C09991260 / invoice 10000
Species:CANINE
Breed:Cavalier King Charles Spaniel
Age (years):8
Diagnosis or signs:Lameness
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div> <div> <div> <p>Verified: YES</p> </div> </div> </div> <div> <div> <div> <p>Client: Claire</p> </div> </div> </div> <div> <div> <div> <p>History: Lt hind limb lameness x 2 days, bunny hopping gait noted, improved from initial presentation but still abnormal, reluctant to use doggy door, cries until door opened, no yelping<br>- did have LHL lameness August last year but resolved with loxicom<br>normal appetite and drinking, excitement /demeanour normal. <br>- currently on 4cyte daily <br>- post-grooming genital irritation (resolved), frequent urination (owner reports normal for patient)</p> </div> </div> </div> <div> <div> <div> <p>Exam:<br>Mentation: BAR, excited<br>Cardio: HR = PR = 120 bpm, Grade 4 heart murmur auscultated today <br>Resp: RR = panting<br>Eyes: bilateral SNS<br>Ears: slight discharge in both ears but no erythema <br>MM/CRT: pink/moist, CRT<2s<br>Abdomen: soft and comfortable <br>Neuro: both palpaebral and menace reflexes present <br>Musculoskeletal: Bunny hopping gait on hind limbs, Lt hind limb lameness, splayed Lt hind limb when sitting, no pain on palpation and ROM of Lt or Rt stifle or hip (very excited in consult room so difficult to assess). No neck pain with ROM. No back pain on palpation . <br>Rectal: Did not perform rectal exam</p> </div> </div> </div> <div> <div> <div> <p>Assessment:<br>Lt hind limb lameness, bunny hopping gait, abnormal sitting posture with Lt hind limb splayed <br>DDx: Lt stifle pathology,hip dysplasia vs cruciate ligament rupture +/- osteoarthritis </p> </div> </div> </div> <div> <div> <div> <p>Plan:<br>- X-rays Lt hind limb (stifle +/- hip) recommended if no improvement after 5 days loxicom</p> </div> </div> </div> <div> <div> <div> <p>Treatment: <br>- Loxicom dispensed, 5 day course<br><br></p> </div> </div> </div> <div> <div> <div> <p>Recommendations & Client Comms: Strict rest, no walks for minimum 7 days, video gait abnormality at home if possible for review, monitor for improvement on pain medication</p> </div> </div> </div> <div> <div> <div> <p>Recheck: Yes, in 5 days if no improvement on pain medication to reassess and perform X-rays</p> </div> </div> </div></html>
Animal clinical history (3 most recent)
2025-12-09T00:00:00Z 09:40:00
O called as Albert has ingested approximately 50g of cadbury milk chocolate.Checked on toxicity calculator and is currently below the threshold for toxicity. Advised O of this, and still gave the option of emesis if she would like to.Advised may have an upset tummy. O happy to monitor at home and will call if concerned.
2025-09-24T00:00:00Z 11:59:00
Insurance Claim sent to Comm BankDiarr $218.70Food 73.76
2025-09-18T00:00:00Z 11:01:00
Owner name: Male OHx:Has been staying with parents for 2weeks. Noticed diarrhoea and more flat when coming back around 2d ago, yesterday noticed more diarrhoea, then today energy seems better but more diarrhoea on walk in morning with dark red-brown discolouration, and leaky in house. Has also been scooting and chewing at back end. No hx of AG issues.Not overly prone to dietary indiscretion. Maybe will chew on things on walks sometimesNot UTD with worming last tablet march this yeardiet - ivory coat dry kibble no changes recentlyPreviously dx GB1 MMVD on echocardiogramPE:Mentation: BAR, friendly very noisy and barkyCardiac ausc: normal R+R, G2/6 heart murmur PMI L side, pulses synchronousResp ausc: normal lung sounds bilaterallyTemp: 39.5CMM: pink, mildly tackyCRT: ~2sEyes: clearEars: cleanNose: NADTeeth: mild calculus accumulation bilaterallyLN: SM, PS, popliteal wnlAbdo palp: soft and comfortableIntegument: perianal region erythemic and anal sphincter mildly oedematousMSK: normal gait at a walkUrogen: prepuce NADA:Problem list- mild dehydration- acute onset diarrhoea- mild pyrexia- scooting/anal irritationPDx - colitis secondary to infection viral vs bacterial vs protozoal vs internal parasitesDDx- gastroenteritis- pancreatitis- neoplasiaSuspect AG impactionPlan:Expressed both anal glands both full and turgid approx 1.5cm diameter each, watery brown fluidRc GIT low fat food only for next 5dDexamethasone 0.1mg/kg SC to relieve perianal inflammationAdministered milbemax 5-25kg tablet po in consultNo need for r/c if improvementCommunication:If no improvement within 48hrs, or becomes flat and lethargic, inappetant, starts vomiting etc then r/c and consider blood testing, faecal antigen testing +/- abdominal ultrasound.19/9 NCB Seems ok, had been vomitting overnight a few times. Seems brighter so owner is one the fence. Explained vet has recommended if vomitting started or albert wasn;t improving them bloods are recommended. Diar has stopped and Albert is brighter so o has booked an appointment for tomorrow and would like to cont to observe. If better tomorrow will cancel or if things change this everning o will call to come in or go to GAE if AH. mc
Previous claim history (4)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2023-04-19 | C5824758 | EAR INFECTION |
| 2022-03-28 | C4617160 | SYRINGOMYELIA |
| 2022-03-12 | C4591604 | SYRINGOMYELIA |
| 2022-03-09 | C4582012 | SYRINGOMYELIA |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 128.95 | 2026-03-05 | — |
| 20000 | tstarc_meloxicam | 75.43 | 2026-03-05 | — |
UPM+
- DG02023GAIT ABNORMALITY - LAMENESS - PRESENTING COMPLAINTDSTP_clinical_signs_-_lameness
Variant (sleepy_king)
GAIT ABNORMALITY - LAMENESS - PRESENTING COMPLAINT
DSTP_clinical_signs_-_lameness
Conf: 0.520
Threshold: 0.37
Above: ✓
Correct?