C09981464 / invoice 10000

Species:CANINE
Breed:Golden Retriever
Age (years):6
Diagnosis or signs:cut on foot
Consult notes
03/03/2026 Hx: cut paw on Sunday night - O's think it was on metal from rabbit cage. Did have a little bit of bleeding initially. O's initially bandaged it, seemed to be about a 1cm incision. Yesterday noticed the cut seemed to be getting bigger. 
Not been bothered by it at all, no licking at all. O's have changed the bandaged initially as bled through but today has been fine. O's have been cleaning with bededine. 
No limping. 
Otherwise been his normal self, EDDU normal. No vomiting or diarrhoea. 
No medications given at home. 
Is due for vaccine too. 

Exam:
BAR, anxious but lovely boy 
C/V: reg rate and rhythm, no murmur 
RR: panting, clear 
MM PM <2
Oral: grade 1-2 dental disease present
Abdo: soft and comfortable 
Skin: RHL digit V small superficial laceration, not actively oozing, no signs of infection present 

Tx:
Cleaned wound with dilute chlorhexidine, dried area. 
Applied bandage, manuka honey on melonin followed by softban, conforming and vetwrap. 

KC SC into scruff
BBpi2 2526207, exp.04/2027

Meloxicam 5mg tablets SID q3 days

Plan:
O to montior at home, if signs of infection appear can dispense amoxyclac 
Meloxicam q3 days
Remove bandage in 3 days 

Animal clinical history (3 most recent)

2025-03-13T00:00:00Z 16:50:03
Hx: EDUD normal. No V+ or D+. On weight loss journey. Diet Hills Science perfect weight, wet food (hills science), occ treat. Gets nexgard spectra monthly. 


Exam: 
BAR, a bit nervous but copes well
BCS 8/9 
G2 dental disease 
Ears bilaterally lichenified, erythemic and dark brown discharge, worse on the left
Exam otherwise unremarkable 

Tx:
KC inj 

Plan: 
Due KC next year, then C5 2027.
Discussed home dental care + recommend S/P.
Recheck ears 12-14 days.

Note: got distracted and forgot to swab ears at this visit --> very much yeasty smelling and presenting ears; trialling PMP, swab at next visit 



2024-10-12T00:00:00Z 11:36:19
Dog has had diarrhea for the past week. O feeds eukanuba dry food 1 cup twice a day. Famioly do give treats and leftovers is regularly exercised

MMpink TPR nomrla ears eye sna docoat good abdo palp nad. 40% overweight

Recommend chicken and rice for next few days then back to normal diet. Also suggest metabolic and mobility hills food in the future

Dog should be 32-34 kgs
2024-03-01T00:00:00Z 17:57:51
Shaking head and discharge Left ear O has cleaner and ear drops at home

MMpink TPR normal overweight Eyes and coat good R ear fne Left ear ++ creamy discharge +++cocci +malsezzia

Clean and treat ears with 7 drops pmp bid and recheck 2 weeks INI take swab for C+S

Previous claim history (10)

DateClaim #Diagnosis
2025-03-13C8448740EAR INFECTION
2024-10-12C7813545GASTROINTESTINAL PROBLEMS
2023-11-05C6493272MASS LESION - SKIN (CUTANEOUS)
2023-09-25C6349501OTITIS EXTERNA : RIG
2022-12-07C5362504GRASS SEED
2022-11-21C5336533GASTROENTERITIS
2022-01-17C4420275SKIN LESIONS
2021-06-26C3857035LAMENESS RF
2021-06-26C4408471MASS LESION - SCROTAL
2021-01-20C3458771INGEST FOREIGN OBJECT

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_vaccination_(canine)145.002026-03-03
upstreamDSTP_routine_care_-_vaccinations_or_health_checks
20000tstarc_bandages_and_dressings35.002026-03-03
30000tstarc_meloxicam37.372026-03-03

UPM+

  • DG01945WOUNDDSTP_wound_or_laceration

Variant (sleepy_king)

WOUND - LACERATION
DSTP_wound_or_laceration
Conf: 0.930
Threshold: 0.60
Above:
Correct?