C10005518 / invoice 10000
Species:CANINE
Breed:Cocker Spaniel
Age (years):4
Diagnosis or signs:Check ears
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><p>Consulting with Vet Nurse: yes<br><br>PRESENTING COMPLAINT: <br>- Ear irritation, possibly from swimming<br><br>HISTORY:<br>- Dog doing a lot of swimming<br>- Hot and humid weather conditions<br>- Owner concerned about possible ear infection<br>- Symptoms were more bothersome a few days ago - scratching ears <br>no c/s/v/d<br><br>Current medications: Apoquel 16mg 1/2 SID once daily, and an anti-anxiety medication<br><br>Weight: 14.9 kg<br>HR: 120<br><br>EXAMINATION: <br>Ears: slightly errythmatous no obvious discharge canals appear normal size TM appears normal <br>DG 2/4 slight calculus build up in front and pre molars <br>p mmbs crt < sec <br>HR 120 = femoral pulses moderate<br>RR pant <br>No obvious murmurs or arrythmias no crackles or wheezes <br>Abdo palp NAD <br>Temp 38<br>Demeanour: anxious during examination<br><br>PROBLEM LIST:<br>- Ear irritation/inflammation<br>- Swimming-related ear issues<br><br>DDx:<br>- Otitis external <br>- allergey <br><br>ASSESSMENT: Ear irritation likely related to swimming and allergies rather than active infection. No significant debris or discharge noted on examination.<br>Attempted to collect ear samples for cytology not much broght out - at this point recommend ear cleaning and adjust the apoquel dosaging for 1 wk then reasses<br><br>TREATMENT in consult room/Meds dispensed:<br>- Ear cleaning performed both ears wiht otoflush <br>- Blood collected and sent off for routine Grey P <br><br>PLAN:<br>- Apoquel 16mg 1/2 tab BID for 1wk <br>- if not improving recheck - next steps would be ear cytology +/- prednisolone <br>- Ear cleaning performed today<br>- Annual blood panel to be performed due to ongoing medications<br>Revisit recommended? If symptoms persist after one week of increased Apoquel<br>Call back scheduled? No</p></html>
Animal clinical history (3 most recent)
2026-03-09T00:00:00Z 12:18:00
are the policy details on file Y/N: YIs this the clients first claim Y/N: Ne-claimWhich visits are we claiming?: 9/3/26Claim submitted (please initial and date):
2025-12-29T00:00:00Z 13:52:00
History:4 wks ago was seen for right side ear infection was treated with neptra \owners noticing that there is pain on touching base of the ear yesterdayWere on Z/D however due to formulation change owners have noticed starting to react to the foodExaminationBARHR 110 = femoral pulses moderateRR 40 chest no obvious murmurs or arrythmais no crackles or wheezesabdo palp nadears: L ear clear no concerns no discharge no rednessR ear small amount of discharge and slight rednesson cytology small amount of discharge present in the R earp mmbs crt<2sectemp 38.4AG right very minimal amount easily expressedand left nothing presentAssessment:ear irritation most likley secondary to irritation from change in diet formulation.at this point ears don't seem to be irritated or infectedcleaned ears today - advised to monitor if still bothering consider topical steroid into earsPlan:Monitor ears for now if not improving or continued itching to call and let us know prior to booking appt - may have to either have a topical steroid medication compounded or consider if responding well to ear cleaning to clean EOD for a few wks while diet is changed to a single protein diet or a different hypoallergenic diet
2025-12-08T00:00:00Z 15:32:00
Reason:Here for AG expression- has been scootingWill be with pet sitter over next few daysComing for casual visits frequently to help with vet related anxiety- seems to have made leaps & boundsTx:AGs expressed, treats accepted++ thick brown dischargePlan:Return for AG expressions as neededContinue casual visits to clinic
Previous claim history (10)
| Date | Claim # | Diagnosis |
|---|---|---|
| 2022-10-13 | C5195845 | URINARY TRACT INFECTION (UTI) |
| 2022-09-15 | C5106366 | VACCINATIONS OR HEALTH CHECKS |
| 2022-09-15 | C5106366 | FLEA/TICK/WORM CONTROL |
| 2022-09-06 | C5106357 | SKIN (CUTANEOUS) ABNORMALITY - ERUPTIONS/HIVES/RASH - PRESENTING COMPLAINT |
| 2022-08-27 | C5106355 | HEARTWORM CONTROL |
| 2022-08-27 | C5106355 | FLEA/TICK/WORM CONTROL |
| 2022-08-20 | C5106340 | VACCINATIONS OR HEALTH CHECKS |
| 2022-08-20 | C5106340 | FLEA/TICK/WORM CONTROL |
| 2022-08-20 | C5106340 | HEARTWORM CONTROL |
| 2022-08-10 | C5106327 | FLEA/TICK/WORM CONTROL |
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation | 119.00 | 2026-03-09 | — |
| 20000 | tstarc_procedure_fee_-_ear_flush | 20.90 | 2026-03-09 | — |
| 30000 | tstarc_procedure_fee | 34.50 | 2026-03-09 | — |
| 40000 | tstarc_diagnostic_test_-_blood_test | 304.80 | 2026-03-09 | — |
UPM+
- DG02319HYPERSENSITIVITY (ALLERGIC) SKIN DISORDERDSTP_skin_-_allergic_disorder
Variant (sleepy_king)
OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.670
Threshold: 0.07
Above: ✓
Correct?
Acceptable?
Reason (acceptable)
Diagnosis description