C10029023 / invoice 10000

Appointment Notes: lethargic not eating SubjectivePresenting Concerns:  Rocky McGirr presented for a 4-5 day history of lethargy, hyporexia, and hind limb weakness.    Diet/Appetite:-   Decreased appetite; has eaten some boiled chicken but is refusing his normal food.  Drinking/Urination:-   Increased thirst noted over the past day.  V/D/C/S:-   One episode of diarrhea was reported last week.-   One episode of vomiting occurred on Wednesday night.  Current Medications:-   Prescribed long-term Galliprant, but has only received one dose in the past week.  Additional Information:-   The owner reports a significant decrease in energy levels, increased panting, and a reluctance to sit down. The patient's back legs collapsed slightly after jumping from a car.ObjectiveMentation: Quiet and flat.  Wt: —  BCS: --/9  T: Not taken  P: 140 bpm  R: —  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: —    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: Tachycardia with a HR of 140 bpm and weak peripheral pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: Non-painful on palpation. Kidneys are palpable, which is suspected to be secondary to weight loss rather than a mass.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: Facial muscle wasting is present. Neurologic: Quiet mentation.  Musculoskeletal: Significant muscle wasting noted. Owner reports hind limb weakness.  Urogenital: Normal external anatomy.  Rectal: Not performed.AssessmentLethargy, tachycardia, and poor perfusion – DDx: Renal disease, hepatic disease, cardiac disease, other systemic illness. The clinical signs are concerning for significant underlying disease and potential hypovolemia or hypotension.PlanPending Diagnostics:-   In-house bloodwork was collected. Results are pending.  Medications/Treatments:-   Recommended referral to a 24-hour emergency and specialist center for hospitalization and further evaluation.-   Discussed that the patient will likely require IV fluid therapy and an abdominal ultrasound.  Additional Discussion:-   The owner was advised that referral is the most appropriate course of action, particularly given the upcoming weekend.-   A plan was made to call the owner with blood results in approximately 20 minutes to finalize the referral.-   The owner has pet insurance and was advised they can request a gap-only claim.    Vital Signs    Weight: 49.6;