C09971694 / invoice 10000
Species:CANINE
Breed:Labrador
Age (years):8
Diagnosis or signs:Consult NB
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div><strong>History:</strong></div> <div>Ā </div> <div> <p>Client History:<br>Saturday - blood in stools. Dripped a bit of blood after defecating as well.<br>Yesterday a little more yesterday.<br>Little bit NQR today.<br>Seems better in himself today.<br>Feeding bones every day - small brisket bone. Belly ache few days after this.Ā <br>Stretching leg out, after 6 hours will settle.<br>3 x times daily. Hasn't defecated today.<br>Still eating, but not as enthusiastic.<br>No vomiting.<br>Hasn't attempted to defecate today.Ā <br>Last bone - on Friday (2x on friday). Has bones daily - has done forever.<br>L eye - bit weepy, bit puffy yesterday.<br>Last normal - Saturday.Ā Yesterday a bit of squinting, and a bit red. Not unsual for him. Usually wiped bicarb soda and it settles.<br><br>Diet: Meat balls - 4leggs.Ā Small amount of kibble - usually from kibbke. Kibble thats grain free. RC canin kibble since Saturday. Just yesterrday. Chicken, veg as well.<br><br>HW/ flea + tick preventative: UTD - negxard spectra<br>Current Medications/ supplements: Nil.<br><br><strong>Objective:<br></strong>Weight: - kg<br>Temperature: Not taken<br>HR: WNL<br>RR: WNL<br>BCS: 5 out of 9<br>FAS: Green<br>Hydration: Hydration appears normal<br>Eyes: no clouding, no debris, sclera is clear<br>Ears: No debris or erythema<br>Oral Cavity: healthy teeth and gums<br>Cardiovascular: no murmur or arrhythmia, strong pulses.<br>Respiratory: Lungs sounds are clear, no crackles or wheezes<br>Abdomen: comfortable on palpation, no mass effect, no fluid wave<br>Musculoskeletal: Normal ambulation, Normal ROM<br>Integument: skin looks normal; hair coat in good condition. No ectoparasites. No masses found.<br>Lymph nodes: Lymph nodes are soft and small<br>Urogenital: External genitalia appears normal; bladder palpates normally<br>Neurologic: Normal mentation<br><br><strong>Subjective: <br>Pet's signalment: Humphrey, Age not stated, Labrador Retriever, Sex not stated, Neuter status not stated<br>History: <br>- Presenting complaint is bloody stool, which started on Saturday (02/27/2026).<br>- Yesterday (02/28/2026), the patient had watery stool that also contained blood.<br>- The patient was lethargic yesterday but appears brighter today.<br>- On Saturday, after a meal, blood was noted dripping from the rectum.<br>- The owner reports the patient has a "sore belly" and tenses when the abdomen is touched; this seems to resolve after several hours.<br>- The patient has NOT DEFECATED today, which is abnormal as he typically has three bowel movements per day.<br>- No vomiting has been observed.<br>- APPETITE IS PRESENT BUT ENTHUSIASM IS DECREASED.<br>- No straining to defecate has been noted.<br>- A WEEPY LEFT EYE was noted yesterday, with some mild squinting. The owner reports a history of occasional eye infections.<br>- History of mild ear infections. The owner cleans the ears monthly. The patient is not currently showing signs of irritation (e.g., head shaking).<br>- The patient occasionally has itchy paws.<br>Diet: <br>- "Four Legs" brand meatballs.<br>- A small amount of kibble; recently switched from an Aldi brand to Acana grain-free kibble on Saturday. The new kibble was discontinued yesterday.<br>- Was receiving a biscuit bone daily; the last one was given on Saturday.<br>- Frozen treats made of chicken and vegetables.<br>HW/ flea + tick preventative: NexGard<br>Current Medications / supplements: None<br>Any vaccine or medication reactions: None reported<br>Recent blood test: None<br><br>Objective: <br>Weight: - kg<br>Temperature: Not stated<br>HR: WNL<br>RR: WNL<br>BCS: 5 out of 9<br>FAS: Green<br>Hydration: Hydration appears normal<br>Eyes: Cornea is clear, pupils are symmetrical. MILD ECTROPION (lower eyelid droop) noted. No significant inflammation.<br>Nasal: Patent and clear. No lesions or other abnormalities<br>Ears: BILATERALLY DIRTY. THE RIGHT EAR CANAL APPEARS MORE INFLAMED AND CONTAINS MORE DEBRIS THAN THE LEFT.<br>Oral Cavity: MILD DENTAL WEAR AND A SMALL TOOTH CHIP NOTED. Gums appear healthy.<br>Cardiovascular: no murmur or arrhythmia, strong pulses.<br>Respiratory: Lungs sounds are clear, no crackles or wheezes<br>Abdomen: TENSES ON PALPATION OF THE CAUDAL ABDOMEN. No mass effect, no fluid wave.<br>Musculoskeletal: Normal ambulation, Normal ROM<br>Integument: skin looks normal; hair coat in good condition. No ectoparasites. No masses found.<br>Lymph nodes: Lymph nodes are soft and small<br>Urogenital: External genitalia appears normal; bladder palpates normally. Rectal exam performed: STOOL IS PRESENT IN THE RECTUM AND IS NOT HARD.<br>Neurologic: Normal mentation<br><br>Assessment: <br>Problem List:<br>1. HEMATOCHEZIA<br>2. CONSTIPATION/DYSCHEZIA<br>3. ABDOMINAL DISCOMFORT<br>4. DECREASED APPETITE<br>5. MILD BILATERAL CERUMINOUS OTITIS EXTERNA<br>6. MILD LEFT EPIPHORA<br><br>Differentials:<br>- Gastrointestinal signs are most likely secondary to dietary indiscretion (ingestion of bones and recent diet change), leading to colitis and constipation.<br>- Foreign body obstruction is a less likely differential.<br>- Pancreatitis is a less likely differential.<br>- Otitis is likely secondary to underlying allergies or conformation.<br><br>Plan: <br>Treatments: <br>- Owner elected for conservative management at home.<br>- Advised to feed a wet/canned food diet to help soften stool.<br>- Advised to DISCONTINUE DAILY BONE FEEDING. Recommended reducing frequency to once weekly or less once GI signs have resolved.<br>- Demonstrated proper ear cleaning technique.<br>Diagnostics Completed: <br>- Physical Examination<br>- Rectal Examination<br>- Bilateral ear cytology (RESULTS: NO INFECTIOUS ORGANISMS SEEN).<br>Diagnostics Declined:<br>- Abdominal radiographs<br>- Bloodwork (including cPLI)<br>Prescriptions: <br>- Dispensed Otoflush ear cleaner.<br>Follow up:<br>- Phone call check-in requested for tomorrow to assess progress.<br>- Recheck immediately if the patient begins straining unproductively, if bleeding worsens, if discomfort increases, or if vomiting occurs.<br><br><br><br></strong></p> </div></html>
Animal clinical history (3 most recent)
2018-04-16T00:00:00Z 14:36:52
Client concerns: Lame LF 3-4 days ago and although inpr a little still quite lame, more so after he gets up History: Private purchase from Breeder that had a pet shop, aparently the mothr in law owns the dog Vacc Status: UTD Parasite Control: SR12 inj, Advantix, Drontal Clinical Exam:Lame LF holding the leg out 2/10 lame still boucing around and otherwise happy Repeatable crep in the L elbow. on extension every time not the same on the RF Concerned Elbow dysplasia, expl to O that may not have a clear lesion at this age as growth plates still open, but Xray now and then if nec will give comparisons to rpt in future Problem List/DDx: Admit for Xrays Options/Plan:Medical care: NSAIDs to keep comfortable until Xrays available,
2018-02-26T00:00:00Z 14:43:10
Fully healed
2018-02-19T00:00:00Z 14:50:55
looks great
Previous claim history (14)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-02-05 | C09884580 | ELBOW DYSPLASIA (CANINE) |
| 2025-11-03 | C09689245 | ELBOW DYSPLASIA (CANINE) |
| 2019-01-09 | C2219615 | ELBOW DYSPLASIA |
| 2018-10-02 | C1868568 | DISCHARGE - PENILE - PRESENTING COMPLAINT |
| 2018-09-11 | C1868548 | MISCELLANEOUS CONDITIONS |
| 2018-08-21 | C1868557 | MISCELLANEOUS CONDITIONS |
| 2018-07-24 | C1868542 | MISCELLANEOUS CONDITIONS |
| 2018-06-19 | C1740495 | ELBOW DYSPLASIA |
| 2018-06-05 | C1740495 | LAMENESS LF |
| 2018-05-29 | C1740499 | MISCELLANEOUS CONDITIONS |
| 2018-05-08 | C1740438 | MISCELLANEOUS CONDITIONS |
| 2018-05-01 | C1671778 | ELBOW DYSPLASIA |
| 2018-04-04 | C1664403 | DIARROHEA |
| 2018-04-04 | C1664403 | PRESENTED FOR INVESTIGATION OF ABNORMAL TEST RESULT - PRESENTING COMPLAINT |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation-revisit | 109.00 | 2026-03-02 | ā |
| 20000 | tstarc_ear_cleaner | 85.93 | 2026-03-02 | ā |
| 30000 | tstarc_diagnostic_test_-_cytology | 62.50 | 2026-03-02 | ā |
UPM+
- DG01185OTITIS EXTERNADSTP_otitis_externa
Variant (sleepy_king)
OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.600
Threshold: 0.07
Above: ā
Correct?