C09975295 / invoice 10000
Species:CANINE
Breed:Pug
Age (years):5
Diagnosis or signs:Infected Wound
Consult notes
Animal clinical history (3 most recent)
2026-03-02T00:00:00Z 12:00 AM
Reason: Got A Scab Off Their HeadAppointment Notes: Overdue remindersVerified: NoHISTORYPresenting for: Henning presented for evaluation of a wound/lesion that the client first noticed last Tuesday, with progressive worsening and hardening of the area.Historical Conditions:- Previous reaction to Cephalexin (tolerable)- Previous treatment with Augmentin in 2022 for wound or nail infection on footEXAMMentation: BARIntegumentary: Full thickness skin wound present on head with surrounding swelling. Wound appears to have skin lifted off with significant bacterial contamination present. Uncertain whether this represents a ruptured abscess or infected wound with scab removal. Considerable bacterial debris noted within the wound.ASSESSMENTInfected wound - uncertain aetiology, possibly ruptured abscess or infected traumatic wound with secondary bacterial contaminationPLANNew Meds/Tx:- Augmentin prescribed (patient previously tolerated this antibiotic in 2022)- Topical Betadine application for wound care- Elizabethan collar recommended to prevent self-trauma if scratching occursAdditional Discussion:- Wound may enlarge as necrotic tissue separates- Monitor for progression and continued self-trauma- Client advised wound appearance may worsen before improvement as damaged skin separates Vital Signs
Previous claim history (20)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-02-02 | C09845588 | TOOTH FRACTURE |
| 2026-01-20 | C09782817 | KERATITIS - CHRONIC SUPERFICIAL (PANNUS) |
| 2026-01-18 | C09808342 | KERATITIS - CHRONIC SUPERFICIAL (PANNUS) |
| 2023-10-24 | C6450902 | ENTROPION |
| 2023-10-03 | C6374211 | KERATITIS |
| 2023-09-25 | C6354455 | KERATITIS |
| 2023-09-22 | C6340198 | CORNEAL ULCER |
| 2023-09-16 | C6320039 | CORNEAL ULCER |
| 2023-09-15 | C6318480 | CORNEAL ULCER |
| 2023-09-10 | C6298603 | CORNEAL ULCER |
| 2023-09-07 | C6316172 | CORNEAL ULCER - NON-HEALING ULCER (INDOLENT) |
| 2023-09-05 | C6279919 | CORNEAL ULCER |
| 2023-09-03 | C6274257 | CORNEAL ULCER |
| 2022-10-25 | C5224180 | VOMITING - OTHER - PRESENTING COMPLAINT |
| 2022-10-25 | C5224180 | OTITIS EXTERNA |
| 2022-07-27 | C4966804 | NAIL BED INFECTION |
| 2022-07-21 | C4949866 | NAIL BED INFECTION |
| 2022-07-12 | C4914574 | KENNEL COUGH |
| 2022-06-11 | C4826395 | OTITIS EXTERNA |
| 2021-10-08 | C4147337 | DENTAL (TOOTH) DISORDER |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 141.00 | 2026-03-02 | — |
| 20000 | tstarc_antibiotics_-_amoxicillin_and_clavulanic_acid | 41.00 | 2026-03-02 | — |
UPM+
- DG01953WOUND, INFECTEDDSTP_wound_or_laceration
Variant (sleepy_king)
WOUND - LACERATION
DSTP_wound_or_laceration
Conf: 0.690
Threshold: 0.60
Above: ✓
Correct?