C09990670 / invoice 10000
Species:CANINE
Breed:Cavoodle
Age (years):5
Diagnosis or signs:Eyes
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div> <div> </div> </div> <div> <div> <p><strong>HISTORY </strong><br><br><strong>EXAM</strong><br><br><strong>ASSESSMENT </strong><br><br><strong>LABORATORY</strong><br><br><strong>TREATMENT </strong><br><br><strong>PLAN</strong><br><br><strong>OWNER COMMUNICATION</strong></p> </div> </div></html> </br><p>HISTORY<br>Presenting for: Rito, a 5.5 year old dog, presented for right ocular discharge and irritation noticed yesterday when the owner came home from work. Large yellow discharge observed with redness and the dog was pawing at the eye. Pain noted when owner attempted to examine the eye.</p><p>Historical Conditions: Previous eye injury from running against bushes, resulting in corneal laceration</p><p>Diet: Eating normally, very well appetite, normal behaviour otherwise</p><p>Current Meds: Up to date with routine preventatives</p><p>EXAM<br>Mentation: BAR<br>Wt: 9.1 kg<br>BCS: 6/9<br>HR: 120<br>R: 24<br>MM: Pink and moist<br>Hydration: Normal<br>Behavioural: Accepts treats readily during examination<br>Eyes: Left eye normal. Right eye shows moderate to marked scleral injection, marked conjunctival hyperaemia, mild to moderate epiphora, mild mucoid discharge. Third eyelid gland visible but normal. Fundic examination normal with clear visualisation of retina<br>Oral: Clean teeth, dental grade 0-1/4<br>Cardiovascular: Heart sounds normal<br>Integumentary: Mild tear staining noted bilaterally (white discharge), more pronounced on right. Some paw licking noted but skin appears normal, likely related to underlying mild allergies. Currently rubbing right eye due to irritation<br>Diagnostics: Fluorescein stain negative. Tonometry 10 mmHg (normal, lower end of range). Fundic examination normal</p><p>ASSESSMENT<br>Right conjunctivitis - likely secondary to contact irritant or allergy. No corneal damage detected. Eye pressure normal, no signs of uveitis</p><p>PLAN<br>New Meds/Tx:<br>- Dexamethasone 0.9 mL SC administered today to reduce pruritus and prevent self-trauma<br>- MaxiDex eye drops BID to right eye for 5-7 days. Shake before use</p><p>Additional Discussion:<br>- If eye becomes cloudy or condition worsens in next 24-48 hours, return immediately<br>- May require Elizabethan collar if continued self-trauma occurs despite treatment<br>- Nail trim performed by nursing staff</p><p>Client Comms:<br>- Nurse follow-up call scheduled for Saturday to monitor progress<br>- Recheck only as needed if no improvement or worsening noted<br>- Treatment should reduce irritation and prevent further rubbing</p>
Animal clinical history (3 most recent)
2026-01-10T00:00:00Z 11:47:00
no answer, LVM to call back
2026-01-09T00:00:00Z 08:47:00
PROCEDURE: Dental**If extractions, pls call O. However, if she doesn't answer, proceed in patient's best interests as long as within estimate**Estimate issued to owner (y/n): 900-1600Deposit taken (y/n): NoContact name and number for day of surgery: 1. Kelly 0406505716 or 2. Jonathan 0477777622Any current medications? What and when last given: NoneREQUESTED EXTRAS: Pre anaesthetic bloods (y/n): YESVaccination (done/needed/declined): doneOther procedures required (specify): CLIP NAILSPreanaesthetic Examination: Laboratory: Pre GA blood...normal.Premed: Medetomidine 0.08/methadone 0.08ml IMInduction/maintenance:Alfaxan Iv to effect, intubate, iso maintenance.DENTAL: moderate tartar on premolars and canines, some gingival recession canines, but only 1-2mm subgingival pockets.103 has chip at tip of crown, but no exposed pulp.Scale and polish all teeth. No extractions needed.Nail trim.
2026-01-02T00:00:00Z 10:24:00
HISTORYPresenting for: Rito, a female cavalier cross cocker spaniel, presented for health check and vaccination. She is due for a C7 vaccine.Current Meds: NexGard Spectra monthlyEDDU normallyEXAMMentation: Bright, alert, and responsiveWt: 8.2 kgBCS: 5/9 (ideal body condition, nice waist)T: 38.9°CHR: 120 bpmR: PantingMM: Pink and moist, CRT <2 secondsHydration: NormalEyes: NormalEars: NormalSkin: NormalLymph Nodes: Within normal sizeAbdominal: Nice and relaxedIntegumentary: NormalMusculoskeletal: NormalASSESSMENTApparently healthy - Ok to vaccinatePLANVaccinations:- KC vaccine plus coronavirus and leptospira vaccine plus C3 triannual. Next vaccination due in one year.Client Comms:- Advised owners about possible lethargy or tiredness after vaccination- Discussed possible allergic reactions to monitor
Previous claim history (3)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-01-09 | C09735240 | DENTAL (TOOTH) DISORDER |
| 2026-01-02 | C09698616 | VACCINATIONS OR HEALTH CHECKS |
| 2025-01-04 | C8154666 | VACCINATIONS OR HEALTH CHECKS |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 110.00 | 2026-03-05 | — |
| 20000 | tstarc_diagnostic_test_-_fluorescein_eye_stain | 18.70 | 2026-03-05 | — |
| 30000 | tstarc_diagnostic_test_-_tonometry | 47.90 | 2026-03-05 | — |
| 40000 | tstarc_corticosteroid_injection | 44.01 | 2026-03-05 | — |
| 50000 | tstarc_eye/ear_medication_-_maxidex | 75.80 | 2026-03-05 | — |
UPM+
- DG00512CONJUNCTIVITISDSTP_eyelid_-_conjunctivitis
Variant (sleepy_king)
CONJUNCTIVITIS
DSTP_eyelid_-_conjunctivitis
Conf: 0.420
Threshold: 0.25
Above: ✓
Correct?