C10020466 / invoice 10000

Here for recheck 
Has been up and down, cant settle
stomach was making odd noises 
no breaky this am but taking treats
wanting attention which does when unwell
drinking water
urinating and defecation normal
Current meds meloxicam - ran out yesterday 


a: 
HR  112  no murmur, no arrythmia
RR  panting = gets anxious in clinic o says this happens and will have a bit of a temp associated
eyes ok
ears good
oral exam tarat gd 2-3 - not current problem
dental grade 3/4
lymph nodes normal
skin/integ normal
abdo palpation NSF
BC 5/9
Temp 39.4
reactive with palpation over T/L spine
CP normal all limbs no known dragging or ataxia

a:  suspect back pain

p: 1 week trial gabapentin (has at home but hasn't given)
rv ini  consider imaging 

Reason for visit/main concern: REcheck for ongoing NQR 
Hyporexia, not drinking, pawing/needy at O, no CSVD+, 
No notable pattern other then reduced abilty to jump, change to pitch of bark
Current medication/supplements: meloxicam SID - O happy has been getting in 
Current preventatives: UTD 
Current diet: dry and wet

OBJECTIVE
BAR - anxious
mm pink and moist, CRT <2sec
Lymph nodes: normal submandibular, prescapular and popliteal
Cardiac auscultation: NAD, no murmur, no arrhythmia, strong synchronous pulse HR: 120
Pulmonary auscultation: NAD, normal BV sounds, no resp effort RR: panting +
Eyes: NAD
Nose: NAD
Ears: NAD
Mouth: NAD
Dental Grade:2-3 /4 
Abdominal palpation: NAD, soft, tolerating deep palpation
Skin: NAD
Neuro: NE, normal mentation
Myo-arthro-skeletal: no lameness, good ROM and muscle mass
Uro-genital: NE
Temperature: 38.6
BCS: 5/9 

ANALYSIS
Hyporexia, NQR

PLAN
Gabapentin PO BID
Ondasetron PO BID
Dental care plan: 
Next point of contact (recall/rv/reminder): recheck Tuesday 
INI RV/after hours emergency centre