C09972563 / invoice 10000
Species:CANINE
Breed:Cavoodle
Age (years):5
Diagnosis or signs:Sore RHL
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><p>Reason for Presentation: Acute onset right hindlimb lameness following running/fetch<br><br>History:<br>Gucci was playing fetch on Saturday when he ran towards the door and lost control of his back legs. His back legs spread backwards and he was unable to stand. He yelped prior to the collapse. He was carried and kept on the sofa, not moving at all. Yesterday he refused to move and was carried everywhere. Today he has started moving around again. He cannot scratch his right ear with his right hindlimb. He has been given paracetamol (quarter tablet) as advised by after-hours service. He has gained weight recently.<br><br>Physical Examination:<br>Vitals:<br>BCS: 5/9<br>Weight: 12.5 kg<br>HR: Normal rate and rhythm<br>RR: Appropriate rate and effort<br>Temp: Not taken<br>MM/CRT: Pink and moist, <2s<br>Demeanour: BAR<br><br>Ears: No discharge, erythema or signs of inflammation bilaterally<br>Eyes: No blepharospasm, epiphora, signs of inflammation, or ocular discharge present OU<br>Nose: No nasal discharge present<br>Oral: No signs of periodontal disease (no gingivitis or calculus present)<br>Respiratory: Normal bronchovesicular sounds, no crackles or wheezes, normal respiratory effort<br>Cardiovascular: No murmur or arrhythmia detected, strong and synchronous pulses<br>Abdominal palpation: Soft and comfortable on palpation, no mass effect or fluid wave evident<br>Musculoskeletal: Right hindlimb - positive cranial drawer test, pain on testing, ligament laxity present but not fully ruptured. Left hind foot - small wound on dorsal aspect with purulent discharge, consistent with infected wound secondary to licking<br>Integument: Healthy haircoat, no obvious dermatopathologies detected<br>Neurological: Normal demeanour, no signs of ataxia, no cranial nerve deficits, a full neurological examination was not performed<br>Urogenital: No abnormalities detected<br>Rectal: Not performed<br><br>Diagnostics:<br>Nil<br><br>Problem list:<br>- Right cranial cruciate ligament sprain<br>- Infected wound left hind foot (dorsal aspect)<br>- Overweight<br><br>Assessment:<br>- Right cranial cruciate ligament sprain (partial, not ruptured)<br>- Infected wound left hind foot<br>- Overweight<br><br>Treatment:<br>- Meloxicam (12 kg dose) PO once daily for 10 days<br>- Chlorhexidine scrub - mix 1:1 with water, apply with swabs twice daily until resolved<br>- Swabs provided for wound cleaning<br>- Strict rest/confinement for 2-3 weeks, no running<br><br>Plan:<br>- Weight loss to target 10-11 kg<br>- If intermittent lameness continues, X-rays and surgical planning to be considered<br>- Hydrotherapy may be beneficial for muscle strengthening once stable<br>- Return if not weight-bearing or worsening<br>- Next vaccination due May (Sydney Animal Hospital, lifetime plan)</p></html>
Animal clinical history (3 most recent)
2026-02-02T00:00:00Z 13:03:00
Reason for Presentation: Scooting and paw chewing.History:Gucci is a 5-year-old male neutered cavoodle. Vaccinations are due in May and are covered by a lifetime plan at Sydney Animal Hospital. He has a history of scooting, which was previously managed with tablets. The scooting has recently increased. He has also been chewing his paws for the last 3-4 days, which is a new behaviour. The owner has noted new plants and vegetables in the backyard. No history of ear infections. No vomiting or diarrhoea. No coughing or sneezing. No limping.Physical Examination:Vitals:BCS: 6/9Weight: UnknownHR: Normal rate and rhythmRR: Appropriate rate and effortTemp: Not takenMM/CRT: Pink and moist, <2sDemeanour: BAREars: No discharge, erythema or signs of inflammation bilaterallyEyes: No blepharospasm, epiphora, signs of inflammation, or ocular discharge present OUNose: No nasal discharge presentOral: Mild calculus present. No signs of periodontal disease (no gingivitis or calculus present)Respiratory: Normal bronchovesicular sounds, no crackles or wheezes, normal respiratory effortCardiovascular: No murmur or arrhythmia detected, strong and synchronous pulsesAbdominal palpation: Soft and comfortable on palpation, no mass effect or fluid wave evidentMusculoskeletal: Appropriate ambulation, weight-bearing evenly on all four legs, normal range of motion in all jointsIntegument: Healthy haircoat, no obvious dermatopatholgies detectedNeurological: Normal demeanour, no signs of ataxia, no cranial nerve deficits, a full neurological examination was not performedUrogenital: No abnormalities detectedRectal: Not performedDiagnostics:NilProblem list:- Scooting> Anal glands expressed, firm material present- Paw chewing> Mild erythema noted, no dischargeAssessment:- Anal gland impaction- Mild pododermatitis, likely allergicTreatment:- Anal glands expressed.- Advised owner to wipe paws with a baby wipe after being outside to remove potential allergens.- Advised owner to add half a teaspoon of psyllium husk (e.g., Metamucil) to food to increase fibre and help with natural anal gland expression.Plan:- Monitor paw chewing. If it continues, further treatment can be considered.- Continue with dental care (Greenies, brushing).- Vaccinations to be done at Sydney Animal Hospital as per lifetime plan.
Previous claim history (7)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-02-02 | C09839142 | SCOOTING |
| 2026-02-02 | C09839142 | HYPERSENSITIVITY (ALLERGIC) SKIN DISORDER |
| 2025-05-26 | C8757959 | HYPERSENSITIVITY (ALLERGIC) SKIN DISORDER |
| 2023-09-23 | C6345140 | PENILE/PREPUTIAL ABNORMALITY - OTHER - PRESENTING COMPLAINT |
| 2023-05-13 | C5889052 | OTITIS EXTERNA : BIL |
| 2021-08-22 | C4012481 | MISCELLANEOUS CONDITIONS |
| 2021-08-22 | C4169409 | CONJUNCTIVITIS |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 119.00 | 2026-03-02 | — |
| 20000 | tstarc_meloxicam | 56.86 | 2026-03-02 | — |
UPM+
- DG02023GAIT ABNORMALITY - LAMENESS - PRESENTING COMPLAINTDSTP_clinical_signs_-_lameness
Variant (sleepy_king)
GAIT ABNORMALITY - LAMENESS - PRESENTING COMPLAINT
DSTP_clinical_signs_-_lameness
Conf: 0.490
Threshold: 0.37
Above: ✓
Correct?