C10003796 / invoice 10000
Species:CANINE
Breed:Cavoodle
Age (years):4
Diagnosis or signs:Consult
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div> </div> <div> <p><strong>HISTORY </strong><br><br><strong>EXAM</strong><br><br><strong>ASSESSMENT </strong><br><br><strong>LABORATORY</strong><br><br><strong>TREATMENT </strong><br><br><strong>PLAN</strong><br><br><strong>OWNER COMMUNICATION</strong></p> </div></html> </br><p>**HISTORY**<br>**Presenting Complaint**: Excessive licking of vulvar area<br>- Owner reports dog keeps licking vulvar area<br>- Groomer noticed possible infection and hair stuck together<br>- Dog shows discomfort during meals, looking around suddenly<br>- Behaviour has been ongoing for a while<br>- Also noted brown discharge in ears from recent grooming visit</p><p>EATING: Normal<br>ENERGY: Normal <br>DRINKING: Normal<br>DEFECATION: <br>URINATION: Normal<br>Meds: Nil<br>C-/S-/D-/V-</p><p>**PHYSICAL EXAMINATION**<br><u>Mentation:</u> BAR<br><u>MM:</u> Pink, moist<br><u>**EENT:</u> Brown discharge in ears, no infectious organisms found on examination<br><u>CARDIAC:</u> NAD<br><u>RESP:</u> NAD<br><u>**SKIN:</u> Vulvar fold dermatitis with skin folding over creating bacterial trap, infection present in vulvar folds<br><u>DENTAL:</u> <br><u>ABD. PALP:</u> NAD<br><u>MSK:</u> NAD<br><u>LN:</u> NAD</p><p>**PROBLEM LIST**<br>- Vulvar fold dermatitis with secondary bacterial infection<br>- Excessive ear discharge</p><p>**DIAGNOSTICS**</p><p>**ASSESSMENT**<br>Vulvar fold dermatitis with secondary bacterial infection due to anatomical skin folding creating bacterial entrapment</p><p>**TREATMENT**<br>Temperature taken: 39.3°C (normal)</p><p>**COMMUNICATION**<br>- Discussed physical examination findings, differentials/assessment & plan<br>- Explained anatomical cause of vulvar fold infection due to skin folding<br>- Discussed need for E-collar to prevent licking<br>- Advised on home care including warm cloth soaking and drying before cream application<br>- Explained that surgical intervention may be needed if condition worsens<br>- Discussed ear cleaning protocol</p><p>**PLAN**<br>- Oral antibiotics BID for 7 days<br>- Topical cream for vulvar area TID for 7 days<br>- Medicated ear cleaner - 3 times this week, then BID next week, then fortnightly maintenance<br>- E-collar to remain on until completion of antibiotic course<br>- Re-check: After completion of antibiotic course<br>- INI consider: Surgical intervention if condition does not resolve or worsens</p><p>JR</p>
Animal clinical history (3 most recent)
2025-01-05T00:00:00Z 11:02:14
Examination Text:Reason: Eye Check L Eye DischargeHistory: Squinting L eye since this morning w ocular discharge.No known trauma etc.Has been otherwise well and is EDDU ok.Examine: BAR on PE, all vitals ok, temp=38.8.Ocular exam:R eye - NSF.L eye - mod blepharospasm with markedly injected sclera and conjunctival hyperaemia. Fluoro NEG. Mild mucoid ocular discharge. Exam of fundus/retina WNLs. No anterior chamber inflam.Assessment: Likely conjunctivitis - alleric or 2ndary to irritant.Treatment: 1. Prednefrin forte bid 5d L eyePlan: Nurse update in 48h.R/c as needed if not improving.--- 07/01/2025 14:22:37 JFO:Called O for update - O reports that it is getting better however she now has it in the other eye. She mentioned she is having trouble putting the drops in the eye.I explained approching from the back could help and gently pulling the chin up and putting in the corner of her eye and letting her blink them in.O will try this but if she is unable she will call to book in with nurse.
Previous claim history (16)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2026-01-29 | C09823594 | VACCINATIONS OR HEALTH CHECKS |
| 2025-05-01 | C8654826 | OPHTHALMIC (EYE) ABNORMALITY - PRESENTING COMPLAINT |
| 2025-04-17 | C8600088 | EYE INFECTION |
| 2025-04-17 | C8600088 | EYE INFECTION |
| 2025-01-29 | C8257903 | VACCINATIONS |
| 2025-01-05 | C8155773 | OPHTHALMIC (EYE) ABNORMALITY - PRESENTING COMPLAINT |
| 2024-02-27 | C6926432 | VACCINATIONS OR HEALTH CHECKS |
| 2023-02-03 | C5549017 | VACCINATIONS OR HEALTH CHECKS |
| 2022-04-28 | C4694917 | DIARRHOEA - PRESUMED SELF-LIMITING |
| 2022-04-18 | C4666895 | DIARROHEA |
| 2022-04-14 | C4663561 | DESEXING |
| 2022-04-14 | C4663561 | OTITIS EXTERNA |
| 2022-04-14 | C4663561 | TEETH CLEANING |
| 2022-04-14 | C4663561 | DESEXING |
| 2022-02-19 | C4502298 | OTITIS EXTERNA |
| 2021-12-30 | C4359605 | VACCINATIONS OR HEALTH CHECKS |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 115.00 | 2026-03-09 | — |
| 20000 | tstarc_diagnostic_test_-_cytology | 75.00 | 2026-03-09 | — |
| 30000 | tstarc_antibiotics_-_amoxicillin_and_clavulanic_acid | 50.52 | 2026-03-09 | — |
| 40000 | tstarc_elizabethan_(buster)_collar | 11.77 | 2026-03-09 | — |
| 50000 | tstarc_skin_medication_-_topical_antibiotics_and_anti-inflammatory | 52.04 | 2026-03-09 | — |
| 60000 | tstarc_ear_cleaner | 32.13 | 2026-03-09 | — |
UPM+
- DG01942VULVAL DISORDERDSTP_vulval_and_vaginal_disorder
- DG00673EAR (AURAL) DISEASEDSTP_otitis_externa
Variant (sleepy_king)
DERMATITIS
DSTP_skin_-_dermatitis
Conf: 0.310
Threshold: 0.25
Above: ✓
Correct?
Acceptable?
Reason (acceptable)
Diagnosis description