C09977678 / invoice 20000

Species:CANINE
Breed:Golden Doodle (Groodle)
Age (years):14
Diagnosis or signs:Follow up for hotspot
Consult notes
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<p>a) Follow up for hotspot - O would like more metacam<br>b) No food but metacam please and more meds for other dog too please<br>c) No other concerns<br><br>Current medication &amp; dose:<br>Metacam 2.5mg chews - O is giving 1 1/2 tablets once daily<br>------------------------------------------<br>GapOnly<br>What is the issue? recheck hotspot &amp; geri bloods &amp; pain recheck &amp; breath rate increased <br><br>Where is the issue? back and legs, skin on neck, panting- pain vs. lungs open diagnosis<br><br>When did it start? last visit  first hotspot, leg stiffness start date unclear- most likely months to years<br><br>Is this a pre-existing condition according to the client? yes from last visit <br><br>What is the next step? blood to lab, xray thoracic spine, dental needed, chest xrays to assess for panting<br>Malaseb &amp; longer on antibiotics<br><br>_____________________________<br><strong>History:<br></strong>EDDU <br><br><strong><br>Examination:</strong><br>Eyes <br>Ears<br>Skin/coat<br>Dental grade<br>MM  CRT &lt;2sec<br><span style="color: #626262; background-color: #ffffff;">LNs<br></span>Heart<br>Lungs<br>Abdo <br>MSK<br>Neuro<br>Lumps<br>Weight/BCS<br>Rectal<br><br></p>
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<div><strong>Assessment:<br><br>Treatment:<br></strong>1. <br><strong><br>Plan:<br></strong>1. <br><br> <br><strong>Follow up/reminders</strong></div>
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Animal clinical history (3 most recent)

2026-02-17T00:00:00Z 11:43:00
a) gash behind the Left earb)c) Were the client details checked?Current medication & dose:------------------------------------------Last vacc was KC 25/8/2025 reminder set for vacc in August later this year mbSubjective:- Hot spot caudal to left pinna- on left neck- Crusty lesions on various body areas including buttocks, initially thought to be food material- Back leg stiffness & weakness and difficulty standing following Sunday activity- Overexertion during pickleball tournament where dog acted as ball boy- Increased panting - Deafness noted, unable to respond to commands- Previous lump on eye present for extended period, previously assessed with recommendation for no intervention- Arthritis symptoms affecting mobility, particularly stairs and slippery floors- Recent house move in November with multiple stair challenges- Weight: 29.1kg (fasted)EXAM:- Hot spot on left neck- Impression smear- cocci ++++++ degen neutrophils ++, chlorhex wash in consult O will rinse off when gets home- Crusty lesions present on along dorsum various body areas, some healing with crust growing out skin ok - Eye examination: cloudy appearance, no evidence of corneal ulceration on fluorescein stain. eyelid lump not causing trauma to eye- Heart: no murmur detected- Respiratory rate elevated at rest, likely pain-related rather than cardiac- Joint examination: significant stiffness in mid-thoracic region, lower back stiffness, knee thickening particularly left knee, shoulder pain on palpation, elbow arthritis present- Postural changes: sits with back legs outstretched rather than normal sitting position- Skin cytology: confirmed bacterial infection- Grade 3/4 dental disease requiring attentionAssessment:Moderate pyoderma left neck- Multisite arthritis affecting elbows, shoulders, knees, possible hip involvement- Dental disease grade 3/4Plan:- Clavulox PO BID one and a half tablets morning and night for 30 days- Anti-inflammatory injection administered today- dex - Topical antiseptic wash applied- chlorhex-, to be left on skin for 10 minutes then rinsed with water- Rest and activity restriction recommended- 4cyte gel pain relief to commence immediately- Metacam tasty chews to commence Friday 20/02/2026 (one and a half tablets)- Anti-pruritic medication provided if scratching develops- apoquel - Skin care: keep area dry, use paper towels for drying or wash and sun-dry regular towels to prevent bacterial spread- Follow-up appointment in 10 days for reassessment and blood work (fasted)- Dental assessment to be scheduled after skin infection resolved

Previous claim history (6)

DateClaim #Diagnosis
2026-02-17C09916910PYODERMA
2026-02-17C09916910ARTHRITIS
2025-09-10C09880784MASS LESION - SKIN (CUTANEOUS)
2021-09-25C4113323ARTHRITIS
2021-05-06C3752463WOUND - LACERATION
2020-11-30C3752484ARTHRITIS

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_antibiotics_-_amoxicillin_and_clavulanic_acid70.652026-03-03

UPM+

  • DG00592DERMATITISDSTP_skin_-_dermatitis

Variant (sleepy_king)

DERMATITIS
DSTP_skin_-_dermatitis
Conf: 0.970
Threshold: 0.25
Above:
Correct?