C09994185 / invoice 10000
Species:CANINE
Breed:Golden Doodle (Groodle)
Age (years):0
Diagnosis or signs:recheck ears
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><p><strong>Subjective</strong><br>Presents for scratching of the left elbow and a recent history of ear issues.<br>- Scratching the left elbow intermittently, described as a knobbly bit of flesh. No licking reported, only scratching with the hind limb.<br>- Owner reports scratching is localised to this area, though occasional scratching elsewhere.<br>- No hair loss or other skin changes noted by owner.<br>- History of ear problem ~22 days ago, treated with ear drops for 7 days.<br>- Yesterday, observed running at an angle with legs leaning to the right at the dog park. Owner unsure if this is significant.<br><br><strong>Objective</strong><br>- Age: 5 months (born 08/10/2025). Appears larger than expected for age.<br>- General: Bright, alert, and responsive. Excited but cooperative for examination.<br>- Skin: left elbow region clipped. No foreign body (e.g., grass seed) palpable or visible. No erythema, swelling, or scabbing noted on initial inspection. A small scab was found on closer examination after clipping. No other skin lesions.<br>- Ears: Ceruminous debris present in both ear canals. No evidence of infection or malodour. Tympanic membranes appear normal on otoscopy.<br>- Gait: Observed walking outside. Gait appeared normal.<br><br><strong>Assessment</strong><br>- left elbow pruritus, likely secondary to environmental allergy (atopy) or a foreign body.<br>- Bilateral ceruminous otitis externa.<br><br><strong>Plan</strong><br>- Skin:<br>- Monitor for any changes in the elbow lesion.<br>- If pruritus persists or worsens, consider systemic anti-pruritic medication.<br>- Ears:<br>- O: Clean ears weekly with an ear cleaner (e.g., Epi-Otic) using cotton pads. Ensure ears are dried thoroughly after cleaning and bathing.<br>- O: Use remaining ear drops (PMP) if scratching of the ears resumes until re-examination.<br>- Advised to present for re-check immediately if ear scratching begins to prevent secondary infection and complications requiring sedation for cleaning.<br>- Follow-up:<br>- Re-check in one week if no improvement or if concerns arise.</p></html>
Animal clinical history (3 most recent)
2026-02-24T00:00:00Z 14:00:00
Subjective:- Excessive scratching noticed since owner returned from overseas 10 days ago; scratching started before owner left- Scratching mainly on left elbow, also near chest and right ear- Licking noted further down on body- First groom occurred 06/02/2026 (scissor cut)- Got muddy after being left outside in rain day before yesterday; mud in ears notedPast Medical History:- Up to date with worming and flea treatments- Currently on Nexgard Spectra (20kg)- Diet: Lyka in mornings, specialty kibble (same since birth, no change)- Regular grooming: brushed daily, teeth cleaned weekly, ears cleaned weeklyObjective:- Weight: 20kg- MM pink, CRT< 2- Good teeth - Heart sounds normal- Lungs sound normal - NAD on ab palp- Skin: looks good overall- Right ear: quite dirty , + yeast - Left ear: not too bad, neg Assessment:OE on R Pruritus - possible atopy Plan:PMP 0.5ml BID in R ear for 7 days Recheck in 2 weeks Discussed antipruritic meds, consider cytopoint. Given not scratching today, elected to monitor first
2026-02-21T00:00:00Z 08:59:00
left elbow skin is dry and hot. benji is very wriggly and fluffy so difficult to see, but redness present. o asked if i could look at because hes been using other leg to scratch it. fur also feels thinner and dry.suggest skin consult & spoke of possible causeso will book in next week.discussed desxing pros & cons of waiting till 12 month mark. will most likely wait till 12 months for development reasonshas been pulling lots. discussed benefits of harness training. has lead & collar atm. o just waiting for him to finish growing before investing in quality harness.benji doing well at puppy traininggiving popantel at home.
2026-01-19T00:00:00Z 10:58:00
final puppy vacc d+ on saturday whole day - started beore rock eatingfound some rocks in backyard saturday arvo - unsure if have ingested any energy good, no v+ normal stools ytd and today eating ok, appetite goodscab under chin - scratching occassionally examination:BA, mm pink and moist, crt 1-2 eyes - nad ears - nad Oral - dentition appropriate for age heart, lungs nad msk nad Client comms:discussed vacc today or hold off givne recent GI signs - O elected to vacc today c4 vacc given SCc5 due in 1 years time
Previous claim history (3)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-02-24 | C09947561 | OTITIS EXTERNA |
| 2026-01-19 | C09776606 | VACCINATIONS OR HEALTH CHECKS |
| 2026-01-19 | C09776606 | FLEA/TICK/WORM CONTROL |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation-revisit | 110.00 | 2026-03-06 | — |
UPM+
- DG01185OTITIS EXTERNADSTP_otitis_externa
Variant (sleepy_king)
OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.800
Threshold: 0.07
Above: ✓
Correct?