C10013118 / invoice 10000

Species:CANINE
Breed:Labrador
Age (years):4
Diagnosis or signs:ear infection
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><span style="font-family: 'Arial'; font-weight: bold; text-decoration: underline;">History:<br></span><p>- O reports going well at home but is really bothered by ears worse on RHS scratching and shaking head constantly <br>- EDDU nad, no v+/d+, no cough sneeze, no new lumps, no lameness.<br>- did use an ear cleaner a couple of days ago and the liquid coming out was dark brown <br><br>Parasite Control: utd<br>Current Medications: neocort, apoquel <br>Previous Medical History: skin issues<br><br><span style="font-family: 'Arial'; font-weight: bold; text-decoration: underline;">Exam:<br></span>Mentation: BAR - beautiful boy <br>CVS: HR 110 bpm, nad on ausculation CRT &lt;2s, pink, moist<br>Resp: nad on auscultation<br>Eyes/Ears/Nose: small superficial laceration to medial canthas of right eye<br>                            ears ++ debris bilaterally <br>Integument: nad - clean shiny coat <br>Abdominal: soft, comfortable<br>MSk: ambulating well around consult room.<br><br><span style="font-family: 'Arial'; font-weight: bold; text-decoration: underline;">Assessment:<br></span>- bilateral ear infection <br>- superficial laceration due to scratching <br><br>Plan <br> - smear right ++++ debris +++ yeast ++ cocci <br>              left + debris + cocci <br> - otoscope exam right +++++ pain ++++ erythema +++ stenosis ++ debris TM intact <br>                             left + debris TM intact <br> - home with dermotic and pred <br> - revisit in 14days</p></html>

Animal clinical history (3 most recent)

2026-01-27T00:00:00Z 09:16:00
Hx -- 10d ago pulled out kitchen draw and it landed and left a gash on the medial lateral aspect of the LHL. Went to emergency the night it happened and opted for staples- All staples removed last week, wound reopened at the top on Saturday afternoon, opted to wait until Tue to reassess- EDDU normally, no concerns - Has been crating overnight and is wearing inflatable e-collar - Not on any medication CE:- Eyes/ears/mouth: Clear, Gr 1 dental, pink MM, CRT <2s- CVS: NAD, HR 100bpm- Abdo: Comfortable- Temp: -- M/S:-- Integument: Wound on mediolateral aspect of LHL- Other:-A - Healing well via secondary intention. No sign of infection. Healthy granulation tissue has filled the gaping wound. Informed O that might expect a larger scar as have allowed secondary healing, but O doesn't mind. Rx & Plan - - Gently cleaned with chlorohexidine and rebandaged as O worried about him knocking the wound while he is left alone. Informed O as long as Theodore is not licking or aggravating the wound, don't have to rebandaged, but if worried about trauma then cover- Sent home on 7d of NSAIDs and antibitoics- Told O to monitor for infection and call with any concerns. No recheck at moment 
2026-01-24T00:00:00Z 09:38:00
staples out, wound is healingCytopoint 40mg given 836645 02/27O to keep in touch with SHZ in case the wound opens up
2026-01-22T00:00:00Z 08:55:00
The top two staples have started to have skin grow over the top. bandaged changed and rv on sat

Previous claim history (9)

DateClaim #Diagnosis
2026-01-24C09805911HYPERSENSITIVITY DISORDER (ALLERGY)
2026-01-22C09793586WOUND - LACERATION
2026-01-17C09775275WOUND - LACERATION
2023-01-10C6046714DESEXING
2022-08-25C5068559ALLERGY
2022-07-28C5068598ALLERGY
2022-06-30C5068606ALLERGY
2022-06-02C5068597ALLERGY
2022-06-02C5068597VOMITING - OTHER - PRESENTING COMPLAINT

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation119.002026-03-11
20000tstarc_diagnostic_test_-_cytology60.802026-03-11
30000tstarc_ear_medication_-_antibacterial_and_anti-fungal84.002026-03-11
40000tstarc_corticosteroids28.602026-03-11

UPM+

  • DG00676EAR (AURAL) INFECTIONDSTP_otitis_externa

Variant (sleepy_king)

OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.610
Threshold: 0.07
Above:
Correct?