C09980880 / invoice 10000
Species:CANINE
Breed:Golden Retriever
Age (years):8
Diagnosis or signs:ears
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div> <div> <p><strong>Itchy ears <br><br>HISTORY:</strong><br>Last couple of days has started shaking his head - seems irritated. <br>R ear looks a little red and had a small amount of blood when owner tried to clean ears using a tissue. <br><br>No other concerns. <br>Very anxious dog. But doing really well since starting on the Fluoxetine. <br><br><strong>EXAMINATION</strong>:<br>Lovely boy <br>MM: Pink and moist <br>CRT < 2 second<br>Demeanour: BAR<br>Hydration: Euhydrated <br>Cardiovascular: Dual heart sounds auscultated, no murmur or arrhythmia detected, SSFP<br>Respiratory: Normal bronchovesicular sounds bilaterally, normal effort<br>Neurological: Appropriate & normal mentation, gait and posture<br>Musculoskeletal exam: good ambulation. Carrying a little too much weight - ideally should be around 35kg <br>Gastrointestinal: Comfortable on abdominal palpation <br>Genito /Urinary: Bladder palpates WNL<br>Integument: Coat condition, ectoparasites visualised <br>Eyes: Symmetrical, no ocular discharge or blepharospasm<br>Ears: External meatus within R ear very inflammed and swollen, and contains thick black/brown ceruminous discharge<br>L ear also appears a little dirty on otoscopic exam, but much inflammation is much less mild <br>Mouth: Dental grade 1/4<br>Lymph Nodes: Submandibular, prescapular and popliteal palpate normally<br>Rectal: both glands feel very full, but easy to express. <br><br><strong>LAB</strong>:<br>Ear smear and diff quik stain<br>-> yeast both ears R side > L <br><br><strong>ASSESSMENT</strong>:<br>Otitis externa - yeast<br><br><strong>TREATMENT:<br></strong>Dermotic 1ml into each ear BID for 7 days<br>AG expression .<strong><br><br>PLAN:<br></strong>Recommend recheck in 2 wks <br>Suggested to try feeding psyllium husk, half a tablespoon BID with food to help stop AGs becoming impacted.</p> </div> </div></html>
Animal clinical history (3 most recent)
2026-01-15T00:00:00Z 12:49:00
Give 40mg oid.
2025-11-10T00:00:00Z 15:43:00
HISTORY:EDDU: acute moist wound on head- owner has applied neocort and pyohex wash also and it has stopped spreading. Has previously had issues with hot spots on skin. Typically lesions appear around his face. Owner thinks they are likely the result of rough play with owners other dog. However possibly also has underlying allergy ? (Seasonal pruritisHeart worm prevention: UTDIntestinal worming: UTDFlea control: UTDTick control: UTDDiet: Current medications:neocort applied to area of acute moist dermatitiscortavance applied to paws twice weeklymalaseb bathing of feet once weeklyears being cleaned fortnightlyEXAMINATION:MM: Pink and moist CRT < 2 secondDemeanour: BARHydration: Euhydrated Cardiovascular: Dual heart sounds auscultated, no murmur or arrhythmia detected, SSFPRespiratory: Normal bronchovesicular sounds bilaterally, normal effortNeurological: Appropriate & normal mentation, gait and postureMusculoskeletal exam: wnlGastrointestinal: Comfortable on abdominal palpation Genito /Urinary: Bladder palpates WNLIntegument: Coat condition generally good, some salivary stainihg interdigital area and has an small area of acute moist dermatitis on top of head, no ectoparasites visualised Eyes: Symmetrical, no ocular discharge or blepharospasmEars: Normal, mild brown waxy auricular discharge bilaterallyMouth: Dental grade /4Lymph Nodes: Submandibular, prescapular and popliteal palpate normallyRectal: moderately full anal sacss, no masses, normal faeces PROBLEM LIST:pruritis- scootinglicking pawslicking floormoist wound on headdirty earsASSESSMENT:moderately ful anal sacsallergic skin disease- atopy vs arf vs FAD vs contact dermatitisdisplacement behaviour- anxiousacute moist pyotraumatic dermatitisallergic skin disease with mild PLAN:cleaned ears with epiotic SIS30g pred one off dose emla applied to head clipped cleaned with pyohexneocort bid for 7 dayspyohex/malaseb weekly during hot humid periodsdiscussed using topical cortavance/barazone for allergic skin disease vs cytopoint/ apoquel ( mentioned risks benefits).
2025-09-18T00:00:00Z 14:17:00
AT spoke to owner on phoneConcerned that Archie is getting more and more anxious at home. Constantly sits and licks his paws and also barking alot (always on high alert)Has tried medication to reduce pruritis, but now owner is thinking the licking may be more behavioural Wanting to try on Fluoxetine AT dispense script for Fluoxetine 30mg SID for 2 wks, then increase to 40mg SIDAlso dispensed script for Catapres. To use daily for 2-3 wks then reduce to PRN. Recommend to start out on 3-4 x 150mg tabs. Review medications in 4 wks either with AT or LP
Previous claim history
| Date | Claim # | Diagnosis |
|---|---|---|
| No prior claims. | ||
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 97.00 | 2026-03-03 | — |
| 20000 | tstarc_diagnostic_test_-_cytology | 71.00 | 2026-03-03 | — |
| 30000 | tstarc_ear_medication_-_antibacterial_and_anti-fungal | 54.58 | 2026-03-03 | — |
UPM+
- DG01185OTITIS EXTERNADSTP_otitis_externa
Variant (sleepy_king)
OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.800
Threshold: 0.07
Above: ✓
Correct?