C09984345 / invoice 10000

Species:CANINE
Breed:Golden Retriever Cross
Age (years):1
Diagnosis or signs:hospital treatment
Consult notes
04/03/2026 Consultation nurse: LVS

Reason for presentation: possible partial pepsi can ingestion 

History for today:
O went out for half hour and when came back noticed Leo has chewed up pepsi can 
No blood anywhere, no bleeding in mouth that O can see 
Otherwise has been healthy 

Previous medical/surgical concerns:
Anxiety
15/10/25 - ingested part of a white board marker
15/08/2025: Behavioural consult (intermittent hyperarousal, emotional dysregulation, frustration intolerant, resource guarding, jumping, mouthing, aggression).
25/07/2025: Castration.
06/2025: Acute gastroenteritis.

Current medications:
Fluoxetine 10mg SID 
Pregabalin 75mg BID 

Examination:
BAR - limited exam as avoidant and busy
BCS 4-5/9
Eyes grossly nad
MM pink/moist
Hydration good
Cardio 140bpm, reg, no murmur
Resp approx 28bpm, intermittently sniffing
Abdo palp n/a 
Temp n/a

Plan: 
Admit for screening x-ray 

Sedation: 
Medetomidine 0.04mls + butorphanol 0.26mls SC with O present - adequate sedation
Atipamezole 0.04mL IM post op

Diagnostic imaging:
Lateral imaging of oesophagus and stomach - no evidence of ingested aluminium can

Plan:
No further intervention needed

Animal clinical history (3 most recent)

2026-02-13T00:00:00Z 14:14:58
WRITTEN SCRIPT 
Last seen: 17.12.25
Pregabalin 75mg x 280 (56 x5)
1 BID
Paula - JP


Repeat prescription
History/Current Medical Conditions:  anxiety
Usual case manager: KW and kat gregory
Medication required: pregab script
Current medications and doses given:
pregab 75mg 1 BID
fluox 10mg SID ?
Sertraline 50mg 1/4 sid
Date of last consultation:12/25
Date of last blood tests:  12/25
Date last prescription repeat sticker applied: 
Comments:
2025-12-18T00:00:00Z 09:58:54
Staff member making call :  TC
Which family member spoken with: Paula

Recall reason: sedate + ultrasound

Patient Report:
Demeanour - Better today
eating - eaten lots
drinking - Y
urine - Y
faeces - not yet

any problems with medicating? 
wound/s healing OK ? 
appointment made for revisit ?  o to report back in a week after ceasing fluoxetine

Previous claim history (8)

DateClaim #Diagnosis
2025-12-17C09639300GASTROINTESTINAL PROBLEMS
2025-12-15C09629405GASTROINTESTINAL PROBLEMS
2025-10-22C9387887DIETARY INDISCRETION - FOREIGN BODY INGESTION - PRESENTING COMPLAINT
2025-10-15C9363760DIETARY INDISCRETION - FOREIGN BODY INGESTION - PRESENTING COMPLAINT
2025-07-25C9030115DESEXING
2025-07-25C9030115BLOOD SCREEN
2025-07-18C8980071VACCINATIONS OR HEALTH CHECKS
2025-06-12C8831784GASTROENTERITIS

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_sedation_for_procedure23.872026-03-04
20000tstarc_opioids_-_butorphanol33.012026-03-04
30000tstarc_consultation175.002026-03-04
40000tstarc_sedation_reversal_agent23.702026-03-04
50000tstarc_procedure_fee_-_radiology290.002026-03-04
60000tstarc_hospitalisation46.002026-03-04

UPM+

  • DG01992DIETARY INDISCRETION - FOREIGN BODY INGESTION - PRESENTING COMPLAINTDSTP_foreign_body_ingestion

Variant (sleepy_king)

DIETARY INDISCRETION - FOREIGN BODY INGESTION - PRESENTING COMPLAINT
DSTP_foreign_body_ingestion
Conf: 0.420
Threshold: 0.19
Above:
Correct?