C09994525 / invoice 10000
Species:CANINE
Breed:Pomeranian Cross
Age (years):1
Diagnosis or signs:Lethargic
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div> <div> <div> <div><span style="color: #ff0000;">Have reminders been checked? Y/N</span><br><span style="color: #ff0000;">Has the owner been advised of this? Y/N</span><br><br><strong>GapOnly claim Insurance Summary</strong><br><strong>First Clinic Signs: start of the week some coughing/sneezing. Lethargic this a.m.</strong><br><strong>Diagnosis/Suspected: open - something viral? allergies, other?</strong><br><strong>Summary/Suspected Cause: open - something viral? allergies, other?</strong><br><strong>Any other conditions being treated/known health concerns(if any): none</strong><br><strong>Existing Treatment/Plan: Monitor. Further action if indicated. Eye flush. Antihistamines discussed</strong><br><br>History:<br>Since Monday waking up sneezing and a bit congested. Reverse sneezing. Can do this when she drinks water as well.<br>- some coughing Monday/Tuesday<br>Watery eyes.<br>Now yesterday morning and today a bit quieter. Slowly eating less. <br>Could be being picky.<br>Goes to the dog park<br>No V+, faeces a bit firmer than normal<br><br>Diet the same - bit of poached chicken, mince, zuchini veges<br>RC dry<br><br>Walked BID<br>Pex:<br> <div>MM pink, CRT <2s. </div> <div>CV/Resp: heart auscultates clear, no murmur noted. Clear breath sounds in all lung fields on auscultation, normal effort.</div> <div>Ocular: Eyes clear, no discharge, no blepharospasm. </div> <div>Aural: Ears no discharge, no erythema, no odour. </div> <div>Nasal: No nasal discharge.</div> <div>Oral: DG _ <br>GI/UG: abdominal palpation - soft and no obvious abnormalities palpated<br>Integ: skin in good condition, no lesions<br>PLN: peripheral lymph nodes palpable < 1cm<br>MSK: Ambulating without lameness.</div> <div>Endo:</div> <div> </div> Prob List: </div> </div> </div> </div> <div> <div> <div> <div><br>Assessment:<br> <br>Tx:<br><br>Plan: </div> </div> </div> </div></html>
Animal clinical history (3 most recent)
2026-02-12T00:00:00Z 15:39:00
-O called has V+ last two days -eating/drinking fine-energy levels normal -no other concerns -asked O if she vomited day after sx prior to the first loxi dose -O let me know wasn't V+ pre loxi doses-isn't taking traz, has been fine , not needed-explained to O loxi can cause gastro upset but I will check that MT is happy for her to stop giving loxi and monitor -called O back re advice - stop loxi, call if still V+ tomorrow and book recheck
2026-02-11T00:00:00Z 10:31:00
Eating and drinking good. Had a small V+ when they got home yesterday however nothing since. Toiletting good. SX site good. Demeanour good. O has no concerns.
2026-02-10T00:00:00Z 08:18:00
Have reminders been checked? YHas the owner been advised of this? YHx:Presented today for spey. Has been doing well at home and no concerns. Fasted overnight EDDU well and no coughing, sneezing, vomiting or diarrhoea.Meds: None Exam:MM: Pink, moist <2 sec HR: No murmur or arrhythmias RR: Lung sounds clear Oral: Both upper and lower left deciduous canines present and lower right 3rd deciduous incisor still present. Temp: 38.8PreGA:MON 0.51 (0 - 0.4)EOS 0.91 (0 - 0.8)GLU 6.2 (3.3 - 6.1)All remaining within normal limits. Sedation:Medetomidine 0.03ml (0.01mg/kg) + Methadone 0.09ml (0.3mg/kg) Heavy level of sedation 24G catheter placed into the left cephalic vein.Induced with 0.3ml alfaxIntubated with an 4.5mm ET tubeMaintained on ISOHartmann's @ 17ml/hrProcedure:Bladder was expressed with manual palpation. The hair was clipped from xiphoid to pubis and the area was surgically prepped. A routine ovariohysterectomy was performed. A midline incision was made and the uterus was identified. Both ovaries and the uterine pedicle were ligated with 3/0 monosyn using strangulating knot. Linea alba was closed with 3/0 monosyn in a simple continuous pattern. Subcutaneous layer closed with 3/0 monosyn in a continuous pattern with buried knots. The skin was closed with 3/0 monosyn in an intradermal pattern. A tattoo was placed into the left ear. A fixomol dressing was placed over the incision.The deciduous left upper and lower canines + lower incisor were extracted with elevation and traction. Meloxicam 0.05ml SC upon wake up.Maintained well under general anaesthetic and recovered uneventfully.Discharge:Normal discharge instructions.Sent home with meloxicam to be given after 11am tomorrow and an E-collar.Take home sedation: Trazodone 50mg BID. Reduce to 25mg BID if too sedating.
Previous claim history (5)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-02-10 | C09880528 | BLOOD SCREEN |
| 2026-02-10 | C09880528 | DESEXING |
| 2026-02-10 | C09880528 | DENTAL (TOOTH) DISORDER |
| 2025-11-12 | C9481782 | VACCINATIONS OR HEALTH CHECKS |
| 2025-11-12 | C9481782 | CONJUNCTIVITIS |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 97.00 | 2026-03-06 | — |
UPM+
- DG01549REVERSE SNEEZINGDSTP_clinical_signs_-_reverse_sneezing
Variant (sleepy_king)
SNEEZING - PRESENTING COMPLAINT
DSTP_clinical_signs_-_sneezing
Conf: 0.460
Threshold: 0.19
Above: ✓
Correct?
Reason (correct)