C10000882 / invoice 10000

Species:CANINE
Breed:Japanese Akita
Age (years):9
Diagnosis or signs:Consult
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><p>VISIT REASON: Lethargy, vomiting<br><br>SUBJECTIVE:<br>History: Lethargic yesterday. Vomited water and small amount of food (carrot) this afternoon. Inappetent today - refused ham (favourite food). Toileting normally.<br>Existing medical conditions/diagnoses: Nil mentioned<br>Current medications: N/A<br><br>OBJECTIVE:<br>- Vitals:<br>- Temperature: WNL<br>- Heart Rate: WNL<br>- Respiratory Rate: WNL<br><br>- Physical Exam:<br>- General Appearance: BAR, appropriate mentation, hydration, demeanour<br>- Eyes: appear comfortable and sighted<br>- Ears: unremarkable but otoscopic exam not performed<br>- Oral Cavity: CRT &lt;2sec, no malocclusions, no calculus, no gingivitis<br>- CV: no murmur, regular rhythm, synchronous regular femoral pulses<br>- Resp: normal respiratory character and effort<br>- Neuro: appropriate mentation, unremarkable gait. Detailed neurological exam not performed<br>- Integument: clean, healthy coat without matting<br>- Abdomen/GI: mild abdominal tension on palpation (may indicate dull discomfort), BCS 6/9<br>- Musculoskeletal: unremarkable<br>- Urogenital: external genitalia unremarkable<br>- Peripheral lymph nodes: palpably normal<br>- Rectal: not performed<br><br>- Diagnostic Results: <br><br>ASSESSMENT:<br><br>- Suspected viral gastroenteritis vs extragastrointestinal disease (not yet apparent on PE)<br>- Offered CBC and biochemistry, O elected supportive care for now<br><br>PLAN:<br><br>- Diagnostic/Treatment Plan: Supportive care trial. <br>- Cerenia 60mg - 1 tablet PO SID x 4/7. <br>- Synbiotic DC (powder on food) once eating.<br>- Bland diet <br>- Recheck Monday/Tuesday if no improvement for bloods (~$260).<br>- Recommendations: Return if no steady improvement by Monday/Tuesday for further investigation including blood screen.</p></html>

Animal clinical history (3 most recent)

2022-09-08T00:00:00Z 11:04:54
Reason for visit: Dog bite right forelimbHistory:Has been bitten by a dog through the fence two days ago. Owner sbandaged the leg - would like a check up to see if stitch up is required. No current medications.Examination:HR:  120RR: pantTemp: 38.6CBCS: 5/9BAR, normal mentation. REyes, ears, nose, mouth normal  MM pink and moist, CRT 1-2 sec, no murmurs or arrythmias on cardiac auscultation, lung fields clear, LN normal size and consistency. Abdomen is soft and comfortable, good range of motion on all four limbs, skin and coat normal. Right forepaw, second interdigital space has a superficial laceration. Graze on the proximal carpus of the right forepawAssessment:Wound on right forepaw to be treated witbandaging and medical managementTreatment:- Clipped and cleaned the wound with iodine and saline- Applied flamazine to the wound and covered in melonin, folowed by vetwrap, then elastoplastPlan:- Change bandage daily with flamazine applied to wound- Clavulox 250mg, 1.5 tabelts PO BID for 5 days
2022-09-08T00:00:00Z 11:02:08
26.8 kilograms
2022-07-09T00:00:00Z 16:52:52
History: Dog fight on right front foot, owenrs other dog bit her, she prviously was bitten on her foot by another dog and so has mild behavioural issues now. Has been bright and happy at home otherwsie, no other concerns, eating and drinking is normal, no vomiting or diarrhea and no coughing. Activity levels normal. No changes in diet or home environment.Exam: Mentation: BAR, friendly, happyBody condition: 4/9Oral examination: There no evidence of periodontal or dental disease. No pain on opening mouth. Soft and hard palate normal.Mucous membranes are pink and moist. Capillary refill time <1 seconds.Ears: No inflammation of external ear canals.Eyes: Palpebral fissure normal size. Pupils mid-size and central. Conjunctivae have no inflammationCardiovascular: Cardiac auscultation revealed no systolic murmur. Good pulse pressure.HR= PR= normal for health status. No arrhythmiaRespiratory: Eupnoeic. The lungs sound normal. There was no upper respiratory tract noise.Musculo-skeletal: Ambulatory. No lameness noted. No joint abnormalities. No neck pain on manipulation. No spinal painon manipulation.Neurological: Appropriate. No abnormalities on brief neurological examinationLymph nodes: Peripheral lymph nodes normal size, shape and consistency.Abdominal palpation: Soft and comfortable. No masses or organomegaly detected.Urogenital: Bladder soft and comfortable.Integument: No ectoparasites detected. Good haircoat. Normal skin turgor.Laceration to stopper pad, half ripped off and there is a deep puncture on lateral aspect of main pad. Rectal exam: Rectal examination was not done.Assesment: dog fight wound - no surgery neededTreatment:keep bandaged home with bandage material and elastoplast to close wound.

Previous claim history (10)

DateClaim #Diagnosis
2017-09-25C1351685HIP DYSPLASIA
2017-09-22C1351682HIP DYSPLASIA
2017-08-07C1330897HIP DYSPLASIA
2017-07-26C1279866HIP DYSPLASIA
2017-07-18C1270819HIP DYSPLASIA
2017-06-10C1293256DERMATITIS
2017-06-03C1293256DERMATITIS
2017-04-03C1179529GAIT ABNORMALITY - OTHER - PRESENTING COMPLAINT
2017-04-03C1179529WEIGHT LOSS - PRESENTING COMPLAINT
2016-11-26C1293256GASTROENTERITIS

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_anti-nausea_medication93.882026-03-07
20000tstarc_consultation149.002026-03-07
30000tstarc_probiotics41.882026-03-07

UPM+

  • DG00986GASTROENTERITISDSTP_gastroenteritis

Variant (sleepy_king)

GASTROENTERITIS
DSTP_gastroenteritis
Conf: 0.780
Threshold: 0.68
Above:
Correct?