C09988735 / invoice 10000

SubjectivePresenting Concerns:-   Gorby presented as a recheck for ongoing concerns from yesterday, including holding his head in a low carriage and inappetence.  Diet/Appetite:-   Off food. Ate a small amount of chicken approximately 3 hours ago and some celery.  V/D/C/S:-   No vomiting or diarrhea reported.  ObjectiveMentation: Quiet, alert, and responsive  BCS: --/9  T: 37.6°C  P: 120-132 bpm  R: 28-32 bpm  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: Mild reaction to gentle palpation of the larynx.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: Borborygmi noted on auscultation. No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: No evidence of ectoparasites, full coat with clear skin.  Neurologic: No anisocoria or cranial nerve deficits noted.  Musculoskeletal: Able to ambulate well. Slight resistance to neck ventroflexion, but otherwise full range of motion.  Urogenital: Normal external anatomy.  Rectal: Not performed.    Point of Care Diagnostics:-   Sedation was performed with butorphanol (0.1 mg/kg IV) and a TIVA of propofol.-   Radiographs (Lateral and VD): No evidence of obstruction. The stomach is empty. Some gas is present within the small intestine.-   Abdominal Ultrasound: No significant findings. The stomach wall measured 0.3-0.4 cm.  AssessmentLethargy and discomfort of unknown origin – DDx: Gastritis, esophagitis, soft tissue discomfort, pancreatitis. Clinical signs are non-specific and diagnostic imaging was unrewarding. The head carriage may be related to abdominal discomfort (prayer-like pose).  PlanMedications/Treatments:-   Prevomax injection (1 mg/kg IV) was administered.-   Paracetamol (10 mg/kg PO) was administered and can be repeated in 8 hours.Sent home with paracetamol PO at above doseONdansetron 1/4 4mg tablet PO before food   Additional Discussion:-   An estimate of approximately $1000 for diagnostics was discussed with the owner.-   The owner has HCF pet insurance and will submit a claim.-   The owner will be called with updates this afternoon.--- 05/03/2026 08:38:09 AM HL:Examinations - Resolved - Follow up SMS through RxWorks sent to client.--- 05/03/2026 08:38:12 AM HL:Hospital - Resolved -    Vital Signs    Weight: 2.5;