So today's talk, what is HootCamp anyway? We'll talk about what we're doing here. We'll have a little warmup. Every session, as we start, we'll have a little a warmup where we'll quiz you about the topics we covered last week. The idea here is we're gonna reinforce the material you saw just a couple days ago. That's one of the fundamentals of how we learn. So we're going to do in class what you should do in your independent study. We're gonna do some fun warmups today just to give you a feel for it even though we didn't have a class before. Our clinical topic today will be a bovine classic case. And at the end of Dr. Brock's discussion, she'll do a live Q&A. So if you guys have questions about that particular cow thing, she's right there to ask. The study strats topic today will be A Study Plan That Works. Study plans aren't exactly exciting, but boy, it is a powerful, powerful tool to help you stay on track. And it's not that complicated. Finally, at the end of each session, we always do a low stakes quiz to reinforce what we just talked about today, okay? And that's something we want you to try to do when you prepare. So essentially, we're trying to give you a roadmap for how to prepare effectively for your NAVLE®. You don't have to learn everything, but you do need to do the work, okay. We're going to give you a really short assignment at the end, super easy, won't take you more than five or ten minutes, and that'll help you when we get back together on Tuesday.

So what is Hootcamp? Well, what we are about is walk before you run. We're trying to give you some basic tools to help you not work harder but work smarter, to prepare effectively, to make sure that the time you do invest in your study sticks. So each session we're going to model three foundations of effective test prep. We're gonna talk about the simple study plan you need to help you stay on track, it's basically a habit, it's not that complicated. We're going to over and over reinforce this concept of active study. Active study means you have to do something to learn. You don't just passively let your eyeballs roll over some notes and throw it away and never think about it again. Active means you quiz yourself. Okay, and we'll practice what we preach. We'll do it in class. Finally, many of you who have heard me speak have heard me talk about the value of strategic guessing. And so we're going to practice strategic guessing throughout every class so that that just becomes a habit. You don't think about it. And you increase your odds of getting questions right when you don't know. And you also don't waste time. When you're done with this class, you'll have a much more clear idea of your own plan and how you can prepare effectively. 

What Hoot Camp is not. This is not a course on every animal disease and treatment in the universe, okay? If you think that we're gonna teach you everything you need to know about everything about veterinary medicine between now and October, that's not what we do here. And that's crazy, it's impossible. Don't even try, okay. You don't need to everything. You just need to know enough. So you're not going to be this guy at the end of this class, okay? But you will know which way to go. Here's another thing this course is not. This course is not a magic trick that's going to make everything easy and fast. I wish I could tell you that we're going to give you the magic knowledge and then you'll know everything and get it all right. But that does not exist, okay, so this is not a magic trick to make everything fast and easy, okay. You're not pulling a rabbit out of the hat. You have to do the work. 

The good news is, it's not rocket science, okay? You do have to do the work. There is no shortcut, but if you do the the work, you'll win. And we cannot do that work for you, but we can point the way. So this course is a map, okay. By the time we're done with this in a few weeks, you're gonna have a clear idea what to do, what to next, and how to keep going in the right direction. 

So the structure will be, as I said, when we open class on Tuesday evening, we're gonna warm up with a short few questions that came from today's session, okay? This is called retrieval practice. It's another way of just saying, we're reinforcing the stuff you heard today with a couple low stakes questions that you'll hear on Tuesday, okay. And that habit of studying some and then quizzing yourself, that is one of the most powerful engines of learning. Okay, so we're gonna do that every single session. It's super helpful because it works. We're talking about actively pulling information out of your head. And the idea here is not so much to make anybody feel bad if they get one wrong. I mean, we all make mistakes. That's okay, we've learned from mistakes. The power of retrieval practice is you're reinforcing that knowledge if you didn't quite remember it all. The real power is you're opening the doors. You're widening the path between information in your brain and your fingertips, okay? That's the value. So that's that'll be the warm up session. 

Let's start with our bovine case today. Today we have a five-year-old third lactation red Holstein cow. She's 10 days in milk. She had a dystocia when she calved. The calf was in breach position. The farmer was able to correct the dystocia himself, but she subsequently ended up retaining and had metritis postpartum with a fever and fetid discharge. The farmer treated her with ceftiogur IM on the farm per his BCPR protocols that are were set up by his herd health veterinarian. So she has not seen a vet yet because he was able to diagnose all these things without a veterinarian. Over the last two days, she has a history of decreased appetite and falling milk production and decreased rumination. This is a farm that happens to use a rumination technology called smaxtech boluses that sit inside the rumen of the cow and collect all kinds of data on activity, rumination and temperature. And the green line that you can see here is her rumination, her time of rumination. And you can over the last several hours that it's just sort of tanking. This black line is normal and you can see that it just tanks from where it was to where it is today. 

So he calls the vet and the vet shows up. TPR is all normal. She's a little bit dopey, not quite herself and a little but dehydrated. Rumen contractions are less than two per two minutes. And there's a ping, asculted on the left side from the 10th rib space to the caudal ventral paralumbar fossa. Sort of on this line from the elbow to the pins. So the hooks to the elbow to the pin is sort of your landmark. And when you, when the far, the veterinarian was asculting and ballotted, so that's when you shove the abdomen of the cow back and forth with your fist, you could hear a sloshing sound inside. So what is your top differential diagnosis for this, poor beautiful cow? Obviously this is not the case cow because she's black and I made her red in the case. You are probably thinking left displaced abomasum, right? Again, it's just pattern recognition. You put all of those things together and you come up with a pattern that you're able to recall pretty quickly. 

So what is a left DA or a displaced abomasum in general, a DA in general? Essentially, something happens to cause the abomasm to fill with gas, usually volatile fatty acids, and It therefore floats up and displaces out of normal position. So it can go to the left. This picture is describing where it goes when it goes to the Left. So this is, this brown circle is the rumen, the blue is the omasum, and the abomasum should sit ventrally on the body wall, sort of running from left to right. When it displaces to the Left, it floats up like this and goes to, let me just get my pointer up here for you. It floats up to the left and it gets basically stuck between the body wall and the rumen. And so when it floats to the left, it's less of a big deal because it can't really go anywhere. The rumen kind of keeps it in place. It's not in its normal anatomic location but it can really get into too much trouble. It can also float up to the right. And in those situations, it floats up over to this side of the omasum and the right abdomen of the cow, if we think about the anatomic structures that are on the right abdomen of the cow, it's the intestines and the cecum and things that are not as sturdy as the rumen is. And so it can, when it flips up to the right, it has the potential to twist on its axis and result in a volvulus, a abomasal volvulus. They used to call these a right twisted abomasum. But it floats up to the right side and twists on its axis. And then it becomes sort of like a GDV in a dog where it's an emergency because we've now sequestered the blood supply to that organ and that's obviously bad. Peak occurrence of DAs are within the first four weeks of lactation. How do these things happen? Kind of big bucket things to think about. Anything that slows down the motility of the abdominal organs, so anything that slows things down, causes decreased emptying, can cause increased gas production in these structures. Things like that, really you're thinking about hypocalcemia in a fresh cow. That would definitely drive hypomotility. Decreased rumen fill, so anything makes her not eat appropriately, so concurrent disease can fall into that category, metritis, mastitis, ketosis, anything that's making her feel dumpy and not eat can cause this to happen. Any other abnormal increased production of volatile fatty acids. So if the diet isn't formulated correctly and they're eating too much grain, for example, you can have just increased production of gas cause this condition. And then genetics play a role. So some cows are deeper bodied. Some cows are higher producing and so are more likely to have hypocalcemia and ketosis, in general, so there's a role to play there. 

When we think about pattern recognition for a DA, I think you guys got this. So classic case, three things, fresh cow, off feed, down in milk, right? That's the pattern. You see those three things in combination together and I want displaced abomasum to be somewhere on your differential list with some more information, obviously. Most of the time, TPR is within normal limits. We'll talk about an exception to that in a second. There is often history of concurrent postpartum disease. So retained placenta, metritis, mastitis, ketosis, usually something is making her feel crappy and that's part of the history. There's often decreased rumen contractions but they can be normal. And sometimes this is another sort of pattern that might come up. They'll talk about the caudal rib cage being sprung. So this is a great picture of this from a cow on our herd, our university herd. You see this last rib here, this is the paralumbar space, and this last rib is sort of popped as if something is pushing it over. This yellow line marks sort of where the ribs should be in line with the body. And typically in an LDA situation, that's because the abomasum is there smushing the rib out. Dehydration can happen, but it's typically only in volvulus cases. 

So let's talk about volvulus. So because we talked about how, when the abomasum floats up to the right side, it has the potential to twist on its axis because there's nothing holding it in place. It can sort of flop around over there and end up twisted. It can twist at a couple of different locations. So sometimes it twists at the sort of where the omasum attaches to the reticulum and so the omasum ends up being part of the twist. Or it can twist at the pylorus and in that case, it's sort of at that pyloric duodenal junction. Dehydration can be very severe, very quickly. So it goes from like not so bad until into super bad. They will have a very distended abdomen and sometimes have that papal shape that they talk about. This is just sort of a good image. This is a cow with the paple shape. Paple stands for pear apple. I don't know who came up with this, but it's pretty great actually. So the left side looks like round and convex like an apple. And then the right side has this distension just but only on the caudal aspect of the right abdomen. This is not pathognomonic for abomasal volvulus, this could also be just ruminal bloat can cause this shape. But again, if we have those sort of things on our pattern recognition, they'll help you. Oftentimes they'll be absent manure or scant manure, especially if it's been prolonged and nothing can get through. Sometimes it will just be liquidy manure, can't always use the manure to diagnose this or to look at the pattern. They will be tachycardic, animals with a volvulus will be a tachychartic and the degree of tachycardia is proportional to the severity. So the higher the heart rate, the worse the prognosis. That's a good thing to remember. They will colicky often, so sort of restless, pacing back and forth, shifting weight, kicking at their abdomen. And death can happen pretty quickly from shock and colic in these guys. 

Okay, so let's go back to our case. We are going to look at our clinical signs or we're gonna think about diagnostics now. So in lots of things with large animal medicine, our diagnostics and our clinical signs are often aligned because we don't have a lot of diagnostic tools available to us. And so for diagnosis of an LDA, I can pretty much use clinical signs. So the ping and all of the history on this cow was pretty suggestive of an LDA. And you would be pretty confident to proceed with treatment with just that information. But we can do blood work. The most common thing that we'll do cowside is a BHBA, beta hydroxybutyrate measurement. We can do that on blood using a cowside meter. And in this case, it was 3.5 millimoles per deciliter. Normal is less than 1.2. So she's definitely ketotic. And then we can do a blood chemistry. Oftentimes, large animal practices will have a chemistry machine, or chemistry disks that they can run in the office. So you can pull a blood sample and bring it back to the office to run. When we look at this girl, her total calc, she's a little tiny bit hypocalcemic. Her, she is hypochloremic. She's hypo, oh, shes low on potassium. I just forgot what that one was called. Anyway, she was low on potassium. And she, her bicarb is normal and she has an elevated base excess. 

So when we think about diagnostics here, oh, and I should have shown that's, that's demonstrating pinging. So, you know, you put the stethoscope on that area and then flick with your index finger and your thumb, like you used to hit your little brother's ear to be jerk. Make sure you hit her hard. Okay, you got, you can't be subtle with this. Remember, we're going through shoe leather. Okay, so diagnostics, the ping over the ribs is very diagnostic. And so when we're thinking about an LDA, we're think about the space from the 10th rib space to the paralumbar fossa on that line between the elbow and the pins, the tubercoxy. You can ping an empty rumen in that area, but it's gonna be really dorsal. So if you hear a ping sound really dorsal and it doesn't go down more ventrally along that line that we talked about. It's more likely a rumen gas cap ping like you would see in a bloat as opposed to an LDA ping. The right-sided DA, so this is a sort of a circle sort of demonstrating where you might hear a right-sided DA. It's a little bit more caudal than the LDA often is. And you want it to make sure that that ping extends up to the ninth rib space if possible. Right-sided pings are much harder to diagnose because lots of other things can ping on the right side. The cecum can ping. That would be way up here in the paralumbar fossa. The intestines can ping sort of in the whole abdominal space. The uterus can even ping in a really, really nasty metritis. There can be gas production by clostridial species and you can have a uterus ping. Again, that would be really dorsal. So the way that we distinguish between the different right-sided pings is that nothing else is really gonna ping that far cranial in the ventral abdomen, except an RDA, but they are a little bit harder to diagnose. You can do ballottment, so sloshing sound when you shove on the abdomen of the cow and you're listening, you'll hear that sloshing sound of a viscous that's full of fluid. Rectal palpation, so an LDA, you can't feel the DA typically. You can't the distended abomasum out of place, but you can feel that the rumen has shifted to the right and that the left kidney, which is palpable, has shifted to the right. This is pretty subtle and it takes a lot of experience to identify. When you're thinking about just answering this question on a exam, that's probably not likely to come up. However, what could come up is rectal palpation of the abomasum on a right-sided DA. So right-sided DAs and definitely a right sided volvulus are palpable per rectum. So when you reach in, you can, your fingers, depending on how long your arm is, your fingers can just sort of touch the caudal aspect of the twisted ortors, or just distended gas-filled abomasum. So right-sided and abomasal volvulus are rectally palpable. 

The ping is often diagnostic enough. The other diagnostics that we would use here are elevated urine or blood ketones. Ketosis can be primary. So ketosis happened first, caused anorexia and decreased rumen motility, and therefore she got a DA. Or ketosis can secondary to the DA. So in that case, she is ketotic because she is not eating, but she's still making lots of milk. So she goes into negative energy balance and she gets ketosis secondary to the displaced abomasum. So they don't have to have ketosis and have a DA. And if they do have ketosis and a DA, ketosis could have happened first and caused the DA or be a result of the DA. Hopefully that makes sense. There is something that sometimes people do, it's hard to know how current NAVLE® is at any state of the world, but there is a test called the LipTek test where you can tap the fluid just ventral to the ping location with a spinal needle and if it's acidic, it's very likely abomasal fluid, obviously. The abomasum is the true stomach of the ruminant and so it's got a pH of about two. So that is something that you can do clinically it's not really done very often in the field. Clinical pathology, hey, there's that word, hypokalemic. Clinical pathology, we will come up with a hypo-chloramic-hypokalemic metabolic alkalosis. And a lot of you guys came up with this on Dr. McLaughlin's practice question. So hypochloremic because they're sequestering chlorine in the abomasum through that HCL that's not going anywhere. Hypokalemic, just because they are not eating, cows can get hypokalemic pretty quickly with just straight anorexia. And then the metabolic alkalosis again is mild to moderate and it doesn't typically require electrolytes, electrolyte correction. Like you don't need to worry about doing fluids on these guys. Most of the time you just wanna fix the primary problem. 

Okay, so in our case here on this red Holstein, who's not red in these pictures, we diagnosed a left displaced abomasum and the owner wanted to try medical management. They didn't have the time or the resources to do a surgery at the time that you were on the farm. And so they said, can we just do a medical management? And you said, we can try. So you sedated the cow and rolled her. So drop her on the right side, roll into dorsal recumbency and then flip back over onto the left side and stand back up and the ping was magically gone. So you ping her again after you stand her up and she no longer pings on the left-side. You followed that up with 500 milliliters of calcium borogluconate IV slowly because she was hypocalcemic. You're only going to do that once. You could follow up with oral calcium supplements if you thought it was important in this case. And then you're going to treat the ketosis. She was very ketotic. So you're gonna treat the ketosis with oral propylene glycol for five days. And that's just a source of sugar that the rumen bugs can turn into, or that the, excuse me, the liver can turn into glucose. Um and gave her palatable super yummy second grass hay for her to eat. So that was what the farmer wanted us to do and so that's what we did as a veterinarian. 

Two days later she was off feed and down in milk again so at that point we recommended surgical management and did a standing right flank omentopexy. We could have done a roll and toggle, but since she had already been rolled, there was concern about doing so again. The surgery went well and the cow made a full recovery. Yay. So let's talk about treatment plans. 

So treatment plans for LDAs or DAs in general, excuse me. Case selection is gonna drive the treatment of choice. So as in anything with production animal medicine, you're gonna look at the whole picture before you come up with a treatment plan. So the value of the animal will matter to farmers, the prognosis of the outcome, like how likely the cow is to recover, farm finances, and then time, obviously. Will all play a role. When we think about, that's like real life, right? But when we think about an exam question, some things that might come into play would be the farmer doesn't have the resources to treat the cow or she's a very high value genetic important animal. Those would be clues for you to say, okay, we could try medical management or we should go straight to surgery. Those would be the kind of keywords you'd be looking for. So medical management, we can only do in a simple LDA. And that's because number one, recurrence is probably likely. We can't do medical management with an RDA because again, remember I told you, an RDA is always an emergency that needs immediate treatment. Calcium sub-Q or IV slowly is warranted if the cow is hypocalcemic. About 20% of DAs are also hypocalcemic. And so it's not ever wrong to give them either oral or sub-q calcium, even if you don't have access to blood work to know for sure if she's hypocalcemic. KCL orally is always a good idea for any cow that's off feed because they're hypokalemic. You can do oral laxatives and stimulants. People have talked about giving them, oh, caffeine, things like that to try and stimulate contractions of the GI tract, which will counteract that hypomotility. Rolling is a possibility. Rolling without doing anything, just trying to roll the left-sided abomasum back into the right position, and the gas will hopefully just release itself. You used to hear things about how farmers would just put them on a truck and drive them around town and the jiggling makes the DA go away, it's something that people talk about. And then rumen transfaunation. So if you have access to a fistulated or cannulated cow, rumen juice from a healthy cow is always a great treatment option for any GI trouble in a cow. 

Surgical treatment is always going to be warranted in an RDA or an abomasal volvulus. We have a couple options for surgery. So the first one I'm gonna talk about is roll and tack or roll and toggle and a blind stitch. These two surgical approaches, we can only use in an LDA. So you cannot use these approaches in an RDA or an abomasal volvulus. In both of these, the idea is that you're going to roll the cow onto her back. The gas in the abomasom is going to push that abomasum up into its normal position on the ventral body wall and then you are going to blindly try to put in a suture to hold that abomasom in place long enough for an adhesion to hold and long enough whatever the primary insult that created that gas to go away and the abomasm to be restored to its normal condition. The roll and toggle uses a toggle pin that you put in first, and then you put this little toggle suture, the toggle suture goes in like this, and then, you tie those two toggle sutures together. Or you can do this with just a really giant, large curved cutting needle and suture. But both strategies are completely blind. You cannot see what you're doing. You have no idea what you are tacking down with the suture and obviously, when we're thinking about the ventral body wall of the cow, there's like giant mammary veins here, things that you wouldn't want to puncture with this giant trocar. The kicker to know for a NAVLE® about this is if there's any complications you just cut the stitch. 

The other more common surgical treatment for this is an omentophexy or abomasalpexy. So you're gonna deflate the gas, replace the abomasum into its correct position, untwist it if it's a volvulus, and then you're going to suture the omentum or the pyloric cirrhosa. So if we're grabbing a piece of the pyloris, that's an abomasopexy. If we are just doing the omentum, that's just an omentopexy. The goal here is that when you suture that the body wall, you create an adhesion. And that adhesion will keep the abomasum in place. You can do this on the right flank, or you can roll the cow up onto her back and do a ventral approach. The ventral approach puts the abomason surgically into a more correct anatomical position where it's supposed to be, but obviously it's much harder to do surgery on a cow's back than it is to have her standing. 

Outcome, pretty great if it's just a simple LDA and honestly, a simple RDA, pretty high survival rate. Abomasal volvuluses have poor prognosis and it has a worse prognosis with a higher heart rate, severe dehydration and a longer history of illness. So when you're thinking about a test, those are the things you wanna think about with a volvulus, really high heart rate, really bad dehydration and longer history of having this disease would lead you to a worse prognosis. Prevent with good feeding, good nutrition, avoid overcrowding, monitor for all those concurrent diseases and treat accordingly, and record-keeping. If the incidence is higher than 1 percent DAs on fresh cows, we want to look at why. 

So, okay, pearls. The abomasum fills with gas, goes to the left or the right. RDAs are always an emergency, the old line that you'll hear from dairy vets, never let the sun go down on an RDA. You're gonna go that day and take care of it. Clinical signs, fresh cow off feed, down in milk, and a ping. That's your pattern. Diagnostics is the ping, and then that hypochloremic metabolic alkalosis. We're gonna do surgery in most cases to fix it. Prognosis is great. If it's simple and caught early, it's guarded if it's a volvulus, and we prevent with good nutrition. 

We're gonna start our sessions here in June going step by step with effective study strategies that are gonna help you. And one of the most important study strategies is to have a study plan that works. And I'm gonna show you some simple things you can do and I'll show you a complicated way to handle it. But if you want my advice, simple is better, okay? To achieve great things, two things are needed, a plan and not quite enough time. This is Leonard Bernstein quote. You do not have enough time to learn everything in the universe of vet med by next October 15th or by April or whatever it is, okay? There's never enough time. There's always too much to do. And so you should not try to learn every thing. Instead, you need a simple plan. You wanna learn the big stuff and you wanna keep moving. And if your plan is good enough and simple enough. I should be able to ask any one of you any day of the week, what's your plan today that's gonna help you get to the finish line and succeed on NAVLE®? And if you have a rough idea of what your priorities are and what your plan is, you'll be able answer, okay? So we're gonna start by talking about that. 

Your study plan is simple but beautiful. We see this, we've been helping people for over 18 years, tens of thousands of colleagues just like you. And we kind of see two kinds of people. One, a lot of people say, hey, I'm just gonna wing it. How hard could it be? Okay. And the other person, they have a plan. And so this might be two people five months ago and the guy, he feels confident and he's like, I'm gonna wing and the lady's got a plan, this is five months ago. And now what do those two people look like? With the test coming in four weeks, okay, when time is short. Here's our young woman. She's confident, she knows what she's doing, she's smiling, and she grew her hair. And then here's the young man who's gonna wing it, didn't have a plan. He's a little worried. You really should have a plan of some kind. You should have sense of what's more important to give your attention to. And you should have rough idea each day or each week what's my goal, okay? You don't need to have every last detail figured out but you do wanna have a rough idea. It does help. 

Study plans, they can be complicated and super detailed where they're trying to tell you what to do every moment of the day. Or they can be simple. I think you know where I land on this. I think you wants simple. And the reason simple is better in my opinion is because the life of a senior in vet school or a new graduate, you are super busy, you're working long hours, you don't have control over your day, things can happen that can mess up all your plans. And so what you need is something that is more simple and more robust so that you can adapt it as life happens to you, okay? But if you want to look at what a complicated plan looks like, in Zuku we have a very detailed three-month and a very detailed six-month plan for how to prepare for NAVLE®, where every day of the week it'll tell you what to do. Do you see how much detail that is? That's just two weeks. Two weeks out of what? 18 weeks or more? And this might be a 24-week thing, I forget. Personally, don't think this is that helpful people like having the guidelines But I find it's hard to stick to this day in day out for four to six months, just too much other stuff is coming at you. If this works for you, it's right there in Zuku, go for it. Okay. If you use the other service, they have something similar. Okay, but I'm gonna recommend you try to keep it a little more basic than that. 

Why do we want to prepare for boards anyway? And why does the study plan matter? The study plan and board's prep matters because we can use the things we study for NAVLE® to help us in real life clinics. Who does not need a little tune up on the big five endocrine diseases of dogs and cats? Who does need that? Who does a tune up on the top five bovine diseases, production diseases of cattle? Or the top five equine diseases, you know, colic, laminitis, things like that. Who does not need that? We all need it. Use your board's prep as an excuse to tune up on what you know anyway. Typically people spend four to six months to prepare for this test, sometimes a little longer, that's fine. But less than that is a little tight, okay? The magic ingredient you have on your side right now is time. Take advantage of that time. It's just like a recipe. One of the magic ingredients in any recipe is time, OK? All you need is a habit of daily practice testing, or almost daily, plus independent study in books and notes. So here's the first ingredient of any good study plan. There are two pieces, a first pass and a second pass. The first pass is longer, and it's what you're gonna be doing for June, July, August. Maybe a little bit into September, okay? This is a steady daily habit of spending two-thirds of your time each week doing practice testing and about one-third of your time doing active independent study. That's where you go to your books, you go your notes, maybe you watch a video, you kind of make it active by quizzing yourself by what did I just study, give your notes to a friend, have them quiz you, make a flash card, whatever works. But it's that two-thirds, one-third, and you do that for the next, let's say, three and a half months. That's the first pass. The second pass, very important. This is when you push. In the final seven weeks or so before your NAVLE® test, you redo everything you just did on the first past. You spend two-thirds of your time in any given week doing the timed tests. Timed test just means random topics. It's the same questions you've been studying for the last three months, but the timed test mean you don't get to pick the topic. You don't see the answers as you go. There is a clock ticking up in the corner of your screen. It's like the real thing, but it's the same questions you've been studying for months. So what you're doing in that final push is you're reinforcing your knowledge just like we're gonna do in this class, okay? Very important. At the same time, in the final seven weeks, you go back to your notes and do an active skim, an active re-review of the stuff you think is important from your first pass. First pass, second pass. That's all there is to it. It's not that complicated. So what does that look like? 

Two-thirds of your time today, two-thirds your time this week, routine, have a habit, I'm gonna sit down and I'm going to dedicate two hours today to my board's prep. And I'm go give an hour and a half of that to practice testing, okay? And take some breaks in there, okay. And then I'm give 30 minutes today to my independent study. I'm gotta hit the books, I'm going to pick up my notes. You know, people have asked me already, like, where can I study this in notes? I mean, you can go to the Merck Manual. If you subscribe to Zuku, go to our notes. It's all there, okay? And what you wanna do is make it active. Independent study means it's active. You read your notes, turn them over, kinda quiz yourself, okay, what is a classic case for, name that disease, look like, okay. That's how you make your study active. That's all it is. And you do this from now through early September. Your goal is to finish your practice test in Zuku and complete your notes review in the seven weeks before your test. When you get to seven weeks out, it's time to change what you do. 

Here's the second biggest mistake that people make when they're preparing for NAVLE®. They ignore that independent study step. You'd be amazed how many colleagues that we've consulted with over the last 18 years where we say, well, what did you, they failed the test and we say well, tell us how you spent your time studying. And maybe they memorized all the Zuku questions, right? Or they memorized something. They didn't do anything else. They didn't study books, they didn't go to the Merck, they didn't do anything else at all. That's not the way to prepare, okay? When you do independent study, you have to make it active by quizzing yourself on stuff you've just read. You want to give about a third of your time per day on that. You particularly pick topics that you know are big or things that give you trouble.

So what's that final push look like? It looks a lot like the first push, but now you're doing it with the timed tests, okay? These tests, I recommend you try to do them in the final seven weeks, 60 questions at a time, because that's the size of blocks of questions you get on your NAVLE®. You're building your stamina for what that feels like. You're getting comfortable with the format. You're getting better at answering questions. This is stuff you've seen before. Remember in the final push you also still give about a third of your time in any given week to that big re-review. You go back and re-re view the stuff you studied for the last three months and you make it active by quizzing yourself. It's not that glamorous, but it works. Okay, your goal is to get as accustomed and comfortable as possible with timed tests and to be quizzing yourselves after you review notes day in and day out. You are doing as a habit what you're gonna do on the day of the test. 

Here's the biggest mistake people make when they prepare for the boards. They simply do not complete the program. This is very common, but it's a big problem. I know how busy it can get. I know hard it can be. But one of the most common things we see among people that fail the test, they didn't complete the timed tests. They might not have even done any timed tests, that is a major fail. Okay, you are really missing an opportunity in that final seven weeks to get better at timed tests. And people say, well, yeah, but I wasn't done with the practice test yet, so I couldn't do the timed test. Don't do it that way. Okay. It's game on. It is time for the rubber to meet the road. When you hit you know, early September, you need to switch your study plan and start doing timed tests. Okay. You got to get better at those. It will help you. You will perform better. 

Where do you start? We're gonna talk more about this in subsequent sessions, but many of you have heard me speak in the past, will hear me talking about triaging information the same way as we triage a clinical case. You wanna start and prioritize by prioritizing time on the big four species. You need about 75% correct of the questions that count in your NAVLE® to pass, okay? Over 78, well 78 percent of questions on the real NAVLE® are in only four species, dog, cat, horse, and cow. So if you're wondering where to prioritize and where to front load your work on your study plan, start with the big four, okay. So, if you are wondering what you should study today, I would say do some practice questions in bovine, review LDAs, And then tomorrow do a little more in bovine pick another topic to study for independent study something like that. Spend some time on the big four. Okay, that's what I would do. We'll talk more about how you fill in the blanks on your study plan, but probably your study plan between now and at least Mid-july should be to try to complete correctly complete all the practice questions in the big four, okay? Do independent study on the Big Four. If you wanted to add one more, see if you can squeeze some pigs in there. That's a nice place to get some points, okay? So if I walked up to you tomorrow and say, what are you gonna do today for your two hours of study or whatever amount of time you have? I hope I hear you say, I'm gonna give an hour and a half to one of the big four and I'm going to do independent study on that same species on some big topic, okay. That's a flexible and simple plan that'll get you through. 

We're going to wrap it up here, folks. It's time for the low stakes quiz. Remember, every session of Hoot Camp, we're going end it with a low stakes quiz on the topic we talked about today. Remember, our topic today was displaced abomasum in cattle. Mostly, this is a dairy cow type question we see. A dairy cow-type problem. So if you see this, I want to help you make the transition from this response, oh my God, a test, my name is Mud. I wanna help you transition from that attitude to this attitude. Awesome, okay? You're gonna hear in these sessions how valuable it is to quiz yourself actively over and over and over to reinforce what you know and to learn from the ones you don't know. Mistakes are your best friend, okay. So we're gonna do a low stakes quiz now. Remember, you can also expect a low-stakes warm-up quiz at the beginning of Tuesday's session. 

Hey, does this look familiar? Here's your first question. I'm gonna give you a chance to read it and then I'll show you your answer choices. We have a high-producing dairy cow that freshened three weeks ago and today she's off feed. On physical exam, her heart and respiratory rates are within normal limits. There's her temperature, very normal. She has decreased rumen motility and the urine test for ketone bodies is positive. So she's off feed, so she's ketotic. There's no evidence of mastitis. Uterus is clear of infection. On the left side, you can hear a high-pitched musical ping that you can hear through your stethoscope during percussion over the ribs on a line between the elbow and the tubercoxy on the left-side. Doesn't ask you what it is, but you know what it. What acid-base abnormality is most likely? So here are your options. Depends on the degree of displacement, respiratory acidosis, respiratory alkalosis, metablic acidosis, metabolic alkalosis. I think we all know what this one is because we just did this one, okay? And what do we have everybody? Metabolic alkalosis. So, you know, the glandular stomach of the cow, the abomasum, it's twisted up, it sequestered all that hydrochloric acid inside itself. It's hiding it from the body and you get a response which is metabolic alkalosis. Okay, what did we do here? We just did what you should do when you study. We showed you the information, that's the study part that Dr. Brock did, and then we reinforce with a little quiz. Study, quiz yourself. Study, Quiz yourself. They call it retrieval practice. You're reinforcing what's in your head. The more you do it, the more solid that information will be in your brain and the better access you'll have to it. Great job. 

How about another one? You diagnose a recently fresh dairy cow. That means she just had a calf. You diagnose this recently fresh dairy cow with a simple left displaced abomasum, which choice is the most appropriate initial treatment option. Emergency surgery to prevent shock, oral calcium transfaunation and gastric stimulus, gastric stimulants, immediate IV, hypertonic, saline, and dextrose, treat concurrent diseases first, a standing right paralumbar fossa omentopexy. So take your time. Look at those answer choices, everybody. And tell us what you think in chat. Answer's B, oral calcium, transfaunation, and gastric stimulants. 

Question three, which of the following diagnostic findings is most suggestive of a displaced abomasum in a recently fresh dairy cow? So these are diagnostic findings. Hyperchloremic, hyperkalemic, metabolic acidosis with ketosis. Severe ketonuria on a dipstick of urine. A high-pitched ping between the left elbow and tubercoxy at ribs nine to 13. Bradycardia and rumen hypomotility or a firm mass palpated in the left paralumbar fossa. All right, let's take a quick look at the chat room, see how we're doing. Oh, you guys are all over this. See, you guys are bovine experts today. I love seeing this. I'm so happy that nobody got tripped up. A couple of people got tripped up by A. They saw all those letters and they were like, oh wait, that looks familiar. But remember it's hypo, hypo and alkalosis. And then nobody guessed B, which is really cool. Cause remember it doesn't have to come with ketosis. It can exist without ketosis, nice job everyone. Good job everybody. Well done. Well Done. 

I think this is our last question today, which management practice is most effective in reducing the incidence of displaced abomasum in a dairy herd? Okay, so this is your sort of advice to the farmer. Increasing the calcium content in the lactating cow ration. Lost my little pointer here. Feeding high energy rations immediately post calving. Restricting access to forage prepartum. A balanced prepartum nutrition to minimize negative energy balance. Whoopsie, having trouble getting my thing to go there. Administering oral electrolytes during the dry period to increase dietary cation-anion difference. So which of these five options, which one is the most effective management practice to reduce the incidence of a DA in the dairy herd? The answer is D, a balanced pre-partum nutrition to minimize negative energy balance, okay? So nutrition is everything in these high producing cows. Well done. And how hard is that to do, Dr. Brock? Feed cows correctly? Yeah. It shouldn't be very hard. It shouldn't be. 

All right, everybody, we're wrapping up session number one. It's been great to have you today. I'm going to give you your assignment for Tuesday. Remember, we are recording this. We will be posting it in useful tools. We need about two weeks to get these up because you have to, from a technical point of view, they have to be formatted for streaming. We'll try to do it sooner, okay? If you're a subscriber to Zuku Review, you'll always be finding these in the videos. So here's your assignment for Tuesday. Quick and dirty, just sketch out what you think a study plan for you might look like between now and November, okay? And it doesn't have to be very complicated, but just in a rough way. We'll be talking more about this later. Number two, try to do a quick review of bovine DAs, and I'm going to post something in the chat box for you guys to go look at, okay. And then finally, your tune-up topic for Tuesday will be pregnancy toxemia in sheep and goats. This is a very important condition. Which in some ways has some parallels with what we just learned about bovine DAs, these peripartum disease processes of production animals. When I talk about a tune-up, I want you to tune up on three big things. Can I describe a classic case? What's my test of choice if there is one? How do I treat it? Where do you start? Go to the Merck manual. You can trust it, it's reliable. This is not something where you want to ask chat GPT, okay? Clinical medicine is a little more complicated than that. Do the work, do your homework. This doesn't have to take long. All three of these things together might take you 15, 20 minutes max.