C09992911 / invoice 10000
Species:CANINE
Breed:Pomeranian Cross
Age (years):2
Diagnosis or signs:Consult
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><br> <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></html> </br><p>HISTORY<br>Presenting for: Draco presented for acute onset of unilateral eye discharge and discomfort noticed this morning, suspected to be caused by trauma from another dog (puppy) at home.<br>Current Meds: Multiple dogs at home, puppy going through active/terror stage and not fully toilet trained<br>Lifestyle Risk Factors: Multiple dogs in household, puppy interactions</p><p>EXAM<br>Mentation: BAR<br>Wt:<br>BCS:<br>T:<br>HR:<br>R:<br>MM:<br>Hydration:<br>Behavioural: Very good during examination, cooperative and calm. Accepts treats readily.<br>Eyes: Left eye shows significant conjunctivitis with purulent discharge, conjunctiva very red and swollen with blepharospasm. Right eye normal - white and clean. Pupils both responding normally to light stimulation. Eye colour normal (heterochromia - one brown, one blue eye). Patient showing significant discomfort and pawing at affected eye.<br>Ears:<br>Nose:<br>Throat:<br>Oral:<br>Cardiovascular:<br>Respiratory:<br>Abdominal:<br>Lymph Nodes:<br>Integumentary:<br>Neurologic:<br>Musculoskeletal:<br>Urogenital:<br>Rectal:<br>Diagnostics: Fluorescein stain - negative for corneal ulceration or scratches. No foreign material detected under eyelids on examination.</p><p>ASSESSMENT<br>Conjunctivitis - DDx: trauma from puppy interaction, infectious cause, foreign body irritation, dust/wind irritation</p><p>PLAN<br>New Meds/Tx:<br>- Topical antibiotic ointment applied to affected eye, to be continued 3 times daily at home<br>- E-collar dispensed for use when unsupervised to prevent further trauma from rubbing<br>- Local anaesthetic applied during examination for comfort</p><p>Additional Discussion:<br>- Clean discharge with saline and cotton ball before applying ointment<br>- Wash hands thoroughly after treatment to prevent spread<br>- Monitor other dogs at home for signs of conjunctivitis if infectious cause<br>- Expected improvement within 48 hours</p><p>Client Comms:<br>- Recheck if no improvement in 48 hours or if condition worsens<br>- Watch for increased swelling, inability to open eye, thick discharge, or changes in corneal appearance<br>- Eye may feel better temporarily due to local anaesthetic but will require ongoing treatment</p>
Animal clinical history (3 most recent)
2026-01-21T00:00:00Z 11:05:00
HISTORY Here for annual vaccinationCheck teeth EEDDU: WNLMeds: NilC-/S-/V-/D-PHYSICAL EXAMINATION Mentation: BARVitals: NADEENT: NADCARDIAC: WNLRESP: NADSKIN: NADDENTAL: 1/4 - little bit of plaque starting to build up but no indication for S&P yetABD. PALP: NADASSESSMENT Fit to vaxDental Health - dental brushing recommended at home brushingVACCINATION Durammune C3 Triannual given SQ Protech Pi2 given SQ Protech Bronchi-shield KC given oral Protein C2i given SQPLAN - C3 due in 3 years - KC + C2i due in 1 yearJR
2024-12-14T00:00:00Z 09:03:12
Examination Text:Reason: Boarding until 16/12/24Owner Contact Details: 0409198843Emergency Number:Amount owner has approved to spend if not contactable: $Regular Vet (if not EVH):Deposit taken (y/n):Vaccinations (done/needed):Heartworm prevention?:Flea tx (date given/type or needed) spectraMEDICATIONS: nilFEEDING: 1 cup BELONGINGS:SERVICES REQUESTED WHILE BOARDING:PROBLEMS NOTED AT HOME:
2024-12-13T00:00:00Z 14:21:32
Examination Text:--- 13/12/2024 14:20:38 CN:Vc form and text sent Boarding 14/12/2024/16/12/2024
Previous claim history (4)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-01-21 | C09789012 | VACCINATIONS OR HEALTH CHECKS |
| 2025-01-17 | C8214708 | VACCINATIONS OR HEALTH CHECKS |
| 2024-12-11 | C8061400 | VACCINATIONS OR HEALTH CHECKS |
| 2024-08-14 | C7591789 | INTOXICATION (POISONING), DRUG - PHENOBARBITAL |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_diagnostic_test_-_fluorescein_eye_stain | 19.30 | 2026-03-05 | — |
| 20000 | tstarc_consultation | 115.00 | 2026-03-05 | — |
| 30000 | tstarc_eye_medication_-_antibiotics_and_anti-inflammatory | 54.79 | 2026-03-05 | — |
| 40000 | tstarc_elizabethan_(buster)_collar | 11.77 | 2026-03-05 | — |
UPM+
- DG00512CONJUNCTIVITISDSTP_eyelid_-_conjunctivitis
Variant (sleepy_king)
CONJUNCTIVITIS
DSTP_eyelid_-_conjunctivitis
Conf: 0.910
Threshold: 0.25
Above: ✓
Correct?