C10003984 / invoice 10000

Species:CANINE
Breed:Cavoodle
Age (years):9
Diagnosis or signs:Ears
Consult notes

Animal clinical history (3 most recent)

2026-03-09T00:00:00Z 12:35 PM
Reason: Recheck Ears Appointment Notes: Overdue remindersHere for otitis externa recheck. O unsure when last dermotic applied. Finished 10d course. No scratching or redness noted. No swimming.BAREars:- RHS: mild discharge, NAD on cytology, TM intact - LHS: moderate discharge, NAD on cytology, TM intact on OEBoth ears cleaned w Otoflush.Otoflush: Please instil 1ml into both ears once a week for 4 weeks. If the ears are clean, you may extend the ear cleaning to once a fortnight. See back if any redness, increased discharge, itchiness or foul smell.Verified: NoBased on the provided transcript, there is insufficient clinical information to generate a comprehensive SOAP format medical record. The transcript contains only brief conversational fragments (Okay. Sorry. That was the one. Okay. Yeah. Okay.) without any substantive medical content regarding the patient's history, physical examination findings, assessment, or treatment plan.To create a proper veterinary medical record, I would need a transcript that includes:- Patient presentation and chief complaint- Medical history and clinical signs- Physical examination findings- Diagnostic results- Veterinary assessment and diagnosis- Treatment recommendations and client discussionsWithout this essential clinical information, I cannot produce the requested SOAP format record.    Vital Signs    Weight: 12.2;       

Previous claim history (27)

DateClaim #Diagnosis
2026-02-18C09921993OTITIS EXTERNA
2026-02-18C09921993FLEA/TICK/WORM CONTROL
2026-01-05C09707281PANCREATITIS
2025-12-12C09616310INAPPETANCE
2025-12-12C09616310VACCINATIONS OR HEALTH CHECKS
2022-05-03C4712660BLOOD SCREEN
2022-05-03C4712660TEETH CLEANING
2021-09-15C4078973EAR INFECTION
2021-07-26C3947388EAR INFECTION
2021-07-09C3901915EAR INFECTION
2021-05-24C3787419EAR INFECTION
2021-05-24C3787419SCOOTING
2021-05-24C3787423VACCINATIONS OR HEALTH CHECKS
2021-02-21C3551929INSECT BITE/STING
2021-01-18C3465238Assessment - Non Routine
2020-12-10C3390318URINARY TRACT INFECTION (UTI)
2020-12-10C3390318HEARTWORM CONTROL
2020-12-10C3390318FLEA/TICK/WORM CONTROL
2020-05-11C2893441DENTAL (TOOTH) DISORDER
2020-03-30C2817397SCOOTING
2020-03-30C2817397FLEA/TICK/WORM CONTROL
2020-03-30C2817397HEARTWORM CONTROL
2020-03-09C2817409KENNEL COUGH
2019-10-14C2500003VACCINATIONS OR HEALTH CHECKS
2019-09-21C2634146CONJUNCTIVITIS
2018-09-25C1853961VACCINATIONS OR HEALTH CHECKS
2018-09-25C1853961PRESCRIPTION DIETS

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation-revisit65.002026-03-09
20000tstarc_diagnostic_test_-_cytology49.002026-03-09
30000tstarc_ear_cleaner51.902026-03-09

UPM+

  • DG01185OTITIS EXTERNADSTP_otitis_externa

Variant (sleepy_king)

OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.990
Threshold: 0.07
Above:
Correct?