C09972307 / invoice 10000

Species:CANINE
Breed:Italian Lagotto Romagnolo
Age (years):1
Diagnosis or signs:lump
Consult notes

Animal clinical history (3 most recent)

2026-03-01T00:00:00Z 9:50 AM
Appointment Notes: Sore bump. JTJLE: HISTORY:  Presentation for Area of erythema and dermatitis on scrotal sac. Dog went to groomers 3 days ago and has since been licking at scrotal area.EDFU normal.Is an anxious dog - owner has been recommenced training prior to this - not done as yet.Current meds: noneVaccination: UTDParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Area of erythema and dermatitis on scrotal sac.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: anxious with other dogs PROBLEM LIST:Area of erythema and dermatitis on scrotal sac. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspect self trauma after mild insult.  ASSESSMENT:  Area of erythema and dermatitis on scrotal sac.Suspect self trauma after mild insult.TREATMENT:  Discharged home on-cephalexin 300mg (-15mg/kg) q12h for 7 days-carprofen 50mgg q24hr for 4 days.-neocort to affected area q12hr as needed.-buster collar (o has one at home) PLAN:Home into owner's care.Discussed that can obtain sedatives (thinking trazadone/gabapentin) for grooming    Vital Signs    MMColour: pink;       Weight: 20.5;       HeartRate: 120;       BodyScore: 5/9;       DentalGrade: 1;       RespirationRate: panting;       PainScore: 0;       
2026-02-11T00:00:00Z 9:11 AM
Reason: VaccinationAppointment Notes: srHISTORY:  Benny presented for an annual health check and vaccination. He is a 2-year-old desexed male weighing 21.5 kg. The owner reports he has not received parasite prevention for a while. There are no other health concerns. Current meds: noneVaccination: Vanguard injectable C5 administered. Distemper, hepatitis, and parvovirus components are due in 3 years. Kennel cough (parainfluenza and Bordetella) component is due in 12 months.Parasite Prevention: Not up to date. Recommenced monthly NexGard Spectrum.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 7/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: Murmur detected.Respiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):not graded- Abdominal: relaxed, no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Pink ears, NSF.Lymph Nodes: NSFEyes: Normal, no signs of blindness.Demeanour/Behaviour: Alert, responsive, friendly, but very energetic and bouncy, making examination difficult. PROBLEM LIST:- Overweight (BCS 7/9)- Heart murmur- Parasite prevention lapsed- Due for annual vaccination DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Not discussed. DIAGNOSTICS:None ASSESSMENT: Benny is a healthy, 2-year-old desexed male dog presenting for routine preventative care. Examination revealed a heart murmur and a body condition score of 7/9. He is active and bright. Vaccinations and parasite prevention have been updated. TREATMENT:  - Vanguard C5 injectable vaccine administered.- Dispensed NexGard Spectrum for monthly parasite control. PLAN:- Commence NexGard Spectrum monthly.- Recommend reducing diet by 20% for slight weight loss.- Re-evaluation in 12 months for kennel cough booster vaccination and health check.- Monitor at home.- Home into owner's care. CLIENT COMMUNICATION:Discussed the importance of consistent parasite prevention with NexGard Spectrum. Advised on a 20% diet reduction to manage weight. Explained the vaccination schedule, with the next booster due in one year. Advised to return if any health concerns arise.--- 12/02/2026 08:08:15 AM ZEI:Vaccinations - Resolved -    Vital Signs    MMColour: Pimk;       Weight: 21.5;       HeartRate: 120;       BodyScore: 7/9;       DentalGrade: 0/4;       RespirationRate: Pant;       PainScore: 0/4;       
2026-02-11T00:00:00Z 8:57 AM
Ignore see next note.    Vital Signs    Weight: 21.5;       

Previous claim history (4)

DateClaim #Diagnosis
2025-10-18C9371702OPHTHALMIC (EYE) ABNORMALITY - PRESENTING COMPLAINT
2025-09-05C9185385DESEXING
2025-09-05C9185385OTITIS EXTERNA
2025-09-05C9185385BEHAVIOUR DISORDER

Line items(lines with upstream diagnosis are skipped by the model)

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation-emergency/afterhours0.012025-12-04
20000tstarc_opioids_-_methadone62.982025-12-04
30000tstarc_meloxicam56.522025-12-04

UPM+

  • DG02023GAIT ABNORMALITY - LAMENESS - PRESENTING COMPLAINTDSTP_clinical_signs_-_lameness

Variant (sleepy_king)

PAIN - OTHER - PRESENTING COMPLAINT
DSTP_clinical_signs_-_pain
Conf: 0.570
Threshold: 0.39
Above:
Correct?
Acceptable?
Reason (acceptable)
Diagnosis description