C09984912 / invoice 10000
Species:CANINE
Breed:Pomeranian
Age (years):6
Diagnosis or signs:Check Ears
Consult notes
04/03/2026 History Shaking head lots yesterday - unsure if ears are bothering him? Has had one infection before a year ago in R ear - resolved with ear drops EDUF normally otherwise BIOP since 2023 - one episode of back pain, resolved with rest and pain-relief. Also reportedly had pancreatitis prior to adoption Physical exam BAR, a little anxious but good when going slow. Did try to bite with otoscope though! MM Pink, moist CRT <2s HR 96 Cardiac ausc NAD RR panting Lung sounds Clear Abdo palp Tense, likely stress-related Pulses: normal, = temp not taken LNs: WNL EENO Dental disease 3/4, could not look into mouth too much as mouth shy. L ear NAD from afar, R ear canal has some yellow brown discharge, but only slightly erythemic. Would not tolerate otoscopic exam Skin NAD MSK & Neuro: Ambulatory, not fully assessed Cytology of ears: L ear NAD R ear ++ cocci. Problem list: 1. R otitis externa Ddx: allergies (atopy, contact, food, etc) vs FB vs parasites vs other Client comm: Discussed cycle of allergies. Given frequency of ear infection at this stage is not too frequent (1x a year), can consider treating as needed, but if more frequent need to trial something to control itch before secondary infection happens. 2. Dental disease Plan: Trial keto/dex/enro drops 0.3ml into R ear BID x7d RV INI O to consider dental soon - has some personal issues to deal with first
Animal clinical history (3 most recent)
2026-03-04T00:00:00Z 10:09:15
History Shaking head lots yesterday - unsure if ears are bothering him? Has had one infection before a year ago in R ear - resolved with ear drops EDUF normally otherwise BIOP since 2023 - one episode of back pain, resolved with rest and pain-relief. Also reportedly had pancreatitis prior to adoption Physical exam BAR, a little anxious but good when going slow. Did try to bite with otoscope though! MM Pink, moist CRT <2s HR 96 Cardiac ausc NAD RR panting Lung sounds Clear Abdo palp Tense, likely stress-related Pulses: normal, = temp not taken LNs: WNL EENO Dental disease 3/4, could not look into mouth too much as mouth shy. L ear NAD from afar, R ear canal has some yellow brown discharge, but only slightly erythemic. Would not tolerate otoscopic exam Skin NAD MSK & Neuro: Ambulatory, not fully assessed Cytology of ears: L ear NAD R ear ++ cocci. Problem list: 1. R otitis externa Ddx: allergies (atopy, contact, food, etc) vs FB vs parasites vs other Client comm: Discussed cycle of allergies. Given frequency of ear infection at this stage is not too frequent (1x a year), can consider treating as needed, but if more frequent need to trial something to control itch before secondary infection happens. 2. Dental disease Plan: Trial keto/dex/enro drops 0.3ml into R ear BID x7d RV INI O to consider dental soon - has some personal issues to deal with first
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 | 110.20 | 2026-03-04 | — |
| 20000 | tstarc_diagnostic_test_-_cytology | 60.50 | 2026-03-04 | — |
| 30000 | tstarc_ear_medication_-_antibacterial_and_anti-fungal | 116.39 | 2026-03-04 | — |
UPM+
- DG01185OTITIS EXTERNADSTP_otitis_externa
Variant (sleepy_king)
OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.880
Threshold: 0.07
Above: ✓
Correct?