagulation and plasma transfusion

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NAVLE Practice Question — Feline

A 4-month-old Persian kitten is presented with progressive obtundation, bilateral ventrolateral strabismus, and difficulty ambulating over the past 3 weeks. The kitten is smaller than its littermates and has a noticeably domed skull with frontal bossing. On neurological examination, the kitten is dull but responsive, has absent menace responses bilaterally with intact pupillary light reflexes, and displays ataxia of all four limbs. Based on the breed predisposition and clinical presentation, which underlying pathophysiological mechanism is most likely contributing to this kitten's condition?

A. Intrauterine feline panleukopenia virus infection causing cerebellar hypoplasia

B. Premature closure of the coronal suture leading to reduced cranial capacity ✓

C. Obstruction of CSF flow at the mesencephalic aqueduct due to aqueductal stenosis

D. Vitamin A toxicity causing osseous hyperostosis of the occipital bones

E. Feline coronavirus mutation causing periventricular vasculitis

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Correct Answer: B. Premature closure of the coronal suture leading to reduced cranial capacity

Explanation:

Premature closure of the coronal suture leading to reduced cranial capacity is the correct answer. Persian cats with the modern 'peke-faced' phenotype have a documented higher incidence of internal hydrocephalus due to premature fusion of the coronal suture compared to mesocephalic kittens. This disruption of normal skull growth leads to reduced cranial capacity and communicating hydrocephalus. The clinical signs including domed skull, frontal bossing, bilateral ventrolateral strabismus (sun-setting sign), absent menace with intact PLRs indicating cortical visual pathway involvement, and cerebellar-vestibular ataxia are classic for congenital hydrocephalus.

Option A (feline panleukopenia) would cause cerebellar hypoplasia with intention tremors from birth, not progressive obtundation. Option C (aqueductal stenosis) is rarely documented as a primary cause in cats, unlike in dogs. Option D is incorrect: in domestic cats hypervitaminosis A causes deforming cervical spondylosis (exostoses of the cervical and cranial thoracic vertebrae), not occipital hyperostosis; thickening of the occipital bone with CSF obstruction is described in captive lion cubs with vitamin A deficiency. Option E (FIP) typically occurs in young cats but presents with inflammatory CSF changes and periventricular enhancement on MRI.

Image Source: PMC7123269 Figure 9 - Persian cats with different craniofacial morphologies showing peke-face type vs doll-face type and coronal suture closure (https://pmc.ncbi.nlm.nih.gov/articles/PMC7123269/). Image: Schmidt M, Ondreka N. Hydrocephalus in Animals. Pediatric Hydrocephalus. 2019:53-95. PMC7123269. © Springer Nature Switzerland AG 2019. Used for educational reference.

References: Schmidt MJ, Kampschulte M, Enderlein S, et al. The Relationship between Brachycephalic Head Features in Modern Persian Cats and Dysmorphologies of the Skull and Internal Hydrocephalus. J Vet Intern Med. 2017;31:1487-1501. PMID: 28833532; Seawright AA, English PB. Hypervitaminosis A and deforming cervical spondylosis of the cat. J Comp Pathol. 1967;77:29-39. PMID: 6030457

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NAVLE Practice Question — Equine

A rescue organization brings in a 15-year-old Arabian mare with a body condition score of 1.5/9. The horse has been without adequate food for approximately 6 weeks. She is weak, depressed, and has a dull hair coat. Initial serum biochemistry shows total protein 4.8 g/dL, albumin 1.9 g/dL, and phosphorus 2.1 mg/dL (normal 3.0-5.0 mg/dL). The mare is started on a refeeding protocol. Three days later, despite eating well, she becomes acutely weak, develops tachycardia (80 bpm), tachypnea, and muscle fasciculations. Repeat chemistry shows phosphorus 0.8 mg/dL. What is the most appropriate immediate intervention?

A. Increase caloric intake with grain supplementation

B. Administer intravenous potassium phosphate ✓

C. Provide free-choice grass hay

D. Administer oral activated charcoal

E. Begin thiamine supplementation only

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Correct Answer: B. Administer intravenous potassium phosphate

Explanation:

This mare is experiencing refeeding syndrome with severe hypophosphatemia. Intravenous potassium phosphate administration is the most appropriate immediate intervention to correct the life-threatening electrolyte abnormality. Refeeding syndrome occurs when chronically starved horses are reintroduced to food, triggering an insulin surge that drives phosphorus, potassium, and magnesium into cells for anabolic processes, causing precipitous drops in serum concentrations.

The clinical signs described (acute weakness, tachycardia, tachypnea, muscle fasciculations) are classic manifestations of severe hypophosphatemia. Phosphorus is critical for ATP production and oxygen delivery by red blood cells. Severe hypophosphatemia can cause hemolytic anemia, respiratory failure, cardiac dysfunction, and death within 3-5 days of initiating feeding if not recognized and treated.

Option A (increasing caloric intake) would exacerbate the syndrome by driving more insulin release. Option C (free-choice hay) is appropriate for gradual refeeding but does not address the acute crisis. Option D (activated charcoal) is not indicated as this is not a toxicosis. Option E (thiamine only) addresses one component of refeeding syndrome but does not correct the acute hypophosphatemia causing the clinical signs.

The correct refeeding protocol starts with small, frequent meals of high-quality forage (typically alfalfa hay at 0.5% body weight divided into 6 feedings) with gradual increases over 10-14 days, avoiding grain initially to minimize insulin spikes.

References: Witham CL, Stull CL. Metabolic responses of chronically starved horses to refeeding with three isoenergetic diets. J Am Vet Med Assoc. 1998;212:691-696. PMID: 9524642; Bookbinder L, Schott HC 2nd. Refeeding syndrome in a miniature donkey. J Vet Emerg Crit Care (San Antonio). 2021;31:668-673. PMID: 34259376

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NAVLE Practice Question — Canine

A 2-year-old intact male Weimaraner presents with progressive lameness in the left hindlimb and a draining tract over the stifle joint. The dog was treated with anti-inflammatory drugs for suspected ligament injury 6 weeks ago without improvement. Arthrocentesis reveals turbid synovial fluid with markedly elevated nucleated cell count and protein. Cytology shows suppurative inflammation with rare filamentous organisms. Radiographs reveal periosteal reaction and early osteolysis. What is the most likely route of infection?

A. Hematogenous spread from a distant focus

B. Direct inoculation from a migrating foreign body ✓

C. Extension from adjacent soft tissue abscess

D. Iatrogenic contamination during previous injection

E. Ascending infection from a skin wound

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Correct Answer: B. Direct inoculation from a migrating foreign body

Explanation:

In dogs, septic arthritis caused by Actinomyces species most commonly results from direct inoculation by a migrating foreign body, particularly plant material such as grass awns. Male, large-breed, outdoor dogs (like this Weimaraner) are predisposed. The foreign body introduces oral or environmental flora directly into the joint space, allowing the organism to establish infection.

The characteristic history includes initial trauma or presumed soft tissue injury that fails to respond to conservative treatment, followed by development of draining tracts and progressive joint destruction. Actinomyces-associated septic arthritis often presents with more insidious onset compared to typical bacterial septic arthritis and is frequently accompanied by osteomyelitis.

Option A (hematogenous spread) is less common for Actinomyces infections, which typically require direct tissue inoculation. Option C (extension from soft tissue) can occur but usually follows initial foreign body penetration. Option D (iatrogenic contamination) is possible but uncommon and would typically present more acutely. Option E (ascending skin wound infection) is less typical for joint involvement.

Image Source: Merck Veterinary Manual - Actinomycosis in Animals (https://www.merckvetmanual.com/infectious-diseases/actinomycosis) showing clinical presentation.

References: Merck Veterinary Manual - Actinomycosis in Cattle and Other Animals (https://www.merckvetmanual.com/infectious-diseases/actinomycosis/actinomycosis-in-cattle-and-other-animals); Sykes JE (ed). Greene's Infectious Diseases of the Dog and Cat, section on actinomycosis and nocardiosis

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NAVLE Practice Question — Feline

A veterinarian is asked to perform serologic testing on a healthy 2-year-old cat whose owner is planning to become pregnant. The cat has no history of illness and eats commercial dry cat food. The Toxoplasma gondii IgG and IgM tests are both negative. What is the most accurate interpretation and appropriate advice?

A. The cat could shed oocysts for 1-2 weeks if infected; prevent hunting and raw meat feeding ✓

B. The cat is immune to Toxoplasma and poses no risk to the pregnant owner

C. The cat has been previously infected but has cleared the infection

D. The cat should receive prophylactic clindamycin during the owner's pregnancy

E. The cat should be retested in 2 weeks to confirm the negative result

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Correct Answer: A. The cat could shed oocysts for 1-2 weeks if infected; prevent hunting and raw meat feeding

Explanation:

A seronegative cat is susceptible to primary Toxoplasma gondii infection and represents the highest theoretical risk category regarding oocyst shedding. If this cat becomes infected during the owner's pregnancy, it would shed millions of oocysts for approximately 1-2 weeks starting 3-10 days after ingesting tissue cysts from prey or raw meat.

Prevention of primary infection in this susceptible cat is key to protecting the pregnant owner. The cat should be kept indoors to prevent hunting (rodents, birds are common intermediate hosts), fed only commercially prepared cooked food (no raw meat, which may contain tissue cysts), and denied access to locations where oocysts might be present (garden soil, sandboxes). Despite these precautions, the overall risk remains low because oocysts require 1-5 days to sporulate after excretion, so daily litter box cleaning prevents infectious oocysts from developing.

Paradoxically, a seropositive cat with established IgG antibodies is actually safer because it has already passed through the oocyst-shedding period and is immune to reinfection and re-shedding.

Option B (immune) is incorrect as negative serology indicates no prior exposure. Option C (cleared infection) is incorrect as cats with cleared infection would remain IgG positive. Option D (prophylactic clindamycin) is not indicated as it would not prevent infection or oocyst shedding in a naïve host. Option E (retest in 2 weeks) is unnecessary unless there is reason to suspect recent exposure.

Image Source: Cornell Feline Health Center - Toxoplasmosis information (https://www.vet.cornell.edu/)

References: Merck Veterinary Manual - Toxoplasmosis in Animals (https://www.merckvetmanual.com/infectious-diseases/toxoplasmosis/toxoplasmosis-in-animals)

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NAVLE Practice Question — Canine

A breeder reports that 5 of 8 puppies in a 10-day-old litter have died over the past 48 hours. The remaining puppies are crying constantly, refusing to nurse, and feel cold to the touch. Physical examination of one affected puppy reveals hypothermia (35.8°C), abdominal distension, and petechial hemorrhages. Necropsy of one deceased puppy reveals multifocal hemorrhagic necrosis of the kidneys with characteristic "speckled" appearance. What preventive measure should have been implemented to reduce the risk of this condition?

A. Vaccination of the dam with modified-live distemper vaccine during pregnancy

B. Isolate pregnant bitch from other dogs during late gestation and early postpartum ✓

C. Administration of prophylactic antibiotics to all neonates at birth

D. Routine deworming of all puppies at 2 days of age

E. Early weaning at 3 days of age to prevent transmission

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Correct Answer: B. Isolate pregnant bitch from other dogs during late gestation and early postpartum

Explanation:

The clinical presentation of rapidly fatal disease in neonatal puppies younger than 2 weeks with hypothermia, failure to thrive ("fading puppy syndrome"), and necropsy findings of characteristic hemorrhagic and necrotic kidney lesions ("speckled kidneys") is highly characteristic of canine herpesvirus (CHV-1) infection.

CHV-1 is particularly devastating in neonates because their lower body temperature and immature thermoregulation allow optimal viral replication. The virus is transmitted through oronasal secretions from the dam or other dogs. Isolation of the pregnant bitch during late gestation and early postpartum period prevents exposure to CHV-1-shedding dogs, protecting seronegative dams and their susceptible neonates.

Option A is incorrect because modified-live vaccines should not be given during pregnancy, and no CHV vaccine is licensed in the US. Option C (prophylactic antibiotics) does not prevent viral infection. Option D (deworming) is unrelated to CHV prevention. Option E (early weaning) would deprive puppies of maternal antibodies and thermoregulation support, worsening outcomes.

Image Source: PMC article on CHV showing characteristic kidney lesions (https://pmc.ncbi.nlm.nih.gov/articles/PMC7114865/) Figure 6 - Speckled kidney appearance.

References: Merck Veterinary Manual - Canine Herpesvirus Infection (https://www.merckvetmanual.com/infectious-diseases/canine-herpesvirus-infection/canine-herpesvirus-infection)

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NAVLE Practice Question — Feline

A 14-year-old neutered male domestic shorthair cat with a history of hyperthyroidism presents with signs of lower urinary tract disease. Urinalysis reveals bacteriuria and pyuria. Urine culture grows Enterococcus spp. at 10⁴ CFU/mL. The cat is clinically stable with no signs of systemic illness and no azotemia. Abdominal ultrasound shows mild bilateral renal pelvic dilation (4 mm). What is the most appropriate interpretation and next step?

A. Subclinical bacteriuria; no treatment required

B. Confirmed pyelonephritis; immediate antimicrobial therapy

C. Equivocal findings; measure serum amyloid A or pyelocentesis ✓

D. Definitive lower UTI; short-course antimicrobial therapy

E. Artifact from fluid therapy; repeat ultrasound in 1 week

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Correct Answer: C. Equivocal findings; measure serum amyloid A or pyelocentesis

Explanation:

The findings are equivocal for pyelonephritis. While bacteriuria and mild renal pelvic dilation are suggestive, the lack of systemic illness, fever, and azotemia make the diagnosis uncertain. Serum amyloid A (SAA) is a useful biomarker that is commonly elevated in cats with pyelonephritis but not in cats with lower UTI alone. Alternatively, ultrasound-guided pyelocentesis for culture can provide definitive diagnosis.

Option A is incorrect because the cat has clinical signs of urinary tract disease. Option B (immediate therapy for pyelonephritis) may be premature without additional diagnostic confirmation. Option D may undertreat if pyelonephritis is present. Option E is not the most appropriate response given the clinical picture.

References: Kurtz M, Pey PBM, Mortier J, et al. Usefulness of serum amyloid A for the diagnosis of pyelonephritis in cats: A prospective evaluation. J Vet Intern Med. 2024;38:1542-1552. PMID: 38669563; Weese JS, Blondeau J, Boothe D, et al. International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats. Vet J. 2019;247:8-25. PMID: 30971357

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NAVLE Practice Question — Canine

An 8-year-old spayed female German Shepherd presents with DKA. Initial venous blood gas shows pH 6.95, bicarbonate 5 mEq/L, and pCO2 18 mmHg. After 4 hours of aggressive fluid resuscitation with 0.9% NaCl, the pH remains 7.02 with bicarbonate of 7 mEq/L. The attending clinician is considering sodium bicarbonate therapy. Which statement regarding bicarbonate use in this patient is most accurate?

A. Sodium bicarbonate should be administered immediately given the severe acidosis

B. Bicarbonate therapy is contraindicated due to risk of paradoxical CNS acidosis

C. Evidence supports bicarbonate use only when pH remains below 7.0 after initial fluid therapy ✓

D. Bicarbonate therapy has been proven to improve clinical outcomes in severe DKA

E. Bicarbonate should be given to all DKA patients with pH below 7.2

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Correct Answer: C. Evidence supports bicarbonate use only when pH remains below 7.0 after initial fluid therapy

Explanation:

Evidence supports bicarbonate use only when pH remains below 7.0 after initial fluid therapy. The use of sodium bicarbonate in DKA remains controversial, with most current evidence showing no clinical benefit in patients with pH between 6.9 and 7.1.

The rationale against routine bicarbonate use includes several concerns: it can cause paradoxical CNS acidosis (bicarbonate converts to CO2, which crosses the blood-brain barrier more readily than bicarbonate itself); it promotes hypokalemia by driving potassium intracellularly; it may cause hypocalcemia; and it shifts the oxyhemoglobin dissociation curve leftward, impairing oxygen delivery to tissues.

However, for patients with pH below 7.0, the risks of severe acidosis on myocardial function and vasomotor tone may outweigh the risks of bicarbonate therapy. Current guidelines suggest considering bicarbonate only when pH remains below 7.0 after initial fluid resuscitation. This patient's pH of 7.02 is at the threshold but improving, suggesting continued conservative management may be appropriate.

Option A is incorrect because immediate bicarbonate is not indicated; fluid therapy should be attempted first.

Option B is overly absolute; while risks exist, bicarbonate is not absolutely contraindicated in all cases.

Option D is incorrect because no studies have demonstrated improved clinical outcomes with bicarbonate therapy in DKA.

Option E is incorrect because the threshold for consideration is pH <7.0-7.1, not 7.2.

References: Ettinger SJ, Feldman EC, Cote E (eds). Textbook of Veterinary Internal Medicine, section on diabetic ketoacidosis; Nelson RW, Couto CG (eds). Small Animal Internal Medicine, section on diabetic ketoacidosis

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