C09972871 / invoice 10000
Species:CANINE
Breed:Chihuahua
Age (years):8
Diagnosis or signs:ghc
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"></html> </br><p>**HISTORY**<br>**Presenting Complaint**: Sore neck, hunched posture, difficulty walking<br>- Episode started approximately 2 weeks ago<br>- Currently on Meloxicam once daily for 2 days and Gabapentin half tablet today<br>- When medicated appears normal and wants to run and play<br>- When not medicated appears hunched, reluctant to lower head to eat, holds head to one side<br>- Chronic issue, has been seen previously for this problem<br>- Goes up stairs well when medicated, struggles when not medicated<br>- Reluctant to take dental chews when in discomfort (usually enjoys them)</p><p>EATING: Decreased (reluctant to lower head, needs hand feeding when uncomfortable)<br>ENERGY: Normal when medicated, significantly decreased when not medicated<br>DRINKING: Normal<br>DEFECATION: Normal<br>URINATION: Normal<br>Diet: Commercial wet food, chicken and vegetables, daily dental chew<br>Meds: Meloxicam, Gabapentin<br>C-/S-/D-/V-</p><p>**PHYSICAL EXAMINATION**<br>Mentation: BAR<br>MM: Pink, moist<br>EENT: NAD<br>CARDIAC: NAD<br>RESP: NAD<br>SKIN: NAD<br>DENTAL: NAD<br>ABD. PALP: NAD<br>**MSK: Stiff around neck, resistant to neck movement, sensitivity along L4-L5, more flat-footed on front feet when uncomfortable<br>LN: NAD</p><p>**PROBLEM LIST**<br>- Chronic neck pain/stiffness<br>- Suspected intervertebral disc disease or pinched nerve</p><p>**DIAGNOSTICS**</p><p>**ASSESSMENT**<br>Chronic cervical pain, likely intervertebral disc disease or pinched nerve. Responds well to anti-inflammatory and gabapentin combination but signs return when medication wears off.</p><p>**TREATMENT**</p><p>**COMMUNICATION**<br>- Discussed physical examination findings, differentials/assessment & plan<br>- Explained chronic nature of condition and that healing can take up to a month or more<br>- Discussed conservative management vs advanced imaging options (CT/MRI)<br>- Explained limitations of radiographs for spinal conditions<br>- Discussed blood test recommendation before adding additional medications<br>- Advised strict rest, heat packs, and gentle massage<br>- Addressed client concerns about previous clinic experience</p><p>**PLAN**<br>Gabapentin 50mg capsules (powder can be sprinkled on food) up to 3 times daily<br>Continue Meloxicam every second day or as needed (keep to lowest effective dose)<br>- Re-check: 2 weeks<br>- INI consider: Blood test before adding additional medications, advanced imaging (CT/MRI) if no improvement with conservative management, strict rest for 4 weeks with heat therapy and gentle massage</p><p>JR</p>
Animal clinical history (3 most recent)
2025-07-18T00:00:00Z 15:33:00
HISTORYPresenting for: Adult dog presented for recheck of elevated ALT and recent behavioural changes including shaking, tail tucking, flatulence and lethargyHistorical Conditions: - Recent elevated ALT on bloodwork- Previous dental cleaningDiet:- Royal Canin pouch (partial) in morning- Crisp brown nose in-betweeners as treats- Recent addition of puppy milk and fish oil for past 2 weeks- Barbecue chicken occasionallyV/D/C/S:- Flatulence noted recentlyOther:- Not interested in usual dental treats yesterday- Running outside after appointment was madeEXAMMentation: BARCardiovascular: Heart sounds normal, no murmurs or arrhythmias notedRespiratory: Normal respiratory effortOral: Mild dental calculus, removes with gentle wipingAbdominal: Normal on palpation, soft , no pain. Musculoskeletal: no reaction or pain at spine/ neck palpation/ manipulation. Integumentary: NormalUrogenital: NormalLymph Nodes: WNLMSK: NADeyes, ears, skin: NADMM: pink & moist, CRT < 2 sec ASSESSMENTGastrointestinal upset - Likely dietary related given recent addition of puppy milkOtherwise apparently healthyALT: 82 (WNL)PLANMedications/Treatments:- Discontinue meloxicam temporarily due to GI upsetDiet Recs:- Discontinue puppy milk- Feed only regular Royal Canin diet- Temporarily stop all treats and toppings- Trial add gastrointestinal diet (sample provided)- Probiotic powder supplement provided for 5 days - add to food once dailyAdditional Discussion:- Monitor for improvement in GI signs over next few days- Return to regular diet if signs resolveClient Comms:- Return if no improvement noted after dietary changes
2025-04-22T00:00:00Z 11:54:00
8 days post dental recheckEDDU normallyBARMM: pink & moist, crt < 2 sec mouth looks great, gums healed completely.no more recheck needed.
2025-04-17T00:00:00Z 10:18:00
0.05ml meth
Previous claim history (1)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-02-25 | C09955399 | PAIN - NECK (CERVICAL) - PRESENTING COMPLAINT |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 110.00 | 2026-03-02 | — |
| 20000 | tstarc_anticonvulsant_medication_-_gabapentin | 72.30 | 2026-03-02 | — |
UPM+
- DG02078PAIN - NECK (CERVICAL) - PRESENTING COMPLAINTDSTP_clinical_signs_-_neck_pain
Variant (sleepy_king)
PAIN - NECK (CERVICAL) - PRESENTING COMPLAINT
DSTP_clinical_signs_-_neck_pain
Conf: 0.940
Threshold: 0.90
Above: ✓
Correct?