Examples of items typical of those that will be used in the Objective Case Management component of the ECEIM diploma e

1. Examples of items typical of those that will be used in the Objective Case Management component of the ECEIM diploma examination Prepared: October 2006

2. FORMAT OF THE OCM EXAM During the OCM examination, candidates are expected to discuss case management of 3 cases with panels of 2 - 3 examiners One examiner will lead the discussion while the other examiner(s) document the answers that candidates give The candidate may choose whether the session is recorded on video tape. Candidates may be given some information on the cases to be discussed to review in the 60 minutes immediately prior to the examination. Divide the time allocated equally between the cases. To ensure that the examination is consistent all candidates will be presented with the same cases. For this reason, it is necessary to ask candidates who have completed the exam early in the day, to remain in a secure room until all candidates have completed the exam. The examination will be conducted in English. Under the current examination regulations, candidates are entitled to have a translator present. Candidates should assume that they are managing the cases in a well-equipped hospital of a specialist standard and that there are adequate financial resources to investigate and treat the cases under discussion. The ECEIM examination committee is aware that regulations governing the availability of drugs for use in horses vary throughout Europe. Candidates are expected to be familiar with the underlying issues regarding these regulations in general terms and to be aware of specific regulations in the country in which they practice. Candidates are not expected to know the specific regulations that are applied in countries where they have not had direct practical experience. Where relevant, it is appropriate for a candidate to comment on the advantages of a drug that may not be available for use in horses in their country. Candidates are assured that they are not expected to have personal experience of drugs that are not available for use in horses in all European countries.

3. USING THIS PRESENTATION This presentation contains two examples of cases that are typical of those that might be used in the OCM examination. The presentation contains the information that the candidate will see both before and during the oral examination session together with comments in red italics indicating what the examiner will ask the candidate you verbally while you are viewing each slide. A table of laboratory reference ranges in standard international units, together with conversion factors to other commonly used units will be given to each candidate to refer to during the examination if necessary. Candidates will find it helpful to be familiar with these specific references ranges before the examination.

4. REFERENCE RANGES FOR ADULT HORSES

5. REFERENCE RANGES FOR ADULT HORSES

6. REFERENCE RANGES FOR ADULT HORSES

7. REFERENCE RANGES FOR ADULT HORSES

8. REFERENCE RANGES FOR ADULT HORSES

9. REFERENCE RANGES FOR ADULT HORSES

10. REFERENCE RANGES FOR ADULT HORSES

11. Examples of items typical of those that will be used in the Objective Case Management component of the ECEIM diploma examination Case A - Prepared October 2006

12. CASE A THE FOLLOWING 3 SLIDES CONTAIN HISTORICAL, CLINICAL AND LABORATORY DATA CANDIDATES WILL BE ASKED TO SPEND NO MORE THAN 20 MINUTES REVIEWING THIS INFORMATION AT THE BEGINNING OF THE SESSION, THE EXAMINER WILL ASK YOU TO: SUMMARISE THE MAIN PRESENTING PROBLEM IDENTIFY & INTERPRET ALL OF THE ABNORMALITIES ON CLINICAL PATHOLOGY LIST THE MAIN DIFFERENTIALS FORMULATE AN INITIAL DIAGNOSTIC PLAN THE EXAMINAER WILL THEN ASK A PREDEFINED LIST OF ADDITIONAL OBECTIVE QUESTIONS THE

13. Case A: Clinical History Prior to referral to your hospital 10 year-old grey pony gelding that is kept at grass with three other healthy ponies. Used for Pony Club activities. No known history of previous medical problems. Vaccinated for influenza and tetanus and given a combination anthelminitic (invermectin & praziquantal) 6 weeks prior to the onset of the current problem. 7 weeks prior to admission: owner called her veterinary surgeon with the complaint that the pony was depressed with reduced appetite. Physical examination revealed no specific abnormalities except a rectal temperature of 38.7oC. Haematology & blood biochemistry � see Table 1. Treatment: fenbendazole at 7.5 mg/kg SID po for 5 days & Trimethoprim-sulphonamide at 25 mg/kg BID po for 5 days. 5.5 weeks prior to admission: No significant improvement in demeanour. Physical examination, including rectal palpation revealed no specific abnormalities except a rectal temperature of 38.9oC. Haematology & blood biochemistry � see Table 1. Treatment: continue Trimethoprim-sulphonamide. 5 weeks prior to admission: A endoscopically-guided tracheal aspirate was unremarkable. A peritoneal fluid aspirate had a nucleated cell count of 5 x 109/l and total protein content of 24 g/l. There were many reactive mesothelial cells, active polymorphonuclear leucocytes and active macrophage. Treatment: continue Trimethoprim-sulphonamide. 4 weeks prior to admission: Owner reported that the pony was brighter. Physical examination remained non-specific. Haematology & blood biochemistry � see Table 1. Treatment: enrofloxacin at 7.5 mg/kg SID po. 1 day prior to admission: Owner reported that the pony was deteriorating further. Physical examination confirmed that the pony was extremely lethargic but no other specific findings were made. The referring veterinary surgeon arranges admission to your hospital.

14. Case A: Laboratory Data Prior to referral to your hospital

15. CLINICAL FINDINGS ON ADMISSION TO YOUR HOSPITAL Physical Examination: thin and depressed. Rectal temperature 40oC. Weight 363 kg. No further abnormalities found. Rectal Examination: No further abnormalities found. Summarise presenting problem FUO, weight loss, increased fibrinogen & SAA & globulin&LDH Differential list/categories THORAX � enodcarditis (no murmur), pleuritis, pulmonary abscess, thoracic neoplasia (no abnormal lung sounds) ABDOMINAL �abdominal abscess/neoplasia, peritonitis GENERALISED � brucella, lymes? Things that can be ruled out/unlikely � IAD & resp viruses � history too prolonged, liver although LHD is high others are not, kidney disease (normal creat( OUTLINE DX plan (in no particular order) Repeat Haem, Biochem,T Wash & peritoneal � NB 2nd time so candidates should not be penalised for not repeating Blood culture Thoracic & Abdominal US including echo Thoracic Rads Summarise presenting problem FUO, weight loss, increased fibrinogen & SAA & globulin&LDH Differential list/categories THORAX � enodcarditis (no murmur), pleuritis, pulmonary abscess, thoracic neoplasia (no abnormal lung sounds) ABDOMINAL �abdominal abscess/neoplasia, peritonitis GENERALISED � brucella, lymes? Things that can be ruled out/unlikely � IAD & resp viruses � history too prolonged, liver although LHD is high others are not, kidney disease (normal creat( OUTLINE DX plan (in no particular order) Repeat Haem, Biochem,T Wash & peritoneal � NB 2nd time so candidates should not be penalised for not repeating Blood culture Thoracic & Abdominal US including echo Thoracic Rads

16. When you enter the examination room, you will be asked Please summarise the clinical problem Identify and interpret the laboratory abnormalities List the differential diagnoses Describe your investigative plan After you have outlined your plan, you will be shown the following pieces of information (regardless of whether you have requested them or not)

17. Haematology & blood biochemistry:You will be told that the results are unchanged from the pre-admission sample (suggestive on an inflammatory focus) Repeat Peritoneal Fluid Analysis: You will be told that the results are unchanged from the pre-admission sample (suggestive of a low-grade, reactive peritonitis) Repeat Tracheal Aspirate:You will be told that the results are normal, and are unchanged from the pre-admission sample Thoracic Radiographs: You will be told that these were normal Interpretation � essentially normal, may suggest reactive response?Interpretation � essentially normal, may suggest reactive response?

18. ULTRASONOGRAPHY You will be asked which organs you would examine and to state the frequency of the transducers that you would use to examine each location Chest Heart � 2.5 � 3.5 Mediastinum �3.5 Pleural cavity & lung surface � 5 Abdomen Spleen, liver, kidneys � 3.5 � 5 GIT 3.5 - 5 Peritoneal cavity 5 - 10Chest Heart � 2.5 � 3.5 Mediastinum �3.5 Pleural cavity & lung surface � 5 Abdomen Spleen, liver, kidneys � 3.5 � 5 GIT 3.5 - 5 Peritoneal cavity 5 - 10

19. REPRESENTATIVE EXAMPLE OF ULTRASONOGRAPHIC FINDINGS Left, 15th intercostal space, transverse plane

20. LAPAROSCOPY

21. Giant cells, occasional neutrophils, epitheliod cellsGiant cells, occasional neutrophils, epitheliod cells

22. You will be told that: Histological examination reveals a chronic granulomatous lesion with many epithelioid and multinucleated giant cells, lymphocytes, plasma cells and varying numbers of polymorphonuclear leucocytes. These findings suggest tubercle formation associated with mycobacterial infection. You will be asked: To list the mycobacterial species that have been reported as affecting the horse To discuss how would you investigate this case further? To decide what treatment is appropriate? To discuss what advice would you give the owner concerning spread of the infection? How could you confirm TB? Ziehl-NEelsen stain, PCR, culture (costly & time consuming) How do you treat TB Rifampin, isoniazid, streptomycin ??? Any other advice to owner (prompt if necessary owner is worried about human health & spread to other horses) Human TB = M tuberculosis & M bovis M Bovis � only one case reported, but if positive should consider euthanasing horse for public health reasons Avian TB � much more likley; AIDs victims and other immunoincompetant groups � small children, elderly etc are at risk, usually other serotypes (M avium intracellularis human, horses mostly subspecies silvaticum or M avium aviumHow could you confirm TB? Ziehl-NEelsen stain, PCR, culture (costly & time consuming) How do you treat TB Rifampin, isoniazid, streptomycin ??? Any other advice to owner (prompt if necessary owner is worried about human health & spread to other horses) Human TB = M tuberculosis & M bovis M Bovis � only one case reported, but if positive should consider euthanasing horse for public health reasons Avian TB � much more likley; AIDs victims and other immunoincompetant groups � small children, elderly etc are at risk, usually other serotypes (M avium intracellularis human, horses mostly subspecies silvaticum or M avium avium

23. Examples of items typical of those that will be used in the Objective Case Management component of the ECEIM diploma examination Case B - Prepared October 2006

24. CASE B THE FOLLOWING 2 SLIDES CONTAIN HISTORICAL, CLINICAL AND LABORATORY DATA CANDIDATES WILL BE ASKED TO SPEND NO MORE THAN 20 MINUTES REVIEWING THIS INFORMATION AT THE BEGINNING OF THE SESSION, THE EXAMINER WILL ASK YOU TO: SUMMARISE THE MAIN PRESENTING PROBLEM, IDENTIFY & INTERPRET ALL OF THE ABNORMALITIES ON CLINICAL PATHOLOGY LIST THE MAIN DIFFERENTIALS FORMULATE AN INITIAL DIAGNOSTIC PLAN THE EXAMINAER WILL THEN ASK A PREDEFINED LIST OF ADDITIONAL OBECTIVE QUESTIONS

25. CASE B: 7 week old male Islandic horse, 70 kg 9 days prior to admission: Foal developed diarrhoea, Faecal ELISA was positive for Rota Virus. Supportive treatment was administered, initial response was good and the diarrhoea abated. Day of admission: The foal stopped nursing and became depressed. There was no diarrhoea but the foal developed signs of mild colic. Clinical examination on admission: T 40,3 pulse 76/minute Respiration rate 26/minute Mucous membranes: pink, refill time < 2 seconds,slightly sticky Showing signs of colic, grinding teeth with an occasional nonproductive cough. Faeces normal, gastrointestinal sounds present, no abdominal distension, soft crackles over ventral lung fields on both sides Rest of physical examination is unremarkable

26. CASE B: LABORATORY DATA ON THE DAY OF ADMISSION Haemoglobin 112 g/L Packed Cell Volume 37 L/L WBC 22.2 x 10 9/L Neutrophils 17.8 x 10 9/L Band neutrophils 2.0 x 10 9/L Eosinophils < 0.1 x 10 9/L Basophils <0.1 x 10 9/L Lymphocytes 2.2 x 10 9/L Monocytes 0.2 x 10 9/L Blood smear Cytology: Erythrocytes: mild anisocytosis, White cells: mild toxic changes in neutrophils.

27. When you enter the examination room, you will be asked Please summarise the clinical problem Identify and interpret the laboratory abnormalities List the differential diagnoses Describe your investigative plan After you have outlined your plan, you will be shown the following pieces of information (regardless of whether you have requested them or not) Summarise presenting problem FUO, weight loss, increased fibrinogen & SAA & globulin&LDH Differential list/categories THORAX � enodcarditis (no murmur), pleuritis, pulmonary abscess, thoracic neoplasia (no abnormal lung sounds) ABDOMINAL �abdominal abscess/neoplasia, peritonitis GENERALISED � brucella, lymes? Things that can be ruled out/unlikely � IAD & resp viruses � history too prolonged, liver although LHD is high others are not, kidney disease (normal creat( OUTLINE DX plan (in no particular order) Repeat Haem, Biochem,T Wash & peritoneal � NB 2nd time so candidates should not be penalised for not repeating Blood culture Thoracic & Abdominal US including echo Thoracic Rads Summarise presenting problem FUO, weight loss, increased fibrinogen & SAA & globulin&LDH Differential list/categories THORAX � enodcarditis (no murmur), pleuritis, pulmonary abscess, thoracic neoplasia (no abnormal lung sounds) ABDOMINAL �abdominal abscess/neoplasia, peritonitis GENERALISED � brucella, lymes? Things that can be ruled out/unlikely � IAD & resp viruses � history too prolonged, liver although LHD is high others are not, kidney disease (normal creat( OUTLINE DX plan (in no particular order) Repeat Haem, Biochem,T Wash & peritoneal � NB 2nd time so candidates should not be penalised for not repeating Blood culture Thoracic & Abdominal US including echo Thoracic Rads

28. Venous Blood Gas pH 7,340 PCO2 37 mmol/L HCO3 18 mmol/L BE -8 mmol/l Na 135 mmol/L K 3.8 mmol/L

29. THORACIC RADIOGRAPHY You will be asked to interpret this radiograph

30. ADBOMINAL RADIOGRAPY

31. GASTROSCOPY You will be asked to interpret this endoscopic image

32. TRACHEAL ASPIRATE You will be told: Endoscopy: mild increase in volume of mucus in trachea Cytology: increased number of degenerative neutrophils Culture: profuse growth of Streptococcus zooepidemicus moderate amount You will be asked: How would you treat this foal�s problems Would you do any further diagnositc investigations at this stage

33. CASE PROGRESS You will be told that: 36 hours after treatment began, clinical examintion reveals: T 39.8 HR 60 RR 48 Mucous membranes pink moist, CRT<2 sec Faeces firm. Poor appetite Attempts to suckle, than backs away. Grinding teeth, Spontaneous reflux at nostrils. You will be asked Would you perform any further diagnostic tests at this stage Would you change your treatment plan at this stage

34. FURTHER INVESTIGATIONS You will be told that Radiographic Contrast study 15 - 30 minutes after administration of barium via nasogastric tube reveals that the stomach is larger than normal. Fluouroscopy shows no signs gastric motility and there is no contrast in duodenum/pylorus. 20 hours after barium administration,most contrast is still in the stomach, witih a small amount in duodenum, sparsely evident in the rest of the small intestine Ultrasonography of Stomach/duodenal region shows a dilated and fluid-filled stomach. With no signs of motility. The pylorus and duodenum readily visualized. The duodenum is around 2.5 cm in diameter, the wall is hyperechoic and thickened and irregular contour in the lumen. There is fluid movement in the duodenal lumen, with no sign of mechanical obstruction within the lumen. You will be asked to Interpret this information Advise on treatment options Advise on prognosis