C09973873 / invoice 10000

Species:CANINE
Breed:Staffordshire Bull Terrier
Age (years):13
Diagnosis or signs:Check Eyes
Consult notes
01/03/2026 Reason:  
History: 
Left eye last night noticed looked different and sunken 

has had gaba and traz previously for anxiety 

Current medications: trilostane

Examine: 
Mentation: BAR
Body condition score: 3/5
MM: PM               CRT: <2
HR:    110            RR: pant
LN: NSF
Temperature: NT

Ocular: Horners, L globe sunken, miotic, third eyelid across. nil stain uptake 
L IOP 17, STT WNL
R IOP 20, STT WNL
Oral/Dental stage: 2
Ears: mild wax down both ears, difficult to assess TM
Cardiovascular: 3/6 heart murmur
Respiratory: NSF
Gastrointestinal: NSF
Integumentary & lumps (measurement, location): NSF
Musculoskeletal: neck pain noted on all range of motion worse so on extension, general stiffness 
Urogenital: NSF
Neurological: menace intact bilaterally, palpebral WNL 

Problem List:
Horners
DDx: ears vs eyes vs neck pain vs idiopathic 

Heart murmur

Assessment: 
Discussed possible causes of horners 
suggested ear cytology - o declined, advised could be middle ear infection causing it.. unable to confirm integrity of TM 
recommended trial pain relief for neck pain to see if horners improved, recommended likely continuing on NSAID long term for DJD 
recommended GHP - o to come back for nurses to collect for send off bloods 

briefly touched on HM - need to revisit at next visit 

Treatment: 
200mg gaba BID 
113.5mg previcox SID 

Plan: 
O to come back next week for nurse blood draw 
recheck INI 
On-going medications required: Y/N (use prescription tab for further supply):

Followup:

Animal clinical history (3 most recent)

2026-03-01T00:00:00Z 09:25:04
Reason:  
History: 
Left eye last night noticed looked different and sunken 

has had gaba and traz previously for anxiety 

Current medications: trilostane

Examine: 
Mentation: BAR
Body condition score: 3/5
MM: PM               CRT: <2
HR:    110            RR: pant
LN: NSF
Temperature: NT

Ocular: Horners, L globe sunken, miotic, third eyelid across. nil stain uptake 
L IOP 17, STT WNL
R IOP 20, STT WNL
Oral/Dental stage: 2
Ears: mild wax down both ears, difficult to assess TM
Cardiovascular: 3/6 heart murmur
Respiratory: NSF
Gastrointestinal: NSF
Integumentary & lumps (measurement, location): NSF
Musculoskeletal: neck pain noted on all range of motion worse so on extension, general stiffness 
Urogenital: NSF
Neurological: menace intact bilaterally, palpebral WNL 

Problem List:
Horners
DDx: ears vs eyes vs neck pain vs idiopathic 

Heart murmur

Assessment: 
Discussed possible causes of horners 
suggested ear cytology - o declined, advised could be middle ear infection causing it.. unable to confirm integrity of TM 
recommended trial pain relief for neck pain to see if horners improved, recommended likely continuing on NSAID long term for DJD 
recommended GHP - o to come back for nurses to collect for send off bloods 

briefly touched on HM - need to revisit at next visit 

Treatment: 
200mg gaba BID 
113.5mg previcox SID 

Plan: 
O to come back next week for nurse blood draw 
recheck INI 
On-going medications required: Y/N (use prescription tab for further supply):

Followup:

Previous claim history (24)

DateClaim #Diagnosis
2026-02-16C09915165HYPERADRENOCORTICISM ("CUSHING'S")
2026-01-28C09821531CUSHINGS DISEASE
2026-01-20C09789809HYPERADRENOCORTICISM ("CUSHING'S")
2025-12-19C09656841HYPERADRENOCORTICISM ("CUSHING'S")
2025-12-09C09601704HYPERADRENOCORTICISM ("CUSHING'S")
2017-08-08C1295581DERMATITIS
2017-08-01C1295579VACCINATIONS OR HEALTH CHECKS
2017-07-01C1243166DERMATITIS
2017-05-16C1194534SKIN LESIONS
2017-04-29C1172491DERMATITIS
2017-03-25C1187581PYODERMA
2017-01-10C1063516DERMATITIS - ATOPIC
2016-12-27C1048017PRURITUS - PRESENTING COMPLAINT
2015-03-05C0567483LAMENESS RF
2015-02-16C0567483FLEA/TICK/WORM CONTROL
2014-10-19C0467251SKIN CONDITIONS
2014-08-26C0467252INTERDIGITAL CYST
2014-07-19C0374174VACCINATIONS OR HEALTH CHECKS
2014-07-19C0374174FLEA/TICK/WORM CONTROL
2014-02-01C0246598SKIN (CUTANEOUS) DISORDER
2013-12-28C0246598PRESCRIPTION DIETS
2013-10-25C0169683DESEXING
2013-08-01C0157273EPIPHORA
2013-08-01C0163557EPIPHORA

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation125.352026-03-01
20000tstarc_procedure_fee51.752026-03-01
30000tstarc_nsaid_-_previcox_(firocoxib)62.772026-03-01
40000tstarc_anticonvulsant_medication_-_gabapentin44.642026-03-01

UPM+

  • DG02277HORNER'S SYNDROMEDSTP_horner's_syndrome
  • DG01126OSTEOARTHRITIS (OSTEOARTHROSIS, DEGENERATIVE JOINT DISEASE (DJD))DSTP_osteoarthritis

Variant (sleepy_king)

PAIN - NECK (CERVICAL) - PRESENTING COMPLAINT
DSTP_clinical_signs_-_neck_pain
Conf: 0.440
Threshold: 0.90
Above:
Correct?
Reason (correct)