primary care

  1. CAPC general guidelines (4)
    • Deworm starting at 2 weeks, repeat every 2 weeks until old enough for monthly
    • year-round monthly parasite control for HW, intestinal, flea/tick (age-appropriate)
    • Fecal 2-4x in first year then 1-2x/year
    • annual testing for HW and tick-borne
  2. Canine Core vax (2)
    • Da2p +/- p: Canine distemper, Adenovirus type 2, parvovirus type 2, +/- parainfluenza (NOT CORE)
    • Rabies: legal
  3. DA2PP guidelines (5)
    • every 2-4 weeks between 6 and 16 weeks
    • one or two doses if >16 weeks.
    • Protects within 7d
    • repeat in one year, then every 3
    • immunity lasts 5-7 years
  4. Canine Rabies vax guidelines (4)
    • Killed
    • immunogenic (no booster required)
    • no earlier than 12 weeks, no later than 16 weeks
    • repeat in 1 year then every 3
  5. canine Leptospirosis vax guidelines (7)
    • non-core
    • Killed bacterin
    • 2-way: canicola + ictero, NOT RECOMMENDED
    • 4-way: canicola (dog), ictero, grippo (raccoon, opossum), pomona
    • protocol: 2 doses, 2-4 weeks apart, starting AT OR AFTER 12 WEEKS.  Judgement call about who should get it--can try to focus on rural but up here everyone is at risk. 
    • repeat annually.  Low-risk vax. 
    • zoonotic
  6. canine Bordetella vax (4)
    • non-core
    • oral: single-dose at 8 weeks or older, annual
    • IN: single dose, 3-4 weeks, annual
    • injectable: 2 doses 2-4 weeks apart, start at 8 weeks. Annual
  7. canine Lyme vax (4)
    • non-core
    • recommended in CAPC and AAHA in endemic areas
    • Protocol: 2 doses 2-4 weeks apart starting at 8-9 weeks, can do extra dose mid-year in first year
  8. Things that can go wrong with vax (6)
    • some dogs don't respond or have low response.  Genetic
    • Maternal Antibodies
    • Injection site rxns: lumps, pain, hair loss
    • systemic: lethargy, anorexia, fever, soreness
    • hypersensitivity or immune-mediated
    • tumorigenesis
  9. canine Influenza vaccine (5)
    • non-core
    • two types (H3N2, H3N8)
    • monovalent and bivalent available
    • 2 initial doses 2-4 weeks apart, then annual
    • risk-based
  10. vax schedule
    • debate on spreading out vs lumping. Compliance, $$$, etc - discuss with client
    • VAX SHOULD NOT BE GIVEN CLOSER THAN 2 WEEKS APART (even different vax - cytokines/lymphokines/interferon etc from first vax can down-regulate immune response to 2nd)
  11. does it matter where vax are given?
    Far enough apart that they'll be drained by different LNs, RECORD
  12. Can a partial vax dose be given to a smaller dog?
    • No (or now) 
    • minimum immunizing dose (killed vax)
    • minimum infectious dose (mod live vax)
  13. What if not all of vax goes in?
    Start over - don't guess!
  14. Can we vax while anesthetized for castration?
    • try to avoid.
    • Hypersensitivity could cause vomiting and aspiration
    • Anesthetics can cause decreased response
    • do after anesthetic recovery
  15. To whom do we report an adverse vax reaction?
    • vax manufacturer 
    • OR
    • APHIS CVB: animal and plant health inspection service, center for veterinary biologics
  16. What should we advise O to watch for after vax?
    more common (2)
    less common (3)
    • More common: injection site rxn (lumps, pain, hair loss) or systemic (lethargy, decreased appetite, fever, soreness)
    • Less common: v/d, facial swelling, difficulty breathing
  17. FVRCP - core vs non, what is included, timing and number of boosters, location
    • Core
    • Panleukopenia, Herpesvirus-1, Calicivirus
    • start as early as 6 weeks, repeat every 3-4 weeks until 16-20, all cats should get 2 vax initially.  Repeat in 1 year then every 3 years. 
    • SQ below right elbow
  18. Feline Rabies vax - types, timing, location
    • core
    • inactivated: 12-16 weeks, repeat in 1 year then every 3
    • recombinant: 12-16 weeks, repeat in 1 year then every 1 or 3 (dep on product).
    • SQ below R stifle
  19. Feline leukemia vax - core vs non, types, protocol (timing and what you do first), location
    • non-core
    • inactivated and recombinant
    • test first
    • recommended for all kittens up to 1 year (more susceptible)
    • 2 doses 3-4 weeks apart, as early as 8 weeks
    • repeat in 1 year and annually for higher risk, q2y for lower risk
    • SQ below left stifle
  20. NOT RECOMMENDED feline vax (3)
    • chlamydophila felis
    • FIP
    • FIV (maybe in high risk?) - screws up testing
  21. Injection site sarcomas
    • vax in tail?  
    • 3-2-1 rule: biopsy a lump if it remains 3 months later, is larger than 2cm or is increasing in size 1mo after vax
  22. Retroviral testing in cats
    • All cats/kittens upon adoption and before vax: impacts health even in single-cat households!  Indoor can escape and be exposed
    • Retest negative in 60d, esp if recent exposure.  Most cats positive within 30d. Kittens may take weeks to months if infected by mom.
  23. Occlusion (3)
    • relationship between maxillary and mandibular jaws
    • relationship between teeth and same jaw
    • relationship between the jaws
  24. 6-point occlusal exam
    • incisors: maxillary in front of mandibular
    • canines: mandibular in front of maxillary, both buccal to palate
    • rostral premolars: interdigitating, mand in front of max
    • caudal premolars and molars: interdigitating, mand in front of max
    • individual teeth: look for buccoversion, individual craziness
    • facial skeleton: brachicephalic, fx, asymmetry
  25. 7 steps in routine conscious oral exam
    • extraoral: facial symmetry! retropulsion, masticatory muscles, LN, mucocutaneous jctn, hypersalivation
    • occlusion: 6-point exam
    • anatomical and development: shape (enamel hypoplasia), number = retained deciduous or supernumerary or missing vs unerupted (dentigerous cysts are destructive)
    • endodontic: pulp. fx, color, shape
    • periodontal: perio ligament, alveolar bone, cementum, gingiva
    • oral soft tissues: vestibule - lumps, bumps and draining tracts. Palate, tongue, tonsils, under tongue etc
    • other: jaw fx, tooth resorption, abrasion/tooth wear
  26. 4 parts of periodontum
    • perio ligament
    • alveolar bone
    • cementum
    • gingiva
    • Plaque and calculus and gingivitis is just a clue!
  27. Don’t forget that _____________ is a diagnostic!!!
    Response to therapy
  28. most common cause of diagnostic error
    Failure to consider the correct diagnosis
  29. describe sensitivity and specificity
    know whether to trust your positives or negatives with each
    • sensitivity: Probability of a positive case being identified as positive. If high, trust your negatives.
    • specificity: probability of a negative case being identified as negative.  high = trust your positives
  30. Does it make sense to screen for acute diseases?
    or for self-limiting diseases?
    • no
    • no
  31. How could an antibody-based test trip you up (be wrong) when it's positive?  Negative?
    • Positive: may not be sick any more!  Or poor Sp, or low prevalence. 
    • Negative: acute presentations, poor Sn
  32. know the difference between parallel vs series
    which requires both to be positive?  What does that do to Sn and Sp? 
    Which requires both to be negative? What does that do to Sn and Sp?
    • Series: One after the other. Improve specificity. Both + = +, either - = -. 
    • Parallel: Both at same time. Both neg = -, pos on either = +. Improve sensitivity.
  33. Define overdiagnosis and describe how it differs from misdiagnosis
    • look too deep and find a problem that isn't causing any issues, that you shouldn't do anything about?  
    • Misdiagnosis is wrong.
  34. what does increasing prior probability do to the positive predictive value of a test?
  35. Two options for what to do next when you get an unexpected positive (prior probability of disease was low, so PPV of result is low) (4)
    • Consider testing in series
    • Consider other diagnoses
    • do nothing
    • re-test at some interval
  36. Idexx hematology analyzer
    • works via flow cytometry. Cells classified on two axis, then algorithm classifies on pre-designed polygon - falls apart when things aren't normal because things aren't separated properly--arbitrary divisions. 
    • If lines look arbitrary, look at a blood smear or send out a smear!
  37. Why shouldn't GPs use US?
    Very user dependent. Most GP don't have the time or resources to get really good at it so not a good test.
  38. PYY
    • Potent anorexigen
    • released from L cells in distal intestine upon fat stimulus, peaks 1-2h post prandially and delays gastric emptying
    • Hypothalamic stimulating/inhibiting (2-12h)
  39. glucagon-like peptide (GLP-1)
    • potent anorexigen
    • L-cells in GI tract - delays gastric emptying and central effects at hypothalamus
    • induce malaise, taste aversion
    • same duration of action as PYY
  40. Leptin
    • normalizes appetite regulation and improved weight loss clinically
    • anorexigen (related to cytokine family, inflammatory)
    • release depends on fat content in body (more adipose = more release post-prandially)
  41. Ghrelin
    • potent orexigen
    • from gastric mucosa
    • only known circulating appetite stimulant
    • increases during fasting and decreases during feeding (gastric distension)
    • more in obese, less in anorexia patients
  42. Adipose as endocrine organ
    obesity induces secretory changes (adipokines), macrophage activation, adipocyte apoptosis, pro-inflammatory changes (mostly CV and DM)
  43. adiponectin
    • richest hormone in blood stream, inversely proportional to adiposity.  
    • Potentiates insulin signaling
  44. Resistin
    • released from adipocytes or interadipocyte macrophages
    • increases with obesity
    • insulin resistance
    • upregulates the inflammatory response
  45. C-reactive protein (and obesity)
    • a marker of inflammation, rising in obesity!!
    • doesn't rise in cat inflammation.
  46. kcal ME/day equations for cats and dogs
    • dog - 95 Wkg0.75
    • cat - 130 Wkg0.4
    • look for the words "light" and "lean" on the package
  47. how much weight loss per week
    • 1-2%
    • weekly or monthly weigh-ins for O compliance
  48. draw and describe the diagram for a confounding variable.  Why is it important in the context of comorbidities?
    • Confounding  →  outcome
    •              ↓           ↗
    •        exposure  ↗

    exposure to outcome relationship differs based on the level of a third variable (comorbidity = confounding factor).
  49. Common comorbidities for dogs and cats
    uncommon comorbidities in dogs and cats
    • All disease processes can be classified as comorbidities.
    • obesity and DM
    • hyperthyroid and CRD
    • hyperthyroid and HCM
    • CKD and food allergy
    • Obesity and OA
    • immune-mediated and OA
    • Cardiac disease and periodontal disease
    • Obesity and immune-mediated
    • Osteosarc and OA
    • lymphoma and cardiac disease
    • Epilepsy and hepatic disease
    • Atopy and IBD
    • Malassezia dermatitis and hepatic disease
    • epilepsy and perianal fistulae
    • PLN and OA
  50. Discuss why comorbidities are important in clinical practice (6)
    • each problem increases length of visit by 2.5 minutes. 
    • More complicated regimens = less compliance and more hospitalization (humans). 
    • predictor of mortality. 
    • competing/antagonistic treatments
    • treatment overlap
    • QOL concerns
    • cause diagnostic issues
  51. Ways comorbidities can lead to concerns with medications
    • interact
    • change metabolism
    • compliance
    • side effects
    • expense
    • contraindications
    • (altered pharmacokinetics - altered absorption, excretion, protein binding)
    • (don't memorize)
  52. CAPC: why give year round preventatives?
    • FOUR R's (plus 2)
    • Relocation of owners and pets from endemic areas
    • reduce resistance
    • rescue organizations (who relocate)
    • Roundworms and other internal parasites
    • safe and effective
    • changes in weather and climate patterns
  53. Why test for HW annually when on preventative
    • resistance!
    • neg HW test does not mean the P doesn't have heartworms!!
  54. Why parasite preventative products fail
    • poor pet compliance: spit out? Derm probs? 
    • poor owner compliance: missing doses, not year round, bathing or inappropriate application (SKIN not hair)
    • Lack of DVM consensus in using: not year round!
    • pets travel to endemic areas: in winter!
    • resistance: developing all the time
    • weather and climate change: 12mo of tick bites!
    • overwhelmed: preventatives can't manage infestation!
    • ALL pets in household not tx: indoor and outdoor, dogs and cats
  55. Managing flea/tick infestation
    • Treat ALL pets in household
    • Check pets DAILY
    • treat INDOOR environment: vacuum and launder, then environmental sprays
    • treat OUTDOOR environment: keep away from breeding areas (under decks), avoid overgrown grass so everything gets SUN, safe and effective pesticides
  56. "Repel" tick products
    LESS LIKELY to attach and bite...but still may.
  57. carnitine, protein and fiber in diet foods
    • carnitine: helps maintain lean mass during weight loss
    • fiber: increases gastric fill
    • protein: maintains lean muscle mass during weight loss (>30% for dogs, >40% for cats)
    • Carnitine and protein may act synergistically
    • (dry lite food often only has 18-20% protein)
  58. where to start RER with cats
    • 70%! 1.2 x RER if an oudoor (maybe...hard to control due to hunting)
    • feed BID - multi-cat households are hard
    • Need to muscle score as well as BCS - can be cachexic and still fat!  High protein!
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primary care
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