C09994155 / invoice 10000

Species:FELINE
Breed:Domestic Medium Hair
Age (years):6
Diagnosis or signs:Unspecified
Consult notes
05/03/2026 HISTORY
Presenting for: Lettuce, a desexed female, presented for severe lethargy during the day today. She looked like she was falling asleep in her food.
Diet: Eating a small amount still
V/D/C/S: No coughing, diarrhoea, vomiting, or sneezing

EXAM
Mentation: QAR, a little flat
BCS: 3/5
T: 39.2°C
HR: 200
MM: Pink
Hydration: Normal skin tone
Eyes: Normal
Ears: Normal
Oral: Mild gingivitis around the canines, no lesions on tongue or in mouth
Cardiovascular: Heart sounds normal
Respiratory: Respiratory sounds and lungs normal
Abdominal: Palpates normally, no pain on palpation anywhere on the body
Diagnostics: Blood work largely unremarkable except for mild hypokalaemia and possible banded neutrophils

ASSESSMENT
Lethargy of unknown cause
Fever of unknown origin

PLAN
New Meds/Tx:
- Fluids and antibiotics overnight

Additional Discussion:
- Patient being admitted for unknown cause of lethargy and fever of unknown origin
- If fever persists tomorrow morning, recommend abdominal ultrasound with Marianne
- If patient remains lethargic, doesn't eat overnight, or has any vomiting, schedule abdominal ultrasound
- If normothermic, bright, and eating, can go home on antibiotics for continued monitoring
- Patient has insurance owners are keen to do whatever is best for lettuce - Better to schedule ultrasound tomorrow if required than go into weekend without ability to perform if still unwell saturday

SE

06/03/2026 AM check
Happy in cage but does have some fear and anxiety as is hiding in the towels. Temp: 38.5, MM: PM CRT < 2, HR: 140, RR: 16 with normal effort, Eating chicken, urinated and performed UA, no defecation, no vomit, Skin tent: WNL, MSK/Neuro: NAD

ASSESSMENT: Normothermic today, eating and not lethargic. 

PLAN: O to visit and to assess how Lettuce is compared to yesterday. Two options continue with SCVU ultrasound today or TGH with antibiotics and represent if persists - but need to be aware that ultrasound can only occur on weekdays.

BT

Animal clinical history (3 most recent)

2026-03-06T00:00:00Z 09:45:02
AM check
Happy in cage but does have some fear and anxiety as is hiding in the towels. Temp: 38.5, MM: PM CRT < 2, HR: 140, RR: 16 with normal effort, Eating chicken, urinated and performed UA, no defecation, no vomit, Skin tent: WNL, MSK/Neuro: NAD

ASSESSMENT: Normothermic today, eating and not lethargic. 

PLAN: O to visit and to assess how Lettuce is compared to yesterday. Two options continue with SCVU ultrasound today or TGH with antibiotics and represent if persists - but need to be aware that ultrasound can only occur on weekdays.

BT
2026-03-05T00:00:00Z 19:54:36
HISTORY
Presenting for: Lettuce, a desexed female, presented for severe lethargy during the day today. She looked like she was falling asleep in her food.
Diet: Eating a small amount still
V/D/C/S: No coughing, diarrhoea, vomiting, or sneezing

EXAM
Mentation: QAR, a little flat
BCS: 3/5
T: 39.2°C
HR: 200
MM: Pink
Hydration: Normal skin tone
Eyes: Normal
Ears: Normal
Oral: Mild gingivitis around the canines, no lesions on tongue or in mouth
Cardiovascular: Heart sounds normal
Respiratory: Respiratory sounds and lungs normal
Abdominal: Palpates normally, no pain on palpation anywhere on the body
Diagnostics: Blood work largely unremarkable except for mild hypokalaemia and possible banded neutrophils

ASSESSMENT
Lethargy of unknown cause
Fever of unknown origin

PLAN
New Meds/Tx:
- Fluids and antibiotics overnight

Additional Discussion:
- Patient being admitted for unknown cause of lethargy and fever of unknown origin
- If fever persists tomorrow morning, recommend abdominal ultrasound with Marianne
- If patient remains lethargic, doesn't eat overnight, or has any vomiting, schedule abdominal ultrasound
- If normothermic, bright, and eating, can go home on antibiotics for continued monitoring
- Patient has insurance owners are keen to do whatever is best for lettuce - Better to schedule ultrasound tomorrow if required than go into weekend without ability to perform if still unwell saturday

SE
2022-03-26T00:00:00Z 11:44:37
Presented for final FIV booster
Clipped nails and one nail growing around into paw pad, not painful/no signs of infection

HR: NAD
Respiration: normal
Temp: //
Living condition: inside
Vaccination Status:
   F3 Current
   FIV due
Parasite Protection: 
   Flea control: Revolution plus
   Tick control: "  "
   Heartworm prevention: Revolution plus
   Worming: "  "
Skin: normal
Ears: normal
Eyes: normal
Heart & Lungs: normal
Muscles: normal
Bones & Joints: normal
Teeth & Gums: normal
Intestinal and Urinary Health: normal
Body Condition Score: 3/5
Behavioural Issues: slight FAS
Recommendations: n/a
CM

Previous claim history

DateClaim #Diagnosis
No prior claims.

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_hospitalisation143.652026-03-05
20000tstarc_fluid_therapy333.502026-03-05
30000tstarc_diagnostic_test_-_urine_test81.852026-03-05
40000tstarc_hospitalisation359.002026-03-05
50000tstarc_consultation143.652026-03-05
60000tstarc_diagnostic_test_-_blood_test442.402026-03-05
70000tstarc_diagnostic_test_-_pancreatic_test75.952026-03-05
80000tstarc_antibiotics_-_amoxicillin_and_clavulanic_acid50.502026-03-06
90000tstarc_anticonvulsant_medication_-_gabapentin58.502026-03-06

UPM+

  • DG01504PYREXIA OF UNKNOWN ORIGIN (PUO)DSTP_pyrexia_of_unknown_origin_(puo)

Variant (sleepy_king)

LETHARGY - PRESENTING COMPLAINT
DSTP_clinical_signs_-_lethargy
Conf: 0.680
Threshold: 0.30
Above:
Correct?
Acceptable?
Reason (acceptable)
Diagnosis description