C09972403 / invoice 10000

Species:CANINE
Breed:American Staffordshire Terrier Cross
Age (years):8
Diagnosis or signs:consult and meds
Consult notes
02/03/2026 Reason : LF lameness
Date of first CSx :  28/02/2026
Hx :  Seb got home from his beach holiday on Saturday. He has been sore on his LF. He played really hard with the other dogs.
Ex :   
Systems:
1. Eyes: NAD
2. Ears: NAD
3. Mouth: MM pink. CRT: 1 sec.
4. Heart: NAD
5. Respiratory/Nasal: NAD
6: Abdomen: NAD
7. Musculoskeletal: LF toe-touching. Painful on shoulder manipulation. No palpable fractures or dislocations.
8. Neuro:NAD
9. Urogenital:NAD
10. Rectal/Anal glands:not examined
11. Skin:NAD
12. BT: normal
13: Behaviour issues:no
14: Lymph nodes:NAD
15: Dental Score:{__}/4
16: Body Condition Score:{__}/5
17. Hydration status : WNL
18. Other findings:{__}

Current Medications and Doses:  {__}

Problem List :  
1.   {__}
2.   {__}
3.   {__}
4.   {__}

Diagnostic Test Results: {__}

Assessment :   soft tissue pain in left shoulder
DDx :   {__}

Prognosis: Good  /  Fair  / Guarded /  Poor
Plan :  on lead exercise and meloxicam treatment trial. INI next step rads under G/A. 

Animal clinical history (3 most recent)

2025-10-04T00:00:00Z 13:29:46
HX: 
Eating grass this morning. Large amounts eaten. One V+. None since 
Often eats grass but not usually this much 
On Single protein diet, regular stools 
No D+
Otherwise well in self
Is one to rip aparat chew toys etc but doesnt usually ingest them 

Ex :   
Systems:
1. Eyes:NAD
2. Ears:NAD
3. Mouth:NAD, MM pink and moist, CRT<2, 
4. Heart:NAD, no murmurs, HR 90, normal pulses
5. Respiratory/Nasal:NAD
6: Abdomen:NAD, soft and comfortable. Borborygmy ++++
7. Musculoskeletal:NAD
8. Neuro:NAD
9. Urogenital:NAD
10. Rectal/Anal glands Firm well formed faeces on rectal 
11. Skin:NAD
12. BT: 38.0
13: Behaviour issues:no
14: Lymph nodes:NAD
15: Dental Score:1/4
16: Body Condition Score:4/5
17. Hydration status : WNL, no prolonged skin tent
18. Other findings:Eating treats really happily in cons 

Current Medications and Doses:  Nil 

Problem List :  
1.   Grass ingestion 
2.   One V+

AX: 
Once off occurrence of V+? ddx GIT FB? Gastro?
Diagnostic Test Results: Nil 

Plan :  
Well hydrated eating and not painful in abdo, treat conservatively for now: probiotics and bland diet 
If any further V+ r/v for abdo imaging to r/o FB but would be very surprised if this is the case!

Previous claim history (17)

DateClaim #Diagnosis
2025-06-13C8837094VACCINATIONS OR HEALTH CHECKS
2025-04-10C8568247VOMITING - OTHER - PRESENTING COMPLAINT
2024-06-26C7396405VACCINATIONS OR HEALTH CHECKS
2024-06-26C7396405FLEA/TICK/WORM CONTROL
2024-06-26C7396405HEARTWORM CONTROL
2024-04-19C7131991COUGHING - PRESENTING COMPLAINT
2023-06-08C5980583FLEA/TICK/WORM CONTROL
2023-06-08C5980583VACCINATIONS OR HEALTH CHECKS
2023-06-08C5980583HEARTWORM CONTROL
2023-04-08C5771492COUNCIL REGISTRATION FEES
2022-05-23C4768772VACCINATIONS OR HEALTH CHECKS
2022-05-23C4768772FLEA/TICK/WORM CONTROL
2021-05-18C3752855VACCINATIONS OR HEALTH CHECKS
2021-02-23C3545711VOMITION
2021-02-23C3545711ARTHRITIS
2020-11-07C3289105LAMENESS RF
2020-10-26C3255288TORN DEW CLAW

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation130.002026-03-02
20000tstarc_meloxicam85.762026-03-02

UPM+

  • DG01845TRAUMATIC INJURYDSTP_traumatic_injury

Variant (sleepy_king)

PAIN - OTHER - PRESENTING COMPLAINT
DSTP_clinical_signs_-_pain
Conf: 0.420
Threshold: 0.39
Above:
Correct?
Acceptable?
Reason (acceptable)
Diagnosis description