C09979104 / invoice 10000

Species:CANINE
Breed:Maltese Cross
Age (years):9
Diagnosis or signs:Checkup
Consult notes
03/03/2026 HISTORY
Presenting for: Rosie presented for potential anal gland issues. 
Has otherwise been well her whole life 
EDUF all normal 
Not on any medications, has never had a reaction to any medications before

EXAM
Wt: 12 kg
Behavioural: Very good and brave during examination
BCS 5.5/9
CVS: NAD
Resp: NAD 
Abdo: Soft and comfortable 
MM's: Pink and moist 
Dental: G2, worst on canines, no sig gingivitis, moderate halitosis, no obvious extractions
Rectal: Bilateral anal sac impaction noted. Right anal sac had ruptured externally (5mm defect). Both anal sacs were blocked and expressed during examination. Right anal sac contents purulent (only coming out of defect, not out of natural duct), and some granular grey material. Left anal sac expressed through duct with some effort, contents dark brown, approx 3ml, granular. Some irritation noted around the bottom area.

ASSESSMENT
Bilateral anal sac impaction with external rupture of right anal sac - Likely due to blocked ducts possibly secondary to soft faeces, allergic inflammation causing swollen tissue, or accumulation of debris in the sacs.
G2 dental disease

PLAN
New Meds/Tx:
- Antibiotics dispensed - 125mg clav BID
- Anti-inflammatory medication: 12 kg dose today, then once daily at 6kg dose starting tomorrow - impressed dosing frequency several times

Additional Discussion:
- Anal sac expression performed today for both sides
- Advised that some anal sac ruptures may require anaesthetic for thorough flushing if conservative treatment fails
- Blood test offered to check liver and kidneys before anti-inflammatory use - owner declined today

Client Comms:
- Recheck appointment scheduled for Friday to assess if swelling has reduced and duct can be naturally expressed, can then recheck again next Tues if going well. 
- If accumulating more material and not expressing naturally, may need flushing procedure next week
- If progressing well, follow-up appointment scheduled for next Tuesday
- Owner advised anal sacs are difficult to treat due to their capsule structure
- Clean twice daily with diltute betadine

Animal clinical history (3 most recent)

2026-03-03T00:00:00Z 11:45:07
HISTORY
Presenting for: Rosie presented for potential anal gland issues. 
Has otherwise been well her whole life 
EDUF all normal 
Not on any medications, has never had a reaction to any medications before

EXAM
Wt: 12 kg
Behavioural: Very good and brave during examination
BCS 5.5/9
CVS: NAD
Resp: NAD 
Abdo: Soft and comfortable 
MM's: Pink and moist 
Dental: G2, worst on canines, no sig gingivitis, moderate halitosis, no obvious extractions
Rectal: Bilateral anal sac impaction noted. Right anal sac had ruptured externally (5mm defect). Both anal sacs were blocked and expressed during examination. Right anal sac contents purulent (only coming out of defect, not out of natural duct), and some granular grey material. Left anal sac expressed through duct with some effort, contents dark brown, approx 3ml, granular. Some irritation noted around the bottom area.

ASSESSMENT
Bilateral anal sac impaction with external rupture of right anal sac - Likely due to blocked ducts possibly secondary to soft faeces, allergic inflammation causing swollen tissue, or accumulation of debris in the sacs.
G2 dental disease

PLAN
New Meds/Tx:
- Antibiotics dispensed - 125mg clav BID
- Anti-inflammatory medication: 12 kg dose today, then once daily at 6kg dose starting tomorrow - impressed dosing frequency several times

Additional Discussion:
- Anal sac expression performed today for both sides
- Advised that some anal sac ruptures may require anaesthetic for thorough flushing if conservative treatment fails
- Blood test offered to check liver and kidneys before anti-inflammatory use - owner declined today

Client Comms:
- Recheck appointment scheduled for Friday to assess if swelling has reduced and duct can be naturally expressed, can then recheck again next Tues if going well. 
- If accumulating more material and not expressing naturally, may need flushing procedure next week
- If progressing well, follow-up appointment scheduled for next Tuesday
- Owner advised anal sacs are difficult to treat due to their capsule structure
- Clean twice daily with diltute betadine
2025-05-27T00:00:00Z 11:08:54
Nobivac Bb/Pi and Proheart inj. Will need a dental prophy before year's end. Otherwise nadpe.
2024-10-11T00:00:00Z 10:10:11
3rd Clav inj. No vomiting. Nothing passed. Improving clearly.

Previous claim history (1)

DateClaim #Diagnosis
2020-05-06C2891787VOMITION & DIARRHOEA

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation111.152026-03-03
20000tstarc_meloxicam62.982026-03-03
30000tstarc_antibiotics_-_amoxicillin_and_clavulanic_acid51.202026-03-03

UPM+

  • DG00182ANAL SAC DISORDERDSTP_anal_sac_disorder

Variant (sleepy_king)

ANAL SAC DISORDER
DSTP_anal_sac_disorder
Conf: 0.970
Threshold: 0.54
Above:
Correct?