Clinical Correlations

Natalie

March 8, 2017

Signalment & History

Natalie is a 2 year-old Jersey cow from a mid-sized dairy. The cow went off feed last night, had a dramatic drop in milk production this morning, and is not passing feces. Referring veterinarian suspected intestinal torsion. The cow freshened in December and has not been bred back yet.

Abnormal Findings

Physical Exam: 

• T: 97.6 (low; normal is 100.5-102.5)
• RR: 36/min (high; normal is 15-30)
• No rumen contractions heard
• No reaction to withers pinch test

Complete Blood Count:

• Elevated red blood cells: 9.6 (Ref range: 5.0-7.0)
• Elevated hemoglobin: 13.7 (Ref range: 9-12)
• Elevated hematocrit: 40.2 (Ref range: 27.0-35.0)
• RBC morphology: Anisocytosis 2+
• Elevated platelet estimate: 872 (Ref range: 100-800)
• Elevated white blood cell count: 11.2 (Ref range: 4.0-10.0)
• Elevated bands: 2.35 (Ref range: 0-0.1)
• Elevated lymphs: 4.93 (Ref range: 2.0-4.6)

Biochemistries:

• Decreased calcium, serum: 7.7 (Ref range: 8.3-9.5)
• Decreased potassium, serum: 3.7 (Ref range: 3.8-5.2)
• Elevated glucose, serum: 83 (Ref range: 48-73)
• Elevated GGT, serum: 30 (Ref range: 4-28)
• Elevated CPK (CK), serum: 1741 (Ref range: 50-320)
• Elevated cholesterol total, serum: 174 (Ref range: 44-150)
• Elevated GLDH, serum: 95 (Ref range: 1-36)

Ultrasound:

• Several loops of small intestine distended with fluid and appeared static. 
• Abomasum empty and also static

1. Problems

Of the plethora of abnormal findings in this case, the three most serious clinical problems are the several loops of small intestine that were distended with fluid, the withers pinch test resulting in no reaction, and the lack of rumen contractions heard.

The most serious clinical problem is the presence of loops of small intestine distended with fluid. In cattle, small intestinal distention is often indicative of an intestinal obstruction (4) or hemorrhagic bowel syndrome (5). An obstruction of the small intestine can be caused by extramural masses, herniation, or hemorrhagic jejunitis, and adhesions and abscesses can form ensuing peritonitis (4). With hemorrhagic bowel syndrome, the jejunum of the small intestine is usually dilated and the fluid present can often be blood (5). Thus, the presence of a fluid-distended small intestine is indicative of other, very serious clinical complications that could be detrimental to Natalie’s overall health. This is the most serious clinical problem because if Natalie is in fact hemorrhaging, this problem will need to be rapidly addressed first, to prevent exsanguination in the intestine and eventual death. 

The withers pinch test resulting in no reaction is the second most serious clinical problem. A variety of gastrointestinal diseases in cattle will result in abdominal pain and can often result in an unusual hunched stance. To detect abdominal pain, a withers pinch test can be performed. With this test, one or two hands can be used to squeeze both sides of the withers. Normally, when the withers are pinched, the back will be flexed ventrally. However, with the presence of abdominal pain, the cow’s back will not flex ventrally. The lack of Natalie’s reaction is indicative of abdominal pain, which could be caused by a variety of issues such as distention of the small intestine, ulcers, or hardware disease, all of which are very serious gastrointestinal complications (1). I believe this is the second most significant clinical problem because it was found on physical examination alone, and it is clearly indicative of some sort of serious abdominal pathology. This can be beneficial for knowing what further diagnostic testing should be done. A withers pinch test can be seen below:

The third most serious clinical problem is the lack of rumen contractions that were heard. Ruminal motility occurs throughout the life of a cow. Ruminal contractions occur to help get rid of gas, mix ingesta, and propel food and other fermented products into the omasum. If ruminal motility is ceased for a long period of time, rumen impaction could occur (2). Cattle should experience 2-5 rumen contractions every two minutes. Rumen contractions allow for the mixing of ingesta, the maceration of fibrous material, and are very important for the animal's overall health. A decrease in the rate of rumen contractions is associated with fever, reduced intake, pain, endotoxemia, moderate to severe distension, abomasal distension, hypocalcemia, or generalized depression. Thus, Natalie’s lack of a rumen contractions is the third most important clinical problem because it could be indicative of a more serious clinical problem such as rumen impaction or acute traumatic reticuloperitonitis (3). 

2. Differentials

Focusing on the findings in this case and upon the gastrointestinal system, I would create a list of three differential diagnoses for Natalie.

Differential 1: Hemorrhagic Bowel Syndrome (also known as bloody gut syndrome, or Jejunal Hemmorrhage Syndrome)

This disease is an acute enterotoxemic disorder found in dairy cattle that often occurs in their first 100 days in milk and can be caused by the bacteria Clostridium perfringens type A and Aspergillus fumigatus. Clinical signs of this disease include decreased feed intake, reduced to scant fecal production, decreased rumen motility, depression, decreased milk production, dehydration, elevated heart rate, dehydration, colic, and fluid with ballottement of right abdomen. If this disease is allowed to progress, hypothermia, muscle fasiculations, peritonitis, or hemorrhage could occur. Diagnostic tests performed such as ultrasonography usually exhibit a dilated small intestine, filled with contents that could potentially be blood, blood clots, or fibrin (5). Natalie exhibits decreased food intake, reduced fecal production, colic, decreased rumen motility, and decreased milk production. The patient's CBC results indicate an increase in red blood cell count, hematocrit levels, and hemoglobin levels, which could be due to a more concentrated blood as a result of dehydration from hemorrhaging. The CBC also showed an elevated platelet estimate, which can be caused by acute blood loss and bleeding. Upon ultrasound, it was found that several loops of small intestine were distended with fluid and appeared static. While the fluid content in Natalie's small intestine is currently unknown, it is very possible that it is filled with blood or blood clots. Thus, hemorrhagic bowel syndrome is the primary differential diagnosis. An image of a distended jejunum filled with blood can be seen below:

Differential 2: Traumatic Reticuloperitonitis

Traumatic reticuloperitonitis occurs when cattle unknowingly ingest metal, which then travels into the reticulum and could potentially penetrate the rumenoreticular wall to migrate through the abdomen or thorax, resulting in symptoms and signs indicative of pericarditis or peritonitis. When metal is ingested, it tends to migrate to the reticulum and get trapped within its reticular laminae, causing penetration of the wall of the reticulum. This could lead to an abscess within the reticulum, and if further migration of the metal occurs, it could result in abscess of other organs such as the liver or spleen, or even penetration throught the diaphragm and into the peritoneal cavity, pleural cavity, or pericardial sac, which will result in traumatic pericarditis. Perforation could result in acute peritonitis, chronic local peritonitis, or sudden death. The signs and symptoms of acute peritonitis include sudden anorexia, subacute abdominal pain, fever, a milk drop of greater than 50% in 24 hours, reduced or absent rumination, firmer feces, grunting, moderate abdominal fill, and difficulty in lying down and getting back up. If this condition has been allowed to progress, then chronic local peritonitis could occur, which could be recognized by a variety of signals including a tensed abdomen, a smaller and less motile rumen, decreased milk yield, a loss of body condition, reduced amount of feces, and a mildly elevated heart rate (3). Natalie has a history of a dramatic drop in milk production, going off feed the night before, not passing feces, a lack of rumen contraction, absence of a withers pinch test reaction (indicating abdominal pain), and a distended small intestine (which could be demonstrated as mild abdominal fill). CBC results demonstrated an elevated platelete estimate, white blood cell count, bands (immature neutrophils), and lymphs (lymphocytes), all of which can be caused by infection or inflammation as a result of perforation from an ingested metallic object. Natalie’s biochemistries also exhibit extremely elevated CPK (CK), serum values, which is indicative of muscle damage such as myocardial infarction, skeletal muscle disease, or cerebrovascular incidents. Penetration of a metal object into the reticulum, liver, spleen, peritoneal cavity, pleural cavity, or pericardial sac would cause severe muscle damage and could result in the elevated CPK serum value discovered upon diagnostic testing. Her biochemistry results also displayed elevated GLDH, serum values, which indicates leakage from damaged or necrotic hepatocytes, which could be a result of perforation by the ingested metal into the liver. Based on Natalie’s history, traumatic reticuloperitonitis, which has resulted in acute peritonitis, is the secondary differential diagnosis for this case. An image of the cow's reticulum in relation to the thorax as well as an image of a metal object penetrating the wall of the reticulum can be seen below:

Differential 3: Rumen impaction due to an indigestible foreign body

Rumen impaction is a condition that results in a build-up of indigestible materials in the rumen, which affects the flow of ingesta, and can result in little to no feces being passed (6). In one study performed, cattle with rumen compaction due to indigestible foreign bodies, such as metal objects, fibres, hairballs, and polythene bags were examined. Clinical signs observed in these cattle with rumen impaction included absence of rumination, reduced rumen motility, and pale mucous membranes. It was also concluded that this clinical problem will often result in reduced milk yield, anorexia, distension of the abdomen, loss of defecation and can have effects on the protein, albumin, calcium, glucose, phosphorus, and BUN of the animal (6). With Natalie lacking rumen contractions, going off of feed, having a decrease in milk production, and not passing feces, rumen impaction is a plausible differential. Natalie’s biochemistries also exhibited lower than normal calcium and potassium values, which could be due to the rumen’s inability to function properly and pass ingesta to the remainder of the gastrointestinal tract, including the small intestine for further digestion and absorbtion of nutrients. Natalie’s biochemistries also indicate a high cholesterol total, serum value, which is often indicative of a metabolic disorder. In Natalie's case, a metabolic disorder could be a result of a rumen impaction affecting the ability of the gastrointestinal system to fully digest and absorb nutrients from ingesta. CBC results indicated an elevated platelet count, white blood cell count, bands (immature neutrophils), and lymphs (lymphocytes), all of which can be caused by infection or inflammation from the presence of an indigestible foreign body. Ultrasound findings also showed an empty and static abomasum as well as a static small intestine. With rumen impaction, ingesta is unable to pass through the rumen, which would result in subsequent areas of the gastrointestinal tract being empty and/or static. After examining various elements of Natalie’s history, I believe that rumen impaction is very likely, and is thus the third differential diagnosis for this case. 

3. Evaluation of Evidence from Case Observations

This case provided a variety of clinical observations. Natalie’s history included her going off feed the night before, having a dramatic drop in milk production, and not passing feces. The average daily milk production of a Jersey cow should be about 35 pounds (7). A decrease in milk production could be a result of many different complications such as mastitis, low nutrient intake (such as deficiencies in energy, protein, calcium or phosphorus intake), a displaced abomasum, lack of water, or a more serious condition, such as foot or leg problems, lung damage, or intestinal damage from enteritis or parasitism (8). In Natalie’s case, the dramatic drop in milk production is most likely due to her lack of feed intake and a more serious, overarching gastrointestinal problem, whether it be traumatic reticuloperitonitis, rumen impaction, or hemorrhagic bowel syndrome. These differentials also cause abdominal pain, which can result in a lack of feed intake and inability to pass feces. Also, with rumen impaction, ingesta is unable to pass out of the rumen and an accumulation of ingested materials will result. A build-up of ingesta in the stomach could also cause a disinterest in food, and an inability of food to pass out of the rumen would result in a lack of feces production.

      Upon physical exam, Natalie’s temperature was found to be 97.6, which is slightly lower than normal (normal range is 100.5-102.5). If hemorrhagic bowel syndrome is allowed to progress, cold extremities and hypothermia can result (5). Upon physical examination, Natalie also lacked rumen contractions, meaning that she was suffering from a decrease or absence of rumen motility, a common symptom of traumatic reticuloperitonitis, rumen impaction, and hemorrhagic bowel syndrome.  A withers pinch test was also performed and resulted in no reaction, which is indicative of abdominal pain, a characteristic sign of gastrointestinal complications and further supporting suspect rumen impaction, traumatic reticuloperitonitis, and hemorrhagic bowel syndrome.

      Upon performing a Complete Blood Count (CBC) it was found that Natalie’s red blood cell count, hemoglobin, hematocrit, platelet estimate, white blood cell count, bands, and lymph were elevated, while her mean cell volume was low. Her red blood cell morphology also exhibited anisocytosis. High red blood cell count can be caused by low oxygen levels, heart failure, or dehydration. If Natalie is having decreased food intake or is suffering from rumen impaction, it is possible that Natalie is dehydrated, and if the liquid component (plasma) of blood is decreased as a result of dehydration, the red blood cells will become more concentrated and their count will be increased (9). Similarly, if Natalie is suffering from hemorrhagic bowel syndrome, the loss of blood that she is experiencing could be causing dehydration, and as a result, an increase in red blood cell count. A higher red blood cell count could result in, and explain, a higher hemoglobin level (10) and a high hematocrit level (11). The anisocytosis found demonstrates the presence of abnormal variations in erythrocyte size (12), and is often associated with anemia. However, some degree of anisocytosis is normal in cattle (13). The elevated platelet estimate could potentially be due to a variety of issues such as acute blood loss and bleeding, infections, inflammation, pancreatitis, or trauma (14). In the case of Natalie, if the elevated platelet count were caused by acute blood loss and bleeding, this could be supportive of hemorrhagic bowel syndrome. If infection or inflammation caused the elevation in platelet count, this could be indicative of perforation from an ingested metallic object with traumatic reticuloperitonitis. An increase in white blood cell count, bands (immature neutrophils), and lymphs (lymphocytes) could be indicative of an infection caused by an indigestible foreign body (rumen impaction) or perforation from traumatic reticuloperitonitis.

      Upon evaluating biochemistry values, it was found that calcium and potassium serum levels were low and that CPK (CK), glucose, and GLDH levels were elevated. The low calcium and potassium levels could be due to a decrease in nutrient absorption in the small intestine as a result of distension or rumen impaction inhibiting proper digestion and passing of ingesta (6). Elevated CPK (CK) serum levels (creatine kinase) is indicative of muscle damage. High levels of CPK can be present with myocardial infarction, skeletal muscle disease, or liver disease (16). As an indicator of muscle damage, it can be inferred that muscle damage has occurred as a result of perforation from a metallic object and traumatic reticuloperitonitis, or from an indigestible object causing rumen impaction. Similarly,  GLDH (glutamine dehydrogenase) is a mitochondrial enzyme used to measure leakage from damaged or necrotic hepatocytes. Thus, elevated GLDH levels could be indicative of liver damage (17) as a result of perforation from traumatic reticuloperitonitis. Elevated glucose levels are also known to cause decreased rumen contractions by affecting the microbiota population (18), which could explain the lack of rumen contractions that were heard upon physical examination.

            Ultrasound results showed that several loops of small intestine were distended with fluid and appeared static and that the abomasum was empty and also static. A fluid-distended small intestine is a symptom of both rumen impaction and hemorrhagic bowel syndrome. With hemorrhagic bowel syndrome, the fluid is most likely blood, a blood clot, or fibrin (5). The static small intestine and abomasum are also indicative of rumen impaction, in which ingesta cannot pass from the rumen to the remainder of the gastrointestinal tract, thus causing them both to be static (6).

4. Understanding

a. A withers pinch test is used to detect abdominal pain. In cattle, there are many gastrointestinal complications that can cause abdominal pain which include traumatic reticuloperitonitis, rumen impaction, hemorrhagic bowel syndrome, abomasal ulcers, or distention of the small intestine with gas. In a healthy cow, when the withers pinch test is executed, there will be ventral flexion of the back. However, in a cow with abdominal pain, there will be a lack of ventral flexion. As false positives are common, if results are unclear, a grunt test could be performed. With this test, pressure is applied to the xiphoid region of the sternum by using fists pushed up with your knee, or with a board lifted up by one person on both sides of the cow. If the cow exhibits discomfort, kicks, or grunts, the abdominal region is most likely painful (1) and further testing can be done to detect a gastrointestinal complication. 

b. Rumen sounds are heard as a result of rumen contraction/motility, and it has been found that chemistry within the rumen can have an effect on its motility. The ingestion of a large amount of carbohydrates (most likely in the form of grains such as wheat, corn, or barley) can have an effect on the microbial population of the rumen. Specifically, it increases the number of gram-positive bacteria, resulting in an increase in lactic acid, lowering the pH of the rumen, and destroying cellulolytic organisms, protozoa, and other organisms that use lactate. This results in decreased rumen motility (18). Thus, hyperglycemia can have an effect on rumen contraction and rumen sounds. 

c. The CBC or complete blood count was performed to measure the number of white blood cells, neutrophils, lymphocytes, monocytes, eosinophils, basophils, and hematocrit. Complete blood counts are performed when a patient exhibits signs of infection, weight loss, cancer, fatigue, or bleeding. With Natalie’s original presenting complaint being a dramatic drop in milk production, going off feed, and not passing feces, I would expect some abnormalities to be exhibited, especially if there is acute bleeding/hemorrhaging with hemorrhagic bowel syndrome. Similarly, abnormalities would be present if an infection had occurred as a result of perforation from a metal object in traumatic reticuloperitonitis or from the presence of an indigestible foreign object causing rumen impaction. 

d. Another diagnostic test that could be valuable in this case would be a Total Protein Test. This test measures the level of proteins in the blood and can be used to detect a variety of diseases or complications. For example, hypoproteinemia and hypoalbuminaemia could be a result of dietary malnutrition and a stress reaction to infection that could be seen as a result of rumen impaction in cattle with an indigestible foreign body (6). Similarly, hypoalbuminaemia could be seen in an animal with severe blood loss, such as a cow with hemorrhagic bowel syndrome (5). Thus, results from this test could help narrow down differential diagnoses, and could point the clinician in the proper direction for further diagnostic testing. 

e. If traumatic reticuloperitonitis goes untreated, it could progress into a constant disappointing milk yield, a loss of body condition, a smaller rumen, and reduced rumen motility. In some cases, if allowed to go untreated, the metal object could perforate the pericardial sac and puncture a coronary vessel or the heart, causing hemorrhage into the pericardial sac and compression of the heart. It could also cause infection by allowing microbiota in the rumen to enter the pericardial sac, and eventual cardiac failure. Thus, if untreated, this disease could result in death (3). If rumen impaction if left untreated, it could result in metabolic disorders, nutrient deficiencies, or intestinal rupture in the area proximal to the impaction or obstruction from the indigestible material (4). If hemorrhagic bowel syndrome is allowed to progress, it can result in gross lesions, edema, ulcers, and necrosis of the affected gut area. If this disease continues to go untreated, it can result in death (5). 

f. To manage Natalie’s problems, I would advise radiographs being taken to visualize if there is an indigestible object in the reticulum or rumen of the animal. If found, I would advise surgery to remove the metal object that could be causing the traumatic reticuloperitonitis or to remove the indigestible item that could be causing the rumen impaction. If Natalie is suffering from hemorrhagic bowel syndrome, I would also advise surgery (without surgery mortality rate is about 77-100%). One surgical option would involve opening up the small intestine to remove blood clots present, manually massaging the intestine to break up blood clots, or resectioning the damaged or abnormal area of intestine (5). According to a study done, there is a 60% survival rate in cattle who undergo surgery, and prognosis is best for those cattle with early detection and surgery with manual massage to remove the blood clots causing the small intestinal distension. However, once surgery is performed, recurrence is always a possibility. Fluid therapy with electrolytes (given orally, intravenously, or both) must also be issued (alone or along with surgery) to regain gastrointestinal motility and anti-inflammatory drugs should be given to minimize inflammation and help with pain (5). 

g. One basic science principles is the idea of reticuloruminal motility. Reticuloruminal motility can be divided into three phases: Primary contractions (mixing cycle), secondary contractions (eructation cycle) and rumination (cud chewing). Primary contractions are for the maceration of fibrous material and for the mixing of ingesta to mix the feed with saliva and allow for microbial digestion. Primary contractions begin with biphasic reticular contractions and the contractions continue in a clockwise direction. The phases of primary contractions can be seen below:

These primary rumen contractions are heard and felt in the left paralumbar fossa. 2-5 rumen contractions should be heard every 2 minutes, and the intensity of these contractions will depend on the contents in the rumen. The rate of primary contractions increases with the sight of food, chewing, and mild distension. The rate of primary contractions decreases with reduced intake, fever, endotoxemia, pain, moderate to severe distension, depression, hypocalcemia, abomasal distension, and the use of tranquilizers or anesthetics. Secondary rumen contractions are stimulated by gaseous distension, and results in belching or the eructation of gas. The normal rate of secondary contractions is 1 every 2 minutes and 30-50 L of methane and carbon dioxide should be produced per hour. These secondary contractions can be inhibited by systemic illness, severe rumen distension, or foam/fluid near the cardia. If eructation can not occur, bloat will result. The final part of reticuloruminal activity is rumination or cud chewing. This allows for the remastication and addition of saliva to ingesta. Rumination is stimulated by coarse ingesta in the cranial rumenoreticulum and each episode should last about 10-60 minutes. Cattle will spend up to ten hours a day ruminating, and the rate of rumination increases while the cow is resting. The rumination process involves a reticular contraction that precedes the primary contraction, relaxation of the lower esophageal sphincter, inspiration to close the glottis, aspiration of the bolus into the esophagus, and reverse peristalsis. The process of rumination or cud chewing can be inhibited by excitement, a high grain diet, or low primary contraction rate (19). 

A second basic science principle in this case is the principle of hemorrhaging. Hemorrhaging is a term used to describe blood loss. It can refer to blood loss outside of the body (external bleeding) or blood loss inside of the body (internal bleeding). The signs and symptoms of hemorrhaging differ depending on where the loss of blood is occuring. In Natalie's case, the blood loss is occuring in her abdomen, specifically in the gastrointestinal tract at the level of the jejunum. This internal bleeding can result in a drop in blood pressure, weakness, and a shortness of breath. Blood found outside of the circulatory system can cause irritation to tissues, and as a result, inflammation and pain can occur (20). In Natalie's case, the hemorrhaging that is draining into her small intestine is causing distension and abdominal pain, which is demonstrated by her inability to respond to a withers pinch test and her decrease in feed intake. Inflammation from the hemorrhaging occuring in her small intestine is also indicated by her CBC and biochemistry values. 

5. Conclusions/Self Reflection

Now that I have completed one scholar assignment, I felt that this project was slightly easier becuase I knew how to utilize scholar more efficiently and I knew how I wanted to format my paper. However, I believe I still had trouble with choosing the three most important clinical problems and the differential diagnoses. I am a very indecisive person, so choosing narrowing down problems and choosing the most important and likely differential was rather difficult for me. This case also presented with a variety of clinical issues that can lead you in a variety of directions for further diagnostic testing. I found that there are a variety of different approaches you can take to this case. However, this is a common occurrence in the world of veterinary medicine. Every clinician will have a different opinion and a different set of clinically significant problems and differential diagnoses. Thus, this paper is good practice for when I am a practicing clininician and will need to evaluate the facts and findings presented to me, make decisions, and explore with further diagnostic testing. I also think this paper is good practice for writing papers that I will be writing later on in my career as a clinician. 

6. References

1. https://research.vet.upenn.edu/Dairy/PhysicalExam/PinchGruntTests/tabid/4080/Default.aspx

2. "Rumen Physiology and Rumination." Rumen Physiology and Rumination. N.p., n.d. Web. 15 Feb. 2017. <http://www.vivo.colostate.edu/hbooks/pathphys/digestion/herbivores/rumination.html>.

3. Orpin, P., and D. Harwood. "Clinical management of traumatic reticuloperitonitis in cattle." In Practice 30.10 (2008): 544-51. Web. 15 Feb. 2017.

4. Constable, Peter D. "Overview of Acute Intestinal Obstructions in Large Animals - Digestive System." Veterinary Manual. Merck Manual, n.d. Web. 16 Feb. 2017. <https://www.merckvetmanual.com/digestive-system/acute-intestinal-obstructions-in-large-animals/overview-of-acute-intestinal-obstructions-in-large-animals>.

5. McGuirk, Sheila M. "Hemorrhagic Bowel Syndrome: Update and Observations." Vetmed.wisc.edu. University of WI-Madison School of Veterinary Medicine, 2014. Web. 16 Feb. 2017. < https://www.vetmed.wisc.edu/dms/fapm/fapmtools/7health/jejunal.pdf>.

6. Vanitha, V., A. P. Nambi, B. Gowri, and S. Kavitha. "Rumen Impaction in Cattle With Indigestible Foreign Bodies in Chennai." Tamilnadu J. Veterinary and Animal Sciences. Department of Veterinary Clinical Medicine, Ethics and Jurisprudence, Madras Veterinary College, June 2010. Web. 15 Feb. 2017. <http://www.tanuvas.tn.nic.in/tnjvas/tnjvas/vol6(3)/138-140.pdf>.

7. "Milk Production." Milk Production Table. N.p., n.d. Web. 15 Feb. 2017. <http://www.tc.umn.edu/~puk/cow/milk.html>.

8. "Troubleshooting Problems with Low Milk Production (Dairy Cattle Nutrition)." Dairy Cattle Nutrition (Penn State Extension). N.p., n.d. Web. 18 Feb. 2017. <http://extension.psu.edu/animals/dairy/nutrition/nutrition-and-feeding/troubleshooting-guides/troubleshooting-problems-with-low-milk-production>.

9. "High red blood cell count Causes." Mayo Clinic. N.p., n.d. Web. 18 Feb. 2017. <http://www.mayoclinic.org/symptoms/high-red-blood-cell-count/basics/causes/sym-20050858>.

10. "High hemoglobin count Causes." Mayo Clinic. N.p., n.d. Web. 18 Feb. 2017. <http://www.mayoclinic.org/symptoms/high-hemoglobin-count/basics/causes/sym-20050862>.

11. William C. Shiel Jr., MD, FACP, FACR. "What does a high hematocrit mean? - Hematocrit: Learn About Different Test Levels." MedicineNet. N.p., n.d. Web. 18 Feb. 2017. <http://www.medicinenet.com/hematocrit/page4.htm>.

12. "Anisocytosis." The Free Dictionary. Farlex, n.d. Web. 18 Feb. 2017. <http://medical-dictionary.thefreedictionary.com/anisocytosis>.

13. "Normal erythrocytes." EClinpath. N.p., n.d. Web. 18 Feb. 2017. <http://www.eclinpath.com/hematology/morphologic-features/red-blood-cells/normal-erythrocytes/>.

14. "Thrombocytosis Causes." Mayo Clinic. N.p., n.d. Web. 18 Feb. 2017. <http://www.mayoclinic.org/diseases-conditions/thrombocytosis/basics/causes/CON-20032674>.

15. "GGT." EClinpath. N.p., n.d. Web. 18 Feb. 2017. <http://www.eclinpath.com/chemistry/liver/cholestasis/gamma-glutamyl-transferase/>.

16. "Test ID: CK    Creatine Kinase (CK), Serum." CK - Clinical: Creatine Kinase (CK), Serum. N.p., n.d. Web. 19 Feb. 2017. <http://www.mayomedicallaboratories.com/test-catalog/Clinical%20and%20Interpretive/8336>.

17. "GLDH." EClinpath. N.p., n.d. Web. 19 Feb. 2017. <http://www.eclinpath.com/chemistry/liver/liver-injury/glutamate-dehydrogenase/>.

18. "Grain Overload in Ruminants - Digestive System." Veterinary Manual. N.p., n.d. Web. 19 Feb. 2017. <http://www.merckvetmanual.com/digestive-system/diseases-of-the-ruminant-forestomach/grain-overload-in-ruminants>.

19. Morin, Dawn E., DVM, MS. Lecture on Physiology of the Ruminant Alimentary Tract. 

20. FAAEM, Benjamin Wedro MD FACEP. "Internal Bleeding Symptoms, Treatment, Causes - What are the signs and symptoms of internal bleeding?" MedicineNet. N.p., n.d. Web. 08 Mar. 2017. <http://www.medicinenet.com/internal_bleeding/page3.htm>.

Images (in order of appearance):

1. https://research.vet.upenn.edu/Dairy/PhysicalExam/PinchGruntTests/tabid/4080/Default.aspx

2. Bovineveterinariannewssource. "Jejunal hematoma in cattle." Bovine Vet Online. N.p., 03 Jan. 2012. Web. 08 Mar. 2017. <http://www.bovinevetonline.com/bv-magazine/Jejunal-hematoma-in-cattle--136593768.html>.

3. "Traumatic Reticuloperitonitis - Digestive System." Veterinary Manual. N.p., n.d. Web. 08 Mar. 2017. <http://www.merckvetmanual.com/digestive-system/diseases-of-the-ruminant-forestomach/traumatic-reticuloperitonitis>.

4. https://classconnection.s3.amazonaws.com/922/flashcards/752922/png/311318895393499.png

5. Morin, Dawn E., DVM, MS. Lecture on Physiology of the Ruminant Alimentary Tract.