C10012996 / invoice 10000

Reviewer

Species:CANINE

Breed:Weimaraner

Age (years):3

Diagnosis or signs:Wound

Consult notes

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<p>Subjective: <br>Pet's signalment: Max, Age not specified, breed not specified, sex not specified, neuter status not specified<br>History: <br>- Patient presented for evaluation of a wound on the foot.<br>- The injury occurred yesterday morning (March 9, 2026) during an altercation with a kangaroo in a dam.<br>- The owner reports a large gash between the toes.<br>- The affected foot is significantly swollen.<br>- The patient was able to bear weight on the limb yesterday after the incident.<br>- The patient was fasted this morning in anticipation of potential sedation for treatment.<br>Diet: Not specified<br>HW/ flea + tick preventative: Not specified<br>Current Medications / supplements: None<br>Any vaccine or medication reactions: None reported<br>Recent blood test: None<br><br>Objective: <br>Weight: 29 kg<br>Temperature: Not taken<br>HR: WNL<br>RR: WNL<br>BCS: 5 out of 9<br>FAS: Green<br>Hydration: Hydration appears normal<br>Eyes: no clouding, no debris, sclera is clear. Pupil sizes are symmetrical <br>Nasal: Patent and clear. No lesions or other abnormalities<br>Ears: No debris or erythema<br>Oral Cavity: healthy teeth and gums<br>Cardiovascular: no murmur or arrhythmia, strong pulses.<br>Respiratory: Lungs sounds are clear, no crackles or wheezes<br>Abdomen: comfortable on palpation, no mass effect, no fluid wave<br>Musculoskeletal: <br>- LARGE LACERATION NOTED BETWEEN THE TOES (digit 4-5) INTERDIGITAL SPACE<br>- SEVERE SWELLING AND CELLULITIS OF THE AFFECTED FOOT and FOREARM<br>- Normal ambulation, Normal ROM<br>Integument: <br>- A large, contaminated wound is present on the foot. The wound was flushed in-clinic and some dirty fluid was expressed. No large debris was removed<br>- Hair coat in good condition. No ectoparasites. No masses found.<br>Lymph nodes: Lymph nodes are soft and small<br>Urogenital: External genitalia appears normal; bladder palpates normally<br>Neurologic: Normal mentation<br><br>Assessment: <br>Problem List:<br>1. Contaminated traumatic wound/laceration to the foot<br>2. SEVERE CELLULITIS<br>3. Pain<br>Differentials: The primary concern is a contaminated wound with a high risk of infection and the potential for a retained foreign body.<br><br>Plan: <br>Treatments: <br>- The wound was flushed in the exam room.<br>- A photo of the wound was taken and added to the patient's file for monitoring progress.<br>- Medical management was initiated due to the significant swelling and the wound being over 24 hours old, which increases the risk of wound breakdown with immediate surgical closure.<br>Diagnostics Completed: <br>- Physical examination.<br>Prescriptions: <br>- Antibiotics: 3/4 tablet by mouth twice daily until the course is complete.<br>- Anti-inflammatory/pain medication: Administer once daily.<br>- E-collar to be worn at home to prevent licking.<br>Follow up:<br>- Strict rest is recommended at home.<br>- The owner is instructed to keep the wound clean and open to the air to allow for drainage.<br>- A staff member will call the owner tomorrow (March 11, 2026) to check on the patient's status.<br>- A recheck examination is recommended in 2-3 days to assess the swelling and determine if further intervention, such as a sedated wound flush, is necessary.<br>- The owner was advised to seek emergency care if the patient's condition worsens or if the wound develops significant discharge.</p>
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Animal clinical history (3 most recent)

2026-02-14T00:00:00Z 10:47:00

Medication to be dispensed: Fluoxetine 20mg x 2 packsDosage: 2 tablets PO SIDComments: Do not stop without veterinary advice, may cause serotonin syndrome.Revisit required: April 2026Medication to be dispensed: Clonidine 100mcg (note prev dispensed 150mcg, none in stock)Dosage: 6-9 tablets PO as required for short acting anxiety reliefComments: O is using approximately 5 x 150mcg tablets prior to stressful scenarios, approximately SIW-BIW. This dose is working well.Revisit required: April 2026

2025-12-17T00:00:00Z 18:34:00

Medication to be dispensed: Fluox and CatapresDosage:Comments:Revisit required:

2025-11-12T00:00:00Z 08:56:00

Medication to be dispensed: Fluoxetine 20mgDosage: 1 and 1/2 tablets PO SIDRevisit: April 2026Medication to be dispensed: Clonidine 150mcg (COMING INTO STOCK TODAY)Dosage: 4-7 tablets as requiredRevisit: April 2026

Previous claim history (6)

Date	Claim #	Diagnosis
2025-10-03	C9303851	VOMITING - OTHER - PRESENTING COMPLAINT
2025-08-14	C9091726	BEHAVIOUR DISORDER
2025-07-23	C9000520	BEHAVIOUR DISORDER
2025-06-23	C8884826	BEHAVIOURAL THERAPY
2025-06-17	C8851138	BEHAVIOUR DISORDER
2025-05-08	C8683287	BEHAVIOUR DISORDER

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

Line	tstarc	Amount	Date	Upstream diagnosis
10000	tstarc_meloxicam	76.98	2026-03-11	—
20000	tstarc_antibiotics_-_amoxicillin_and_clavulanic_acid	71.20	2026-03-11	—
30000	tstarc_consultation-revisit	109.00	2026-03-11	—

UPM+

DG01948WOUND - LACERATIONDSTP_wound_or_laceration

Variant (sleepy_king)

WOUND - LACERATION

DSTP_wound_or_laceration

Conf: 0.940

Threshold: 0.60

Above: ✓

Correct?

Yes No