C09997078 / invoice 10000
Species:CANINE
Breed:Labrador
Age (years):5
Diagnosis or signs:See notes
Consult notes
06/03/2026 HOSPITAL NOTES: ---------------------------------------------------------------------------------------------------------------- Dog Venous ** A. Gases: pH: 7.394 (7.350-7.450) pCO2: 40.0 (35.0-38.0 mmHg) pO2: 55.0 (85.0-100.0 mmHg) cHCO3-: 24.4 (15.0-23.0 mmol/L) BE (ecf): -0.4 (-5.0-0.0 mmol/L) cSO2: 88.0 (90.0-100%) B: Chem: Na+: 151 (139-150 mmol/L) K+: 4.0 (3.4-4.9 mmol/L) Ca++: 1.41 (1.12-1.40 mmol/L) Cl-: 112 (106-127 mmol/L) TCO2: 23.6 (17.0- 25.0 mmol/L) Hct: 20 (35-50%) cHgb: 12.2 (12.0-17.0 g/dL) BE (b): (-5.0-0.0 mmol/L) C: Meta: Glu: 7.2 (3.3-6.4 mmol/L) Lac: 1.14 (0.60-2.90 mmol/L) BUN: 13 (10-26 mg/dL) Urea: 4.7 (3.6-9.3 mmol/L) Crea: 74 (44-115 umol/L) BUN/Crea: 15.6 (0.2-400.00 mg/mg) ------------------------------------------------------------------------------------------------------------------- 06/03/2026 GAP Hx Presented for 2d Hx of inappetance, vomiting and lethargy Bloods unremarkable Abdo US/rads show large abdominal effusion- abdominocentesis performed, cloudy pink tinged fluid Cytology large round cells and neuts, no evidence of bacteria. Fluid glucose equal to blood glucose Ddx neoplasia, inflammatory Plan: send to PVE Cannington for care and CT scan, and hopefully get novovet to get onto cytology quicker that idexx.
Animal clinical history (3 most recent)
2025-08-28T00:00:00Z 11:28:25
Record complete (Y/N): y Reason: Vaccination History: Bruce has presented for vaccinations, no concerns, EDUF normal, no V+/D+ and he is not on any medications. Pre-existing conditions: overweight Current medications: no medications being provided at time of examination Prophylaxis: vaccination and parasite prophylaxis is UTD Appetite: normal Drinking: normal Urination: normal Defecation: normal D+, V+, coughing? none PE Mentation: BAR BCS: 4/5 MM: pink and moist CRT: 1-2s HR: 110 bpm, no murmurs or arrhythmias detected PR: normodynamic and synchronous RR: normal effort and no abnormal lung sounds Temp: not taken Ocular: no abnormalities noted on cursory examination of both eyes Oral/dental stage: 1/4 Ears: no abnormalities noted on cursory examination of both ears LN: submandibular, prescapular and popliteal are small, symmetrical, non-painful and WNL on examination Abdo: no pain on abdominal palpation, no organomegaly or masses palpated Integument: normal skin turgor, no significant abnormalities Urogenital: no significant abnormalities MSK: ambulatory, normal gait and strength noted. No evidence of lameness Rectal exam: not performed Neuro exam: no evidence of neurological impairment or altered mentation. Full neurological exam not performed Treatment: Fit for vaccination Vaccination given: Nobivac DHPPi C4 SC + Nobivac BB PO Batch number: 2515101, 02541174C Next vaccination due: KC1 Aug 2026
2025-08-21T00:00:00Z 11:37:31
*** NO SHOW for today's vaccination app *** sms sent
2024-12-18T00:00:00Z 14:20:40
Reason/concerns: Scratching face History: O has noticed Bruce scratching the sides of his face for the last several weeks, now has crusty lesions on the sides and top of face Otherwise is doing well, O has no other concerns. Nil V+, D+, EDUF as normal Vaccination UTD, prophylaxis UTD (TWP) Examine: Mentation: BAR, likes treats BCS:4 /5 MM: Pink CRT: 1-2 seconds HR: 80 beats/min RR: Pant breaths/min Temperature: NE degrees Celsius Mandibular LN mildly enlarged Ocular: No abnormalities noted on cursory examination of both eyes. Oral/Dental stage: 1 Ears: Mild erythema on cursory examination of both ears. Cardiovascular: No audible murmur or arrhythmia Respiratory: Respiratory rate and effort normal Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated. Integumentary: Thick, dense matting and crusts of L and R side of face, several multifocal crusts on dorsal aspect of head. Ventral erythema of FL bilaterally Musculoskeletal: Normal gait and strength noted. No evidence of lameness. Problem and assessment List: 1. Hotspots/ superficial pyoderma A. Lesions clipped up to reveal ~ 6cm x 4cm superficial ulceration LHS, and ~4cm x 3cm superficial ulceration of RHS. Cleaned with dilute chlorhexidine. Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis): - None performed Treatment with medication dose rates (if any): Cephalexin 24mg/kg BID for 14 days Prednisolone 20mg tapering Client Communication & Plan: Recheck in 14 days
Previous claim history (7)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2024-12-18 | C8095045 | HYPERSENSITIVITY (ALLERGIC) SKIN DISORDER |
| 2023-04-04 | C5763361 | DIARROHEA |
| 2022-09-15 | C5105657 | MISCELLANEOUS CONDITIONS |
| 2022-09-03 | C5072703 | DIARRHOEA - PRESUMED SELF-LIMITING |
| 2022-09-03 | C5073801 | DIARROHEA |
| 2022-08-31 | C5065926 | DIARROHEA |
| 2022-08-28 | C5052988 | VOMITING - OTHER - PRESENTING COMPLAINT |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_diagnostic_test_-_blood_gases | 87.45 | 2026-03-06 | — |
| 20000 | tstarc_diagnostic_test_-_blood_test | 295.00 | 2026-03-06 | — |
| 30000 | tstarc_procedure_fee_-_radiology | 625.00 | 2026-03-06 | — |
| 40000 | tstarc_sedation_for_procedure | 212.00 | 2026-03-06 | — |
| 50000 | tstarc_hospitalisation | 180.00 | 2026-03-06 | — |
| 60000 | tstarc_consultation | 109.00 | 2026-03-06 | — |
UPM+
- DG02146VOMITING - OTHER - PRESENTING COMPLAINTDSTP_clinical_signs_-_vomiting
Variant (sleepy_king)
ANOREXIA - PRESENTING COMPLAINT
DSTP_clinical_signs_-_anorexia
Conf: 0.200
Threshold: 0.82
Above: ✗
Correct?
Acceptable?
Reason (acceptable)
Diagnosis description