C10017379 / invoice 10000

Species:CANINE
Breed:Moodle
Age (years):1
Diagnosis or signs:limping
Consult notes
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<p>hx:<br>monday afternoon limping back left HL<br>o took for a walk then seemed to improve.<br>was licking at the pad.<br>O soaked epsom salts and has been ok since <br><br>examine:<br>has a small erosion on the central pad of the left HL<br>does not appear to have any swelling or discomfort today. was likely very sensitive when it happened<br>should become less sensitive over time. <br>avoid wet surfaces for the next few weeks<br><br>had a discussion about desexing - pro's and cons<br>also spoke about pre-anaesthetic bloods etc.<br><br>vaccination is due in a month<br><br></p>
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Animal clinical history (3 most recent)

2025-07-03T00:00:00Z 17:58:00
See previous Hx - going well clinically. Head shaking & scratching stopped within a few days of treatment starting.Owners have been compliant with dermotic.Otoscope exam - both ear canals clean but moist.Swabs collected - both sides low numbers yeast cells (<2/hpf, sometimes none at all).Infection is resolving but not yet cleared so continue with dermotic for 4-5d further.After that continue with ear cleaner once/week as preventative.
2025-06-26T00:00:00Z 15:46:00
Ears:General Hx: EDDU normally, has been head shaking & scratching at earsO:Examination:Discharge:- Brown/red/black discharge on otoscopic examinationBoth ears moist & inflamedIn house cytology:- Pure growth Yeast spp both earsA:Otitis externa:P: Discussed use of drops & also ear cleaner as an adjunct O opting for: Dermotic - gave demo of its use R/v 7-10 sooner INI or worsening. Plan to repeat cytology to confirm infection is resolved.Use otoflush 2-3x/week, no less than 30-60minutes before dermotic
2025-04-05T00:00:00Z 11:44:00
HX: RC puppy food. 2x day feeds + left out kibble.O wormed 2 weeks ago. Unsure about desexing. Will decide later.Attending puppy school. Vacc slightly early (due in a few days), discussed with O coming back next week for ideal vacc effect, however owner is going to be away so alternative would be vacc would be delayed a few weeks which is not ideal so O would like vacc done today. Discussed not mixing with unvacced dogs or places where they might have been for another 2 weeks.Exam: BAR. mm/b pink, CRT<2s. BCS 2.5/5. Otherwise NADPE.Vacc C5, booster 1 year.Gave inj site a massage to help reduce chances of lump formation at site. If any concerns, please see vet to check. (Had a lump possibly related to vacc last visit.) 

Previous claim history (5)

DateClaim #Diagnosis
2025-07-03C8919812OTITIS EXTERNA
2025-06-26C8889917OTITIS EXTERNA
2025-06-26C8889917Preventative/Elective Procedure
2025-04-05C8547945VACCINATIONS OR HEALTH CHECKS
2025-03-12C8442606VACCINATIONS OR HEALTH CHECKS

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_consultation84.002026-03-11
20000tstarc_intestinal_worm_control10.342026-03-11
upstreamDSTP_routine_care_-_flea/tick/worm_preventative_medication

UPM+

  • DG02023GAIT ABNORMALITY - LAMENESS - PRESENTING COMPLAINTDSTP_clinical_signs_-_lameness
  • DG02937FLEA/TICK/WORM CONTROLDSTP_routine_care_-_flea/tick/worm_preventative_medication

Variant (sleepy_king)

MASS LESION
DSTP_mass_lesion_-_unspecified
Conf: 0.330
Threshold: 0.44
Above:
Correct?
Acceptable?
Reason (not acceptable — misleading)
Diagnosis description