C09996122 / invoice 10000
Species:CANINE
Breed:Labrador Cross
Age (years):1
Diagnosis or signs:Revisit
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><p>Subjective: <br>Pet's signalment: (Name not stated), 11-month-old, Labrador Retriever, Female Intact<br>History: The patient is presenting for a follow-up examination regarding a previously noted hooded vulva and to discuss scheduling an ovariohysterectomy. The owner reports the patient is doing well. Her first estrous cycle concluded approximately two weeks ago. There has been a period of decreased appetite, which the owner attributes to receiving an excess of treats. The owner also notes the patient's anal glands were recently expressed. There is no history of recurrent urinary tract infections or other clinical signs associated with her vulvar conformation.<br>Diet: Not specified, but owner notes patient receives many treats.<br>HW/ flea + tick preventative: Not discussed.<br>Current Medications / supplements: Owner has prescribed calming tablets at home.<br>Any vaccine or medication reactions: Not discussed.<br>Recent blood test: None.<br><br>Objective: <br>Weight: - kg<br>Temperature: Not taken<br>HR: WNL<br>RR: WNL<br>BCS: 5 out of 9<br>FAS: Green<br>Hydration: Hydration appears normal<br>Eyes: no clouding, no debris, sclera is clear. Pupil sizes are symmetrical<br>Nasal: Patent and clear. No lesions or other abnormalities<br>Ears: No debris or erythema<br>Oral Cavity: healthy teeth and gums<br>Cardiovascular: no murmur or arrhythmia, strong pulses.<br>Respiratory: Lungs sounds are clear, no crackles or wheezes<br>Abdomen: comfortable on palpation, no mass effect, no fluid wave<br>Musculoskeletal: Normal ambulation, Normal ROM<br>Integument: skin looks normal; hair coat in good condition. No ectoparasites. No masses found.<br>Lymph nodes: Lymph nodes are soft and small<br>Urogenital: External genitalia appears normal; bladder palpates normally. VULVA IS HOODED WITH A SIGNIFICANT PERIVULVAR SKIN FOLD. MILD VULVAR SWELLING AND EDEMA ARE PRESENT, CONSISTENT WITH THE RECENT ESTROUS CYCLE. A TRACE AMOUNT OF VULVAR DISCHARGE WAS NOTED. The conformation does not appear to predispose the patient to urine pooling.<br>Neurologic: Normal mentation<br><br>Assessment: <br>Problem List:<br>1. Hooded vulva with excessive perivulvar skin fold, currently asymptomatic.<br>2. Post-estrus changes (approximately 2 weeks post-heat).<br>3. Healthy patient presenting for routine ovariohysterectomy planning.<br><br>Differentials: Stable on exam<br><br>Plan: <br>Treatments: None at this time.<br>Diagnostics Completed: Physical examination.<br>Prescriptions: None.<br>Follow up:<br>- Ovariohysterectomy has been scheduled for Thursday, April 2, 2026. This will be approximately six weeks post-estrus.<br>- A discussion was had regarding the benefits of delaying spay until after the first heat cycle in large breed dogs.<br>- A vulvoplasty is not recommended at this time due to the absence of clinical signs such as recurrent UTIs. This can be reconsidered in the future if the patient becomes symptomatic.<br>- Pre-anesthetic blood work was recommended and will be performed on the day of the procedure.<br>- The use of pre-operative anxiolytic medication was discussed and will be determined on the day of surgery based on the patient's anxiety level.<br><br></p></html>
Animal clinical history (3 most recent)
2026-01-24T00:00:00Z 17:08:00
Traz/Gaba for situational anx (mainly vet)Needs freq visits for AG and other and anx escalating
2026-01-24T00:00:00Z 10:36:00
Anal glands manually expressed today. Full both sides, N consistency.Getting very stressed due to frequent expression. crying and trying to run away. O interested in chill protocol for future Advised to keep record of frequency or manual expressions, may need to book appt with vet if continues
2025-12-24T00:00:00Z 13:57:00
Anal glands manually expressed.
Previous claim history (9)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-01-24 | C09807033 | BEHAVIOURAL THERAPY |
| 2026-01-01 | C09697222 | ALLERGIC REACTION |
| 2026-01-01 | C09708273 | ALLERGIC REACTION |
| 2025-12-24 | C09674616 | Preventative/Elective Procedure |
| 2025-10-11 | C9339276 | HYPERSENSITIVITY (ALLERGIC) SKIN DISORDER |
| 2025-09-03 | C9177068 | EYE CONDITIONS |
| 2025-08-29 | C9155046 | DESEXING |
| 2025-08-29 | C9155046 | FLEA/TICK/WORM CONTROL |
| 2025-08-29 | C9155046 | HEARTWORM CONTROL |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation-revisit | 104.00 | 2026-03-06 | — |
UPM+
- DG01942VULVAL DISORDERDSTP_vulval_and_vaginal_disorder
Variant (sleepy_king)
ANAL SAC DISORDER
DSTP_anal_sac_disorder
Conf: 0.260
Threshold: 0.54
Above: ✗
Correct?
Acceptable?
Reason (not acceptable — misleading)
Diagnosis description