C10017437 / invoice 10000

Reviewer

Species:CANINE

Breed:Cavoodle

Age (years):2

Diagnosis or signs:Consult NB

Consult notes

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<div><strong>History:</strong></div>
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<p>Client History:<br>Concern for ear infections - both ears.<br>No issues like this previous.<br>Usually lets O touch ears, but was quite un comfort. Smells a bit currently.<br>Odd head shake, not unusual for him. <br>Remainder of skin otherwise fine.<br>EDDU normally. No vomiting, diarrhoea, coughing, sneezing.<br><br>Diet: Turkey mince, kibble - Blackhawk.<br>HW/ flea + tick preventative: UTD - every 3 months.  Last vac 2/25.<br>Current Medications/ supplements: Nil.<br><br>Subjective: <br>Pet's signalment: (Hugo, 2 years, Cavapoo, MN)<br>History: <br>- Presenting for evaluation of both ears.<br>- Owner notes the patient is resistant to having his ears handled, which is a new behavior.<br>- AN ABNORMAL ODOR IS DETECTED FROM THE EARS.<br>- Occasional head shaking is reported, but the owner does not feel it is increased from baseline.<br>- No increase in scratching or rubbing has been observed.<br>- No other dermatologic signs (pruritus, licking, chewing) are reported.<br>- Appetite and thirst are normal. No vomiting, diarrhea, coughing, or sneezing.<br>- Owner noted a SMALL RED BUMP on the patient's left lip/gum area approximately two weeks ago (late February 2026).<br>- Patient has a history of a front limb condition that may predispose him to osteoarthritis.<br>Diet: <br>- Turkey mince and Blackhawk kibble.<br>HW/ flea + tick preventative:<br>- Receives a product for fleas and worms every 2-3 months; product name is unknown.<br>Current Medications / supplements:<br>- None.<br>Any vaccine or medication reactions:<br>- None reported.<br>Recent blood test:<br>- None.<br><br>Objective: <br>Weight: - kg<br>Temperature: Not taken<br>HR: WNL<br>RR: WNL<br>BCS: OVERWEIGHT; ribs are difficult to palpate and there is a poor waist tuck.<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: OTOSCOPIC EXAM REVEALED A MILD AMOUNT OF DEBRIS BILATERALLY. Tympanic membranes were visualized and appear intact AU (both ears).<br>Oral Cavity: MILD TO MODERATE GINGIVITIS AND DENTAL CALCULUS PRESENT. A SMALL, RED, FLAT MACULE IS NOTED ON THE GINGIVA OF THE LEFT MAXILLA.<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: Normal ambulation, Normal ROM<br>Integument: skin looks normal; 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. BILATERAL OTITIS EXTERNA (YEAST)<br>2. DENTAL DISEASE (GINGIVITIS, CALCULUS)<br>3. OVERWEIGHT BODY CONDITION<br>4. GINGIVAL MACULE, LEFT MAXILLA<br>Differentials: Diagnosis of otitis externa secondary to yeast overgrowth confirmed via cytology.<br><br>Plan: <br>Treatments: <br>- Initiate otic medication (corticosteroid/antifungal/antibacterial) AU SID for 5 days.<br>Diagnostics Completed: <br>- Otoscopic examination.<br>- EAR CYTOLOGY: Revealed a MILD OVERGROWTH OF YEAST.<br>Prescriptions: <br>- Dispensed otic medication.<br>Follow up:<br>- Recheck examination scheduled for one week to re-evaluate ears. Owner instructed to stop medication two days prior to the appointment.<br>- Plan to administer C5 vaccination at recheck if patient is clinically well.<br>- Recommended a professional dental cleaning procedure to address current dental disease. Information will be provided to the owner.<br>- Advised owner to monitor the gingival macule for any changes in size or texture.<br>- Discussed the importance of weight management for long-term joint health, aiming for a leaner body condition score.</p>
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Animal clinical history (3 most recent)

2025-02-28T00:00:00Z 13:04:00

Nurses: Kim and KezProcedure Performed: Hugo underwent a castration and hernia repair on 14 February- Post-operation, EDDU all fineWound Appearance:- During the post-op check, the hernia repair wound looked slightly angry, with irritated scabbing- A little redness was still present, with a bit of inflammation. Informed O to keep an eye on it and let us know of if any issues- The castration area has healed well with no swelling, discharge, or agitation. Hugo was not preloaded despite informing O he needs to be preloaded (last reason was due to energetic behaviour, discovered today he is usually reactive when trying to touch him) Managed to remove all sutures including the hernia area despite it looking angrier than the castration. Was thrashing around, with the muzzle on and getting super stressed. Informed O needs to preload next time for all physical examinations etc in future, and keep and eye on the hernia repair. If any odd sutures that were mistakenly missed, to come back in PRELOADED Vet assesment: N

2025-02-18T00:00:00Z 09:05:00

Nurses: Ash and KezProcedure Performed: Hugo underwent a castration and hernia repair on 14 February- Post-operation, Hugo has been eating, drinking, and using the bathroom normally- The owner has been keeping Hugo calm at home.Wound Appearance:- During the post-op check, the hernia repair wound looked good with no infection, only slight scabbing, which is normal.- A little redness was noted, and the owner was advised to clean it with diluted betadine.- The castration area is healing well with no swelling, discharge, or agitation.Plan:- Hugo is scheduled for a suture removal post-op check on 28 February, exactly two weeks after surgery.- Hugo will be preloaded for the suture removal due to his energetic nature- Continue wearing the elizabaethen collar to prevent self trauma vet assesment: N

2025-02-15T00:00:00Z 09:47:00

Reason for call: post op follow up Outcome of call: eddu all well, sleepy, slowly getting energy back, o have no concerns. POC booked for tuesday Follow up required: Yes / No

Previous claim history (3)

Date	Claim #	Diagnosis
2024-07-26	C7510171	LIMB DEFORMITY, DEVELOPMENTAL - CARPAL VALGUS
2024-07-22	C7492875	LIMB DEFORMITY, DEVELOPMENTAL - CARPAL VALGUS
2024-03-18	C7005873	VACCINATIONS OR HEALTH CHECKS

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

Line	tstarc	Amount	Date	Upstream diagnosis
10000	tstarc_ear_medication_-_antibacterial_and_anti-fungal	106.20	2026-03-11	—
20000	tstarc_diagnostic_test_-_cytology	62.50	2026-03-11	—
30000	tstarc_consultation-revisit	109.00	2026-03-11	—

UPM+

DG01185OTITIS EXTERNADSTP_otitis_externa

Variant (sleepy_king)

OTITIS EXTERNA

DSTP_otitis_externa

Conf: 0.900

Threshold: 0.07

Above: ✓

Correct?

Yes No